Penny-pinching Americans are increasingly rethinking how much they are willing to pay for pretty.

Charles Ashley Mann, a cosmetic dentist in Raleigh, N.C. is booked three weeks out instead of four, and demand for veneers, the most expensive procedure, is down.

But Mann said he thinks his patients are reluctant rather than unable to pay $1,100 to cover a badly stained or crooked tooth with a porcelain veneer. Demand for professional teeth whitening, a procedure that costs $625, is up, he said.

"I think people have the money, but they don't want to spend it because of the economic atmosphere," Mann said.

Worried about declining home prices, a slowing job market and skyrocketing cost-of-living expenses, consumers are increasingly eating in, vacationing in the backyard and keeping their wheels longer.

They're also cutting back on medically unnecessary procedures from liposuction to laser eye surgery — luxury purchases that have long been a gauge for how financially confident consumers feel.

Iatria, a day spa with three locations in the Raleigh-Durham area, has seen demand for gift certificates decrease in the past six months.

Some clients who came every four months to get Botox injections now wait longer between visits, risking the reappearance of wrinkles, said Erika Mangrum, Iatria owner.

"But people are not giving up on their Botox," Mangrum said.

Dr. Michael Law, a plastic surgeon in North Raleigh, is getting fewer inquiries from new patients, said his wife and practice manager, Kile Law. Also, callers have begun to ask about financing options, which the Laws have never offered.

At Raleigh Plastic Surgery, bookings were down in November, December and January, usually a busy time, practice administrator Nancy O'Neill said.

But business has rebounded recently, partly because of tax refunds and federal rebate checks.

O'Neill wonders what will happen if the economy continues to ail after the summer, traditionally a slow time for cosmetic medical procedures.

"In the fall, that'll be the real tell-tale," O'Neill said.

Following a sharp decline after the 2001 recession, the number of cosmetic medical procedures nationally climbed dramatically, according to the American Society for Aesthetic Plastic Surgery.

Including cosmetic dental work, laser hair removal and vision-correcting laser eye surgery, Americans spent $18.5 billion last year to indulge their vanity. Though that total is expected to fall this year, some consumers won't stop spending on their looks, especially as the economy sours.

Research has shown that cosmetic medical procedures boost earnings in certain professions, N.C. State University economist Michael Walden said. "Looks do pay off," he said, especially to close deals, increase sales and make business contacts.

Jane Mansell, 57, a Raleigh real estate agent, said she never thought about skipping her laser skin treatment to reduce fine facial lines.

"In this business, you have to look your best," Mansell said.

But others are shifting their priorities. David Harmon of Market Scope, a market research firm that tracks laser eye surgery targeted to rid patients of glasses and contact lenses, projects a 17 percent decline in procedures this year.

When money is tight, Walden said, "people will look for ways to postpone luxuries and stretch their income."