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human nature: Science, technology, and life.

Tuck OffThe healthy recession in cosmetic surgery.

By William Saletan
Updated Tuesday, April 8, 2008, at 7:52 AM ET

What's cutting into the cosmetic-surgery market?

If your local real estate agent's face is hanging low these days, it might be more than sadness. The recession's latest victim is cosmetic surgery. "Plastic surgeons from the Southland to South Florida said some colleagues are struggling to stay in business," Ricardo Alonso-Zaldivar reports in the Los Angeles Times. A breast implant company disclosed a decline in surgeries late last year; a laser eye-surgery firm has lowered its forecast based on a similar trend early this year. A professional breast augmenter frets that in January and February, business for some of his colleagues was off 30 percent to 40 percent.

Excuse me while I celebrate.

It's not the suffering that gratifies me. It's the reaffirmation of the distinction between necessary and unnecessary procedures. People have always practiced medicine, albeit clumsily. And they've always adorned themselves, to the point of reshaping their heads and bodies, as the Mayans and Chinese did. (Even the Bush administration has yielded to nipple rings.) But despite the occasional overlap, medicine and body art remained two different things. One aimed at health, the other at beauty. One was necessary, the other elective. If your treatment looked really cool but all the patients died, it was a failure.

Modern cosmetic surgery has challenged that distinction. It has done so not in theory but in practice, by making aesthetic procedures so safe and lucrative that people who would otherwise have devoted their careers to medicine turned instead to cosmetic work.

Depending on how you count it, on an annual basis, the cosmetic-surgery industry—subset of the "luxury healthcare sector" and parent of the "facial aesthetics market"—is now worth $12 billion to $20 billion a year. Two weeks ago, the New York Times reported that last year, among 18 medical specialty fields, the three that attracted med-school seniors with the highest medical-board test scores were the most cosmetically oriented: plastic surgery, dermatology, and otolaryngology.

Cheerleaders hail the industry's expansion as a manifestation of upward mobility. First it was "democratized," as it became affordable to the middle class. Now it's being "globalized," with Europeans touted as the new clients whose influx will take up any slack in U.S. demand. I'm a big fan of capitalism, always glad to see it praised for the wealth it creates and spreads on the way up. But in this case, I prefer the discipline it imposes on the way down.

A month or two ago, the industry seemed invincible. "For a growing number of Americans, Botox is no longer a luxury, it's a necessity," the Associated Press declared. Despite the recession, doctors, companies, and financial analysts were projecting double-digit growth, and not just in lips and bust lines. Their confidence was based on several theories. One was that people valued bodily appearance more than jewelry, fancy handbags, and other luxuries. Another was that social pressure to look young would force us to keep shelling out. A third was that cosmetic procedures were "addictive," largely because patients feared regressing to their previous appearance. "You get used to the way you look," one analyst observed. "It's an incredibly effective dynamic."

Some people do seem addicted. "I would rather have Botox than go out to dinner," one woman tells the Los Angeles Times. But her addiction seems to have found its limits. The real-estate bust has forced her to give up her four-figure treatments. Another woman has put off a tummy tuck. A third has postponed a face lift. "I can't allow myself the luxury of thinking about something that I can't have," she explains.

More effectively than any bioethicist, the recession is reminding people that cosmetic work isn't medicine. "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," a financial analyst tells the Times. In the new, sobered economy, the paper reports, some cosmetic doctors are diversifying into "reconstructive surgery for cancer patients and others that is covered by insurance." Insurance!

Say what you will about coverage-denying bean counters, but they do enforce the essential priority of urgent procedures over elective ones. In a health-care industry controlled by tight budgets and insurers, you might even see the cream of the med-school crop shift back to the kind of work that keeps people alive. I hope they're well-paid for it, and I hope the next rising tide lifts millions more families into the ranks of the insured. But let's never forget what the bad times taught us about what matters and what doesn't.