Minimally Invasive Aesthetic Procedures: Implications for Plastic Surgeons

Norra MacReady


June 30, 2008


The role of noninvasive procedures as part of a thriving practice will loom large over the next 5 years as plastic surgeons grapple with profitability issues and public perceptions of risk, according to a panel on practice trends presented at The Aesthetic Meeting 2008, the annual meeting of the American Society for Aesthetic Plastic Surgery (ASAPS).[1]


The Survey Says

Richard A. D'Amico, MD, Medical Director of the Plastic Surgery Skin Care Center in Englewood Cliffs, New Jersey, described 2 surveys[2] conducted in 2007 under the auspices of a Cosmetic Medicine Task Force formed as a joint venture between ASAPS and the American Society of Plastic Surgeons (ASPS). One survey examined consumers' attitudes and perceptions influencing their choice of plastic surgery procedures, and the other shed light on the variety of cosmetic services offered in plastic surgery practices.

Both societies are concerned about the growing number of "noncore providers" entering the field of cosmetic medicine, and they established the task force essentially to address this concern. A parallel and perhaps related trend is the growing popularity of minimally invasive or noninvasive procedures, including laser and light therapies, injectables, and dermal fillers. These now account for 80% of cosmetic procedures. According to ASAPS statistics,[3] in 2007, the administration of botulinum toxin was the top nonsurgical procedure, followed by injections of hyaluronic acid-based dermal fillers. Together, they accounted for more than double the top 5 surgical procedures combined. As the demand for less invasive procedures remains strong, ASAPS and ASPS are concerned that plastic surgeons may increasingly be pushed to the sidelines.

The consumer survey was launched because "we wanted to learn what the public was thinking," said Dr. D'Amico, president of ASPS and co-chair of the task force. The survey was conducted over the Internet from July 9 to July 16, 2007, and gathered responses from 1015 women who either had undergone a noninvasive cosmetic procedure or were considering undergoing one within the next 1 to 2 years. Most of the subjects were not strangers to cosmetic procedures: 201 had already undergone a noninvasive procedure administered by a plastic surgeon; 289 had undergone a similar procedure performed by a core provider who was not a plastic surgeon (dermatologic surgeons, dermatologists, and otolaryngologists); and 257 had had noninvasive procedures performed by a noncore provider (anyone who performs cosmetic procedures who is neither a plastic surgeon nor a non-plastic surgeon core provider). A total of 412 respondents had yet to undergo any cosmetic procedure at all (the numbers add up to more than 1015 because some women had undergone multiple procedures). For the purposes of the survey, the term "noninvasive" procedures encompassed minimally and moderately invasive procedures such as microdermabrasion, laser treatment of leg veins, chemical peels, and soft-tissue fillers, as well as genuinely noninvasive procedures like facials, cellulite wraps, and deep tissue massage.

In general, overall satisfaction with outcomes was highest among patients who underwent their procedures with plastic surgeons. The one exception was injectables, as shown in the Table .

One of the most interesting findings was the public's perception of the risk entailed in each type of procedure, said Dr. D'Amico. Most consumers viewed surgical procedures as high risk, but perceived "virtually no risk" associated with noninvasive or minimally invasive procedures. Injectables were deemed riskier than other noninvasive or minimally invasive procedures, but not as risky as invasive surgery. When it came to choosing a provider, perceived risk was inversely related to cost: the less risky a patient believed a procedure to be, the more her choice was governed by cost, and vice-versa. This is good news for plastic surgeons, because it means that injectable procedures, which consumers view as moderately risky, can be good revenue providers. Dr. D'Amico explained that currently, many plastic surgeons underestimate the revenue potential of these procedures.


The Surgeons Speak

The second survey consisted of telephone interviews with 260 members of ASAPS and ASPS. Virtually all of them offered some kind of less-invasive treatment along with surgery:

  • Botulinum toxin: 94%

  • Dermal fillers: 93%

  • Facial peels: 81%

  • Nonmedical skin care: 66%

Despite their popularity, these procedures still comprise a small part of most plastic surgeons' practices; the survey found that for 91% of surgeons, noninvasive treatments generated less than 25% of their revenue. However, 65% of the surgeons predicted that revenues in this area would continue to grow, with 50% expecting growth of 10% to 25% in the year ahead. Offering patients a continuum of care, providing state-of-the-art techniques, enhanced ability to compete in local markets, identification of potential future plastic surgery patients, and generation of additional revenue all were cited as reasons for offering nonsurgical procedures.

Plastic surgeons who chose not to offer certain noninvasive procedures most commonly cited lack of efficacy as a reason. That was especially the case for cellulite treatments: 77% of surgeons who did not offer these treatments said they didn't think they worked well enough. Forty-eight percent gave the same reason for not offering microdermabrasion, 38% for body wraps, and 37% for light therapies.


Other Trends

Also on the panel, plastic surgeon Roxanne Guy, MD, from Melbourne, Florida, said that noninvasive and minimally invasive procedures will become more effective as their popularity grows over the next 5 years. That's because patients still are not satisfied with the long-term results of these treatments and will continue to demand products and techniques with more persistent effects. In keeping with the quest for greater convenience and cost-effectiveness, she also predicted 2 related trends: a growing demand for over-the-counter products that can be used at home and a reduction in patients' willingness to wait for appointments.

Echoing the comments of the other panel members, Rod J. Rohrich, MD, Chairman of the Department of Plastic Surgery at the University of Texas Southwestern Medical Center, Dallas, Texas, cited the advent of longer-lasting facial fillers along with the increase in noninvasive techniques as important trends for the next 5 years. He also predicted that products such as fillers and implants will be customized for individual patients.

Renato Saltz, MD, co-chair with Dr. D'Amico of the Cosmetic Medicine Task Force, vice president of ASAPS, and a plastic surgeon in Salt Lake City, observed that many plastic surgery practices include medical spas as part of their continuum of care. However, the spas are not big generators of revenue. "The surgical practice is the profit center," he said. Dr. Guy noted that, after 3 years, her practice's medical spa is finally turning a profit, but "it takes constant care and feeding. It takes work."