“Doctor, I want to look good, but I am afraid of surgery. I don’t want the downtime, and I am scared of looking strange. By the way, I want to look good by this weekend. What can you do for me?”

How often have you heard something like that?

The enormous demand for nonsurgical procedures continues to outpace aesthetic surgical procedures. Get used to the idea: Your practice’s health may depend on offering nonsurgical procedures.

According to American Society for Aesthetic Plastic Surgery 2006 data,1 patients request these procedures at a growth rate of more than four times that of aesthetic surgical procedures. These popular treatments are featured in the news, magazines, and talk shows. They are common fodder for discussions at cocktail parties and on the sidelines of suburban soccer games.

Physicians with or without aesthetic training—as well as many nonphysicians—currently offer these procedures. Although controversial, this trend is likely to continue.

Physicians with expertise in aesthetic facial anatomy are uniquely qualified to perform office-based facial-rejuvenation procedures, including neurotoxins and fillers, which are two important treatments in this sector of facial rejuvenation.

These treatments can be especially important to your practice, as patients who are satisfied with the outcome are likely to speak well of your practice. In addition, they tend to be recurring patients who frequently become surgical patients.

Overall, these procedures can provide a very high value to your practice in terms of revenue and growth. Both the new and established cosmetic surgeon would be prudent to add and excel at them.

Your practice can only be as good as the treatments you recommend. If you recommend a treatment and it doesn’t work as described, then your patients will be unsatisfied … with you. They may hesitate to choose you for surgery or other procedures.

In aesthetic medicine, all that matters is patient satisfaction. You must achieve a high percentage of patient satisfaction—95% is a good target.

Keep the Customer Satisfied

It is a common marketing lore that one happy customer tells seven people but a single unhappy customer tells 11. I believe that this ratio is even more skewed in aesthetic medicine, as many happy patients are disinclined to share their experience. The reason for this: fear of appearing vain to others, or it could be an attempt to keep their youth-promoting secret to themselves.

One unhappy customer can damage your marketing and brand building faster than your happy customer can help you build it. This translates to around a 20-to-1 ratio of happy to unhappy patients.

Admittedly, this is not scientific and it may vary based on location and patient population, but it is a general guideline to consider when offering a treatment or procedure.

Too often, the latest and greatest in fillers, devices, and lasers come to market with a promise of being the next best thing. For example, we are promised “facelift results without surgery.” It is best to remain very skeptical of the latest devices—products come and go very quickly, and you don’t want to subject your patients to any product that is not proven.

Before you recommend or invest in a product, be certain you have evaluated Institutional Review Board peer-reviewed studies that have been duplicated. In addition, talk with trusted colleagues to determine whether or not the product has been used clinically in the United States or elsewhere.

If you choose products that have been proven safe, reliable, and effective both in research trials and in clinical settings, then you can expect good results, happy patients, and positive word of mouth.

Cosmetic surgeons should consider the added marketing value achieved by offering neurotoxins, fillers, and skin-rejuvenation procedures. When you operate, you have a finite limit to how many people you can please in a year. Only a certain percentage of these people will be vocal about you and your practice, helping to spread your name, because most are secretive about their surgery.

For example, if you perform 400 aesthetic surgeries per year, probably 10% to 20% of those patients will be vocal advocates. That adds up to 40 to 80 people. Consider how many neurotoxin and filler patients you can treat in a year, and consider their referrals. These procedures allow you a potential to perform 2,000 injectable treatments per year. If half of those are repeated on the same patient, then figure your practice treats 1,000 people per year with an office injectable. That’s 2.5 times the potential for positive marketing compared with surgery.

As the nonsurgical procedures are more accepted in our culture than surgery, a happy patient is more likely to talk about their experience and could become a vocal advocate for your practice. In addition, the satisfaction rate is very high for nonsurgical procedures. In a best-case scenario, you can expect at least 5% to 10% more people to spread goodwill concerning your practice.

In this example, perhaps 150 to 200 people per year will speak well of your practice. Though clearly the above formulas are assumptions, most certainly these numbers can be extrapolated to your practice.

For the Early Practice

Offering fillers and neurotoxins is a great way to introduce you to the community and to build trust with new patients. Patients may be skeptical of a new plastic surgeon in the community who is yet established as skilled and reliable. Initially, these skeptical patients may trust a new cosmetic surgeon with a neurotoxin or filler treatment as opposed to one who offers a facelift or blepharoplasty.

Furthermore, you can grow your surgical practice via injectables. It is a very logical and effective strategy. When patients are in your office for a neurotoxin or filler, they have an opportunity to get to know you, your staff, and your practice. In the earlier stages of your career, you will probably have more time to spend with them.

Over time, this patient will become comfortable with your treatments and may convert to becoming a surgical patient.2

The Established Practice

Your practice should not only offer but also excel in nonsurgical treatments. Initially, many established practices decided not to offer these procedures in lieu of their more robust surgical schedules. Your aesthetic patients are probably going to seek out a physician who offers these nonsurgical procedures, and it might as well be you and not your competitor. These patients bring a long-term value to your practice, and you should do all you can to hold onto them and keep them happy.

If you want or love to perform lengthy, aggressive facial aesthetic surgeries with requisite 6-to-8-week recovery periods, you probably should continue doing what you love.

However, over time, procedures and products become obsolete or surpassed by easier, less expensive, or less invasive methods that achieve the same results.

Consider, for instance, all of the aggressive surgical procedures, such as gastrectomies and cardiac surgeries, you learned about in medical school and residency that are on the decline because of improved medicines or techniques.

You might want to employ a nurse or physician assistant (PA) injector to perform nonsurgical procedures. If you do, develop and require a strong noncompete agreement with this person so that he or she cannot leave your practice and take your patients. It is natural for these patients to establish a strong relationship with your injector. Therefore, without this agreement, any termination or “divorce” in your relationship may result in patients leaving your practice.

In addition, compensation plans for the extended injectors can be challenging. Incentive plans and bonus plans based on a per-patient procedure may seem the most logical choice; however, too often such a system sets up disagreements among the provider, your staff, and even you. Extended injectors also may start to feel “ownership” in the patients they treat and leverage their commitment.

Other methods of compensation, including bonuses based on overall growth of the practice, can be fiscally responsible, fair, and acceptable to all. Specific expectations and limitations should be spelled out and understood between you and your staff prior to their employment. This includes the noncompete signature and compensation plans, which can be difficult situations to remedy after the fact.

Steven H. Dayan, MD, FACS, is clinical assistant professor at the University of Illinois. He can be reached at .


  1. American Society of Aesthetic Plastic Surgery, Cosmetic surgery national database statistics, 2006. Available at: www.surgery.org. Accessed October 18, 2007.
  2. Dayan S, Lertsburapa K, Patel A. Influence of botulinum toxin a injection in the practice management of facial plastic surgery. Arch Facial Plast Surg. 2007;9(3):211-212.