Does anyone really need cosmetic surgery? All those without an answer, your insurance company would gladly fill you in as follows: Aesthetic procedures (as the fake-flesh trade refers to them) are elective operations with no health-related payoff. Barring reconstruction after an injury, they are medically unnecessary, and insurers won't pay for them. Still, if your tummy could use some tucking or your chin cries out for chiseling, it's nice to know those options exist. Just ask the 400,000 people in the United States every year who find the reason and cash to undergo cosmetic procedures.

For people with HIV, however, questions about benefits from cosmetic surgery -- and answers affirming its value -- were practically moot until recently. And for many doctors behind the curve on AIDS treatment, the issue remains moot. "I've had patients tell me of plastic surgeons who still say they don't do surgery on people with HIV at all," says Joe Eviatar, MD, assistant professor of ophthalmology at New York Medical Center, whose private practice is 30 percent HIV positive.

Years ago, many physicians and PWAs felt the same way, because the prognosis for an AIDS patient was assumed to be bad. There seemed little point in a person with severely curtailed life expectancy going through the expense and discomfort of a medically unjustifiable procedure. "When I viewed my life as finite, I wouldn't have bothered," says David Black (name changed), one of Eviatar's clients. More important, the physical stress of any surgical procedure has the potential to make a patient's condition worse.

But with the anticipated boundaries of life pushed outward by the protease inhibitors, Eviatar says the number of PWAs seeking cosmetic surgery has doubled in the past year. People with HIV want cosmetic surgery for the same future-oriented reasons anybody else does: To look more attractive in social settings and to appear younger and more energetic in competitive business circles. (According to the American Society of Plastic and Reconstructive Surgeons, the most popular procedures are liposuction to remove fat deposits, and eyelid surgery to erase bagginess.)

Given a better prognosis, many HIV positive people have little to fear from elective surgery. "For the procedures I do, the evidence so far -- and it's only anecdotal -- is that people with HIV seem to do just as well as people without HIV," Eviatar says. "HIV itself is not enough reason to discourage these surgeries if the patient is realistic about risks and outcomes, and is motivated."

There are, however, several important factors that patient and doctor should discuss before agreeing on a go-ahead. "Any disease that stresses the body may delay healing following an operation," Eviatar says. "In that respect, having AIDS is no different than being an older person with diabetes and hypertension." Some factors are especially important for people with HIV, however.

Your overall health is the most significant, and CD4 counts are only one concern. "A person with a CD4 count of 300 who's in poor health can be at worse risk than a person with a count of 100 who's doing well," Eviatar says. "There's a tendency now to look less at CD4 cells and more at other markers."

One of these is simply how you feel. Are you active? Energetic? If not, or if depressed, it may be wise to put off surgery until you're more clear headed or able-bodied. Cosmetic surgery isn't a cure for low self-esteem or sadness. At most, it could start you on a path of proactive concern for yourself and your health.

Any significant condition that's not getting better -- diarrhea, for example, or actively progressing Kaposi's sarcoma -- also suggests you're not a great candidate for elective surgery. Take control of problems that endanger your health or life before going under the knife voluntarily.

You'll also need a healthy platelet count. Platelets help blood to clot, and your supply of them is an issue in procedures where there's risk of complications that involve excessive bleeding.

Finally, you'll want to make sure any drug treatments you're on won't complicate healing. David Black, who is also a doctor for people with HIV, says protease inhibitors such as ritonavir (Norvir) may interact with some pain medications, making them either less or more sedating. He recommends making sure your surgeon investigates potential interactions between your AIDS drugs and any antibiotics or anesthetics used in a cosmetic procedure.

Fortunately, PWAs have little to be concerned about other than doctors' ignorance. Still, despite his optimism, Eviatar emphasizes the prudence of caution and the importance of discussing risk with your physician. "You certainly don't want a surgeon who rushes you and says, 'Don't worry, everything will turn out great.'" You don't want to spite your face to cut your nose.