We live in an age when a youthful appearance has become extremely desirable and in the eyes of many, almost necessary. As a result, the number of cosmetic procedures is skyrocketing, rising 38% from 2000 to 2005. Now, more than 10 million cosmetic procedures are performed in the United States every year and the numbers continue to climb, according to 2006 American Society of Plastic Surgery statistics. It is not then surprising that many dermatologists have moved into or are considering starting their own cosmetic dermatology practice.
However, according to Sarah Boyce Sawyer, M.D., Assistant Professor of Dermatology at the University of Alabama at Birmingham, adding cosmetic procedures to your general dermatology practice is not as simple as buying a few microdermabrasion kits and doing some advertising.
“There are hard factors to consider, such as the monetary investment into equipment and staffing; starting a cosmetic practice can be expensive,” says Dr. Sawyer. “There are also other more elusive considerations, such as your ability to deal with cosmetic patients, your skill set, and whether or not your location can support the investment.”
Evaluating Yourself and Your Practice
The first step in adding cosmetics to your practice is to realistically evaluate your practice to try to figure out how much of your practice will be cosmetic and how much will remain general dermatology. You also have to look at how you’d like your medical and surgical breakdown to be. Evaluated matters such as your own physical dexterity. In addition, learn how to set an expectation and how to counsel.
“I do the counseling and procedure myself so the patient doesn’t feel like I came in and then ran out of the room and let my nurse do the procedure,” says Dr. Sawyer. “Interacting with cosmetic and general dermatology patients simultaneously can be trying, so I recommend setting aside cosmetic clinic time separate from general dermatology time.”
Financial considerations are, of course, extremely important. With lasers costing $85,000 to $100,000 you have to be certain you can recoup your investment. Lasers or the other expensive devices may not be the place to start. Dr. Sawyer recommends beginning with something lower in overhead expense, such as superficial chemical peels, microdermabrasion or Botox.
Before you invest money for a new cosmetic procedure or staffing, you must familiarize yourself with state laws. Be aware of the laws pertaining to which staff members are qualified to perform procedures, the laws regarding the use of certain medications or devices, and whether your state has a sales tax on cosmetic procedures. Fortunately, most dermatologic cosmetic procedures are low risk and have a low frequency of malpractice claims and so they’re not going to impact your malpractice premiums.
Training and skill level are important, but just because you didn’t learn a procedure in residency doesn’t mean that you can’t do it. “A lot of the companies that make cosmetic-related products are more than willing to pay for physicians to train with their products or devices,” says Dr. Sawyer. “There are opportunities out there; you just have to know who to ask in your area, and it varies.”
It’s important to develop the necessary skills to perform any new procedure you are going to add to your practice. Other physicians who have been performing the procedure can help train you to develop the skills needed to perform those procedures, says Dr. Sawyer. You may find other dermatologists who are experts in the area you want to expand into through attending conferences, or a company may provide you help in getting trained.
“Sometimes it comes in the form of an honorarium to go spend a day with a specific doctor, but in the long run if this is something that you want to pursue, it’s worth the investment.”
A Good Place to Start
Botulinum toxin type A (Botox Cosmetic) injections are the most commonly performed cosmetic procedure in the United States, with 3.8 million injections in 2005. Botox procedures are fast, especially with a repeat Botox patient, with most taking only about 10 minutes. They are very safe and have been used for medical purposes in neurology and ophthalmology for more than 50 years.
“The only long-term side effect that we know of with Botox is some atrophy of the facial muscles, which isn’t a bad thing because then it makes it much harder for them to make the motion that’s causing that wrinkle,” says Dr. Sawyer. In terms of risk counseling, “I counsel patients about eyelid droop, headache and bruising.”
On average, Botox lasts about 3 months. Dr. Sawyer recommends scheduling the patient’s next visit for 3 months out before they leave the office.
Botox costs about $485 for a 100 unit bottle. Each cosmetic area treated typically needs between 20 to 80 units. Since each patient needs a different amount of Botox, the best approach is to charge per unit and explain that to the patients up front. How much you actually charge depends largely on the location of your practice, but typical charges range between $12 and $20 per unit.
When purchasing Botox, buy only genuine Botox from a reliable supplier. Leave your Botox in the freezer until you are ready to use it. When reconstituting Botox for cosmetic purposes, Dr. Sawyer uses 1 cc of preserved saline per unit. Botox that is diluted this way will last about a month with proper storage. Do not refreeze reconstituted Botox.
When To Add Lasers
Laser treatments are commonly requested by patients in a cosmetic dermatology practice. Though it may not be the first step in adding cosmetic procedures to a general dermatology practice, most likely you will eventually want to use them. However, the cost is a real issue, and you need to make sure that you’re getting the right device for your practice and your patient population.
“When deciding on a laser, you need to find devices that you can use for a variety of different treatments. Also, you don’t want to duplicate what another dermatologist has down the street — do something different,” cautions Dr. Sawyer. “A vascular laser, such as a 585 nm pulsed dye laser or an Nd:YAG laser would be a good first choice for a cosmetic dermatologist.”
These lasers can be used to treat rosacea, erythematous scars and striae, telangiectasia and angiomas. Vascular lasers can also be used for photorejuvenation and to treat warts.
“I treat a number of conditions with my pulsed dye laser and, with the advent of photodynamic therapy, a vascular laser is a great buy,” says Dr. Sawyer.
“I’ve been treating lots of acne patients who have been through the medical regimen, and I’ve had some really fabulous results using my vascular laser with 20% 5-aminolevulinic acid (Levulan Kerastick). Overall, vascular lasers have more medical dermatology applications than some of the other devices.”
A hair removal laser can be a good option if you already have a many cosmetic skin care patients. There are now variable pulsed 1064 nm lasers that can effectively remove hair on dark-skinned patients.
“Laser hair removal is a very popular procedure, but to a large degree it has become a commodity, and physician-delivered treatments are always going to be the most expensive treatments on the block,” cautions Dr. Sawyer. “People come to me for hair removal only because they’re the type of patient who wants a doctor to do the procedure, versus a non-physician whose prices may be less expensive.”
You have to crunch the numbers as to whether it is most cost-effective for you to buy, lease or rent a device. Generally the more patients you treat with a device, the more likely it is that you should buy one. If you rent, you need to schedule your patients on the day that you will have the device, and you may consider having those patients pre-pay so that they actually show up for the treatment.
“When considering the cost of a laser, you need to look into the cost of service contracts after your warranty expires,” warns Dr. Sawyer. “You also need to consider the cost of a service contract after the warranty expires and also the cost of consumables such as cryogen or dye kits for a pulsed dye laser.”
Bread-and-Butter Procedures To Add
According to Dr. Sawyer, microdermabrasion is the third most common non-surgical procedure, with more than 835,000 performed in 2005. What makes this procedure attractive to a practice is that in most states an aesthetician can do the microdermabrasion, freeing doctors to see other patients. The machines cost between $2,000 and $17,000. The average price in 2005 for a microdermabrasion treatment was $177, according to the American Society of Plastic Surgeons. Just make sure your patients know the difference between dermabrasion and microdermabrasion.
When choosing a microdermabrasion machine, Dr. Sawyer recommends that you look for a device that uses a closedloop system that keeps the clean and dirty crystals separate. Also, find out how reliable your machine is, and make sure of the level of support you will get with your system. For example, make sure that you’ll get a new device in a day or two if there is a problem; otherwise you’ll be rescheduling patients.
Chemical peels are also a great place to start when first offering cosmetic procedures. Superficial peels are effective for photodamage, melasma and acne. You can start with one of the many pre-packaged peel kits.
“The companies that make peel kits are more than happy to come to your office and explain why their peel is better than anyone else’s,” says Dr. Sawyer. “Once you are comfortable and you figure out the mixes you want to use, you can buy the acid separately, and it is considerably less expensive than the kits.”
Once you feel comfortable doing superficial peels, try some medium-depth chemical peels for actinic keratoses. With medium-depth peels, nerve blocks may be necessary, although Dr. Sawyer does not do them for this procedure. “The way I do a medium-depth peel is to treat one cosmetic unit at a time, and I find that even though it’s painful, patients like it a lot better than getting multiple nerve block injections,” she explains. “I give them the choice and they always say, ‘No, let’s just do it.’”
A wide range of fillers are available, with a large variation in the duration of the effect. The most common fillers are collagen and hyaluronic acid. According to Dr. Sawyer, one of the big mistakes that physicians make is not realizing the difference between all the available fillers and trying to use the same filler in all applications.
“They’re not all created equal, and it’s probably going to be impossible for you to pick one. You’re going to have to have two or three in your office once you start treating many patients,” she says. “They all have positives and negatives about them. It’s very important to know what facial area requires what filler.”
Dr. Sawyer cautions that fillers have a steep learning curve, and it can take years for a physician to become truly comfortable with the various types of fillers. “When I first learned how to use fillers, it was easy to want to use just one or two fillers because I felt comfortable with them; but it’s important to recognize the true benefits and limitations of all the different fillers.” Dr. Sawyer recommends having sales representatives bring in samples of a new filler for training.
Dispensing Products: Your Patients Will Like it
If you’re going to have a cosmetic practice, then you probably should be willing to dispense at least a few of your most recommended products. Many physicians are reluctant to dispense products because they don’t want to be “pushing products.” However, patients are happy to buy products from you rather than facing the confusing decision of too many products to evaluate.
“We started dispensing to be convenient for the patients,” says Dr. Sawyer. “We’re not making a fortune, but our patients are certainly happy that they can buy what they need from us.”
Dr. Sawyer suggests tracking your most recommended products, then settling on products from two or three different companies. “Buy five products from one line and two products from another, and dispense your favorite bleaching cream, whether that’s a
compound or commercially available product,” she says. “That way, it doesn’t look like you’ve been bought out by one company. It’s also a great idea to dispense your favorite sunscreens or sunscreen-containing make-up.”
Setting Fees and Marketing
When setting fees, Dr. Sawyer recommends that you set fees based on a per unit charge when applicable, and have a price list so that patients don’t feel as if you’re pulling a fee out of the air. For hair removal, have a set zone size and charge per zone. For Botox, charge by the unit. Fillers can be charged by the syringe. For sclerotherapy, Dr. Sawyer currently charges by time.
“I charge $100 for 10 minutes of sclerotherapy. If a patient has many leg veins and it takes me 30 minutes, it’s going to cost $300. If they have one little area that’s only going to take me 10 minutes, it’s $100,” she says. She also charges by size for tattoo removal.
When marketing your cosmetic practice, keep advertising clear and simple. Highlight one or two services, and provide a price for those services. Beyond advertising, you can conduct seminars, attend local conferences and do local radio and television interviews, either for general or cosmetic dermatology. Even if you’re doing a seminar on general dermatology, you can mention your cosmetic
procedures.
“It is important to track your advertising, which you can do by asking new patients how they heard about your practice,” she explains. “You need to know if that Yellow Pages ad that you spent hard-earned money on is really why these patients are coming in.”
Take Your First Steps
Dermatology is at the forefront of a huge wave of interest in non-invasive procedures to help improve patients’ appearances. As a dermatologist, you are well positioned to ride this wave because you are trained in skin surgery and you understand photoaging, ultraviolet light, sunscreens, retinoids and laser physics. But to truly take advantage of the growing interest in cosmetic procedures, a dermatologist has to be more than a good physician. You must be a good guide for your cosmetic patients, you must provide the right services and products and you must do all that you can to ensure that your cosmetic patients walk away happy.
“It is important to keep one thing in mind when thinking about adding cosmetic procedures,” says Dr. Sawyer. “That is, cosmetic patients are not sick, they’re shopping. Their total experience with your practice must be a completely positive experience, or you simply won’t be able to successfully build your cosmetic practice.”
Dr. Sawyer is Assistant Professor of Dermatology at the University of Alabama School of Medicine in Birmingham, AL. She has particular interest and expertise in laser surgery, varicose vein treatment, skin cancer therapy, and cosmetic procedures including tumescent liposuction, soft tissue fillers, chemical peels and care of photoaged skin.
The Do’s and Don’ts of a Cosmetic Consult
• Schedule adequate time and keep the message clear. Patients remember only a
fraction of what you tell them.
• Make patients feel safe and not pressured and that they are making a good choice.
• Differentiate your practice without criticizing other treatments or other physicians.
• Make referrals to other doctors when necessary.
• Express your opinions with tact and concern. Do not over-criticize patients’ features.
• Provide treatment options with buzz words, then in the same order discuss each
treatment in depth.
• Give an example of a recent good outcome (including yourself or a family member).
• Use many before and after photographs.
• Do not talk too quickly or in monologue form.
• Do not bombard patients with risk information too soon.
• Set up realistic expectations. Do not use words such as “eliminate” or “remove”.
Say “helps to soften” or “can help to remove” instead.
• Inform patients if multiple treatments may be needed.
We live in an age when a youthful appearance has become extremely desirable and in the eyes of many, almost necessary. As a result, the number of cosmetic procedures is skyrocketing, rising 38% from 2000 to 2005. Now, more than 10 million cosmetic procedures are performed in the United States every year and the numbers continue to climb, according to 2006 American Society of Plastic Surgery statistics. It is not then surprising that many dermatologists have moved into or are considering starting their own cosmetic dermatology practice.
However, according to Sarah Boyce Sawyer, M.D., Assistant Professor of Dermatology at the University of Alabama at Birmingham, adding cosmetic procedures to your general dermatology practice is not as simple as buying a few microdermabrasion kits and doing some advertising.
“There are hard factors to consider, such as the monetary investment into equipment and staffing; starting a cosmetic practice can be expensive,” says Dr. Sawyer. “There are also other more elusive considerations, such as your ability to deal with cosmetic patients, your skill set, and whether or not your location can support the investment.”
Evaluating Yourself and Your Practice
The first step in adding cosmetics to your practice is to realistically evaluate your practice to try to figure out how much of your practice will be cosmetic and how much will remain general dermatology. You also have to look at how you’d like your medical and surgical breakdown to be. Evaluated matters such as your own physical dexterity. In addition, learn how to set an expectation and how to counsel.
“I do the counseling and procedure myself so the patient doesn’t feel like I came in and then ran out of the room and let my nurse do the procedure,” says Dr. Sawyer. “Interacting with cosmetic and general dermatology patients simultaneously can be trying, so I recommend setting aside cosmetic clinic time separate from general dermatology time.”
Financial considerations are, of course, extremely important. With lasers costing $85,000 to $100,000 you have to be certain you can recoup your investment. Lasers or the other expensive devices may not be the place to start. Dr. Sawyer recommends beginning with something lower in overhead expense, such as superficial chemical peels, microdermabrasion or Botox.
Before you invest money for a new cosmetic procedure or staffing, you must familiarize yourself with state laws. Be aware of the laws pertaining to which staff members are qualified to perform procedures, the laws regarding the use of certain medications or devices, and whether your state has a sales tax on cosmetic procedures. Fortunately, most dermatologic cosmetic procedures are low risk and have a low frequency of malpractice claims and so they’re not going to impact your malpractice premiums.
Training and skill level are important, but just because you didn’t learn a procedure in residency doesn’t mean that you can’t do it. “A lot of the companies that make cosmetic-related products are more than willing to pay for physicians to train with their products or devices,” says Dr. Sawyer. “There are opportunities out there; you just have to know who to ask in your area, and it varies.”
It’s important to develop the necessary skills to perform any new procedure you are going to add to your practice. Other physicians who have been performing the procedure can help train you to develop the skills needed to perform those procedures, says Dr. Sawyer. You may find other dermatologists who are experts in the area you want to expand into through attending conferences, or a company may provide you help in getting trained.
“Sometimes it comes in the form of an honorarium to go spend a day with a specific doctor, but in the long run if this is something that you want to pursue, it’s worth the investment.”
A Good Place to Start
Botulinum toxin type A (Botox Cosmetic) injections are the most commonly performed cosmetic procedure in the United States, with 3.8 million injections in 2005. Botox procedures are fast, especially with a repeat Botox patient, with most taking only about 10 minutes. They are very safe and have been used for medical purposes in neurology and ophthalmology for more than 50 years.
“The only long-term side effect that we know of with Botox is some atrophy of the facial muscles, which isn’t a bad thing because then it makes it much harder for them to make the motion that’s causing that wrinkle,” says Dr. Sawyer. In terms of risk counseling, “I counsel patients about eyelid droop, headache and bruising.”
On average, Botox lasts about 3 months. Dr. Sawyer recommends scheduling the patient’s next visit for 3 months out before they leave the office.
Botox costs about $485 for a 100 unit bottle. Each cosmetic area treated typically needs between 20 to 80 units. Since each patient needs a different amount of Botox, the best approach is to charge per unit and explain that to the patients up front. How much you actually charge depends largely on the location of your practice, but typical charges range between $12 and $20 per unit.
When purchasing Botox, buy only genuine Botox from a reliable supplier. Leave your Botox in the freezer until you are ready to use it. When reconstituting Botox for cosmetic purposes, Dr. Sawyer uses 1 cc of preserved saline per unit. Botox that is diluted this way will last about a month with proper storage. Do not refreeze reconstituted Botox.
When To Add Lasers
Laser treatments are commonly requested by patients in a cosmetic dermatology practice. Though it may not be the first step in adding cosmetic procedures to a general dermatology practice, most likely you will eventually want to use them. However, the cost is a real issue, and you need to make sure that you’re getting the right device for your practice and your patient population.
“When deciding on a laser, you need to find devices that you can use for a variety of different treatments. Also, you don’t want to duplicate what another dermatologist has down the street — do something different,” cautions Dr. Sawyer. “A vascular laser, such as a 585 nm pulsed dye laser or an Nd:YAG laser would be a good first choice for a cosmetic dermatologist.”
These lasers can be used to treat rosacea, erythematous scars and striae, telangiectasia and angiomas. Vascular lasers can also be used for photorejuvenation and to treat warts.
“I treat a number of conditions with my pulsed dye laser and, with the advent of photodynamic therapy, a vascular laser is a great buy,” says Dr. Sawyer.
“I’ve been treating lots of acne patients who have been through the medical regimen, and I’ve had some really fabulous results using my vascular laser with 20% 5-aminolevulinic acid (Levulan Kerastick). Overall, vascular lasers have more medical dermatology applications than some of the other devices.”
A hair removal laser can be a good option if you already have a many cosmetic skin care patients. There are now variable pulsed 1064 nm lasers that can effectively remove hair on dark-skinned patients.
“Laser hair removal is a very popular procedure, but to a large degree it has become a commodity, and physician-delivered treatments are always going to be the most expensive treatments on the block,” cautions Dr. Sawyer. “People come to me for hair removal only because they’re the type of patient who wants a doctor to do the procedure, versus a non-physician whose prices may be less expensive.”
You have to crunch the numbers as to whether it is most cost-effective for you to buy, lease or rent a device. Generally the more patients you treat with a device, the more likely it is that you should buy one. If you rent, you need to schedule your patients on the day that you will have the device, and you may consider having those patients pre-pay so that they actually show up for the treatment.
“When considering the cost of a laser, you need to look into the cost of service contracts after your warranty expires,” warns Dr. Sawyer. “You also need to consider the cost of a service contract after the warranty expires and also the cost of consumables such as cryogen or dye kits for a pulsed dye laser.”
Bread-and-Butter Procedures To Add
According to Dr. Sawyer, microdermabrasion is the third most common non-surgical procedure, with more than 835,000 performed in 2005. What makes this procedure attractive to a practice is that in most states an aesthetician can do the microdermabrasion, freeing doctors to see other patients. The machines cost between $2,000 and $17,000. The average price in 2005 for a microdermabrasion treatment was $177, according to the American Society of Plastic Surgeons. Just make sure your patients know the difference between dermabrasion and microdermabrasion.
When choosing a microdermabrasion machine, Dr. Sawyer recommends that you look for a device that uses a closedloop system that keeps the clean and dirty crystals separate. Also, find out how reliable your machine is, and make sure of the level of support you will get with your system. For example, make sure that you’ll get a new device in a day or two if there is a problem; otherwise you’ll be rescheduling patients.
Chemical peels are also a great place to start when first offering cosmetic procedures. Superficial peels are effective for photodamage, melasma and acne. You can start with one of the many pre-packaged peel kits.
“The companies that make peel kits are more than happy to come to your office and explain why their peel is better than anyone else’s,” says Dr. Sawyer. “Once you are comfortable and you figure out the mixes you want to use, you can buy the acid separately, and it is considerably less expensive than the kits.”
Once you feel comfortable doing superficial peels, try some medium-depth chemical peels for actinic keratoses. With medium-depth peels, nerve blocks may be necessary, although Dr. Sawyer does not do them for this procedure. “The way I do a medium-depth peel is to treat one cosmetic unit at a time, and I find that even though it’s painful, patients like it a lot better than getting multiple nerve block injections,” she explains. “I give them the choice and they always say, ‘No, let’s just do it.’”
A wide range of fillers are available, with a large variation in the duration of the effect. The most common fillers are collagen and hyaluronic acid. According to Dr. Sawyer, one of the big mistakes that physicians make is not realizing the difference between all the available fillers and trying to use the same filler in all applications.
“They’re not all created equal, and it’s probably going to be impossible for you to pick one. You’re going to have to have two or three in your office once you start treating many patients,” she says. “They all have positives and negatives about them. It’s very important to know what facial area requires what filler.”
Dr. Sawyer cautions that fillers have a steep learning curve, and it can take years for a physician to become truly comfortable with the various types of fillers. “When I first learned how to use fillers, it was easy to want to use just one or two fillers because I felt comfortable with them; but it’s important to recognize the true benefits and limitations of all the different fillers.” Dr. Sawyer recommends having sales representatives bring in samples of a new filler for training.
Dispensing Products: Your Patients Will Like it
If you’re going to have a cosmetic practice, then you probably should be willing to dispense at least a few of your most recommended products. Many physicians are reluctant to dispense products because they don’t want to be “pushing products.” However, patients are happy to buy products from you rather than facing the confusing decision of too many products to evaluate.
“We started dispensing to be convenient for the patients,” says Dr. Sawyer. “We’re not making a fortune, but our patients are certainly happy that they can buy what they need from us.”
Dr. Sawyer suggests tracking your most recommended products, then settling on products from two or three different companies. “Buy five products from one line and two products from another, and dispense your favorite bleaching cream, whether that’s a
compound or commercially available product,” she says. “That way, it doesn’t look like you’ve been bought out by one company. It’s also a great idea to dispense your favorite sunscreens or sunscreen-containing make-up.”
Setting Fees and Marketing
When setting fees, Dr. Sawyer recommends that you set fees based on a per unit charge when applicable, and have a price list so that patients don’t feel as if you’re pulling a fee out of the air. For hair removal, have a set zone size and charge per zone. For Botox, charge by the unit. Fillers can be charged by the syringe. For sclerotherapy, Dr. Sawyer currently charges by time.
“I charge $100 for 10 minutes of sclerotherapy. If a patient has many leg veins and it takes me 30 minutes, it’s going to cost $300. If they have one little area that’s only going to take me 10 minutes, it’s $100,” she says. She also charges by size for tattoo removal.
When marketing your cosmetic practice, keep advertising clear and simple. Highlight one or two services, and provide a price for those services. Beyond advertising, you can conduct seminars, attend local conferences and do local radio and television interviews, either for general or cosmetic dermatology. Even if you’re doing a seminar on general dermatology, you can mention your cosmetic
procedures.
“It is important to track your advertising, which you can do by asking new patients how they heard about your practice,” she explains. “You need to know if that Yellow Pages ad that you spent hard-earned money on is really why these patients are coming in.”
Take Your First Steps
Dermatology is at the forefront of a huge wave of interest in non-invasive procedures to help improve patients’ appearances. As a dermatologist, you are well positioned to ride this wave because you are trained in skin surgery and you understand photoaging, ultraviolet light, sunscreens, retinoids and laser physics. But to truly take advantage of the growing interest in cosmetic procedures, a dermatologist has to be more than a good physician. You must be a good guide for your cosmetic patients, you must provide the right services and products and you must do all that you can to ensure that your cosmetic patients walk away happy.
“It is important to keep one thing in mind when thinking about adding cosmetic procedures,” says Dr. Sawyer. “That is, cosmetic patients are not sick, they’re shopping. Their total experience with your practice must be a completely positive experience, or you simply won’t be able to successfully build your cosmetic practice.”
Dr. Sawyer is Assistant Professor of Dermatology at the University of Alabama School of Medicine in Birmingham, AL. She has particular interest and expertise in laser surgery, varicose vein treatment, skin cancer therapy, and cosmetic procedures including tumescent liposuction, soft tissue fillers, chemical peels and care of photoaged skin.
The Do’s and Don’ts of a Cosmetic Consult
• Schedule adequate time and keep the message clear. Patients remember only a
fraction of what you tell them.
• Make patients feel safe and not pressured and that they are making a good choice.
• Differentiate your practice without criticizing other treatments or other physicians.
• Make referrals to other doctors when necessary.
• Express your opinions with tact and concern. Do not over-criticize patients’ features.
• Provide treatment options with buzz words, then in the same order discuss each
treatment in depth.
• Give an example of a recent good outcome (including yourself or a family member).
• Use many before and after photographs.
• Do not talk too quickly or in monologue form.
• Do not bombard patients with risk information too soon.
• Set up realistic expectations. Do not use words such as “eliminate” or “remove”.
Say “helps to soften” or “can help to remove” instead.
• Inform patients if multiple treatments may be needed.
We live in an age when a youthful appearance has become extremely desirable and in the eyes of many, almost necessary. As a result, the number of cosmetic procedures is skyrocketing, rising 38% from 2000 to 2005. Now, more than 10 million cosmetic procedures are performed in the United States every year and the numbers continue to climb, according to 2006 American Society of Plastic Surgery statistics. It is not then surprising that many dermatologists have moved into or are considering starting their own cosmetic dermatology practice.
However, according to Sarah Boyce Sawyer, M.D., Assistant Professor of Dermatology at the University of Alabama at Birmingham, adding cosmetic procedures to your general dermatology practice is not as simple as buying a few microdermabrasion kits and doing some advertising.
“There are hard factors to consider, such as the monetary investment into equipment and staffing; starting a cosmetic practice can be expensive,” says Dr. Sawyer. “There are also other more elusive considerations, such as your ability to deal with cosmetic patients, your skill set, and whether or not your location can support the investment.”
Evaluating Yourself and Your Practice
The first step in adding cosmetics to your practice is to realistically evaluate your practice to try to figure out how much of your practice will be cosmetic and how much will remain general dermatology. You also have to look at how you’d like your medical and surgical breakdown to be. Evaluated matters such as your own physical dexterity. In addition, learn how to set an expectation and how to counsel.
“I do the counseling and procedure myself so the patient doesn’t feel like I came in and then ran out of the room and let my nurse do the procedure,” says Dr. Sawyer. “Interacting with cosmetic and general dermatology patients simultaneously can be trying, so I recommend setting aside cosmetic clinic time separate from general dermatology time.”
Financial considerations are, of course, extremely important. With lasers costing $85,000 to $100,000 you have to be certain you can recoup your investment. Lasers or the other expensive devices may not be the place to start. Dr. Sawyer recommends beginning with something lower in overhead expense, such as superficial chemical peels, microdermabrasion or Botox.
Before you invest money for a new cosmetic procedure or staffing, you must familiarize yourself with state laws. Be aware of the laws pertaining to which staff members are qualified to perform procedures, the laws regarding the use of certain medications or devices, and whether your state has a sales tax on cosmetic procedures. Fortunately, most dermatologic cosmetic procedures are low risk and have a low frequency of malpractice claims and so they’re not going to impact your malpractice premiums.
Training and skill level are important, but just because you didn’t learn a procedure in residency doesn’t mean that you can’t do it. “A lot of the companies that make cosmetic-related products are more than willing to pay for physicians to train with their products or devices,” says Dr. Sawyer. “There are opportunities out there; you just have to know who to ask in your area, and it varies.”
It’s important to develop the necessary skills to perform any new procedure you are going to add to your practice. Other physicians who have been performing the procedure can help train you to develop the skills needed to perform those procedures, says Dr. Sawyer. You may find other dermatologists who are experts in the area you want to expand into through attending conferences, or a company may provide you help in getting trained.
“Sometimes it comes in the form of an honorarium to go spend a day with a specific doctor, but in the long run if this is something that you want to pursue, it’s worth the investment.”
A Good Place to Start
Botulinum toxin type A (Botox Cosmetic) injections are the most commonly performed cosmetic procedure in the United States, with 3.8 million injections in 2005. Botox procedures are fast, especially with a repeat Botox patient, with most taking only about 10 minutes. They are very safe and have been used for medical purposes in neurology and ophthalmology for more than 50 years.
“The only long-term side effect that we know of with Botox is some atrophy of the facial muscles, which isn’t a bad thing because then it makes it much harder for them to make the motion that’s causing that wrinkle,” says Dr. Sawyer. In terms of risk counseling, “I counsel patients about eyelid droop, headache and bruising.”
On average, Botox lasts about 3 months. Dr. Sawyer recommends scheduling the patient’s next visit for 3 months out before they leave the office.
Botox costs about $485 for a 100 unit bottle. Each cosmetic area treated typically needs between 20 to 80 units. Since each patient needs a different amount of Botox, the best approach is to charge per unit and explain that to the patients up front. How much you actually charge depends largely on the location of your practice, but typical charges range between $12 and $20 per unit.
When purchasing Botox, buy only genuine Botox from a reliable supplier. Leave your Botox in the freezer until you are ready to use it. When reconstituting Botox for cosmetic purposes, Dr. Sawyer uses 1 cc of preserved saline per unit. Botox that is diluted this way will last about a month with proper storage. Do not refreeze reconstituted Botox.
When To Add Lasers
Laser treatments are commonly requested by patients in a cosmetic dermatology practice. Though it may not be the first step in adding cosmetic procedures to a general dermatology practice, most likely you will eventually want to use them. However, the cost is a real issue, and you need to make sure that you’re getting the right device for your practice and your patient population.
“When deciding on a laser, you need to find devices that you can use for a variety of different treatments. Also, you don’t want to duplicate what another dermatologist has down the street — do something different,” cautions Dr. Sawyer. “A vascular laser, such as a 585 nm pulsed dye laser or an Nd:YAG laser would be a good first choice for a cosmetic dermatologist.”
These lasers can be used to treat rosacea, erythematous scars and striae, telangiectasia and angiomas. Vascular lasers can also be used for photorejuvenation and to treat warts.
“I treat a number of conditions with my pulsed dye laser and, with the advent of photodynamic therapy, a vascular laser is a great buy,” says Dr. Sawyer.
“I’ve been treating lots of acne patients who have been through the medical regimen, and I’ve had some really fabulous results using my vascular laser with 20% 5-aminolevulinic acid (Levulan Kerastick). Overall, vascular lasers have more medical dermatology applications than some of the other devices.”
A hair removal laser can be a good option if you already have a many cosmetic skin care patients. There are now variable pulsed 1064 nm lasers that can effectively remove hair on dark-skinned patients.
“Laser hair removal is a very popular procedure, but to a large degree it has become a commodity, and physician-delivered treatments are always going to be the most expensive treatments on the block,” cautions Dr. Sawyer. “People come to me for hair removal only because they’re the type of patient who wants a doctor to do the procedure, versus a non-physician whose prices may be less expensive.”
You have to crunch the numbers as to whether it is most cost-effective for you to buy, lease or rent a device. Generally the more patients you treat with a device, the more likely it is that you should buy one. If you rent, you need to schedule your patients on the day that you will have the device, and you may consider having those patients pre-pay so that they actually show up for the treatment.
“When considering the cost of a laser, you need to look into the cost of service contracts after your warranty expires,” warns Dr. Sawyer. “You also need to consider the cost of a service contract after the warranty expires and also the cost of consumables such as cryogen or dye kits for a pulsed dye laser.”
Bread-and-Butter Procedures To Add
According to Dr. Sawyer, microdermabrasion is the third most common non-surgical procedure, with more than 835,000 performed in 2005. What makes this procedure attractive to a practice is that in most states an aesthetician can do the microdermabrasion, freeing doctors to see other patients. The machines cost between $2,000 and $17,000. The average price in 2005 for a microdermabrasion treatment was $177, according to the American Society of Plastic Surgeons. Just make sure your patients know the difference between dermabrasion and microdermabrasion.
When choosing a microdermabrasion machine, Dr. Sawyer recommends that you look for a device that uses a closedloop system that keeps the clean and dirty crystals separate. Also, find out how reliable your machine is, and make sure of the level of support you will get with your system. For example, make sure that you’ll get a new device in a day or two if there is a problem; otherwise you’ll be rescheduling patients.
Chemical peels are also a great place to start when first offering cosmetic procedures. Superficial peels are effective for photodamage, melasma and acne. You can start with one of the many pre-packaged peel kits.
“The companies that make peel kits are more than happy to come to your office and explain why their peel is better than anyone else’s,” says Dr. Sawyer. “Once you are comfortable and you figure out the mixes you want to use, you can buy the acid separately, and it is considerably less expensive than the kits.”
Once you feel comfortable doing superficial peels, try some medium-depth chemical peels for actinic keratoses. With medium-depth peels, nerve blocks may be necessary, although Dr. Sawyer does not do them for this procedure. “The way I do a medium-depth peel is to treat one cosmetic unit at a time, and I find that even though it’s painful, patients like it a lot better than getting multiple nerve block injections,” she explains. “I give them the choice and they always say, ‘No, let’s just do it.’”
A wide range of fillers are available, with a large variation in the duration of the effect. The most common fillers are collagen and hyaluronic acid. According to Dr. Sawyer, one of the big mistakes that physicians make is not realizing the difference between all the available fillers and trying to use the same filler in all applications.
“They’re not all created equal, and it’s probably going to be impossible for you to pick one. You’re going to have to have two or three in your office once you start treating many patients,” she says. “They all have positives and negatives about them. It’s very important to know what facial area requires what filler.”
Dr. Sawyer cautions that fillers have a steep learning curve, and it can take years for a physician to become truly comfortable with the various types of fillers. “When I first learned how to use fillers, it was easy to want to use just one or two fillers because I felt comfortable with them; but it’s important to recognize the true benefits and limitations of all the different fillers.” Dr. Sawyer recommends having sales representatives bring in samples of a new filler for training.
Dispensing Products: Your Patients Will Like it
If you’re going to have a cosmetic practice, then you probably should be willing to dispense at least a few of your most recommended products. Many physicians are reluctant to dispense products because they don’t want to be “pushing products.” However, patients are happy to buy products from you rather than facing the confusing decision of too many products to evaluate.
“We started dispensing to be convenient for the patients,” says Dr. Sawyer. “We’re not making a fortune, but our patients are certainly happy that they can buy what they need from us.”
Dr. Sawyer suggests tracking your most recommended products, then settling on products from two or three different companies. “Buy five products from one line and two products from another, and dispense your favorite bleaching cream, whether that’s a
compound or commercially available product,” she says. “That way, it doesn’t look like you’ve been bought out by one company. It’s also a great idea to dispense your favorite sunscreens or sunscreen-containing make-up.”
Setting Fees and Marketing
When setting fees, Dr. Sawyer recommends that you set fees based on a per unit charge when applicable, and have a price list so that patients don’t feel as if you’re pulling a fee out of the air. For hair removal, have a set zone size and charge per zone. For Botox, charge by the unit. Fillers can be charged by the syringe. For sclerotherapy, Dr. Sawyer currently charges by time.
“I charge $100 for 10 minutes of sclerotherapy. If a patient has many leg veins and it takes me 30 minutes, it’s going to cost $300. If they have one little area that’s only going to take me 10 minutes, it’s $100,” she says. She also charges by size for tattoo removal.
When marketing your cosmetic practice, keep advertising clear and simple. Highlight one or two services, and provide a price for those services. Beyond advertising, you can conduct seminars, attend local conferences and do local radio and television interviews, either for general or cosmetic dermatology. Even if you’re doing a seminar on general dermatology, you can mention your cosmetic
procedures.
“It is important to track your advertising, which you can do by asking new patients how they heard about your practice,” she explains. “You need to know if that Yellow Pages ad that you spent hard-earned money on is really why these patients are coming in.”
Take Your First Steps
Dermatology is at the forefront of a huge wave of interest in non-invasive procedures to help improve patients’ appearances. As a dermatologist, you are well positioned to ride this wave because you are trained in skin surgery and you understand photoaging, ultraviolet light, sunscreens, retinoids and laser physics. But to truly take advantage of the growing interest in cosmetic procedures, a dermatologist has to be more than a good physician. You must be a good guide for your cosmetic patients, you must provide the right services and products and you must do all that you can to ensure that your cosmetic patients walk away happy.
“It is important to keep one thing in mind when thinking about adding cosmetic procedures,” says Dr. Sawyer. “That is, cosmetic patients are not sick, they’re shopping. Their total experience with your practice must be a completely positive experience, or you simply won’t be able to successfully build your cosmetic practice.”
Dr. Sawyer is Assistant Professor of Dermatology at the University of Alabama School of Medicine in Birmingham, AL. She has particular interest and expertise in laser surgery, varicose vein treatment, skin cancer therapy, and cosmetic procedures including tumescent liposuction, soft tissue fillers, chemical peels and care of photoaged skin.
The Do’s and Don’ts of a Cosmetic Consult
• Schedule adequate time and keep the message clear. Patients remember only a
fraction of what you tell them.
• Make patients feel safe and not pressured and that they are making a good choice.
• Differentiate your practice without criticizing other treatments or other physicians.
• Make referrals to other doctors when necessary.
• Express your opinions with tact and concern. Do not over-criticize patients’ features.
• Provide treatment options with buzz words, then in the same order discuss each
treatment in depth.
• Give an example of a recent good outcome (including yourself or a family member).
• Use many before and after photographs.
• Do not talk too quickly or in monologue form.
• Do not bombard patients with risk information too soon.
• Set up realistic expectations. Do not use words such as “eliminate” or “remove”.
Say “helps to soften” or “can help to remove” instead.
• Inform patients if multiple treatments may be needed.
