NY Times: More doctors turning to the business of beauty.

From the NY Times: More doctors turning to the business of beauty.

Five years ago, cosmetic medicine was primarily the domain of plastic surgeons, facial surgeons and dermatologists — medical school graduates who undergo several years of training in facial skin and its underlying anatomy. But now obstetricians, family practitioners and emergency room physicians are gravitating to the beauty business, lured by lucrative cosmetic treatments that require same-day payments because they are not covered by insurance and by a medical practice without bothersome midnight emergency calls.

Dermatologists and plastic surgeons refer to their new colleagues as “out of scope” or “noncore” physicians, and they strongly object to the intrusion, insisting that cosmetic medicine requires lengthy training.

But the dispute also has all the elements of a turf war, with specialists reluctant to cede ground in a field in which Americans spend an estimated $12 billion a year.

“Dentists are doing Botox, and urologists are doing hair transplants and vein removal,” said Dr. Ellen Gendler, a dermatologist in Manhattan who is a clinical associate professor at New York University School of Medicine. “Everyone wants to be a plasticologist.”

...Still, Dr. Kilanko said she understood the discomfort over physicians who practice outside their board certification, and she objected to the suggestion that a dermatologist might perform a Caesarean section after a day course in obstetrics.

“They would have no business performing a C-section,” she said. “But you can’t compare the knowledge of the anatomy, level of difficulty and risk of complications of a C-section with Restylane injections.”

Dr. Gendler, the Manhattan dermatologist, vehemently disagreed.

“They don’t think it’s brain surgery until they have a problem,” she said. “Then the first thing they do is send the patient to a dermatologist.”

Silicone Injections: Illegal 'pumping parties' can be life threatening.

Via Physorg

A study of individuals who underwent illegal silicone injections revealed a high fatality rate from pulmonary silicone embolism, or obstruction of the lungs. The study was presented today at the annual meeting of the Radiological Society of North America.

The U.S. Food and Drug Administration banned silicone injections in 1992, but people still seek them out because they are cheaper and easier to get than professional plastic surgery or hormone therapy and provide immediate results. In surgical clinics, transgender patients are often required to undergo psychological testing before receiving treatment.

Unfortunately, the illicit nature of the injections makes it hard to estimate how common they actually are. However, the increasing popularity of the "pumping party"—where a host will inject a number of people with silicone in the same sitting—indicates both the demand and the ready availability of the substance.

Med Spa Burnout? Be happy you're not a urologist?

A day in the life of a urologist. Sometimes everyones just on a different page.

Via UroStream: The setting is a medical examining room. List of characters includes a physician and a patient. The action is all undertaken by the patient while the physician is present. Which of the following scenario would you consider rude?

• Playing games on your cell phone
• Answering above mentioned cell phone
• Clipping your nails
• Chewing gum
• Being drunk
• Being drunk and asking for pain meds
• Being drunk, asking for pain meds and blaming lack of pain meds for being drunk.
• Eating a yogurt
• Eating and then spilling your yogurt on the floor, and having the physician clean it up.
• Pooping in the uroflow machine (device to measure your urinary flow and NOT designed for BMs)

It was a very long week....

Contribute to Medical Spa MD

 

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Medical Spa MD welcomes contributions from readers. Just click on the link above and paste your submission into the text field.

 
I am happy to allow contributors to either use their own name, or use a pseudonym (Aesthetic MD). If you want to use a pseudonym I need to know who you are, but I will of course keep that information in confidence. I always make clear when it's my writing or that of a contributor both by giving a by-line in the title and by using indentation and different fonts. Links and backlinks may be included. You don't need to worry about formatting or images.

There are only a few groundrules for contributors. The topic has to be on some aspect of cosmetic medicine or business that should be of interest to medspaMD readers, but as most contributors are readers that's usually assumed.

Finally, although I print much of what I'm sent, medicalspaMD of course retains editorial control. Just use common sense and of course if you expressly do NOT want something published please tell me. You do give medicalspaMD all rights for info you submit -- but I'll reserve the right to say more about that if in some happy future day this site ever starts adding to my bank account rather than subtracting from it!

The Uninsured Patient Experiment

It appears that hospitals are a hit and miss proposition with elective procedures. From the Healthcare Advocate Blog.

The Uninsured Patient Experiment:

• The list price varies by 75% ($1,013 to $3,970).
• The best uninsured price varies by 92% ($204 to $2,600).
• List price discounts range from 0% to 86%.
• To get many of the discounts hospitals offer the balance needs to be paid in full at the time of service or a large down payment made, to receive it.
• Some hospitals are unwilling to divulge the price over the phone and others will not call back.

Foam-Sclerotherapy Study: Over 90% complete occlusion.

The study, reported in the August issue of the British Journal of Surgery, suggests that ultrasound-guided foam sclerotherapy safely achieves complete occlusion in 91 percent of varicose-vein cases.

192 patients were referred for varicose vein treatment over a 15-month period. Eleven of these patients selected surgery, while the remainder opted for ultrasound-guided foam sclerotherapy. The latter treatment involved the use of polidocanol in a 1:3 mixture with air. Under ultrasound guidance, 1 percent foam was injected into superficial veins, while 3 percent was used for saphenous trunks.

Of the 220 legs treated with ultrasound-guided foam sclerotherapy, 163 showed complete occlusion of varicosities after one treatment. With a second treatment, 32 additional legs achieved complete occlusion, and one more responded positively after a third treatment. According to the study the overall rate of complete occlusion was 91 percent.

The study goes on to say that the ultrasound-guided foam sclerotherapy was generally well tolerated and that there were no serious complications. The study noted that several patients did experience phlebitis and pigmentation, which could have cosmetic implications. They conclude that further research is needed.

Plastic Surgery as an anti-depressant

According to a study presented at the recent American Society of Plastic Surgeons 2006 conference here, plastic surgery not only can improve self-esteem but also acts as a natural mood enhancer. I would think that a number of followup studies are needed before anyone starts prescribing plastic surgery as a treatment for depression. 

UPI reports that the study, authored by Bruce Freedman, M.D., medical director of Plastic Surgery Associates of Northern Virginia, focused on 362 patients who had had cosmetic plastic surgery. Seventeen percent of that total, or 61 patients, were taking antidepressants at the time of their surgery. Six months after surgery, that number decreased 31 percent, dropping it to 42 patients. In addition, reports Dr. Freedman, 98 percent of the patients said cosmetic plastic surgery had markedly improved their self-esteem.

The UPI report quotes Dr. Freedman as noting in his presentation that: “Plastic-surgery patients are taking a proactive approach in making themselves happier by improving something that has truly bothered them. While we are not saying cosmetic plastic surgery alone is responsible for the drop in patients needing antidepressants, it surely is an important factor.”

Stem Cells & Cosmetic Medicine

Via ABC News: Could stem cells make you more beautiful?

The prospect is a tantalizing one. To erase wrinkles and fine lines, or to get bigger breasts, without cosmetic surgery. Forget silicone, forget collagen. All you would need is stem-cell therapy.

"Stem-cell research appears promising for medicine and particularly for plastic surgery," said Dr. Ronald Friedman, director of the West Plano Plastic Surgery Center and a board-certified plastic surgeon practicing in Plano, Tex.

New law could help Australia become leader in stem cell research

Lawmakers begin debating legislation this week that would lift a ban on cloning human embryos for stem cell research -- a bill that, if passed, could make Australia a world leader in research into diseases such as diabetes and Alzheimer's.

Catalog of clinical dermatology images

Catalog of clinical dermatology images

Via University of California, San Diego:

Plastic Surgery: 50 reasons not to get a boob job.

With silicon breast implants just reapproved by the FDA, there's sure to be a lot of attention over the next few years about cosmetic medicine and safety.

While not quite 50, here are some strongly worded opinions on 48 reasons not to get a boob job.

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. 

Sona MedSpas: An unhappy franchise owner.

Ron Berglund, a Sona medspa owner, left this comment on one of the most widely read articles on this site: What's wrong with medical spa franchises? The article Ron refers to is referenced here: Medspa boom is a bust for some.

"You may want to check out the November 21 issue of the Wall Street Journal. There is a very informative article about mdeical spas (primarily the Sona MedSpa and Radiance franchises).

Having been a franchisee (St. Paul, MN) for almost three years and now facing personal bankruptcy and financial ruin, I can vouch for the accuracy of the article. I have personal knowledge that perhaps 33% (and maybe over 50%) of the Sona franchisees have either already failed or are struggling. The Sona business model-- and I am guessing most of the franchised medspa models-- are replete with flaws, problems and booby traps.

For starters, any business that tells you to spend 25% of gross revenues on marketing and advertising is giving you a recipe for financial disaster down the road. Relying almost entirely on inflated revenues from prepaid multi-treatment packages (allowing you to take in - and spend-- thousands of dollars today without making any provision for the steadily growing future service liabilities) are also a trap for the undercapitalized and unsophisticated. Finally, Sona encouraged us to commit the mortal sin of cosmetic practice-- they coached us to overpromise results to the point of commiting fraud with thousands of clients. When the Sona-required lasers failed enable us to deliver these impossible results we were literally murdered with demands for additional treatments.

I predict a huge "shakeout" in 2007 as other medspa franchisees hit the courthouses with litigation and financial nightmares. The profitable delivery of esthetic medical services is a tricky and demanding challenge for anyone. I believe it takes a unique combination of business and marketing acumen together with great medical skill and emotional intelligence to navigate these tumultuous waters without drowning."

Ron Berglund 

The article Ron refers to is referenced here: Medspa boom is a bust for some.

From the same thread.

JustCurious asks: How does a medspa franchisee handle closing its doors? Aren't there agreements (in years) that must be signed with the franchisor and wouldn't there be penalties for closing shop? I've notice several medspa franchises closing or selling their business within 2 years of opening their doors and I'm wondering (a) what motivates them to close or sell so quickly and (b) what the penalties of closing/selling could be. Also, if a franchisee sells their medspa in this "billion dollar industry" so quickly, is that usually an indication of a failing business?

Dear Just Curious: Thanks for the response to my recent comment. You are asking two additional questions which are very important with regard to the subject at hand. First, you are asking how does a medspa legally close its doors. Closing shop would be no problem if all transactions were handled on a "pay as you go" basis. Unfortunately, most med spas sell primarily multi-treatment "packages". The Sona model encouraged us to do that almost exclusively. We typically sold five-treatment packages for laser hair removal, and often offered BOGO promotions wherein the client would purchase -- and pay cash up front for --five treatments at the "regular" price (full bikini @ $975 for example) and then would receive five FREE treatments for the underarms area. I had an excellent first year of operations since I was taking in thousands of dollars each month for treatments to be performed in the future. After signing up an average of 100 clients per month and pushing the future service obligation forward, you end up "painting yourself into a corner" and facing an insurmountable liability for performing treatments already paid for. Jeff Nebot had the same problem in St. Louis, except that his numbers were typically about triple my numbers. As this isn't enough of a problem, just imaging what happens when you try to sell or close the business!! You have several thousand clients who have prepaid and are legally entitled to the treatments they have already paid you for-- but you cannot afford to keep the Pnonzi scheme going! Believe me-- this makes any medspa almost impossible to sell because any prospective purchaser is scared to death to walk into this huge liability. That is the primary reason Jeff Nebot and I ended giving away our centers for free. Our buildout, furniture and equipment in St. Paul had cost us almost a million dollars and Jeff Nebot's investment was probably twice as much. I know first hand of several former Sona franchisees losing more than a million dollars on the whole mess-- in addition to a million headaches. There was a story posted on the Internet about the former Salt Lake City Sona franchisee closing her doors and failing to provide hundreds of clients with their pre-paid treatments. The article stated that Utah authorities chased the owners down in Texas and instituted some type of legal proceedings against them. I never heard how the matter was resolved, but I heard that the state was trying to impose some stiff penalties against the (Sona) owners.

Your second question asked how can it be that all these problems are occuring when this "med spa boom" is supposed to be happening all around us. The answer-- in my opinion-- is that the so-called med spa "boom" is to a large extent hype. I predict that the majority of the marginal operations will fall by the wayside during the next twelve month and the survivors will be the operatoins that are well funded and operated on sound business principles. Sona and many of the other franchised systems were attempting to offer a "get rich quick" scheme and also a model which-- for the most part-- utilized the physician as essentialy a mere figurehead. My personal belief is that the only truly successful med spa model requires three key components: 1. The physician is the key to the business-- similar to the dentist in the traditional dental office model; 2. The physician needs to be "on site" for a number of reasons-- business, professional and regulatory; and 3. The model requires superb marketing including a ton of cross-promotion and "guerrilla" marketing. Due to competition. typical profit margins and a number of other factors, med spas simply cnnot afford to allow advertising and marketing expenses to exceed over 10% of gross revenues. Whereas most physicians already have from 5000 to 15,000 patients in their data base who can serve as a "warm" client base for a med spa, all of the franchised med spa models start with zero and need to "buy" each client they recruit. Believe me--these outrageous advertising expenses eventually catch up with you! There is a reason the typical fast food franchises absolutely require that advertising expenses remain in the neighborhood of 7% of gross revenues. In order to survive in the low margin marketplace, there is no other way.

Ron Berglund 

When Young Doctors Strut Too Much of Their Stuff

White lab coat and tie seems to be what patients expect from someone their trusting their body parts to. It's common among many physicians in cosmetic medicine to forego the lab coat in many situations. Hmmmmm....

Via NY Times: When Young Doctors Strut Too Much of Their Stuff.

There was just one problem. As she delivered her thoughtful patient presentations to me and the other attending doctors, it was hard not to notice her low-cut dress.

...One colleague commented that a particularly statuesque student “must have thought all her male patients were having strokes” when she walked in their exam room wearing a low-cut top and a miniskirt.

In a study published last year in The American Journal of Medicine, patients surveyed in one outpatient clinic overwhelmingly preferred doctors photographed in formal attire with a white coat to photos of doctors in scrubs, business suits and informal clothes — jeans and a T-shirt for men, an above-the-knee skirt for women. The patients also said they were more likely to divulge their social, sexual and psychological worries to the clinicians in the white coats than to the other doctors.

Lips and Silikon 1000...a good combination?

Grandma...is that you?

A good friend of mine recently confessed to me that she had seen one of my competitors and gotten Silikon 1000 in her lips.  I usually treat her for Restylane that we use judiciously in her nasolabial folds and her lips.  We also use a little Botox around her eyes.  She is 31 years old and has a beautiful face.  Her lips are full, but she wants "luscious!"  Her assistant had had it done with Dr. T and "she looked amazing."  And when my friend went to his office, his entire staff of young women all had gorgeous bee-stung lips. 

Now, for a moment, just forget all the stories of granuloma risk and inflammation.  Let us pretend that Silikon 1000 in the lips is 100% safe.  I actually do have Silikon 1000 in my office.  But I've only used it in a handful is situations.  One woman had been "butchered" (her term, not mine) by a oral surgeon and felt it left 2 divots in her lower lip.  I carefully filled these in.  Another woman's right upper lip dropped lower than her left from lingering Bell's palsy.  I used it to even out her lips. 

I have two patients who want to look like Angelina Jolie. I can't seem to put enough Restylane into their lips. One of them is from Texas and she said to me, "Honey, bigger is ALWAYS better!"  But the vast majority of my patients who want lip augmentation want only a slightly fuller look.  And so what happens when Angelina is no longer the superstar?  What happens when thin, straight, bead-like lips are in style?  Or what happens when all these young, beautiful woman with these mammoth sized lips get old and are grandmothers?  Their faces will continue to age in the normal, dynamic manner.  But those Silikon lips will be permanent!  I keep getting the visual of a faded tattoo on the side of  a wrinkled, sagging breast.