“Aging is the pits,” a 50-something female patient told Dr. Alan Matarasso.

She’s contemplated a facelift and Botox, and she’s pointed out her wrinkles with dismay.

“Listen, I’m a surgeon, I love to operate,” Matarasso told the patient. “But you don’t need a facelift, you look fine!”

Women flip through glossy magazines at Matarasso’s office in Manhattan’s Upper East Side, waiting for their turn to tweak their appearance. He lifts, he tightens, he augments, he reduces.  His steady hands refashion bodies and faces, casting them as newer models.

About 44 percent of plastic surgery procedures in 2008 were follow-ups, and 45 percent of patients underwent multiple procedures at once, according to the American Society of Plastic Surgeons in Arlington Heights, Ill.

In 2008, Americans spent almost $11.8 billion on cosmetic procedures. Numbers for 2009 won’t be available until the spring, but several measures show that plastic surgery took a hit, like most businesses.  

Still, for some patients, there will always be more to be done. Despite sagging numbers in plastic surgery demand, Matarasso said it’s important to say no. In fact, he said a “large measure” of requests ought to be turned down, because many women are hypercritical of their own appearance. After all, there is a fine line between a simple nip and tuck and a plastic surgery addiction.

There were over 10 million cosmetic procedures in America last year, up from 2.1 million in 1997. Clearly, plastic surgery is gaining ground: 23 percent of women were more favorable toward plastic surgery than they had been five years earlier. And of last year’s procedures, 92 percent of which were performed on women, according to the American Society for Aesthetic Plastic Surgery in New York.

Women over 35 accounted for over three-quarters of the procedures, the most common of which are Botox, breast augmentation, liposuction, eyelid surgery and tummy tuck. These procedures, in addition to neck lifts and face lifts, target loose skin, wrinkles and excess fat, which shows that Matarasso’s patient isn’t the only woman who loathes the aging process.

“We acknowledge that people age,” said Dr. Karol Gutowski, a plastic surgeon at Chicago’s NorthShore University HealthSystem. “The goal is to accentuate the positives and soften the signs of aging.”

But even young women are getting in on the plastic surgery trend. Breast augmentations surpassed liposuction as the most popular procedure in 2008, and are by far the most popular procedure for women aged 19-34.

Taylor Gafford, 26, had a breast augmentation in February 2009.  She said she had wanted the procedure since she was 16, and after having two kids she said she “definitely needed it.” Her fiancé, Tavin Harmon, was opposed to the idea, and Gafford said they “fought about it until the day of the procedure,” when he finally convinced her to go one size smaller than she planned, to a C-cup.

Nine months later, the Greenville, Texas, native is fully recovered. Now that everything is said and done, she said Harmon “doesn't have a problem with them at all.” Though she said she’s glad she underwent the procedure, she wished she hadn’t agreed to the smaller C-cup. However, they’ve talked about having two more kids, in which case Gafford said she’d have another breast augmentation (this time to a D-cup) and breast lift.

“This surgery was so easy and pretty much pain-free, so I would definitely do it again,” Gafford said.

Trite phrases suggest that beauty is in the eye of the beholder, or that is it only skin-deep. But vanity and the pursuit of beauty are not the only reasons for cosmetic surgery. For some, plastic surgery is a way to boost confidence and unburden oneself.

Jill Allen, 23, had a breast reduction in 2003. She said she felt uncomfortable and “very self conscious” with the way she looked, since she developed earlier than her peers.  She consulted a suburban Detroit plastic surgeon, who deemed her a good candidate for the procedure.  

Though Allen said the recovery process was “pretty painful”—she was “out of commission for about a week,” couldn’t lift anything heavy for three months, and could barely move her arms for a few weeks—she’s very happy she underwent the reduction and is considering having another one.

“It’s literally like having a huge weight lifted of your shoulders, pun intended!" she said. “I’m much more confident with myself after the surgery.”