SAN FRANCISCO -- Perhaps it is fitting that this most visual of American cities, blessed with bridges and hills and bay ready-made to be movie sets, has become the plastic-surgery capital of the world.
And burgeoning local interest in changing personal appearance holds some lessons, experts say, about the changing face of life in many of America's most favored cities.
Surgeons and economists agree that the plastic surgery business has grown so rapidly here because San Francisco has acquired -- courtesy of a western boom in agriculture, computer and weapons industries -- the critical mass of lawyers, bankers, accountants and other professionals with the money to have their wrinkles and fat removed and the sophistication not to be embarrassed about it.
According to the American Society of Plastic and Reconstructive Surgeons, the San Francisco primary metropolitan statistical area has one plastic surgeon for every 23,879 people, well in front of No. 2, Miami-Hialeah (1 per 34,375). Seven of the top 10 cities are in the Sunbelt, including five in California -- Sacramento, San Jose, Anaheim-Santa Ana, San Diego and San Francisco. The Washington area (1 per 42,775) is in 11th place.
"The Bay Area is definitely an attractive place to live, and there is no question that physicians tend to locate their practices in desirable areas," said Roger Purdy, an official with the California Medical Association headquarters here.
San Francisco is near the top of the list in the concentration of many professions, particularly doctors and lawyers, but the boom in opportunities for this particular medical specialty goes beyond stunning scenery and pleasant weather.
Dr. Fred Suess, a plastic surgeon with his main office on Geary Boulevard, said the abundance of architects, bankers and other "professional and investment-oriented individuals brings with it a ripple effect -- people in business-oriented, high-profile professions are going to be concerned about the physical impression that they make."
In addition, most Californians -- particularly those a short drive from Silicon Valley -- are apt to be receptive to new technology and life styles, making plastic surgery an option as welcome, even routine, as a dental bridge or contact lenses.
"The population here has a lot of well-educated professional people who are very open to new ideas and willing to try new techniques," said Terry Harvey, office manager for the Plastic Surgery Medical Group on Bush Street.
San Francisco and environs enjoy some historical advantages in attracting practitioners. Arthur Beckert of the California Medical Association noted that the medical school at the University of California, San Francisco, has an illustrious national reputation. Training programs for plastic surgeons at St. Francis Hospital and 30 miles down the peninsula at Stanford turn out new practitioners each year. Hospitals in San Francisco and the rest of the West have a reputation for being more willing than eastern hospitals to grant privileges to new doctors without previous local ties.
Suess said he came to San Francisco from New York, where he grew up, in 1974 because the city "had a lot of attributes that I liked about New York" -- such as theater and a real urban center -- without New York's crowding and crime.
He had always been told a plastic surgeon needed a ratio of at least 50,000 people for every practitioner to build a healthy practice, but that rule did not anticipate the recent surge in demand.
Former First Lady Betty Ford's unembarrassed explanation of her face lifting -- "I want to look as good as I feel" -- prompted many women to follow her example. As conservative businessmen shed glasses for contact lenses and began to use hair dryers, their reluctance to consider more radical cosmetic changes faded. Some specialists say some clients may have been influenced by research indicating that better-looking executives are more likely to win promotions and better-looking ex-convicts are less likely to return to crime.
Suess argues that the women's movement, by obscuring differences between male and female habits and ambitions, also helped legitimize plastic surgery for everyone. About 20 percent of patients are men.
Suess says the most popular cosmetic surgery, with a 73 percent increase in the last three years, is liposuction, the removal of fat from hips, buttocks, thighs and other parts of the body.
Possible harmful side-effects from the surgery, in which fat is suctioned out through a small incision, include blood or fat clots that may dislodge and block heart, brain or lungs. But the society says patients in good physical and mental health with good skin elasticity remain good candidates for a procedure that is safe if done properly.
Patients who have exercised regularly without losing fat in certain areas feel entitled to have it taken out. At $4,000 for a typical liposuction of the hips, thighs and buttocks, this form of plastic surgery is not cheap. Insurance companies usually pay only for work done to remove marks of injury or disease.
"But there are just a larger number of people now that have more disposable income," Suess said. "They compare the cost of a liposuction to a new car, and say, 'I'll have the car just a few years, but I'll enjoy the effects of the liposuction for the rest of my life.' "