THE BLOG
11/13/2010 12:25 pm ET | Updated Nov 17, 2011

Under the Knife or on the Couch? When Narcissism and Plastic Surgery Collide

The word "narcissist" has become a popular choice to describe all sorts of perceived personality flaws, and many times it is used incorrectly. A person may have narcissistic tendencies but not the full-blown disorder. There is a narrow border between a conceited, boastful individual and one who has a true narcissistic condition. Plastic surgeons have an inordinate amount of contact with patients with this disorder because of what we do. The nature of cosmetic surgery deals with the process of altering one's appearance in an effort to look better. Patients with narcissistic personality disorder are drawn to our offices not so much to improve their looks, but more importantly to garner attention from others.

Narcissistic personality disorder is a mental disorder in which people have an inflated sense of their own importance and a deep need for admiration. Those with this disorder believe that they are superior to others and have little regard for other people's feelings. But behind this mask of ultra-confidence lies fragile self-esteem, vulnerable to the slightest criticism.

Sigmund Freud and other psychoanalysts of his time coined the phrase "narcissist" after the character in Greek mythology, Narcissus. He was the pathologically self-absorbed young man who fell in love with his own reflection in a pool. Freud believed that we all have some degree of "healthy narcissism" within our personality to garner self-esteem. Freud suspected that the personality disorder was simply a magnified extreme manifestation of this healthy narcissism. A highly confident individual with strong self-esteem is not a narcissist, but the line drawn between that person and a narcissist can be quite narrow.

My perception of Freud's "healthy narcissism" is what I call "healthy vanity." A person with healthy vanity has a high-level of self-assurance and a solid comfort with himself or herself. You try to look and feel your best because of pride and self-esteem. Healthy vanity allows you to be able to see and work with your good and bad points to the best of your ability. It means having a realistic and healthy view of yourself (good and bad!) and others around you. Healthy vanity means that you don't value yourself more than you value others! A person with healthy vanity may spy their reflection in a mirror while passing by and comment, "Hey, I look pretty darn good today!" A narcissist will look in the mirror and say, "I don't know what I would do if I weren't so good-looking!" Healthy vanity is a positive and healthy trait.

My mother had a large dose of healthy vanity. She lived well into her 90s and never missed her weekly trip to the hairdresser, because she always wanted to look her best. She conceded that she was getting on in years, but that time spent each week on herself made her feel better and, more importantly, more confident. Self-esteem should not have an age barrier!

A narcissist, on the other hand, is someone obsessed with looks, status or anything that can be lorded over others who are less fortunate. They often monopolize conversations, have a sense of entitlement, and can become angry and controlling if they perceive that they are not getting what they want or deserve. They have to have the best of everything, the most expensive car, and socialize in perceived elite circles. They can be perfectionists to a fault, and expect constant praise and admiration. Narcissists are often notoriously unable to understand that their inflated views of themselves verge on the pathological.

Our super competitive society feeds this disorder. Many patients diagnosed with narcissistic personality disorder are first seen by plastic surgeons. A study performed in 1999 examining 133 patients requesting cosmetic surgery of the face revealed that 25 percent of these patients had extreme narcissistic tendencies!

It is for this reason that plastic surgeons must carefully evaluate each patient and rule out this disorder before operating on them. Pointed questions during the initial interview with a new patient can be instrumental in determining whether the patient is a realistic candidate with realistic expectations for cosmetic surgery or one with extreme narcissistic tendencies who will never be satisfied with the operation, no matter how successful. It is so important to understand exactly each prospective patient's motives and expectations for surgery. Patients who mention extremes with regard to their reason for requesting surgery raise a red flag. One example is the petite and attractive young lady who presents for breast augmentation and desires DDD sized implants so that she will turn heads when she walks into a room. She already has a fine figure but just wants to do something to be noticed, not for her, but for an external quality. Or the chap who has a small bump on his nose and just wants 1.4 mm removed (no more, no less!) and expects a guarantee of perfection with the postoperative result.

Cosmetic surgery is not the treatment for people with severe narcissistic tendencies, and they must be referred to qualified mental health professionals to deal with the abnormality. Narcissism is a psychological issue that should be addressed. It is, at the very least, a serious personality flaw, or, in worst cases, a recognized psychological disorder. Its antisocial aspects can have an extremely negative effect on a sufferer's daily life, personal relationships, and performance at work.