Plastic Surgery & Cosmetic Surgery Trends For 2008

The ASAPS (American Society for Aesthetic Plastic Surgery) reports 10.2 Million Cosmetic Procedures in 2008. The Aesthetic Society, after collecting multi-specialty procedural statistics since 1997, says the overall number of cosmetic procedures has increased 162 percent since the collection of the statistics first began. The most frequently performed nonsurgical procedure was Botox injections and the most popular cosmetic surgical procedure was breast augmentation.

Top nonsurgical cosmetic procedures among men and women in 2008:
Botox - 2,464,123
Laser Hair Removal - 1,280,964
Hyaluronic Acid (including Hylaform, Juvederm, Perlane/Restylane) - 1,262,848
Chemical Peel - 591,808
Laser Skin Resurfacing - 570,880

Top surgical cosmetic procedures among men and women in 2008:
Breast Augmentation: - 355,671
Lipoplasty (liposuction) - 341,144
Eyelid Surgery - 195,104
Rhinoplasty - 152,434
Abdominoplasty - 147,392

source: ASAPS press release

“For the first time in the twelve years these statistics have been collected liposuction is a runner up in popularity to breast augmentation. There is no doubt that this turnabout will generate discussions in the medical community and the public at large,” Alan Gold, MD, Aesthetic Society president, reflects that “changes in fashion, i.e. décolletage baring styles, might be a factor behind this change.”

TRENDS AND DEMOGRAPHIC DATA

Top surgical and nonsurgical cosmetic procedures among men and women in 2008:
Surgical	# procedures	Nonsurgical	# procedures
Breast Augmentation:	355,671	Botox	2,464,123
Lipoplasty (liposuction)	341,144	Laser Hair Removal	1,280,964
Eyelid Surgery	195,104	Hyaluronic Acid (including Hylaform, Juvederm, Perlane/Restylane)	1,262,848
Rhinoplasty	152,434	Chemical Peel	591,808
Abdominoplasty	147,392	Laser Skin Resurfacing	570,880

Top cosmetic procedures for WOMEN:
Surgical	# procedures	Nonsurgical	# procedures
Breast augmentation	355,671	Botox	2,239,024
Lipoplasty	309,692	Hyaluronic Acid (including Hylaform, Juvederm, Perlane/Restylane)	1,200,420
Eyelid surgery	166,426	Laser Hair Removal	1,101,255
Abdominoplasty	143,005	Chemical Peel	554,492
Breast Reduction	139,926	Laser Skin Resurfacing	532,008
____________________________________________________________________________________________________
Women had almost 92 percent of cosmetic procedures. The number of procedures (surgical and nonsurgical) performed on women was over 9.3 million, a decrease of over 11 percent from the previous year. Surgical procedures decreased 15 percent; nonsurgical procedures decreased by 11 percent. Since 1997, surgical procedures increased 104 percent, while nonsurgical procedures have increased 233 percent.

Top cosmetic procedures for MEN:
Surgical	# procedures	Nonsurgical	# procedures
Liposuction	31,453	Botox injection	225,099
Rhinoplasty	30,174	Laser hair removal	179,708
Eyelid Surgery	28,678	Hyaluronic Acid (including Hylaform, Juvederm, Perlane/Restylane)	62,428
Gynecomastia	19,124	IPL laser treatment	46,887
Hair transplantation	18,062	Microdermabrasion	39,824
____________________________________________________________________________________________________
Men had over 8 percent of cosmetic procedures. The number of procedures (surgical and nonsurgical) performed on men was over 800,000 a decrease of over 21 percent from the previous year. Surgical procedures decreased 18 percent; nonsurgical procedures decreased 22 percent. Since 1997, surgical procedures have decreased over 15 percent while nonsurgical procedures have increased 239 percent.

Frequency of cosmetic procedures by AGE GROUP:
% of total	Age	# procedures	Top surgical procedure	Top nonsurgical procedure
45%	35-50	4.6 million	Liposuction	Botox
26%	51-64	2.7 million	Eyelid Surgery	Botox
22%	19-34	2.2 million	Breast augmentation	Laser Hair Removal
6%	65 and over	634,667	Eyelid Surgery	Botox
2%	18 and under	160,283	Rhinoplasty	Laser Hair Removal

Racial and Ethnic Distribution

Racial and ethnic minorities accounted for 20 percent of all cosmetic procedures in 2008. Hispanics again led minority racial and ethnic groups in the number of procedures: Hispanics, 8 percent; African-Americans, 6 percent; Asians, 4 percent; and other non-Caucasians, 2 percent.

Location and Fees
Over fifty-three percent (53 percent) of cosmetic procedures in 2008 were performed in office-based facilities; 26 percent in freestanding surgicenters; and 19 percent in hospitals. Americans spent just under $12 billion on cosmetic procedures; $7.2 billion was for surgical procedures, and $4.6 billion was for nonsurgical procedures.

Plastic surgery secrets revealed: Vanity goes undercover.

Melanie Berliet, a Vanity Fair writer, went undercover to test her hypothesis that plastic surgeons try to sell additional procedures to patients that they don’t “need.” The 5’9”, 120-pound 27-year-old, who wears a size 34B bra, went into the consultations under the guise of wanting breast augmentation.

Some of the plastic surgeons did not come out looking very good. The three surgeons had different reactions to her physique, but all of them recommended procedures she hadn’t originally asked for.

The one plastic surgeon who did fair pretty well had this exchange with the author:

He goes through the standard health questions, then asks, “How can I help you today?”

“I was just hoping to get a professional opinion about my options in terms of plastic surgery.”

The doctor squints and replies, rather emphatically, “The way it works is: you tell me if something specifically bothers you, and I’ll tell you if I can address it. But I’m not here to sell you services or goods, because there may be something that you don’t see that I see.”

“And you won’t share?,” I ask, somewhat startled.

Dr. Racanelli explains that he has an ethical problem with pointing things out, because he’s heard of cases in which patients felt they were talked into a procedure. He continues, “If there’s a specific area of concern, then you and I can discuss it at length ... I’m not here to, like, pitch you.”

“Is it a legal problem?,” I ask.

“No. Not a legal problem. It’s just the way I like to do things.”

In that case, I tell him, I’d like to talk about my nose and boobs.

Satisfied, the doctor proceeds. Most of what he says is familiar. He says I’m tall enough to carry a full C-cup, and observes that my nose has a “dorsal hump” and a “bulbous tip.”

“Is there a way to image what it might look like?”

“There’s a way to image, and it’s a very successful marketing tool,” he replies. “I do not do it, and the reason is: the only person who knows what your nose is going to look like after surgery is God.” Despite my general discomfort with superfluous references to a higher power, I feel the urge to jump out of my seat and give Dr. Racanelli a standing ovation.

The AMA & Retail Medical Clinics

You'll notice below that the precourser is physicians complaining that "retail clinics interfere with the traditional practice of medicine". Sounds like something I've heard before.

Via Kevin MD: It's obvious they are taking a more aggressive stance against the growing threat of retail clinics:

The American Medical Association wants authorities to investigate whether quickie retail-based health clinics run by pharmacy chains pose conflicts of interest that put profits ahead of patient health.

The nation’s largest physicians’ group on Monday adopted a resolution vowing to seek an investigation after several AMA doctors complained that the clinics interfere with the traditional practice of medicine.

The AMA wants state and federal agencies to look into whether pharmacy chain-owned clinics located in the stores urge patients to get their prescriptions filled on site, which the AMA maintains would pose a conflict. It also said that insurance companies should be banned from waiving or lowering co-payments only for patients who get treatment at store-based clinics.

Tough to say how this is going to shake out. It may be better to collaborate, rather than take an adversarial approach.
Update:

Doctor Anonymous with more. He thinks once the inevitable malpractice lawsuits hit these clinics, they will die quickly.

Seth Godin & Your Med Spa or Skin Clinic

In sitting down to write this post I was struck with the width of the topic. Not Seth Godin, but cosmetic medicine (laser clinics, med spas, skin clinics) and how successful medical practices are built and run. It's no easy task. Which brings up Seth Godin.

Seth has a job. He describes it as being Seth Godin, noticing things that don't have an existing vocabulary and giving words to people so that they can talk about concepts that didn't have words before. Seth's quite good at this as, since there's a scarcity of Seth Godin's in the world and he's the only one.

Scarcity. Superstars. Best in the world. Remarkability. Mantra.

All things I've blogged about but not really focused on in a coherent pattern.

In effect, I've missed the forest for the trees. I'm going to try to talk about a few of those trees. They're the ones you're using to build your business.

There are now many smart docs reading this site. Some comment, most do not. It's a statistical fact that only about 1% of any interaction you have (including blogging) elicits a response from the people you're interacting with. I'll guess that many come and scan the list of recent comments along the left side of the page rather than read what I'm writing about. That's good, fine, and by design. Decentralized but organized systems win every time.

Seth is used to talking about markets and retail. This site is for physicians in retail medicine (It say's so right at the top.) so I'm going to use some of Seth's words and some of my own. I think they're good ones.

Doctors in retail medicine have been operating at a disadvantage. Due to certain idiosyncrasies of the medical marketplace they've not had access to the resources that other retailers take for granted. The medical spa franchises are a first studdering step to bring systems to the marketplace. My own feelings are that the current crop are doomed to fail because they don't fulfill what is needed to succeed. Scarcity? Remarkability? Best in the world? No. If you've sat through any of the medspa franchise discovery days what you hear is this: Turn key operations. Low hanging fruit. Uniformity. Those are not the words that build successful businesses. These are the words that build commiditzed, mediocre, average, and struggling businesses.

The good news? There's also a scarcity of superstars. There's room at the top. Medicore's where the crowd is.

bariatric surgeries on Medicare patients

Evidently the bariatric bone aint connected to the bank account bone.

 
Kevin MD posts a link to how a practice cannot live on Medicare patients alone:

Total reimbursement for 292 patients was $516,158—mostly from surgical fees of $407,063. The cost to run the practice was calculated at $444,592 a year: $207,065 for salaries, $55,150 for malpractice insurance and $182,377 for other expenses. All the figures were based on costs from Dr. Madan’s practice.

After expenses were paid, the surgeon’s pretax earnings totaled $71,566.

But as Elliot notes in a comment on Kevin MDs blog:

He was not paid 71k for 300 bariatric surgeries. He's a lousy businessman is the story. Medicare reimburses more than 10k per bypass so he generated some 3,000,000 in revenue for someone. I am certain he got North of 500k for his part so where did all the money go? Lousy businessman should give up his dream of becoming rich by running his own practice and go to work for someone else.

Something here just doesn't make sense... $207 for salaries and amost another $200k for other expenses?

Mall Medicine: Bloomingdales & Botox.

Yet another article on medical spas in malls.

 
If you believe all the articles talking about the growth of medical spas and cosmetic practices... don't.

Medspas are medical practices like others. Some win and some will loose and go out of business. (Read Ron Berglund's series on his Sona medical spa franchise.)

If you took all these articles at face value you'd think that everyone but you is making money hand over fist. You'd be wrong. Retail medicine is a business. Those that are good at it succeed. Those that are not go out of business and sell their IPL's on Ebay.

Wall Stree Journal Article on Medical Spa Franchises: Medspa boom is a bust for some

Via Wall Stree Journal. Read the entire article here.

Read the Medical Spa MD series: Inside a medical spa franchise.

Medspa Boom Has Become a Bust for Some

By RHONDA L. RUNDLE
November 21, 2006

...Medspa ownership turnover generally reflects business stumbles rather than safety issues. Ms. Leavy says many of the troubled spas are affiliated with franchise chains with flawed business models, such as those requiring too much of a franchisee's revenue to go for marketing. (She estimates that about 10% of medspas are franchises, although other industry experts put the percentage at 30% or higher.)

Several Sona franchisees, though not Mr. Nebot, are in private arbitration over problems that include misrepresenting a complicated business as a turnkey operation and failing to provide needed support. Sona officials declined to comment.

Several franchisees of Radiance MedSpa Franchise Group PLLC, a franchiser in Scottsdale, Ariz., say the company's financial projections overestimated revenue and underestimated initial start-up costs, including working capital.

The president of Radiance, Charles L. Engelmann, recently said: "There are currently 32 open stores and we will have 47 or 49 open by the end of the year. None of the stores have closed." He also acknowledged that some franchisees are attempting to get their money back.

One common pitfall for medspa operators is the failure to properly account for prepaid services, such as discounted packages of laser or light-based facial treatments. At Mr. Nebot's shop, for instance, clients would routinely pay $1,000 in advance for a package of laser hair-removal treatments to be delivered over a year or more. The shop's rooms were then filled with nurses treating customers who had paid months earlier. Finding new customers with fresh cash was a constant struggle.

Mr. Nebot says he felt like a cartoon character, "running faster all the time but falling further behind." He used radio advertising to draw more clients, moved to a larger space and extended his operating hours. To avoid alienating customers, he gave away free treatments to those who complained that their hair kept growing back after they finished the five-treatment regimen they purchased.

In the wake of the recent legal changes in Florida, some medical-spa owners there must shell out an extra $60,000 a year or so to a dermatologist or plastic surgeon to oversee operations.

"I can't be my own medical director any more, which is an added expense I can't afford," says one Florida physician who is not a dermatologist. He says he is "facing personal bankruptcy and trying my best to get out while there is something left for my family" after miscalculating what it would take to market, advertise and build his business. Indeed, many medspa owners are doctors who hope to make easy cash at a time when income is shrinking from their traditional medical practices.

Some franchisers have run afoul of state regulators by violating laws against the corporate practice of medicine. In February 2005, California denied a franchise application from HealthWest Inc., a Los Angeles firm that had more than a score of Inaara MedSpas around the country. California ruled that HealthWest had "falsely represented" to owners that they could legally own a medspa without a medical background. HealthWest has gone out of business, but some Inaara shops broke away from the founders and still are operating as independent, stand-alone shops. (Note: The former owners of HeathWest are now 'licensing' medspas under the name Solana.)

Another bust was Skin Nuvo International LLC, which filed for bankruptcy and sold its 37 stores to a private equity firm that in turn sold them to Pure MedSpa, a Toronto company.

Sleek MedSpa, a closely held chain in Boca Raton, Fla., recently acquired SkinKlinic's Fifth Avenue flagship in Manhattan, but SkinKlinic's two other stores, one in Las Vegas and the other in Greenwich, Conn., have closed. SkinKlinic's founder, Kathy Dwyer, is a former senior executive of cosmetics giant Revlon Inc. Attempts to reach her for comment were unsuccessful...

Wall Stree Journal Article on Medical Spa Franchises: Medspa boom is a bust for some

The following article on problems with medical spa franchises ran in the Wall Stree Journal. It's a telling article that points the finger at the current crop of medical spa franchises. I signed up and read it after Ron posted his comments on being an unhappy Sona owner.

Medspa Boom Has Become a Bust for Some

By RHONDA L. RUNDLE: November 21, 2006

Jeff Nebot thought he had struck gold. Two years after opening a laser hair-removal franchise in St. Louis, annual revenue hit $3 million. And over time, the lavish salon added other cosmetic services as Mr. Nebot joined the rush of entrepreneurs into the emerging business of medical spas. Medspas (also called medispas) offer such medical treatments as Botox injections and laser hair removal in a luxurious environment rather than a doctor's office. The field has been rapidly expanding in recent years as entrepreneurs and doctors alike have sought to profit from the dual quests of many affluent consumers: prettification and pampering. For an increasing number of those who entered the business, the boom is proving a bust.

"Several Sona franchisees, though not Mr. Nebot, are in private arbitration over problems that include misrepresenting a complicated business as a turnkey operation and failing to provide needed support. Sona officials declined to comment.

Several franchisees of Radiance MedSpa Franchise Group PLLC, a franchiser in Scottsdale, Ariz., say the company's financial projections overestimated revenue and underestimated initial start-up costs, including working capital.

The president of Radiance, Charles L. Engelmann, recently said: "There are currently 32 open stores and we will have 47 or 49 open by the end of the year. None of the stores have closed." He also acknowledged that some franchisees are attempting to get their money back.

"I can't be my own medical director any more, which is an added expense I can't afford," says one Florida physician who is not a dermatologist. He says he is "facing personal bankruptcy and trying my best to get out while there is something left for my family" after miscalculating what it would take to market, advertise and build his business. Indeed, many medspa owners are doctors who hope to make easy cash at a time when income is shrinking from their traditional medical practices.

You can read the entire article on the Wall Street Journal site here. It does require a subscription. 

The Angry Physician Syndrome: Hostile MDs entering cosmetic medicine.

Hostile doctors and the clinics they run.

Having consulted with many physicians about incorporating some form of cosmetic practice into their clinic, I've noticed that one of the biggest problems that these physicians have is changing the way they 'think' of medicine. (Noticed is something of a simplification since 'beaten over the heat' is a more accurate description.)

Cosmetic medicine is a new world for doctors who are used to third party reimbursement, nasty collections letters, physician referrals and seeing 30 or more patients a day. Docs today are angry; Irritated by long hours, pissed at malpractice premiums, feeling unappreciated and defensive.

Dr. Charles is Hostile:

There's no justice in Germany either. A German court ordered an OB/GYN doctor to pay $769 a month in CHILD SUPPORT to one of his former patients - a woman who got pregnant despite the IUD (contraceptive device) he inserted. This is horrendous. Sue your doctor if you get pregnant? An unintended yet healthy baby is evidence of bodily harm? No contraceptive is 100% accurate! The article says that "the implant could no longer be found in the woman's body." This does not mean it was the doctor's fault. IUD's fall out in up to 7% of women in the first year of use. That's part of the reason they have a string that dangles out of the cervix into the vagina, meant to be checked on a regular basis by the woman to ensure proper placement. This is totally outrageous, uncivilized, and another reason why it takes serious courage to try to help anyone in this world of blame.
[update - thanks to the correction of a German commenter, it was not an IUD that failed but another device, probably like Implanon but I don't know what's available in Germany. The underlying principle is still unbelievable. Overlawyered has some more links to this, and a decent discussion starting in the commentary.]

The Trial Lawyers Association is changing its name to the American Association for Justice. George Orwell is smiling somewhere, the skies are getting clearer every day, and no child is being left behind.

A doctor acquaintance of mine just got destroyed with a $20,000,000 jury award in a bogus malpractice case. I typed it into google and found this page, which is unrelated. I felt nauseous reading the top guy's credentials. The best thing he's done is apparently winning "the largest medical malpractice verdict ever won in the District of Columbia ($24 Million), (which was) reported by USA Today, Dateline NBC, Jet Magazine, the Washington Post, the Baltimore Sun and affiliates of ABC, CBS and NBC." Way to go! I bet his pockets were full after that one! Those doctors on the other end deserved utter destruction, all those years they spent working 120 hours a week for $30,000 a year, all those hopes they had of helping people, of making a difference. All those efforts pale in comparison to the $24,000,000 he got the jury to cough up.

Dr. Charles is right.

But... cosmetic medicine is a different animal and angry docs fare poorly when the anger they have towards the system spills over into their interaction with patients and staff. (Yes, I know angry docs fare poorly everywhere.)

Whenever I'm interviewing a physician I ask myself if they're an angry doc. If I think they are, it's a non-starter. I can work with a lot but can't change the way that someone fundamentally views the world and their situation. I can't change the way that an angry physician deals with patients, staff, and me. It just doesn't work. It's true that there are lots of angry docs out there and you might know some that you think are successful and that the fact that they're angry doesn't hurt them as a business. I don't.

If you're thinking about entering cosmetic medicine because you're angry and think that someone owes you, get ready for more of the same. In cosmetics as in regular medicine, it's still all about them.

Update on 2006-11-21 00:56 by Medical Spa MD

Follow-up: Dr Charles sent me a very nice email that included the following:

"...Although you said "I'm right", I did find your post kind of annoying, labeling me as an "angry MD."  There is so much more than that unipolarity in defining my approach to medicine, but at times we all get angry."

I did not mean to apply a blanket angry label to Dr. Charles. In fact, he seems to be a well read and thoughtful physician with a respected blog. My apologies to Dr. C. Nothing at all personal intended.

This post, and other I'm sure I will write, are meant to delineate the difference between general and cosmetic medicine for docs looking to make a change or choice. 

Of course anger is not only confined to physicians, pharmacists have it too.