By Gale Scott

The scene is much the same at plush plastic surgery offices across the city. The supply of affluent, cosmetically challenged customers has dried up as the economy has shifted down.

“It's like someone turned off the patient spigot,” says Dr. Malcolm Roth, chief of plastic surgery at Maimonides Medical Center in Brooklyn.

In response, many members of the city's elite corps of lavishly compensated surgeons are going to unheard-of lengths—at least for them—to drum up business. Some are taking a scalpel to fees (but only if patients ask for a break). Others are sending out discount coupons and offering payment plans. And for the first time, scores of doctors are hiring publicists in a search for the limelight.

The moves come in the face of a 20% to 50% drop in the number of cosmetic procedures performed in the city—an unusual setback for a medical specialty that had emerged unscathed from less severe economic downturns. In fact, demand had been growing steadily, spurred by increasingly higher standards of beauty, and practitioners have gotten rich meeting that demand.

Many cosmetic surgeons boast annual incomes in the seven-figure range. Dr. Mark Sultan, plastics chief at Beth Israel Medical Center, earned $4.1 million in 2006. That made him the second-highest-paid doctor on the payroll of any New York City hospital, according to a 2008 Crain's Health Pulse survey of hospital salaries.

Princely salaries

Some of Dr. Sultan's peers might be doing even better. The 2008 list, compiled from IRS 990 forms filed by nonprofit hospitals, did not include most of the city's plastic surgeons, who derive their income from for-profit private practices.

Such princely salaries are not the only thing that sets cosmetic surgeons apart. They live in a world most doctors simply wouldn't recognize. Patients clamor for their services, and the surgeons can charge whatever they want—without having to worry about what insurance will pay. Because patients pay the fees for cosmetic procedures directly, practitioners escape the billing and reimbursement morass.

Not surprisingly, sympathy for these surgeons is in short supply.

“Couldn't happen to a nicer bunch of guys,” says one Harlem breast cancer surgeon. “They deserve it.”

But plastic surgeons are mounting a counterattack on the threat to their income. Dr. Minas Constantinides, chief of facial plastic surgery at NYU Langone Medical Center, is among those fighting back. In a finely tuned marketing move, he recently sent patients Sex and the City-themed promotional offers. They include “The Charlotte,” 30% off laser hair removal; and “The Samantha,” 10% off the first syringe of dermal filler Juvederm and $200 off the second.

Dr. Steven Pearlman, who operates at Lenox Hill Hospital, used a similar ploy after seeing his cosmetic business shrivel by 20%.

“For the first time ever, I sent out "To my loyal patients' discount cards,” Dr. Pearlman says. He agrees that it may not be the classiest thing a well-respected surgeon can do, but it worked.

Talking Wall Street

In a city that has long been driven by Wall Street money, Park Avenue facial specialist Dr. Yael Halaas has come up with a spiel that fits with that ethos. “We're telling people it's a great time to invest money in yourself [with cosmetic surgery],”she says.

That pitch worked on a woman who had been laid off from her executive position at a high-end retail chain. She recently re-entered the job market with her eyelids lifted, wrinkles filled and cheeks lasered smooth, Dr. Halaas says.

Some of her peers are taking a different tack by pushing compromises. Many report success at persuading patients who balk at $20,000 facelifts to tough it out with $800 injections of dermal filler and Botox.

Dr. Pitman is saving his patients money by removing less of their fat. He is doing more low-volume liposuction procedures, which he can perform in his office suite under a local anesthetic. That means he can turn a $10,000 hospital procedure into one that costs as little as $5,000. He also recently hired Behrman Public Relations, becoming its fifth plastic surgeon client. A year ago, the firm had only one.

Meanwhile, cost-conscious patients have never had it so good.

Kathryn Madden, a Manhattan psychologist and author, says she found differences of thousands of dollars for the same procedure at five of New York's best-known surgeons. She ultimately signed up for a $9,000 chin tuck at Lenox Hill by Dr. Scot Glasberg and was anticipating looking her best for an upcoming book tour.

“But then my accountant called, and I canceled the surgery,” Ms. Madden says.

Dr. Glasberg says he's getting used to cancellations but is not particularly worried. Patients tend to be repeat visitors for life.

“It's a great field,” he says. “We'll be fine.”