It seems like almost everyone is offering Botox, Juvederm, Restylane, and lasers.  From the Dentist, Family Practice doc, Chiropractor, to the ER doc.  Although there is nothing illegal about this, often times their message is deceptive, against regulations, or not completely forthright.  In addition, many take short cuts on their costs, which can ultimately affect your outcome.  I will expose these practices in my article today.

First and foremost, when getting cosmetic procedures done, a good outcome is the desired result.  Choosing the right physician or provider is paramount to your satisfaction.  Factors that should be considered are:

1. Qualifications
2. Reputation
3. Awards/Honors
4. Who is providing the procedure
5. Technology/Equipment
6. Botox parties
7. Licensing
8. Costs

I will detail each of these areas in the remainder of the blog so you can have a complete understanding of my thoughts and opinions.

A physician’s qualifications should be easily and openly available to the general public.  Often there are websites and ads that will state the physician is “Board Certified” without mention as to the field they are certified in.  The only recognized Board Certifications in Florida for Medical Licensure are the 24 boards  which are part of the American Board of Medical Specialties (ABMS) which is the recognized Gold Standard for Board Certifications.  Any other stated Board Certifications should be further evaluated as to the training requirements, examinations, and renewal processes.   The specialties which receive training in their residencies in Plastic Surgery/Cosmetic Procedures are Dermatology, Plastic Surgery, and Otolaryngology (ENT).   Dentists and Maxillofacial surgeons do to, but they are not part of Medical Specialists.  Why is it so important to choose a physician trained/Board Certified in a Cosmetic Specialty?  A recent article from the CEO of Realself.com explains that patient satisfaction rates are much higher for the Board Certified Physician in a Cosmetic Specialty than other physicians.  An excerpt from the article:

RealSelf.com has analyzed tens of thousands of self-reported consumer reviews across hundreds of cosmetic procedures that were posted to the site. Our data shows patient satisfaction rates are 15% higher on average among those who had procedures performed by doctors that qualify for participation on RealSelf – board-certified aesthetic experts, versus doctors from other fields of medicine.Taking a closer look at the data, we specifically analyzed reviews among the most common injectable treatments, and the results were even more staggering.  For Botox – which has more than 800 reviews on RealSelf.com – board-certified doctors scored 27% higher in satisfaction ratings. Juvederm scored 25% higher. Even more significantly, Restylane was 35% higher in favor of board-certified physicians, followed by Radiesse at 35%.

Going to a physician which has provided a service to one of your friends that is happy with their results is one of the best ways to choose your doctor.  If several of your friends are happy, even better.  Its hard for everyone to be completely satisfied with their cosmetic procedures so take some minor dissatisfaction with a grain of salt.  The same is true with “online reputation”.  Make sure there aren’t several negative posts about the physician you plan on seeing.  Unfortunately there might be malicious reviews from competitors or one unhappy patient which have to be considered when doing online research.  Very high profile physicians with a large media presence are often highly sought after by the public to get their procedures done at their offices.  Make sure they are the ones doing your procedure and it hasn’t been relegated to a PA or nurse because the physician is too busy or out of town.  Although these physician are usually a good choice, their schedules often limit their availability, making the convenience factor very low and their ability to discuss questions/complications very difficult.

The companies which make/distribute the products or services used for Cosmetic Procedures will often rate/award physicians based on their volumes used.  For instance, for every vial of Botox or box of Juvederm (2 syringes), Allergan will give the physician1 point.  Over the course of 12 months, a physician will accumulate points and be assigned a status level.  The bottom line is that if a physician is a higher level provider on a certain procedure or product, he sells more of that procedure or product than some other provider of a lower status level.  Don’t take that status level to be gospel though.  Often a company will pool the purchases from a practice which has multiple providers and give the entire practice a high status level.  Also, just because a physician has a certain high status level, doesn’t mean he/she is providing that service.  Its possible the PA is doing all the work and the physician is doing very little to achieve that level.   In general though, if a physician is doing or selling more of a product, there is a reason for it, and probably is very good at it.

There are several magazines which tout physicians who were voted or recognized as “The Best”.   The consumer needs to be very skeptical with magazines that do surveys to determine who is ‘Best” in a given specialty of Medicine.  There is no way to determine how the votes are tallied, who audited the results, how many were sent from the same location, etc.  The winners always are advertisers when it involves our local magazine and newspaper.   Another one to watch for is the physicians who have been voted “One of the 100 Best Plastic Surgeons in the country”.  I get emails weekly asking if I want to be listed as such and get a certificate  of this “award”, provided I pay their fees.  This is simply a marketing company, trying to exploit the doctor and deceive the consumer.  It is also important to note, that in the state of Florida, it is against the Medical Board’s advertising regulations for one physician to say that he “possesses skills, qualifications, or other attributes which are superior to another physician” or to advertise any professional achievements which are not recognized by the board.

Cosmetic Procedures are not always done by physicians.  Particularly in busy practices, Botox, Dermal Fillers, and Lasers are provided by either PA’s or Nurses.  Although PA’s and Nurses can be excellent in providing these services, they have not received nearly the training that the physician has.  Also, when there is a complication, albeit rare, its better to have a physician to recognize and treat it immediately.  In the state of Florida, laws are fairly strict as to who can perform these procedures in an effort to protect the public.  Often these are ignored because enforcement is very lax.  Other than a physician, or dentist, only a PA or Nurse Practitioner can inject Botox, or dermal fillers, or use a laser or light based (IPL) device.  The only exception is an Electrologist can use a laser for laser hair removal only.  The bottom line is that you know who is providing the services when you make your appointment so you can make an informed decision about safety and costs.

There are hundreds of different lasers and devices on the market currently.  A few actually have public name recognition such as Fraxel, Coolsculpting, Zerona, and SmartLipo.  Fraxel has spent millions of dollars in research, technology development, and marketing to become the worlds leading resurfacing laser.  It’s reputation has enabled it to sell its machines for a premium and to also charge the physician for each procedure.  The end result is that the physician’s costs are higher than other laser resurfacing devices.  I have been told by several clients that they had a Fraxel laser by a physician who doesn’t own a Fraxel, but a similar and less expensive device.  Fraxel has a patent on its technology which can’t be duplicated.  The message is that the patient needs to know what device they are actually paying for.

When a physician buys a laser or device, it doesn’t automatically mean that their results will be similar to the examples on the company’s website.  There is significantly more to operating a laser than just turning it on and pressing buttons.  Individualizing treatment parameters and patient selection are paramount to successful outcomes.   Experience is key to successful outcomes and to minimize complications.  I have seen two recurring issues with inexperienced laser surgeons.  First is that they treat too aggressive on darker skin or tan individuals.  Second, they tend to under treat in other cases for fear of complications.

If the physician is not showing any of his own before and afters then there are some reasons to be concerned.  What’s the best of both worlds is when the physician is showing his own before and after photos and they are also being used by the company on their websites and advertising.  Fraxel is using my photos for their recently launched Fraxel Dual ads and there are several pictures on their website.  Coolsculpting had a nationally distributed brochure with one of my clients as well.

A new laser purchased from a company comes with the latest technology upgrades and service warranty for 1-3 years.  There is a premium paid, just as when you buy a new car.  There is a large market for used lasers, particularly on Ebay.  These laser are about 20-25% of the cost of a new laser.  A physician who purchases a laser in the after market is saving money, but is not getting the state of the art laser.  This physician can sell the treatments at a lower cost.  The patient may never be aware that there are newer, more advanced versions of this laser with better safety, more comfort, and better outcome profiles.  Many laser companies will not back these second hand lasers with warranties or servicing unless a huge fee is paid (which usually is not feasible).  As a result, the patient is potentially being treated with a laser that hasn’t had the latest servicing or updates and there might be a potential safety issue.  If a physician is listed on a company’s website, they have purchased the laser from the company.  If they aren’t, they probably have purchased it second hand and this must factored into your decision making.

Laser companies like to sell complete packages, bundling several lasers together into one stand alone box.  This ends up being both a space saver and money saver for the physician.  This is generally a good idea for starting a practice because with one purchase you can basically cover all your laser needs.  The big but is…..one laser company usually is not great in all of its lasers.  They usually have one, maybe two that will be the market leaders and the rest are 2nd rate.  An experienced laser surgeon will have multiple different lasers which are rated the gold standard for each of their procedures and will be continually upgrading as technological advancements are made.

There are many technologies that never lived up to their promises.  Red flags need to go up for a physician that continues to offer these services and he/she needs to be closely scrutinized.  Is the physician getting results which are consistently better than most others or is there more of a financial incentive?  Start looking at the other services offered and try to come to a conclusion as to whether the physician is actually doing their homework on their services across the board.  Its very difficult to stay on the forefront of technology and not get duped by an over promising new device.  Serious due diligence which includes discussions with the company, researchers, and physicians and traveling to different conferences and offices is required to find the next great new product.  Physicians who base their decisions solely on the company’s sales pitch will be buying worthless machines which they ultimately will try to sell to the public with misleading advertisements to try to recoup their bad investment.

Botox parties seem like a fun and easy way to get Botox injections.  If you delve into this practice further, you can see the pitfalls of this concept.  First and foremost, at least in Florida, a physician’s license includes a location.   Any location a physician practices, he/she has to have a separate location noted on his/her license.  The same is true regarding malpractice insurance.  In essence, you are receiving care from a physician that is not licensed to practice and is not covered by malpractice if this is done in someone’s home.  Although rare, emergencies can occur with these injections and your friend’s house is ill prepared to handle these.  Lighting and positioning is often suboptimal for the injections.  In most cases, alcohol is consumed at these parties, so the informed consent process is not fully understood by the patient receiving Botox.  Often times, the physician delivering the care is hard to get a hold of afterwards when there is a problem.  Lastly, do you really want to get your Botox from a physician who relegates himself to these parties?  You have to ask yourself why is he/she doing these?

Licensing seems like it shouldn’t even be an issue in this day and age, but it is.  Even with all the stories about people pretending they are physicians, injecting materials from your local hardware store into people’s butts or faces, it is still happening in hotel rooms across the US.  People claiming they are doctors from South America or Europe with elaborate stories are still doing this, and educated, wealthy clients are falling for it.  Look up you physician online to get his licensing records, malpractice, and discipline history.

I have been approach by several 3rd party companies selling Botox, Restylane, and similar products at fairly significant discounts to what I normally pay.  When I approach Medicis as to how this 3rd party could do this, they sent me literature that stated it was illegal to buy their products from anyone but their distributor (McKesson).   The quality of the products obtained from these 3rd parties could be of lesser value or even counterfeit.  Botox, for example needs to be stored at a low temperature or the efficacy will deteriorate.  There is no telling that the same rigorous conditions were kept at the storage facilities at these 3rd party companies as they are in the normal distribution channels.  Do determine if your physician is buying directly from the company, search the company’s website and see if your doctor is listed.  If he is not, he probably buys through a third party and you must be cautious.

The final factor which should be consider is the costs of a procedure.  The consumer often is too price driven and skips or ignores all the available information about a physician.  Why get a cosmetic procedure for a cheap cost if the results are undesirable, short lived, or there are complications?  As I clearly outlined above, there are several ways a physician could lower his operating costs, which result in an inferior or more risky procedure for the consumer.  It’s very disheartening when we get a call at our office and the only questioned asked is “How much is you Fraxel treatment?”  There is so much more to our Fraxel treatment than price (we have the Fraxel Dual, the latest version of Fraxel which is faster, more comfortable, better results than prior versions; I have been using it since 2009; my patient photos are plastered all over their website and in their national ad campaigns; I can tailor the procedure with one laser or combine the 2; I have done clinical research for the company, etc) but all the person on the other end is interested in is the bottom line.  As the saying goes, “you get what you paid for”, and be very cautions about low pricing.

In summary, I hope this blog has enlightened the consumer of the reality of the Cosmetic Physician.  Making an informed decision is ultimately going to make a happy patient, which is good for everyone, including the well intending physician,  and the Aesthetic industry.