Ah...happiness...that elusive, and for so many, that all-too-fleeting experience. Is it all about physicality? Must we attain extreme, physical beauty to have real happiness? Well, it certainly seems so.

There are innumerable media images of physical perfection skillfully designed to brainwash and psychologically degrade us. Insidiously, we unknowingly acquiesce and integrate these alleged essential ingredients for happiness into our sense of human worth and value. Are we so weak and blind that we cannot see that this is a societal dictate mandating that we conform to an arbitrary caricature of beauty? Furthermore, who are the perpetrators of these heinous messages and crimes against individuality? Is it Hollywood? The cosmetics industry? Or even worse, the medical profession?

Who's Responsible?
Sure Mrs. Jones, you do have a basal cell carcinoma on your leg, but let's talk about that later. For goodness sake, look in the mirror; you actually go out of the house with those infraorbital wrinkles, lentigos, perioral rhytids, unwanted facial hair and vessels? Let's talk about that skin cancer stuff later.

Your eyes, cheeks, lips, chin, breasts, buttocks, love handles, abdomen and legs certainly are not what they used to be; in fact, even worse, they never were. If only you could achieve physical perfection - the power, money, glamour and happiness that the "beautiful people" possess could be yours.

This well-orchestrated lie perpetrated by the film, cosmetic and medical industries has led to a society obsessed with physicality. We are in awe of television, movie and magazine images that portray physical beauty that is often enhanced by physical means as well as by computerized image touch-ups. Our perception of "reality" is increasingly blurred by digitalization. This all culminates in a society that abhors aging - and the aged.

What role should dermatology play in addressing this cultural phenomenon while remaining true to science and alleviation of human suffering?

I believe that extreme makeovers can lead to surgical scars and short and long-term complications can lead to even more devastating consequences. I advocate for healthy cosmesis and targeted intervention in pursuing a healthy existence.

The Cosmetic Pyramid
Healthy cosmesis lies midway between total self-neglect and extreme makeover. Inherent in this definition is appropriate self-care (grooming, diet, exercise, stress management) and moderate attention to cosmetic concerns. Healthy cosmesis requires respect for the unique qualities and seeks to enhance the beauty of the individual. "Correction" should be reserved for rationally selected, targeted interventions or features that elicit physical discomfort, social stigmatization or significant emotional distress. As dermatologists, we're uniquely positioned to provide patients with services and interventions that promote healthy cosmesis.

A pyramid concept is helpful in addressing the needs of our patients. The base of the pyramid is composed of healthy basic skin, body and emotional functioning. Identifiable skin lesions, such as benign and malignant neoplasms, and common skin conditions, such as rosacea, acne and psoriasis should be identified and addressed. Basic skin care and sun avoidance are included as well.

As we move up the pyramid, issues of satisfaction with skin function and overall appearance are addressed.

Moving still further up the pyramid, specific areas of dissatisfaction, such as static wrinkles, dyspigmentation, varicosities, volume loss, dynamic wrinkling, nuisance benign growths, hair loss and body image-satisfaction, etc. can be addressed.

Finally, life, marital, and job satisfaction and existential issues reside at the top.

Satisfying Patients
As dermatologists, we can address most needs within the pyramid construct with medical, surgical and cosmetic interventions. Treatment of common dermatoses and skin cancers, removal of unwanted lesions, hair restoration/removal, injectible fillers, microdermabrasion, Botox, topical rejuvenation products and laser therapies can have dramatically positive impact on quality of life while maintaining the identity of the patient.

Patient satisfaction and improvements in quality of life are expected outcomes for appropriate patients. We must help patients choose wisely, selectively and realistically. Careful analysis of risk-benefit equations can be helpful. Vigilance for patients with body dysmorphic disorder and other psychopathology can minimize the likelihood of dissatisfied patients.

Certain caveats must be stressed. Satisfaction is often more contingent upon personality than objective clinical outcome. After cosmetic procedures, some patients become aware of imperfections that were invisible to them before and believe they were a result of the procedure. Photo documentation and skillful "lowering of brain neurotransmitter status are the main predictors of happiness. Cosmesis is important and can interact positively with these things. Extreme makeover represents the potential demise of the individual. Healthy cosmesis honors and embraces the individual.

As dermatologists, we can assist patients and provide a safe, honest and informed passage through the cosmetic world avoiding the potential damage of extreme makeovers.