Overall dissatisfaction with one’s looks motivates a whole list of behaviors—losing weight, buying a wardrobe, trying a new hairstyle, piling on moisturizer, and, of course, even having plastic surgery. The desire to trade up on appearance is a natural consequence of living in an image-conscious culture. Youth and beauty are commodities, and ultimately, aesthetic surgery offers what this culture values most: aesthetic improvement and the preservation of youthfulness and vitality.

In many ways, aesthetic medicine has also become a commodity—a transformation influenced by several key factors, including extensive regulation of the health care industry and the development of managed care, which have served to strangle the revenue stream for physicians. As a result, many physicians and surgeons are transferring their practices away from reconstructive and insurance-reimbursed procedures and increasing their aesthetic caseload.

Contributing Factors

Technological advancements that have made procedures faster and simpler are also driving this change. The dynamics of the industry are changing rapidly as minimally invasive procedures become more popular and plentiful. Even the patient mix is changing—emerging groups include men, teens, individuals with diverse ethnic and racial backgrounds, and patients from lower socioeconomic levels.

The increased demand is very real. However, there is still plenty of room for growth. For example, based on extensive media coverage, it may seem like everyone is receiving Botulinum Toxin type A treatments.

But according to Allergan, only about 3% of the potential market is currently indulging in aesthetic enhancements. Still, as more practitioners enter the market, the market dynamics change, particularly when it comes to physician’s fees.

“It is a matter of the economics of supply and demand,” explains Lloyd Krieger, MD, a plastic surgeon in Beverly Hills, Calif. “The more surgeons who enter the market, the lower the fees are per procedure. The number of plastic surgeons is only one part of the equation; you have to figure in the number of providers in the market. As patients become more price sensitive, providers need to have flexibility in their pricing structure.”

The proof is in the numbers. “In New York, California, and Texas, there is a proportional decrease in fees as surgeon density increases,” Krieger says. “New York has 34% more plastic surgeons proportionally than the state of Texas. Its fees are 30% lower in real dollars.” This pattern is evidenced in the more mature aesthetic surgery markets all over the country.

Physicians lament the ongoing trend toward the “demedicalization” of aesthetic procedures. Many are concerned that aesthetic surgery is in danger of turning into just another product, rather than the premium exclusive service it was a few decades ago.

For example, it has become very simple and almost natural to pay for a tummy tuck with a credit card, just as one might purchase a Plasma television or other luxury item. Once considered to be the coveted domain of Hollywood’s elite, aesthetic surgery today is available to everyone who desires it. When patients start accepting aesthetic treatments as routine and easily accessible, many practitioners fear it will not be long before patients come to perceive that practitioners are interchangeable and the results from one liposuction procedure are equivalent to the next one.

It is no secret that makeover television has brought aesthetic surgery into the living rooms of anyone with access to a television, a computer, or an iPod. Although these programs have raised awareness about aesthetic procedures, they also have paved the way for a host of misconceptions among consumers. The television shows that portray aesthetic surgery as a “quick fix” have had a significant influence on consumers’ decisions to seek aesthetic enhancements.

Over the past several years, the decision-making process for many patients has become shorter. They do some online research, read a growing assortment of articles featured in media outlets, perhaps see a few practitioners in consultation, and sign up—often minus the guilt, stigma, and fear of times gone by.

In an editorial on this topic published in Skin & Allergy News, Roy G. Geronemus, MD, director of the Laser & Skin Surgery Center of New York in New York City, wrote: “The downside to these intense (and extensive) ‘makeover’ programs is that the procedures are made out to be much more glamorous than they really are. Additionally, there is no on-camera discussion of potential complications, postoperative effects, long-term risks, and the healing phase.”1

Changing Demographics

Some practitioners express concern that lower fees and accessible credit plans encourage patients who previously would not have qualified for a procedure to seek out treatments. Some of the aesthetic patients that come into practices for consultations today would likely have been turned away 5 years ago for a variety of reasons.

In 2007, the standards for how to measure who is an appropriate candidate seem to have relaxed across the board. For example, in the 1980s, a patient who presented with a history of antidepressant use might have been turned away at a plastic surgeon’s door. In today’s competitive environment, that information filled in on an intake form would hardly raise an eyebrow.

The demographics of the marketplace are shifting rapidly as well. The growing middle and lower-middle classes have bought into the concept of self-improvement through aesthetic surgery and injectable procedures.

To get an idea of how accessible aesthetic treatments are, consider the fact that the popular discount Grattan Catalogue in the United Kingdom offers to make an appointment for subscribers to have a Botulinum Toxin treatment or lip injections at a nearby clinic, an announcement printed alongside special savings on cookware and lingerie.

New York’s Jacob Javits Convention Center, which also served as the site for the American Society for Aesthetic Plastic Surgery’s 2007 Annual Meeting held in April, hosted “Body Beautiful, The Ultimate Cosmetic Surgery Expo” (www.makeyourbodybeautiful.com) in September. This event featured exhibitors from aesthetic surgery and dentistry where consumers consulted one-on-one in what was marketed as “an intimate environment with board-certified plastic surgeons and a multitude of other pros.”

These trends put aesthetic treatment choices in the hands of consumers, rather than those of practitioners. “Cosmetic surgery is moving toward a commodity,” Krieger says. “The structure of our industry today is that there is a very low barrier to entry, even though it is still the practice of medicine.

“Individual providers are losing their power base,” Krieger continues, “and it is becoming increasingly difficult to differentiate your practice from your competitors. The woman who delivered my neighbor’s babies is doing liposuction now.”

Competition is coming from many arenas as more nontraditional specialists are entering the aesthetics market. The next frontier of such persons includes family practitioners, gynecologists, and emergency-department physicians.

See also “Get Engaged!” by Cheryl Whitman in the June 2007 issue of PSP.

Indeed, it is widely accepted that virtually any health care professional so inclined can open an aesthetic practice by simply leasing an intense pulsated-light system. Laser hair removal is often seen as the soft launching point into aesthetics. Sadly, some practitioners may not even have a basic understanding of aesthetic procedures when they enter into the lucrative practice of aesthetic medicine.

Monitoring Mail-Order Medicine

One troubling development for practitioners is the advent of mail-order medicine. It has become commonplace for private practices to receive faxes promoting discounted generic hyaluronic acid fillers, Botulinum Toxins, and fat-dissolving solutions from Canada, South America, and Asia.

Industry leaders have been working steadfastly with the FDA over the past couple of years to identify and shut down the widespread flow of unlicensed and unapproved products coming into the United States. However, the scope of this task is daunting, and for every exporter that is reported to authorities, many more are eager to take up the slack. Some of the more clever counterfeit rings have become adept at reproducing logos and labels of the major brands, which makes it doubly difficult to track them.

Educating Professionals

Medical aesthetics as a whole is not a field that has historically established formal standards and treatment algorithms. New technologies are launched faster than the busy physician in practice can master, which has created an overwhelming crunch for ongoing education. Every new device or dermal filler that enters the market requires some level of hands-on physician training to optimize outcomes and determine safety protocols.

In response, professional education in aesthetic products and procedures is being offered increasingly by the larger players and some smaller vendors. Company-sponsored professional education has skyrocketed in popularity among aesthetic physicians, who are eager to take advantage of the added value they receive by attending these events in terms of clinical education as well as practice management.

Many suppliers seek to define their position in the market by advancing training courses and Webinars for physicians and their staff. Web-based physician education that fosters a free exchange of ideas and information is paving the way of the future as physicians’ time becomes more limited.

Anticipating the Future

The demand for aesthetic treatments will likely continue to grow. “The aesthetic market is only going to increase over the coming years,” says James H. Wells, MD, FACS, past president of the American Society of Plastic Surgeons. “With more specialized training in these areas, more ‘rejuvenation products’ being developed, the popularity of the ‘medical spa,’ and the aging of the Baby Boomers with increased disposable income, growth of this market is the only logical course.”

These developments will present new challenges for practitioners and consumers in the near future. “The problem for the public is to find the truly qualified physician as opposed to the person trained in the weekend course, with limited information and skills,” Wells says. “The patient needs to spend time finding that trained person and not listen to the loudest and fanciest ad. They have to do their homework and interview several physicians before making that decision. Being a patient takes patience.”

Wendy Lewis is a contributing writer for Plastic Surgery Products; author of Plastic Makes Perfect: The Complete Cosmetic Beauty Guide (Orion, 2008); and the editorial director for MDPublish.com, a medical marketing and publishing group. She can be reached via her Web site, www.wlbeauty.com.


  1. Geronemus RG. The side effects of TV makeovers. Skin & Allergy News. 2003;34(12):13. www.skinandallergynews.com/issues/contents?issue_key=S0037-6337(05)X7027-9. Accessed September 7, 2007.