Minimally invasive procedures climb; what effect on surgery?

Minimally invasive procedures climb; what effect on surgery?

Karen Nash

Minimally invasive cosmetic procedures increased in popularity by more than 40 percent last year. Three million more people underwent such procedures in 2003 than did in 2002, according to the American Society of Plastic Surgeons (ASPS).

The top five procedures performed were Botox injections, chemical peels, microdermabrasion, laser hair removal and collagen. Thermage[R] is another latest trend (See chart on pg. 12 for more specific data.)

Why enter?

Most cosmetic surgeons entered their fields because they like to do surgery; On Track asked cosmetic surgeons around the country how they feel about this proliferation of non-surgical treatments. We asked if doctors have incorporated minimally invasive procedures into their practices and how they use them–as marketing tools, adjunct therapies or to provide patients with nonsurgical alternatives.

The surgeons who spoke to On Track offer many of the popular procedures in their practices, but they don’t all actually perform the procedures themselves. And they still prefer to do surgery.

Gary D. Hall, M.D., in Kansas City, Kansas, says in his office, those duties are split.

“My aesthetician does microdermabrasion; I do the Restylane and Botox. She does laser hair removal; I do laser resurfacing,” he says.

“I don’t really even talk to patients about microdermabrasion or laser hair removal. If they are interested in those types of things, I may mention it briefly, then I bring in my aesthetician and let her finish up and I move on to other things. I actually spend most of my time doing surgery.”

Then why offer those procedures?

“Patients want it. (Non-invasive procedures) really are very effective and good–and I’d rather be doing them than having people who aren’t qualified offering them.”

Dr. Hall has a practice that is close to 75 percent cosmetic and he has a special interest in body contouring. He says he does not market the noninvasive procedures they perform.

“It’s just something that we offer patients. Some people will call and ask about them, and we will tell them that we have them. And some patients come in, and we tell them that these non-invasive therapies are probably more in line with what they need rather than the surgical procedure for which they may not be psychologically or physiologically ready. These things get results and can get patients by for another year or two.”

Thomas A. Hagerty, M.D., director of surgery at Benedictine Hospital in Kingston, N.Y., says, “Microdermabrasion? We have an aesthetician who does that. She is interested in that. I am more interested in the surgical procedures, just because that is more the bread and butter of what I do.”

Handing off

Increasingly, microdermabrasion is a procedure that surgeons are handing off to their ancillary personnel.

In Winter Park, Fla., Jeffrey M. Hartog, M.D., has a medical aesthetician to perform microdermabrasion. He is more involved in some of the other treatments. “I have a nurse practitioner who does some of the Botox, but I do a lot of it. I think procedures that are ‘stand alone’–like laser hair removal–are appealing in their own right. We have two locations and about five or six aestheticians and two nurse practitioners, so it is a significant business on its own. But I also think they compliment what I do.”

Dr. Hartog says that managing people’s expectations of what they will get out of these adjunct procedures is key to using them successfully.

“If a person is coming in for a facelift and is really not ready for it, then don’t tell them they’re going to get a lift. Just make sure they are clear about what they can and can’t get for the procedures we do. Be honest with the patient, and if you manage their expectations, they’re happy.”

Media help

Pamela S. Henderson, M.D., in Scottsdale, Ariz., says sometimes the media attention brings people in for Botox, but that is not what they really need.

“(The media) can be used to draw people in, but I don’t pretend a procedure will do something that it won’t. I had a patient come in recently who wanted her brows lifted with Botox. I said we can do that to some degree, but when she showed me in the mirror what she wanted to look like, it was quite unrealistic.

“So I talked her out of it. I told her Botox is a great procedure, but you’re going to be disappointed if this is your expectation. I suggested that if that was the result she wanted, that she save up for surgery, and then come back. She appreciated the honesty and that I wasn’t trying to talk her into something that wouldn’t give her what she wanted.

Ronald E. Iverson, M.D., Pleasanton, Calif., has practiced for 31 years and says he was slow to jump into some of these ancillary services, but he has found they play a significant role in patient care.

“I have to admit I was not the first one to do all this years ago when it all got started. But the nurse who works with me is very active in skincare and she thought it would be worthwhile–and it’s turned out well. It doesn’t take too much of my time and some people who do come in purely for basic skincare and see the nurse for skincare may end up getting referred back for their blepharoplasty or that facelift a few years down the road–so, although I don’t do any real external marketing, I can see where it would definitely work.”

Faithful patients

Even without the marketing, Dr. Iverson says that by offering these services, the practice base is solidified.

“Ten or 15 years ago, a doctor would do a facelift and then after the six-month or one-year follow-up–say goodbye. Then many times you would never see that patient again.

Many times when the patient got ready to have something else done, they would talk with their friend or neighbor and rather than coming back to you–even though they had a wonderful result, potentially they would go somewhere else.

“One of the things these services do is keep the patient involved with you. Your name is there, they see you, and if you have a staff who takes good care of them when they come in, you are the first one they will think of for their next surgery.”

Dr. Hagerty says that if done right, the treatments are good to offer.

“I haven’t found them to be a big money-maker in my practice, but I do the ones that I like and the ones I agree with in principle.

“I was slow to get on board with Botox, but people want it. Now I think it’s safe if it’s done right–and I do it according to (Food and Drug Administration) recommendations for its cosmetic use.”

A solo practitioner for nine years, Dr. Hagerty says the action of Botox benefits patients in a number of ways.

“It’s a non-surgical process that gives a surgical effect. It gives patients a sense of what might happen if they went ahead and had surgery–so it’s sort of a presurgical treatment.

“On a periodic basis, if a patient has a special event coming up, sometimes a bit of Botox, in combination with other things, as an adjunct to microdermabrasion or laser resurfacing, can provide a nice result.”

Not settling

Dr. Hagerty does not think people settle for these minimally invasive procedures rather than going ahead with surgery.

“They’re different procedures and they give different results. Resurfacing does one thing; a facelift does something else. These are adjunctive therapies.”

The Thermage[R] procedure is one of the latest in the minimally invasive arsenal. Surgeons who spoke to On Track said the full benefits of the treatments have yet to be documented.

Dr. Hagerty and Dr. Hall say they prefer to wait until more data is collected on treatment results. Dr. Henderson, a facial plastic surgeon for 10 years, uses the Thermage[R] procedure and thinks a better understanding of the procedure and what it can do might help more to be gained from the procedure.

“When Thermage[R] first came out, I don’t think we really had a clear understanding of who to use it on and who not to. I find that patients who are in the pre-surgical-40s age range are really better candidates for it. I will try to talk patients out of doing it when I feel they really need a surgical procedure and they’re not going to get the results they want.”

Dr. Henderson has had varying results with the treatments.

“I had a patient who has a really low pain tolerance and in her situation, we used a really low setting. I thought, ‘Gee, I’m doing this and we’re not going to get anything. This is nowhere within the parameters of what the manufacturers recommend.’ And she had my best results.”

Some surgeons opt for alternatives to Thermage[R], including intense pulse light photofacial machines and lasers.

Dr. Iverson says he uses the Gentle Waves[R] LED Photomodulation Process. Then he does microdermabrasion, a micro peel and a number of lesser peels before getting to the level of C[O.sub.2] resurfacing.

“If these things don’t generate much income for the practice, they do keep patients coming back to the office because they get involved in the process” he says.

National statistics on minimally invasive procedure trends (2000-2003)


Botox injection ** 786,911 855,846 1,123,510

Cellulite treatment 23,952 * 61,971 54,464

Chemical peel 1,149,457 1,338,419 920,340

Laser hair removal 735,996 * 687,721 587,540

Laser skin resurfacing 170,951 175,927 194,808

Laser treatment of leg veins 245,424 * 157,191 107,155

Microdermabrasion 868,315 * 1,035,769 900,912

Sclerotherapy 866,555 * 616,879 511,827

Soft Tissue Fillers

Calcium hydroxylapatite


Collagen 587,615 796,526 441,718

Fat 65,270 72,632 54,823

Hyaluronic acid (Hylaform,



INVASIVE PROCEDURES 5,500,446 * 5,798,881 4,897,097


COSMETIC PROCEDURES 2003 2000 vs.2003

Botox injection ** 2,891,390 267%

Cellulite treatment 44,579 *

Chemical peel 995,238 -13%

Laser hair removal 623,297 *

Laser skin resurfacing 180,855 6%

Laser treatment of leg veins 113,852 *

Microdermabrasion 935,984 *

Sclerotherapy 482,575 *

Soft Tissue Fillers

Calcium hydroxylapatite

(Radiance) 61,951 N/A

Collagen 576,255 -2%

Fat 61,852 -5%

Hyaluronic acid (Hylaform,

Restylane) 44,925 N/A




COSMETIC PROCEDURES 2001 vs. 2003 2002 vs. 2003

Botox injection ** 238% 157%

Cellulite treatment -28% -18%

Chemical peel -26% 8%

Laser hair removal -9% 6%

Laser skin resurfacing 3% -7%

Laser treatment of leg veins -28% 6%

Microdermabrasion -10% 4%

Sclerotherapy -22% -6%

Soft Tissue Fillers

Calcium hydroxylapatite

(Radiance) N/A N/A

Collagen -28% 30%

Fat -15% 13%

Hyaluronic acid (Hylaform,

Restylane) N/A N/A



* ASPS members were not asked to report this procedural data in 2000.

** The number reported for 2003 Botox injections is the number of

anatomic sites injected.

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