Botox. Breast implants. Bulging biceps. Facial laser resurfacing. Fake chins. Liposuction. Liposculpture. Personal trainers. Penile and pec implants. And the list goes on and on.

Body image is big business. Just open any magazine geared toward “healthier living” and you will find most of its income comes from organizations geared at making one look and feel better. But are there intrinsic benefits to some of these processes or is it all just empty make-over magic?

The truth is that likely everyone worries about their appearance. It is, after all, our front line in first impressions. And it is what we see in the morning mirror. Like most concerns, though, it is likely that being focused on your appearance poses no serious problems until it turns from a health interest to an obsession.

According to most studies, the number of men under the age of 30 having plastic surgery has more than doubled in the last five years. But is that such a bad thing?

“I took this women’s study class one time,” says Bill Milken of Hillcrest, “and I was the only guy in the class. When the subject of body image and plastic surgery came up, the general consensus in the class was that it was the media’s fault. Everyone seemed to be blaming it on this intense implicit pressure by the media to show us what the ideal woman should be.”

Milken chose to stand up and disagree.

“I said, ‘Hey, you can have all the media in the world telling you what you should be, but that doesn’t mean you have to buy into it,’” ventured Milken. “I mean, is it the chicken or the egg? Did women in the ’80s begin to realize they could have the bodies they wanted and begin a simple supply and demand scenario, or were they all chained and dragged down to the plastic surgeon’s office?”

Lucky for him, Milken says, the class knew he was a gay man, and he talked a lot about his own battles over self-image and body image. While part of it is the media, Milken refuses to defer to that argument as the end-all to the discussion.

Eric Denigan of Mission Hills agrees. “Remember those Hanes ads at Robinson’s May where they had these life-size cutouts of a doctor, a fireman and a construction worker with all their upper clothes on and then just underwear? And these were gorgeous men with great looking bodies. OK, so I thought, ‘Yeah, these guys are hot, but no underwear is going to make me look like that.’”

Further, Denigan says, it was nice to see that sex was selling in the men’s section. “You figure there are really only two primary groups of people who buy underwear in the men’s section: gay men and married women. I liked the fact that the media was saying, ‘Hey ladies, buy these boxer briefs and your husband can look just like this.’ I liked that someone was finally shifting the stagnant paradigm of it being the woman’s responsibility to look beautiful.”

The ironic point for Denigan, though, was that he was out shopping for underwear for his husband. “I laughed out loud when I thought of my partner posing for one of those ads. Besides, he wouldn’t wear Hanes to save his life!”

Regardless of how one sees oneself – or others, for that matter – few can argue that body image is purely subjective, and deeply personal. It is as varied as there are grains of sand in Coronado, says Robert Cardell of University Heights.

“The old saying is that one man’s trash is another man’s treasure,” explains Cardell. “I happen to be a really short guy, so I try to stay thin. But I like tall, sturdy guys. And I don’t mean muscle-bound, I just mean nice and healthy. Guys who eat healthy, could keep up on a pair of roller blades on a Saturday afternoon ride through Balboa and still have energy to cuddle afterwards.”

Tim Rutherford of Normal Heights says that his distinctive look – which he calls the “Vin Diesel look” and is very much a result of hours in the gym – is easily explained, but his partner is a local drag queen. Rutherford says that many people are confused by his attraction to Raul.

“Raul spends a great deal of his time getting facials, trying out different make-up at the Clinique counter, and shopping at Sax Off Fifth for bargain gowns,” explains Rutherford. “He is often called ‘nelly’ or not ‘straight-acting’ enough. That’s pure bullshit. When we met about 13 years ago, I had no idea Raul was a drag queen by night. He was such a beautiful, well-groomed, slim man. He seemed like the perfect gay male, from his coiffed hair to his pedicure.”

After about four dates, Rutherford said Raul had to fess up. “He took me to his closet, and opened the doors. There were these absolutely gorgeous gowns and wigs. Then it hit me. But my first thought was, ‘Well, that makes sense. If he is such a beautiful man, why wouldn’t he be such a beautiful woman?’”

For Raul, says Rutherford, the drag persona never prevented him from attracting a boyfriend, it only prevented him from attracting the wrong type of boyfriend – the close-minded ones.

Rutherford says he also has a good friend who people describe as having “the body of a Great Dane and the voice of a poodle.” And strangely, says Rutherford, while a lot of men who meet his friend find that very alarming, they also find him very sexy.

“It’s because he is comfortable with himself,” argues Rutherford, “and few of us can say that. Keeping up my health is the most important part of my day. And mental health is part of that equation.”

“Raul makes me feel very handsome,” says Rutherford, “even when I don’t feel that way about myself. In fact, when I mentioned to him that I wanted to have a certain plastic surgery procedure done, he didn’t flinch. He totally understood.”

For years, Rutherford would refuse to have side-profile photos taken, because while the rest of his body was in great shape genetically, he had what is commonly called a “weak chin.”

“Really,” says Rutherford, “it was beyond weak. It was non-existent. It was like my bottom lip touched my collar bone.”

It was the one area that Rutherford felt self-conscious about. After hours of discussion with Raul, assuring him that this was the only procedure he would have done, they agreed to give it a try.

“I will never regret it,” says Rutherford. “I have absolute confidence now when someone is taking a photo or having someone near my face. It really did change my life. I have never wanted to have another procedure done. Just that one. It’s amazing what five hours in a doctor’s office can do for the rest of your life.”

Rutherford understands, though, and explains without hesitation, that plastic surgery should be limited to one or two cosmetic things that impede on the psyche of the individual.

“You can’t just go out and say, ‘I want a mega make-over,’ or whatever those extreme television shows portray as possible,” says Rutherford. “At some point, you have to love yourself as a whole.”

Phillip Restine of Hillcrest has a theory about when the gay male community became so concerned with keeping up appearances.

“With the onset of AIDS, there was suddenly this masculinity and healthy-look crisis,” recalls Restine, age 53. “I think in some way, people tried to show that they were healthy and not infected by becoming more involved in their physique and personal appearance.”

Combating the physical decline brought on by living with HIV was a huge concern for many of Restine’s friends. More and more, says Restine, men began embracing the gym and steroids as esteem-builders.

But the ironic turn of events, avers Restine, is that even those who didn’t contract HIV found themselves scrambling to the gym so that they would not be mistaken for someone who was infected.

“And frankly,” says Restine, “I fear we have not gotten over that. The only good news I can see is that hopefully all this focus on the body does some good with exercise and making people feel better about themselves, so that they can lead more productive lives.”

Restine maintains, however, that the jury is still out on that one.

Brian Fuller of North Park remembers a long flight to the Gay Games in Sydney a few years back, and recalls with a smile a prime example of brutal insecurity of self-image – along with a little self-deprecating honesty – paying off.

“Here was this guy,” says Fuller, “who came over and was standing next to me talking to me for about 30 minutes. We started to experience some turbulence and the captain turned the fasten-seatbelt sign on. But here this guy was still standing there chatting away until a flight attendant asked him to be seated.”

Fuller said he was clearly not prepared for what happened next.

“The guy looks me and says, ‘Thank God. I didn’t think I could hold my stomach in for much longer,’” Fuller recalls with a chuckle. “That sort of honesty went a heck of a lot farther than any washboard abs.”

For Kevin Helmen of Hillcrest, washboard abs are a thing of the past.

“At this point I just say, ‘Hey, I’m 42, I remember when I had washboard abs. I just carry around a load of laundry on them now,” says Helmen.

But that doesn’t mean that Helmen isn’t a regular at the gym. It simply means his priorities – and his workout routines – have changed. Helmen, like millions of men and women alike, have come to terms with their changing metabolism.

“I work out at least four to five times a week,” explains Helmen, “but I am more focused on my general health than I am on musculature sculpting.”

In fact, studies consistently show that low-impact resistance strength training is critical to bone care. As more and more men are suffering from osteoporosis, maintaining bone strength is a growing issue. Most studies agree that a person stops building bones and/or bone density around the age of 30. After that, the body is on “borrowed bone time.”

Helmen recognizes that he needs to do everything he can to keep his body healthy, and that includes a proper balance of calcium, nutrition and strength training.

“But that doesn’t make me a gym bunny, or whatever they are called,” says Helmen, referring to a subculture of the gay community that spends several hours daily at the gym. “But if I want to live long enough to meet Mr. Right and then celebrate 20 years together, I need to keep my body in shape.”

One thing that Helmen despises is gym chit-chat.

“What concerns me sometimes,” says Helmen, “is when I am working on bench pressing and the guy spotting me wants to have a conversation about sex, gossip, drugs, clubbing or fashion. I feel like I am talking with a teenage girlfriend.”

That is where finding like-minded people comes in, argues Helmen. “I know this may sound crazy, but finding the right workout partner is almost as hard as finding the right boyfriend. The person has to be totally committed to health and hard work, and be on-time and responsible. They have to read you when you are struggling, or challenge you when you need to be pushed.”

Strangely, for Helmen, he hasn’t found the right partner in either life or fitness.

“Maybe they’ll be one in the same,” says Helmen, with a glimmer of hope in his voice.

One of the most common procedures today is the facial chemical peel. Chemical peels use a chemical solution of trichloroacetic and alphahydroxy acids to peel away the outer layer of the skin. Chemical peels are most commonly done for cosmetic reasons, such as wrinkles, uneven pigmentation or acne. However, recent studies show that a growing number of dermatologists recommend chemical peels for patients with pre-cancerous growths.

Jennifer Nightham of North Park has spent the last two decades out in the sun, and her doctors started to have same concerns about skin cancer.

“I couldn’t believe it when my doctor recommended I consider a facial peel,” says Nightham. “My first thought was, ‘Am I that ugly?’ and then she explained that there is growing evidence that a deep chemical peel can remove layers of pre-cancerous growth.”

But the horror stories are not always left to novels. Sometimes, reality is as strange – or embarrassing – as fiction.

“I have this friend who had a deep chemical peel,” recalls Henry Aleman of South Park. “I guess it was like a 1930s horror flick. He had to stay out of the light for over a week. He couldn’t even turn on a lamp in his house without being some ridiculously low wattage. We called him ‘PEELephant Man.’ Vanity thy name is…”

According to Kurt Cunningham, owner of Skin Deep salon, those procedures that are indeed pure vanity still remain.

“Waxing is a perfect example,” says Cunningham, who says he is seeing more and more men coming into his salon, and his clients are getting younger and younger. “Ten years ago, I might have had a few clients who would come in to have their backs waxed. They would be in their 40s or 50s, and a hairy back just wasn’t what they wanted. Let’s face it, though, waxing is a painful process. You have to want to have it done to go through with it.”

Today, though, Cunningham says that more and more young men are coming to the salon for vanity services. Not that he is complaining, having just opened his new salon on Adams Avenue.

“What is really interesting,” says Cunningham, “is that I have a growing number of straight men coming into the salon. And they aren’t coming in kicking and screaming, being dragged by their girlfriends. They are coming in on their own volition.”

Cunningham, who also has his own Skin Deep skin care line, has long been promoting the benefits of skin care.

“Remember when there really was no such thing as SPF UV sun block?” explains Cunningham. “When Banana Tropics just had sun tanning lotion? Now my clients are telling me that they are using facial creams that have SPF in them or lip balms, too.”

All of this fuss, then, says Cunningham, over what might be considered vanity also has an upside.

“The skin is the largest organ in your body,” says Cunningham. “Why would you not take care of it? If someone said, ‘Hey, I am going to expose your heart to some rays that are harmful,’ you would absolutely refuse. Why should it be any different for skin?”

Allyson Lincoln is working on her Ph.D. in psychology and has a theory. She calls it the “Tommy Theory,” after The Who’s Tommy, a smash-hit musical based on the group’s songs. The main piece is “See Me, Feel Me.”

Lincoln’s theory goes something like this: Simply put, men are more likely stimulated through the sense of sight and women through the sense of touch.

Lincoln explains.

“My theory is based more on observational behavior than empirical data,” says Lincoln. “Over the past 50 years or so, women have spent a great deal of their resources, including time and money, on looking beautiful by certain Western standards. Until recently, with this whole metrosexual thing, men have gotten by just by being ‘Mr. Right.’ How they dressed, how they groomed themselves, none of this seemed to matter much for the straight man. That is why you would see all these gorgeous women with these less-than-Calvin Klein-model-like physiques.”

Lincoln points to couples like Lyle Lovett and Julia Robertson as an example. Obviously, avers, Lincoln, Lovett must have had one great sense of touch. “How else do you explain the connection? Have you ever heard him interviewed? It wasn’t the brains. It had to be his ability to physically pleasure her.”

And so this trend has continued among straight women, where looking their best means halting aging and getting implants, nips and tucks, and gastric bypass surgeries. Lincoln asseverates that this is due to the fact that straight women know that straight men are turned on by visual stimuli.

Likewise, says Lincoln, gay men know their audience: other men. So the logical conclusion is that gay men would, like straight women, spend a great deal of resources on their appearances. With this belief that men are visually stimulated, in order to catch another man’s attention it would only be natural that they would take time to work out, have facials, tan or have plastic surgery.

So where does that leave Lincoln, an open lesbian?

“Well, based on my theory, the good news is, I really don’t worry too much about my appearance,” says Lincoln. “Because ultimately, I believe that women are more evolved than men in this regard in that they are stimulated by touch, and not just sight. Why do you think you see two lesbians who look like they are the happiest people on earth but have never seen a Loreal counter at Nordstrom?”

This idea, then, that men lean toward sexual objectification through a visual sensation rather than through a kinesthetic, or touch, sensation means that gay men resemble heterosexual women in that they place more importance on their own physical attractiveness and overall body image than do those of the same gender but opposite sexual orientation.

Lincoln, while deferring to a more anecdotal method than empirical, does cite a number of studies (including one done by Dr. M. Siever in 1990) where heterosexual men were the least plagued with doubts or concerns about their own bodies, although they did place a high level of importance on the attractiveness of their female partners. In addition, the study showed that while heterosexual men were more likely to view their bodies as tools with which to physically compete, heterosexual women and gay men were more likely to view their bodies as sexual commodities with which to attract men.

Beth Brunner, in her ground-breaking study “Sexual Orientation and Body Image Dysmorphia,” found that homosexual females were far more likely than heterosexual females to report that they were happy with the way they looked (42.1 percent to 20.5 percent).

Brunner points to a number of studies that show that it may actually depend more on gender-related personality traits than sexual orientation. In other words, the role of gender-related personality traits or dimensions of masculinity and femininity – regardless of your physical gender – may be a greater influence.

According to one study, says Brunner, “Gender traits are viewed as highly pertinent in the study of disorder eating because they provide one of the ways for studying the sociocultural context underlying disordered eating. Specifically, gender traits reflect stereotypes about the beliefs and behaviors typically attributed to men and women, which are acquired as they learn about their world and their roles in it.”

Using this measure of masculine and feminine dimensions, Brunner was able to compare various findings about body image. Essentially, lesbians scored significantly lower than heterosexual women on all the disordered eating measures, body dissatisfaction, drive for thinness and bulimia. One explanation, offers Brunner, is that the lesbian culture is more tolerant of different body sizes and shapes because it places less emphasis on thinness and attractiveness.

Compare this to the gay male subculture, which places great emphasis on a more lean and muscular body ideal and overall physical appearance, and you may have reasonable explanation, says Brunner.

Mitch Ferrel of North Park sees these studies’ results in his everyday life.

“I think most businessmen were devastated when Casual Friday hit,” says Ferrel, an executive at a technology firm based back East, with offices here in San Diego. “Suddenly, getting dressed in the morning was not as easy. Out went the simple choice of every suit goes with every white dress shirt which goes with every tie. The biggest challenge we faced was which way to part our hair.”

Now, though, says Ferrel, knowing how to be a smart dresser on the casual side is critical. And it really goes beyond just the shirt and pants to a general grooming learning curve, argues Ferrel.

“How else do you explain the huge success of ‘Queer Eye?’” asks Ferrel. “I have to say, though, that they really should do a ‘Queer Eye for the Queer Guy.’ Most of my friends have no idea that a brown belt should never be worn with black shoes.”

Dr. Stephen Edwards, who has written a great number of works on distorted body image and health problems, believes that young men today feel more pressure to look good than they did just five years ago. However, he does argue that the pressures for men are still less than the pressures for women when it comes to the media.

“Muscularity is not an issue for women whereas it is for men,” writes Dr. Edwards. “Being too thin is not a problem for women, where as for men this would be equated with being weedy.”

As a general rule, then, body image concerns from Dr. Edward’s perspective for women would be associated with eating disorders, whereas with men exercise addiction is a concern, as is the use of anabolic steroids.

Dr. Edward’s current research is showing strong trends of an increase in body-dissatisfaction among males. “It has been known that boys go through a phase of relative dissatisfaction with appearance in early adolescence,” writes Dr. Edwards, “but physical changes through puberty bring them closer to their ideal.”

Increasingly, though, Dr. Edwards is finding that men undergoing a mid-life crisis (i.e., men between the ages of about 45 and 55) are most likely to be dissatisfied with their appearances.

This dissatisfaction, though, may drive the men to better physical health, which in turn may lead to better mental health.

“One of the advantages that men have over women when it comes to body-dissatisfaction,” says Phil Garcia, a local personal trainer, “is that women go on these binge diets and end up with all kinds of horrible eating disorders. Men, on the other hand, are more likely to head to the gym.”

And this, says Garcia, is a good thing. “Getting these guys in better physical condition, along with recommended dietary changes – as opposed to turning to anorexia or bulimia – not only helps with their mental state, but also with their physical state. Exercise and diet have to be combined for physical fitness, but one good thing about changing your exercise habits is the internal chemicals exercise releases, such as the endorphins.”

“Historically,” writes Dr. Edwards, “body image has been driven by interest in the eating disorders. Given the low figures for males, it wasn’t really a research priority. Now this is changing.

Laural Gideon is an expert on body image, having studied the subject for the last decade.

“As the mental representation of the physical self, body image impacts one’s sense of understanding and control over the world,” says Gideon. “The vehicle through which we experience our surrounding environment, the body comes to symbolize the individual and his or her emerging self. The visual, auditory, intellectual and kinesthetic experiences of the physical self contribute to the formation of body image.”

Thus, argues, Gideon, this self-image shapes our behavior, alters perceptions of ourselves and others, and defines our feeling of worth and value in the world. Body image, specifically a negative or distorted one, can affect one’s physical health, happiness and choice of lifestyle.

Using that model then, argues Helmen, positive body image – that is, being comfortable with who you are and knowing what benefits can be derived from physical fitness and choice of lifestyle – can lead to happiness.

“The idea [of] creating a man from the inside out seems alien to most people,” says Helmen, “and impossible to most. I think that is wrong. You can work on the whole person, the mind and the body and the spirit, finding the right balance for you.”

And, says, Helmen, finding that balance does not require scales.