I just answered a letter from a young woman who had sent photographs of herself, explaining that she had “low self-esteem from sunken eyes and a bumpy nose.”  She wondered what plastic surgery could do for her.

I have answered many inquiries in the past, but two things made this one different: first, most patients described a visible problem: crookedness, a bump on the nose, or breathing problems. This young woman described things that I couldn’t see.  Her eyes were simply lovely, wide, open and engaging.  Her nose was straight and symmetrical, with excellent aesthetics.  In fact, at first I thought that the letter wasn’t serious, but I had to assume that it was.

Secondly, it is always tricky for the surgeon when the patient’s goal is “self-esteem.”  Surgery can correct deformities or function; it cannot create a sense of self – value.  That is not to say that patients who are self-conscious about their appearances don’t feel better after successful corrective surgery, but there is a difference between dissatisfaction with a feature and shame.

What my research has shown and that I discuss in my upcoming book, The Face of Trauma, is that various types of abuse and neglect are very common in families, much more common than I would have guessed (over 50% in my patients).  Particularly common and harmful is emotional abuse: “You’re stupid.” “You were the ugliest baby I ever saw.” “Why aren’t you as pretty/smart/athletic as your sister?”

Although it is perhaps not meant to be, this language is destructive, and creates a sense of deficiency in a child as he or she grows up: “There’s something wrong with me.”  Emotional abuse is particularly bad because it can occur all day long, in contrast to other types of abuse, which are usually not as frequent.  The cumulative effect is a sense of shame, and when the child or young adult connects that sense of shame to his or her appearance, plastic surgery can become an option, along with extreme dieting, excessive muscle building, or other types of physical modification.  Taken by themselves, exercise and healthy diet, even corrective plastic surgery are not bad – – the issue is always its motivation.  When they are done to improve health and care for the body, each are fine.  But when they are done to create a sense of self-worth, they are never successful.

I tried to explain to this young woman the way I saw her in the photographs she sent: attractive, engaged, and full of life.  I hope that with help she will be able to revise her self-image so that if she ever has surgery, she has it for the right reasons.