I think you’re underestimating the importance of looks in men, especially nowadays, and especially in show business. If the surgery was brought on by narcissism, he would’ve started on that path well before he aged. He was never a looker.
I assumed he always got nipped and tucked. In his admission he's had a lifelong affair with himself. Might not have been a looker but according to his self-perception he was. And has confessed to erotic narcissism. This could simply be an extreme case of vanity. I'm no clinician.