Cosmetic Surgery at the Mall?

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On Oct. 31, a middle-aged woman was getting Restylane injections to plump up the lines around her lips. It’s a fairly routine procedure these days—according to the most recent statistics from American Society for Aesthetic Plastic Surgery, such injections were given more than a million times in 2005. But what happened in this case was anything but routine.

“The patient, who had no previous history of seizures, began having a grand mal seizure in the middle of the procedure,” says Dr. Sue Ellen Cox, a Chapel Hill, N.C., dermatologist. While Cox is quick to point out that the seizure was completely unrelated to and not caused by the Restalyne injections, the patient was lucky to be in a medical office when it occurred. “If she had been having a treatment in a non-medical facility, it could have been a disaster,” says Cox. Instead, Cox and her staff were equipped with the knowledge and tools to avert disaster: They got an IV in and gave her valium to break the seizure while waiting for paramedics to arrive.

But more often, cosmetic procedures—Botox injections, wrinkle fillers, laser treatments and the like—are being done far from the doctor’s office. And worse yet, far from any doctor. The growing popularity of these non-surgical facial rejuvenation techniques has fueled the growth of an entire new industry known as the “medi-spa.” The term has become sort of an umbrella name that encompasses anything from an area within a dermatologist’s or plastic surgeon’s office where they offer cosmetic procedures to a storefront at the mall where you can get a shot of Botox along with a manicure or haircut. And it’s those in the latter category that are putting patients at great risk.

Take the experience of Paula, a 44-year-old in Raleigh, N.C. She was a regular at a local high-end spa, where she got her hair and nails done and even indulged in the occasional micro-dermabrassion treatment to smooth out her complexion. So when she wanted to get rid of a few freckles and brown spots caused by sun damage, she signed on for what the spa billed as a “photo-facial.” “I thought I had done my homework,” she recalls. “I checked to make sure the aesthetician was licensed and I even asked around town to see if others recommended her.”

Unfortunately, that was not enough to save her from disaster. The aesthetician’s extremely powerful laser was set way too high for Paula’s skin. Paula insisted on stopping the treatment because it was just too painful to bear, and she left the office with open, oozing blisters. “I took one look at my face in my car mirror and drove straight to the emergency room,” she says. ER staffers treated and wrapped the burns, but that was just the beginning of a long and painful recovery. “If the slightest breeze touched my face, it was excruciating, and my skin bled for over a week.”

Once the burns healed, she was left with several deep scars as well as noticeable white spots where the burns permanently destroyed her skin’s pigment. She has spent more than $10,000 treating the burns, and had Restylane injections to fill in some of the worst scars—none of which was covered by her health insurance. Even her initial trip to the emergency room wasn’t covered—the insurance company considered all of her follow-up treatment to be part of a voluntary cosmetic procedure rather than a medical condition.

“I realize now,” Paula says, “that it should have been a physician doing this treatment, not an amateur.”

Most dermatologists and plastic surgeons couldn’t agree more. “Many of these cosmetic treatments are safe and effective in the right hands—a board-certified dermatologist or plastic surgeon,” says Dr. Foad Nahai, a plastic surgeon in Atlanta and president-elect of ASAPS. “But a lot of these medi-spa facilities don’t have the level of supervision of a doctor’s office.”

According to a recent survey by the American Society for Dermatologic Surgery, 45 percent of dermatologic surgeons reported seeing an increase in the number of patients coming in for corrective treatments after a cosmetic procedure (performed by a non-physician) gone awry. Nahai stresses, however, that having an M.D. after your name doesn’t necessarily make a doctor an expert in cosmetic facial rejuvenation procedures. “You want to be under the care of a physician who is familiar with the skin and with facial anatomy; not just a family practice doctor who took a weekend course.”

Why are so many doctors—everyone from gynecologists to ophthalmologists—suddenly forsaking their primary practices and turning themselves into cosmetic specialists? “One word: Money,” says Dr. Kenneth R. Beer, a dermatologist in Palm Beach, Fla. Doctors who are getting killed financially by managed care and ever-rising malpractice insurance costs can at least double their incomes by setting themselves up in a medi-spa and training to perform cosmetic treatments. “But it’s not intuitive that the skills involved in delivering a baby transfer to taking care of the skin,” says Beer. “Dermatologists spend three years just learning about the skin. Taking a weekend course in cosmetic procedures is a good introduction, but it’s not enough to understand the nuances.”

Despite the tremendous growth of the cosmetic surgery business, there is shockingly little regulation at the moment. “Nothing can stop a doctor from operating outside of his specialty,” says Nahai. “Most people see this as a turf battle, with plastic surgeons and dermatologists trying to keep it all for themselves. But really it’s an issue of patient safety.”

It’s also an issue, cosmetic specialists feel, that calls for more patient education. Since there are no federal regulations mandating who can and cannot perform cosmetic procedures and no laws to guarantee truth in advertising, patients need to do some serious sleuthing in order to figure out who’s treating them. “Consumers are flooded with glossy ads for medi-spas and cosmetic treatments, but they have no idea if there’s even a licensed physician behind the ad,” says Beer.

Open any phone book and you’ll see numerous ads for “board-certified” doctors offering Botox, Restylane, laser treatments and other cosmetic procedures. The problem is, the vast majority don’t specify in which specialty they are board certified. According to Beer, nearly half the ads listed under “dermatology” in his local phone book are for non-dermatologists. California is currently the only state that mandates that if you advertise as “board certified,” you also have to disclose which board it is. But in the other 49 states, the ad could be that of a board certified gynecologist, anesthesiologist, urologist or any other medical specialty.

To get to the truth, consumers really have to do some homework. To investigate which board has certified a doctor, you can look them up on the Web site of the American Board of Medical Specialties. If the doctor you are seeing is not a board certified plastic surgeon or dermatologist, you should go in with a list of questions—such as, Did their medical training include facial rejuvenation? How long have they been doing the procedure in question? If there are complications, how are they prepared to handle them?

And if the services are being performed by someone who is not an M.D. at all—a physician assistant, nurse injector or just an aesthetician—you should ask even more questions. In these situations, the office or medi-spa is normally under the “supervision” of a physician. But that could mean the doctor is in the next room or on a golf course hours away. So not only do you want to find out about the background, training and experience of the person doing the treatment, but you also should know about the accessibility of the doctor in case of complications.

In an effort to help prospective patients navigate these murky waters, the American Academy of Cosmetic Surgery recently launched an educational campaign called Be Wise About Beauty. The site offers advice on finding a qualified surgeon, provides questions patients should ask their doctors, and gives detailed information about a variety of cosmetic procedures.

The bottom line is that you want to put your face in the best, most qualified and experienced hands possible. “People treat these procedures as more of spa treatment than a medical procedure,” says Nahai. “But even though injections and lasers aren’t really surgery, don’t treat them like a haircut, treat them like you’re going in for a face-lift.”

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