A beautiful young woman visited a cosmetic surgeon, wanting him to perform a breast lift and reduction. The procedure she desired was less invasive than the traditional method-the incision encircles the areola rather than running from there down to where breast meets ribcage-but also more complicated, intended for a subset of patients more problematically endowed than she. The surgeon declined her request and advised her not to pursue the surgery. Her breasts were close to perfect. Thirteen other surgeons apparently agreed, also refusing to operate.The 15th surgeon she visited said yes "and ruined her," one of the first 14 surgeons told me. "I still hear about her. She's never recovered. Her life is over."The brilliance of this story-and I'm not at all questioning its veracity; I've heard others like it-is how it carves two birds with one scalpel. From it we learn that (1) there are butcher-surgeons out there and (2) there are unhinged patients, too. While I believe the doctor told me this story out of caveat emptor goodwill, it's actually the second implication that lingers. Because it's just such reports of the Unhinged Subject-the sad, desperate ones; those suffering from body dysmorphic disorder; the Michael Jacksons and Jocelyn Wildensteins (the New York socialite who has allegedly spent millions on countless surgeries, with the result of looking almost feline)-which in part have helped cosmetic surgery's popularity.That's no typo: I mean "helped," not "hurt." As long as supermarket tabloids publish images of the latest iteration of characters like Michael and The Bride of Wildenstein, the rest of us can mollify ourselves. Hey, we're not that pathetic, we'd never pursue that level of transmogrative grotesquery, so what's wrong with the occasional nip or tuck? Each skin peel and cheek implant that Michael gets-pardon; allegedly gets-thrusts him so much further into Freaksville that we're bound to separate the world into Us and Them. And because of the stunning advances the last decade has seen in cosmetic-surgery techniques, instruments, and medicines, Us and Them no longer means Those Who Don't and Those Who Do but rather Those Who Sort of Like Themselves and Those Who Privately Loathe Themselves.With such a broadening pool of patients, though-from 1997 to 2005, according to the American Society for Aesthetic Plastic Surgery (ASAPS), cosmetic procedures in this country increased by 444 percent, to 11.5 million-how does the surgeon tell, from just an initial consult, who's an Us and who's a Them? How can he tell which patient will translate into a "Doc, you changed my life!" holiday card, and which a malpractice suit? (Virtually every top surgeon, insists one, has been the subject of at least one suit.) For their part, prospective patients, if diligent, have ample guidance-checking out board certification, membership in reputable national organizations, word of mouth-when trying to distinguish the mostly good surgeons from the bad ("the guy down the street," as several surgeons routinely label the amoral butcher who expresses no qualms about doing anything to anyone). The doctor, though, often relies solely on intuition, from cues picked up in a brief conversation, to determine a patient's psychological soundness. But is that a reliable system? The staggering number of hours top surgeons put into sharpening their technical skills notwithstanding, there's no accurate measure for judging people and their real needs. And while admittedly it's in their interest to steer clear of patients they suspect can't ever be satisfied, there is also the incentive in place to now and then embrace an obsessive, whose patronage may result in a vigorous ongoing business relationship. Cosmetic surgery, more than any medical specialty, brings together doctor and patient speaking different languages. The cosmetic surgeon-"a psychiatrist with a scalpel," as one doctor charitably characterized it-is first and last a technician, trying to determine if the desired procedure can be done, and done well. The patient, meanwhile, wants to know if she or he will look-and hence feel-better. Yes, they're both ostensibly concerned with aesthetics, but in the same way the federal government is ostensibly concerned with a balanced budget."We're not taking care of a functional disorder or removing cancer," says Dr. Cap Lesesne, a top Park Avenue surgeon. "We're operating on perception."At the initial consult, the surgeon often asks some version of, "What don't you like about yourself?"-the recurring salvo asked of potential patients by the plastic surgeons on the popular TV show Nip/Tuck. But even though the question seems nonpartisan, surgeons are still, well, surgeons. ("What's the difference between God and a surgeon?" the wife of one of the Nip/Tuck surgeons quizzed a friend. "God doesn't think he's a surgeon.") So doctors have been known to volunteer an opinion or two-even though it's elective surgery, and even though no one asked. "One surgeon I went to about my naturally hooded eyessaid I needed my upper and lower eyes done, and an upper and lower browlift, too," said Jan (not her name), who writes about beauty for a national women's magazine.

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Some of us are too narcissistic even to consider cosmetic surgery; some of us are so insecure that if we did pursue it we'd never be happy with the result.

"Then, on his own, he said the bump in my nose was quite bulby. I'd always thought my nose was my best feature. But ever since he-someone who's essentially a sculptor-said that, I've never looked in the mirror and not thought something was wrong with it."