The aesthetic rush in medicine

Cosmetic medicine is a booming industry.

The American Society of Plastic Surgeons (ASPS), which claims to be the largest plastic surgery specialty organization in the world and represents 93% of all board-certified plastic surgeons in the United States, reports that Americans spent $16.5 million on cosmetic procedures in 2018. And member surgeons performed 17.7 million cosmetic procedures in 2018, up 2% from 2017.

Dermatologic surgeons report performing more cosmetic procedures, too. The most recent statistics from the American Society for Dermatology Surgery (ASDS) show a 76% increase in cosmetic procedures by ASDS members from 2012 to 2018. ASDS members reported performing about 9 million cosmetic procedures in 2018 - a 7% increase over 2017.

“Our members have had a dramatic-exponential-increase in nonsurgical aesthetic services,” says American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) Immediate Past President Phillip R. Langsdon, M.D. AAFPRS represents more than 2,500 facial plastic and reconstructive surgeons worldwide.

Nonsurgical aesthetic procedures include popular neuromodulators injections, including onabotulinumtoxinA (Botox, Allergan), facial fillers and facial skin rejuvenation procedures with ever-evolving lasers, pulsed light and radiofrequency devices, according to Langsdon.

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But it’s not only plastic surgeons, facial plastic surgeons, oculoplastic surgeons and dermatologists that are offering cosmetic procedures. Primary care physicians, as well as oral maxillofacial surgeons, obstetricians and gynecologists, general surgeons and many other types of physicians and surgeons are offering aesthetic surgeries and nonsurgical options. Non-physicians are also offering non-surgical treatments, including nurses and dentists in some states.

The American Academy of Cosmetic Surgery (AACS) has more than 1,600 members from an assortment of medical and surgical specialties and is focused on providing cosmetic surgery education, including AACS certified fellowship programs. AACS’s membership breakdown reflects the diversity of specialties offering cosmetic procedures today and includes 12% from dermatology, 12% from general surgery, 9% obstetrics and gynecology, 5% in ophthalmology, 18% in oral and maxillofacial surgery, 8% in otolaryngology, 16% in plastic surgery, and 20% in the “other” category, which, according to AACS, is not broken down.

A small percentage of family practice physicians appear to be providing cosmetic services. The American Academy of Family Physicians (AAFP) included a question about cosmetic procedures in its member survey in 2015, asking whether respondents provided Botox services. At that time, 3.7% of survey respondents answered “yes.” AAFP also is among the physician organizations that are offering clinical and procedural courses in aesthetic medicine. The 2019 AAFP annual conference included aesthetic medicine topics, but many of those aesthetic medicine topics are related to treating conditions that are directly related to medical diagnoses, such as skin cancer, rather than for elective cosmetic reasons, according to AAFP.

Scope of practice

There are specialties that include aesthetic procedure or surgery training in formal educational training programs such as residencies and fellowships, according to Langsdon.

“There are what we call core specialties that receive formal training during their residency or fellowship programs in facial aesthetics-in nonsurgical facial aesthetic treatments. Those are facial plastic surgery, otolaryngology, plastic surgery, dermatology and ophthalmology,” Langsdon says. “Out of those specialties-out of those fields that are trained in U.S. residency or fellowship programs-there are advanced training areas where people gain more training. That’s where the fellowships in facial plastic surgery, the fellowships in oculoplastic surgery, and in dermatology and in plastic surgery come in.”

Joe Niamtu, III, D.M.D., an oral and maxillofacial surgeon and fellow of the American Academy of Cosmetic Surgery and the American Society for Laser Medicine and Surgery, says the lines pointing to which doctors are best trained in cosmetic procedures aren’t only best determined by specialty. Aesthetic competency, Niamtu says, is best based on a doctor’s training, experience and outcomes.

Niamtu, whose Midlothian, Va., practice is 100% cosmetic, says he performed about 100 facelifts in 2019 and has performed about 1,200 facelifts total.

“My specialty was one of the founding specialties of the American Society of Plastic and Reconstructive Surgeons. It actually started as the American Association of Oral Surgeons in 1921,” Niamtu says. “A lot of cosmetic facial surgery grew out of what happened in WWI. Plastic surgery, oral and maxillofacial surgery and otolaryngology all make contributions to facial reconstruction and a lot of the cosmetic techniques were spun off of those treatments of war injuries.

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Doctors from many different specialties are qualified to perform cosmetic procedures, according to Niamtu.

If a physician has strong training in a procedure, they are competent and have safe and predictable results – and they are practicing legally with with malpractice coverage, then they are the right physician to perform the procedure, Niamtu says.

Forces behind aesthetic growth

Aesthetic medicine is a growing force across medical specialties because it combines patient demand and the opportunity to grow a new revenue stream that could help offset declining reimbursements in other areas of a practice, according to an email interview with Cristy Good, MPH, MBA, CPC, CMPE, senior industry advisor, and Andrew Hajde, CMPE, assistant director of association content, at Medical Group Management Association (MGMA).

Among the popular cosmetic options that doctors of different specialties now offer: neurotoxins, dermal fillers, laser photo rejuvenation, laser hair removal, microdermabrasion and chemical peels, according to the MGMA experts.

While it can be a good option for many practice types, going into aesthetic medicine may not be the best business decision for some practices. It could be a mistake for primary care physicians, for example, to offer aesthetic services if they haven’t received adequate training and don’t have the appropriate staff, equipment or time to perform these procedures, according to the MGMA email.

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“You need to know [the] patient population …. Cosmetic patients versus those with a medical condition have different expectations of their physician and the office in general,” according to MGMA. “A financial analysis should also be completed.”

There are liability issues to consider, according to Good and Hajde.

“Anytime you are using any procedure of any kind, you are taking a risk and your malpractice insurance needs to be aware so that you have appropriate coverage. This is why many physicians don’t like to work outside of their core scope, as it can increase their risk when they are infrequently performing procedures or have limited training,” they write.

The MGMA experts recommend practices start by offering uncomplicated and low-risk procedures first, such neurotoxins and dermal fillers.

“Again, all procedures have risk, but certain types of procedures are considered to be easier for a physician to learn,” they write. However, for more complex procedures, a physician should make sure he has plenty of training and has contemplated any risks for himself or his patients, they add.

Niamtu says the most comprehensive and credible aesthetic education happens during formal residency or fellowship training in an aesthetic discipline.

Physicians should look for nonprofit aesthetic educational programs-many of which are offered through established core aesthetic specialty societies, according to Langsdon.

“There are many people offering training out there. Basically, these are for-profit entities that are trying to get in on the education goldrush,” Langsdon says.

Good training is key, according to Langsdon. Once physicians are adequately trained in an aesthetic procedure or procedures, Langsdon recommends they start providing a portion of those services and work their ways up.

“What I don’t advise is for somebody to be lulled into the idea that this is a magic goldrush and run out and buy a bunch of lasers and devices. That is a mistake because the majority of people that do that fail. You can get Botox in Memphis in as many places as you can get gas for your car. And you see these places open and close. The ones that sustain are the ones that have a good strong base in practice, and if they can build from that they have a better chance for success,” Langsdon says. 

Read Aesthetic Authority updates for more insight into incorporating aesthetic procedures into practice.