It used to be a high point of Goldy Anthony's life. Every six weeks or so, as a kind of personal morale booster, she and a group of girlfriends would make appointments to see a Beverly Hills plastic surgeon for little touch-ups -- getting lips plumped and frown lines on the forehead smoothed out. He was "an artist" with Botox and Juvederm, she said.
Afterward, in a carefree mood, the ladies would dine at a popular restaurant on the Sunset Strip.
No more. The sub-prime loan crisis, the housing slump and the general decline of the economy have claimed another covey of victims. Anthony is in the real estate business, and under current conditions, the cosmetic treatments -- at $1,800 or more a pop -- can no longer be squeezed into her budget. It's the same with others in the group.
"We used to make appointments together," Anthony said. "Then they started saying, 'I can't go next week.' People didn't have the money, but they were ashamed to tell you."
"I would rather have Botox than go out to dinner, but it's just gotten so bad," said Anthony, 41, who is looking for a job since her career in the mortgage business went sour. She has not had the facial treatments in months.
And what's been happening in Beverly Hills is apparently happening around the country. After years of steady growth, the cosmetic surgery business seems to be going through a rough patch.
Doctors don't like to talk about it publicly, but plastic surgeons from the Southland to South Florida said some colleagues are struggling to stay in business.
A leading manufacturer of breast implants recently reported that surgeries declined toward the end of last year.
"I think we're going to feel it," said Dr. Richard D'Amico, president of the American Society of Plastic Surgeons, who practices in New Jersey and teaches at a New York City medical school. "When people get concerned about the economy, they tend to cut back on the discretionary items."
At a time when several million families face the loss of their homes and possible financial ruin, the travail of relatively prosperous women -- and, increasingly, men too -- is hardly the stuff of tragedy.
But cosmetic surgery was a multibillion-dollar industry last year, so a slowdown is a blow to more than vanity. Doctors alone collected more than $12 billion in fees for such procedures, and nearly that much more went for nurses, anesthetists, operating rooms, materials and other costs.
The economic impact is even bigger when the expected decline in the rest of the "luxury healthcare sector" is factored in, including such procedures as Lasik surgery to correct vision problems.
"While healthcare spending as a whole has traditionally moved independently of the economy -- a safe haven -- that really isn't the case with plastic surgery," said Jeff Viksjo, a Morningstar analyst. "Consumer confidence is at multiyear lows, and it's clear to us that patients, as a whole, will cut back."
The American Society of Plastic Surgeons does not compile monthly statistics. Last year saw a slight drop in more complicated procedures such as face-lifts, while cheaper procedures such as Botox increased. The overall number of procedures increased 7%, so "2007 was still a good year for most folks," D'Amico said.
Beyond the economics, there is another dimension: Once largely confined to movie stars and rich socialites, cosmetic surgery has been democratized -- thanks in part to the popularity of "makeover" television shows and decades of prosperity that have put such treatments within reach of large numbers of people.
Botox, breast enhancement and "body sculpting" have joined designer clothes, upscale cars, and kitchen and bathroom upgrades as common symbols of the good life and success.
"No one can have a practice built on the ultra-wealthy, because there aren't enough of those people to go around," said Dr. Robert Kotler, a Beverly Hills surgeon who specializes in the face. "The reality is that cosmetic surgery became popular when the middle class became enamored of it: flight attendants, professional people, businesswomen -- people whose appearance is important to them."
In Los Angeles, a world capital for plastic surgery, doctors are hoping that globalization will provide a cushion. Some are looking to European patients, who can capitalize on the weak dollar and combine their plastic surgery with a Hollywood vacation.
"This is a mecca," said Dr. Stuart Linder, who specializes in breast augmentation. "I have women flying in from all over the world because this is Beverly Hills."
But Linder said his surgeries were off by about 5% in January and February. He has heard some doctors are off by 30% to 40%.
Many doctors are trying to diversify into less costly -- and less invasive -- procedures or into reconstructive surgery for cancer patients and others that is covered by insurance.
Kotler, who helped promote the cosmetic surgery boom on television and with a book, said he has also seen some drop-off in his practice.
"What we do is strictly a choice made by the patient," Kotler said. "There is no medical urgency."
Nonetheless, for patients, the emotional pull can be strong. Judy Wade, who divorced in 2005 after 35 years of marriage, has put off a face-lift that she had hoped would help spark her social life.
A Las Vegas businesswoman, Wade, 66, owns rental property in that city and in the Florida Panhandle. A few years ago, the Florida investment had seemed like a sure thing; real estate in the Panama City area was appreciating briskly. But rents have since come down, and her costs have not.
"I can't allow myself the luxury of thinking about something that I can't have," she said of the $29,000 procedure she had planned to undergo. "It's one of those nonproductive emotions, so I don't allow myself to do that."
Cathy Hollingsworth is not in the real estate business; she manages a clothing store. But the 42-year-old mother of two from San Jacinto said she is holding off on $20,000 worth of surgery because she doesn't think it would be fair to her family in a shaky economy.
Hollingsworth, who once weighed more than 300 pounds, had gastric bypass surgery and shed 170 pounds. "Unfortunately, I was left with all the skin," she said.
A tummy tuck and breast augmentation were supposed to deal with the problem, but now they're on hold.
Her husband's job with an engineering firm appears to be secure, but the four-bedroom home the family bought 2 1/2 years ago has lost value. On their street in a brand-new subdivision, four or five houses now sit empty.
"If we weren't upside-down in the house, I probably would take the money out and have it done," said Hollingsworth, but "I don't want to make my family do without.
"I'll have to see how long I can tolerate wearing a girdle."