It looks so wholesome, in a Hollywood sort of way—a beautiful actress walking across a soccer field in a Beverly Hills park with her young son, lugging a folding chair to his weekly game. But nothing is what it seems. While the paparazzi try to get a shot of Tom and Rita or Warren and Annette and their little athletes, this actress looks around furtively for one of the soccer dads, who happens to be a publicist for a local cosmetic surgeon. He has arranged a face-lift consultation for the 35-year-old right here on the sidelines. After an introduction, some small talk, and a few cheers for the kids, the doctor says to her, "Face me, but look straight ahead." She lifts her chin and flips her hair out of her eyes, pretending to watch the game. The doctor examines her inconspicuously and pronounces his diagnosis sotto voce. The actress nods and whispers to him that she'll send her assistant around on Monday to make arrangements.

Celebrity plastic surgery is a clandestine world unto itself with its own rules, lies, codes of behavior, disguises, assumed names, and risks. Its driving force is a simple truth, best articulated by Cher in an interview on her sixtieth birthday: "Looking your age is not a great thing in our business." With that in mind, many stars do whatever is necessary to keep their youthful appearances—and their jobs. "Almost nobody [in Hollywood] doesn't get surgery," says Michael McGuire, a Santa Monica plastic surgeon and former president of the California Society of Plastic Surgeons. But he says that famous people approach the process differently than civilians. "They don't want dramatic changes," he explains. "They do their cosmetic surgery in small bites."

It would seem that celebrities, who have the best of everything, would also have the finest medical care that money and their considerable influence can buy. But that's not always the case. Stars often put themselves at risk by their demands for anonymity, their insistence on special treatment and rushed recoveries, and their tendency toward impulsiveness. Daniel Baker, a New York City plastic surgeon, says that he spends as much time talking stars out of surgery as he does actually operating on them. "Sometimes when actors aren't busy they think, Maybe I'd better do something—and then they screw themselves up." Many of them want after-hours consultations when a doctor's full staff is not present (which removes another safety measure), or they want the surgeon to visit them on movie locations or at home. Essentially, they want the work done, but without any publicity, inconvenience, or detectability.

While most people believe that celebrities are completely within their rights to keep their cosmetic procedures private, "the obsession with secrecy is probably the main obstacle to good patient care," says Steven Hoefflin, a Santa Monica plastic surgeon who has worked on many famous faces. Hoefflin says the use of aliases, for example, turns office visits into a nightmare. Once in his practice, the book that decoded all of the Hollywood pseudonyms got lost, so no one could get patients' charts when they returned for checkups and more work. According to Hoefflin, celebrity patients often won't even submit to regular physical exams and blood tests. And forget about stars filling out their patient-history forms themselves. "They just assume it will be 'taken care of,'" says Laurie Polis, a New York City dermatologist. "They routinely leave off personal contact information from forms, presumably to insure their privacy. But after finding ourselves unable to follow up without a lot of hassle, we realized that was not acceptable."

While many performers wouldn't dream of dickering about price (in some cases, according to McGuire, they feel the more expensive the work is, the better it will be, others expect to receive surgery gratis, as if it were a pair of Joe's Jeans or Dior sunglasses. Hoefflin recalls the ingenue who switched to another doctor when she discovered he was actually going to charge her. Anthony Griffin, a Beverly Hills plastic surgeon featured on Extreme Makeover, is still smarting from the actress who wanted a breast reduction right before a big awards event. She said, "I need it done tomorrow," the doctor remembers. "We moved things around to accommodate her, made house calls on Sundays, and when I sent the bill, she never paid it."

Starstruck physicians and their staffs sometimes overlook routine procedures when someone well-known arrives in the office. "There have been times when I had to chastise a colleague or employee for asking for an autograph," Polis says. And while she is supposed to do a full-body cancer check as part of every initial consultation, Polis admits that when she first started her practice, she was too intimidated to demand them from celebrities. "Can you imagine a new, young dermatologist asking a major box-office Star to disrobe for a skin exam when he just came in to get a pimple injected?" she asks.

Barron Lerner, a physician and medical historian at Columbia University, calls this condition the "VIP syndrome." Lerner has studied famous patients for his forthcoming book, When Illness Goes Public (Johns Hopkins Press), and says "celebrity patients may get worse care because they intimidate their physicians. Doctors, enamored of their patients and distracted by their fame, may not be willing to speak up when they disagree with their patients' requests or demands."

When bad plastic surgery happens to celebrities, their respective spin machines go into high gear. Sophia Loren was rumored to have had a heart attack after getting liposuction, but she denied it, saying she had just accompanied a friend to the doctor. After a big television star was allegedly burned by an ultrasonic liposuction cannula, her publicist filled the gossip columns with news about a traffic accident. One of the longest-running stories involves Star Jones Reynolds and her near-fatal complications following a breast lift. After losing 150 pounds from unconfirmed gastric-bypass surgery, the talk-show host had allegedly been turned down for the breast procedure by one surgeon because she had a low blood count. Jones found a doctor willing to perform the surgery, but after the procedure, she began to bleed uncontrollably. A transcript of the 911 emergency tape obtained by the New York Daily News quotes someone from the clinic saying, "We have a patient who is on our surgery table who we cannot stop from bleeding." And although initially Jones tried to deny the incident, she confirmed it on The View a few days later; saying "I did not almost die ... [the doctors] knew I was anemic and, just in case I ended up needing some blood, which I did, they were prepared. They gave me the blood, and literally I was fine right afterward."

Even when the surgery itself is a success, the recovery can go awry when the patient disregards doctor's orders—and celebrities seem to be especially guilty of this. "They will squeeze major liposuction into insufficient recovery time," Hoefflin says. "You can't do a movie a week later and keep within the safety box." They've also been known to ignore orders to quit smoking or drinking, which can compromise healing. And some stars simply try to bulldoze over their physicians' advice. Patrick Sullivan, a plastic surgeon in Providence, operated on a 42-year-old Broadway actress who wanted to bring her own staff to care for her after her procedures—except that they were fellow actresses with no nursing experience (she trusted only her friends to keep her confidence). Sullivan balked and insisted that she have a registered nurse visit her daily during her recovery.

Despite confidentiality agreements signed by hospital personnel, photographers and reporters often seem to find out when a celebrity is leaving a surgical facility, plastic surgeon John Grossman recalls one dramatic departure from his Denver clinic when a singer had to put on green scrubs and walk out flanked by nurses all dressed identically, just so she could slip past the paparazzi waiting outside. Soon after her marriage to Michael jackson, Lisa Marie Presley had some body surgery performed by Edward Terino, a doctor with a practice in Thousand Oaks, California. But with photographers hiding behind every bush, Presley fled with a blanket over her head. (Terino is popular with fellow Scientologists because he practices "silent surgery"—no conversation or music is allowed in the operating room on the principle that it might be heard by the anesthetized patient subconsciously and affect her later.)

After all the complicated arrangements to keep everything quiet, famous patients often slip up and give away their own identity, Gerald Pitman, who practices in Manhattan, remembers a world-renowned pop star who called the doctor at home after having surgery. When Pitman's young son answered and asked who was calling, the patient gave his real name, and the child's jaw dropped. Pitman had to lecture his son on the importance of honoring patient privacy. "I'd as soon give a name of a patient as jump off a bridge," Pitman says. Another of Pitman's famous patients checked into the hospital under a pseudonym and promptly forgot to use it. Later, one of Pitman's colleagues let him know that "the lady who pushes the gurney tells me you're operating on so-and-so."

Because of their patients' need for secrecy, surgeons can rarely get praise for their work on famous faces—and sometimes another doctor will take the credit, because the real doctor can't protest without revealing confidences. According to one surgeon, the only benefit to operating on a star besides the financial one—if the star actually pays—is "the occasional free ticket to a concert." The downside is that celebrities can take advantage of their doctors, asking them to rush to Malibu in the middle of the night to stitch up their child's cut knee. (One surgeon was allegedly called out of drug rehab to give Botox to a star halfway around the world on a concert tour.)

The very rich and titled can be even more difficult. Grossman has several patients who are Middle Eastern royalty. "Once, on vacation in Santa Fe, I got a call that 'Her Highness needs to see you tomorrow;" Grossman remembers, I flew to Beverly Hills and sat for several hours in a garage with her security people. Finally, I said, 'I don't have any more time' and left. Afterward, there were great apologies and gifts."

For some doctors, it's easier to discuss celebrity plastic surgery than to actually perform it—and just as beneficial. One publicist advises his surgeon client, to send out press releases speculating about whether Tom Cruise got Botox or Ashlee Simpson had a recent nose job. The fact that these doctors have never met the celebrity in question is immaterial, says the publicist: "The public thinks they did. It's less headache, and the doctors themselves become celebrities." Two different plastic surgeons even have websites devoted entirely to gossip about stars they have never touched. However, this can backfire, as it did with Sharon Stone and Renato Calabria, a Beverly Hills plastic surgeon. When articles in Us Weekly and In Touch about Calabria's alleged work on Stone later appeared on Calabria's website, Stone took legal action. Though he wasn't quoted as the source of the information, Stone sued Calabria for defamation. Stone later dropped the suit, and Calabria agreed to perform surgery on disadvantaged children. Naomi Campbell is suing Jean-Louis Sebagh, a French dermatologist, in a London court for £50,000 for ads in Hello! magazine that implied that she endorsed his products. In her suit against the doctor, Campbell denied needing or having any cosmetic procedures, and has used the popular expression, by way of explanation, "Black don't crack." (At press time, the suit was still pending.)

With all of these problems, many doctors wonder if celebrities are worth the trouble. While being chosen by a star is flattering, Baker says, "You'll get more referrals working on a housewife who'll tell her friends." Therefore, he says, if a superstar wants surgery, he puts a financial premium on it. "They take a lot of extra time," Baker explains. "They expect it, and they demand it." So when a celebrity tells reporters that her youthful figure is a product of exercise and healthy living, and not her liposuction, doctors tend to understand the subterfuge. "When you see a patient on a TV talk show ascribing her good looks to clean living and genetics." says Craig Foster, a Manhattan based plastic surgeon, "it gives you a small degree of satisfaction knowing you gave God and Mother Nature a little boost."