Has the current economic recession rocked your world or are you sailing through just fine? It’s one thing to weather the storm; what are you doing to weather the recovery?

Despite doom-and-gloom forecasts made by mainstream media’s “bad news bears” and other punditry, an economy that is down has only one way to go: Up.

At press time, though, the average revenues of private cosmetic surgeons are down as much as 35%. In addition, some practices in the United States are down even more—as much as an astounding 80%.


California has been one of the hardest-hit states. Factors include the housing meltdown, rising unemployment rates of more than 10% when the national average is closer to 8.5%, and an increase in state taxes. That leads to serious issues for plastic and cosmetic surgeons trying to make sense of their practice business models.

With a practice located in Sacramento, Calif—which is the location of the state capital and a place many see as the “epicenter” of the foreclosure epidemic, Patrick McMenamin, MD, can feel the sting of the down economy, the stock market dips, as well as the government’s budget constraints that pull at the purse strings of his patients. “We used to be almost recession-proof in Sacramento due to the strong government influence, but now even that is way down.”

In Southern California and among the palm tree-rowed streets of Beverly Hills, some physicians are hurting and “some of us are not hurting, or if so, very little,” claims Robert Kotler, MD, FACS, who practices in Los Angeles.

Kotler senses that the US economy’s constriction is likely to be permanent. “Therefore, fewer patients with a level of discretionary income to afford cosmetic surgery and allied services,” he says. “To thrive, practices will have to lower their fee schedules or give added value, or both, to stay competitive. Some practices that have not long invested in branding themselves as distinct, by virtue of excellence or focus on certain procedures, will not survive. The hybrid cosmetic and reconstructive surgery practices will be the first to become extinct.

“One rep told me that there are three general plastic surgeons doing 80% of the breast augmentations in the Beverly Hills area.” Kotler shrugs at the thought, concluding that, in general, the “superspecialist”-type practitioners are holding up well against the economy, and the “jack-of-all-trades” is in the tank.

As current president of the American Academy of Cosmetic Surgery (AACS), McMenamin speaks with physicians throughout the United States and offers the following advice to them:

“First, know your message. What are your values, and what do you want for your patients and from your career as a surgeon? I believe those who relate the best to their patients and offer a higher-quality level of service, as well as a quality result, will flourish while others will perish. We will probably see a trend toward group practices, as well as consolidation, since it’s getting tougher to be a sole private-practice physician. It’s a tough business model.”

The outlook looks optimistic, he says, even in the capital of a US state that is suffering the most during the recession. We have already weathered the worst of it, and cosmetic services are way below value, he adds.

“People are tired of living in doom and gloom, and they are ready to prosper again. Look around you. We are lucky and should count our blessings for what we do have. It could be a lot worse,” he notes.


The trend in aesthetic practices, McMenamin says, has been shifting from large numbers of full-blown surgical procedures, which are way down in popularity in all areas of the United States, to an increase in less-invasive procedures.

For example, though the recession has affected all classes of patients, McMenamin sees an increasing trend of females between 45 to 65 years old who are interested in his laser facelift procedure. This procedure addresses the needs of the cash-strapped aesthetic patient during shaky times.

“Some patients are sick and tired of all the bad news they are flooded with,” he notes. “[They] want faster procedures that are quicker, less expensive, with minimal downtime, but effective.”

Replacing surgeries with gobs of smaller, less costly (to patients) procedures means physicians must contend with a new and different business model.

Other practitioners claim that the more your practice has to offer in terms of products and services, the more consistent your revenue stream will be during slow times.

“There are two take-home points from the economic decline that we have seen in the last 9 months,” explains Michael Kluska, DO, a physician practicing in Greensburg, Pa. “First and most important is that cosmetic surgery is indeed a luxury. Patients, no matter how bad they want a procedure, will definitely place cosmetic surgery on the back burner. That said, all physicians who provide cosmetic surgical services must realize that it is truly in their best interest to still try to maintain an insurance-based clientele as well. This income helps bridge the gap during down times.”

The cosmetic or plastic surgeon who “bends their prices with current economic trends will be able to still maintain patient flow,” Kluska adds. “Running specials on noninvasive procedures keeps potential surgical patients in the practice loop until they are able to afford bigger-ticket items.”


According to J. Kevin Duplechain, MD, FACS, a plastic surgeon based in Lafayette, La, “The recession has allowed aesthetic practitioners to closely focus on the day-to-day. The cosmetic business in our [area] is good, and although the very high-level procedures—such as total facial rejuvenation—have slowed slightly, patients still want the chance to look their best. Currently, they are opting for procedures that are a little less invasive, because of downtime. I think everyone values their job right now, and so time off needs to be minimized and predictable.”

Duplechain has also increased the number of patients he sees daily. “Rather than having a patient who calls in for an injectable and put them on for a regular appointment in a month, we try to get them in sooner,” he explains. “A month may just be too long for a new patient to wait these days. We have actually changed the way the nurses work when I see patients. I had two nurses working with me and one nurse who answered phones. With the increase in the number of patients, we have all three nurses working with patients on days when I am in. I think patients still want high levels of service when they see a plastic surgeon, and having more manpower available does that.”

Duplechain enjoys opening up his schedule in order to consult with new and existing patients in more depth and for a longer period. “[We] can spend more time establishing a relationship, and I can see a few more people each day.”

Rather than being tucked away in the operating room for 2 to 3 days per week doing high-value surgical procedures, more of McMenamin’s time is now spent in the front office dealing directly with his patients, echoing Duplechain’s comments.

This increased face-to-face time with his patients allows McMenamin to solidify his relationships with patients on the smaller procedures, so they come back for the bigger procedures when the economy turns around. “It’s all about the patients,” McMenamin says. “My patients are looking for that special relationship that includes personal interaction with me. They also want quality and top-grade service, so we bend over backward to give it to them.”


When patients are scared and uncertain, they stick to what and whom they know best, McMenamin claims. As his current patients are keeping him in business during this crazy time, McMenamin has shifted his marketing strategy to make every dollar count. Current promotional efforts go toward communicating with current patients via in-house patient seminars, e-mail blasts, and direct mail postcards. This helps ensure that his patients turn to him whenever they are ready for aesthetic enhancement.

Duplechain, as with many plastic surgeons, has likewise looked closely at advertising costs and has seen what works and what does not. He believes the Internet and internal marketing efforts offer the best bang for the buck.

“With so much fluctuation in the economy, I think these things will help us prosper during this period of time. I am definitely trying to offer services to patients in a way that will keep them coming back when things do get better,” Duplechain says.

McMenamin has changed his way of promoting his practice. Money that used to go to the Yellow Pages has been redirected to Google AdWords to attract new patients via the Internet. In addition, McMenamin’s redesigned Web site touts personal interaction and easy flow of information between physician and patient. This allows prospective patients to learn and feel comfortable to the point where they are ready to schedule a consultation.

“I want my message to be personal and to articulate the quality of my work with a higher level of service,” McMenamin says. “The more capable you are of relating to your patients, the more successful you will be during tough times. I only want happy patients, and that comes from good, solid communication skills.”

To ensure happy outcomes, McMenamin is brutally honest about results his patients can expect. He shows books of photos at different stages of recovery, different outcomes (good and not so good), as well as a variety of patient demographics. This lets each prospective patient identify with another patient, he adds.


Lawrence Martin, MD, is a board-certified facial plastic surgeon in Arlington Heights, Ill, which is a Northwest suburb of Chicago. Though Martin’s surgical procedure revenues are down almost 50%, minimally invasive procedures performed on current patients are holding steady. “I’m seeing more of my surgical patients holding off on surgery but still opting to do something. They are resistant to committing to surgery and are waiting for a turnaround in the economy.”

To help sustain him through these rough times, insurance-based procedures are holding steady as well. Martin has always maintained an equal balance of cash-paying cosmetic patients and insurance-based patients.

Although he hasn’t seen any major change in his patient demographics, Martin is seeing a trend in working patients in their 40s and 50s. They are unwilling to take the week or two off for surgical downtime for fear of losing their job. “They want quick fixes with no downtime,” he remarks. “I have gotten very proficient with injectables and the art of fine-tuning faces for maximum result with little or no downtime.”

Amid the dark clouds of the recession, Martin’s silver lining is in how creative and resourceful he has become to sustain his revenues. Rather than performing the volume of facelifts he was performing, he’s doing substantially more perioral rejuvenation. Using Botox to raise the corners of the mouth and a variety of fillers to smooth lip and marionette lines and plump lips—and then peels around the mouth—is giving his patients what they want. “I’ve even been injecting permanent silicon in lips for my established patients who want a long-lasting result,” he adds.

In addition, Martin and his staff are getting better at increasing the average order size per patient by adding Botox and retail to the treatment.


Martin has noticed lots of competitors vying for the same patients by using large-scale advertising efforts. To combat the competition, Martin has increased his promotional budget and is spending more on patient mailings and in-house patient seminars, where he sees a really good return. “I can seat 20 patients for one of my seminars and 12 to 14 of those attendees book procedures,” he says.

Concentrating on current patients is a strategy that is working well during this difficult time. Martin sends out patient newsletters with lots of before-and-after photographs, an e-mail campaign and evening hours to attract patients and increase the revenues per year they spend with him. He and his staff are also concentrating on word-of-mouth referrals like never before— “I have placed much more emphasis on referrals from my patients, and it’s paying off,” he says.

Though Martin has not yet cut staff, he is looking to hire someone who could take on all aspects of the marketing. That person, he says, “should be the practice manager and fill in as a scrub nurse.”

While business has slowed down, Martin is like many other practitioners, including McMenamin—he now has the extra time to spend with his patients, and that’s paying off in referrals. “I’ve always done my own injectable procedures, and I know that will lead to more when times improve,” Martin says.

In addition, he has been able to cut his overhead expenses, redoing the health insurance policy at a lower rate and renegotiating the office rent. All of these efforts have kept Martin’s practice alive during a hard-hit time.

Martin has mixed feelings for those wanting to get into aesthetic medicine at this time. “Most physicians wanted to be a doctor as far back as grade school, but now, you need to ask yourself how much you want to compete? Is it worth it? As Yogi said, ‘When you get to a fork in the road, take it,” meaning explore and cover all options,” he says.


Jennifer Walden, MD, is a board-certified plastic surgeon in private practice for the past 5 years in a very nice office in the Upper East Side of Manhattan.

Surprisingly, she is not feeling the pinch of the economy as are others around the country, attributing her success to her patient demographics and her expertise in breast augmentation.

See also “Getting Real About the Economy (Minus the Spin)” by Jeffrey Frentzen in the April 2009 issue of PSP.


Her patients, typically females from 29 to 49 years old, “want breast augmentation, no matter what,” she says. “They have been planning for surgery and will find the resources to have the surgery.” This includes an increase in patients using her financing options. Unlike others, Walden continues to offer free initial consultations as she is confident in her conversion rates.

As Walden prefers to work in the operating room, her nurse does the majority of the injectables. “The injectables portion of my practice is also holding steady and serves only a minority of my patients,” she adds.

It also helps that Walden takes insurance to help keep her income flowing consistently; however, she does not perform reconstructive procedures. She concentrates on breast reduction, lesions, and skin cancer.

“Insurance allows for moles and lesions, and that’s the bread and butter of plastic surgery,” she notes. “Insurance cases are the best-kept secret and make up 10% to 15% of my practice. Patients will get their nose done and then their breasts at the same time. Just today, I did a female patient’s function septum and cosmetic liposuction of her neck, chin, and buckle fat pad removal.”


What keeps her practice sailing so smoothly through these choppy times? The Internet. Walden has embraced this medium, and it has evolved into a good way to reach out to her preferred patients—younger females who want larger breasts.

Having a strong online presence has been very beneficial for Walden—just check out her Facebook page and Web site, video appearances on YouTube, portal sites, and vendor sites. She is a prime example of a plastic surgeon who has become ubiquitous on the Internet. She contracts with an Internet company to handle maintenance of her Web site.

“I get 60% of new patients from the Internet,” she says, and this online exposure has also led to name recognition and media appearances—she has been seen offering medical commentary on the Fox Network as well as other national media outlets. “Just living in New York City gives you exposure to the media outlets, so that helps,” she says.

To gain even more name recognition, Walden works with product vendors “when it makes sense,” she notes.

She has partnered with Allergan to promote the firm’s new Natrelle Beauty Patient Pre-Consultation Kit, and she has also participated in Allergan’s consumer outreach “nights of beauty” as well as various community charity events. She’s also sent out vendor postcards to her patients who could be interested in new products and procedures.

Walden has been doing so well that she not only has kept her current staff busy, she even hired a new assistant. However, she is careful with spending. “I have reduced my discretionary spending, so there are not a lot of extras right now.

Is the idea of the future consistently rosy for Walden? Not really. Manhattan has been and always will be a very tough market for plastic and cosmetic surgeons. Actually, the economy could get worse before it gets better, she says. “New physicians just coming out, you should consider going into practice with another physician or a group or in a city and town where it’s not so highly competitive.”


In the final analysis, no amount of editorializing can replace the power of a physician testimonial.

Robert H. Burke, MD, DDS, FACS, practices in a Michigan college town in a state that has been hit very hard by the recession. “Unemployment rates are the highest in the nation, home values have plummeted, our major industry—automobile manufacturing—has almost disappeared. Nobody has any money,” he says. “We could have failed, but we didn’t. Here is what we did: Application of the fundamentals, reevaluation of our strengths and weaknesses, a commitment to providing worthwhile value to the consumer. Remember that we are physicians first with unique knowledge and skill that we direct to help our patients obtain the best outcomes within their particular circumstances.

“One must maintain a positive attitude,” Burke continues. “Negativity leads to self-defeat through doubt in your abilities and those of your employees. I believe that most patients that I see have a built-in doubt detector, and when activated are more likely to seek another opinion and have their treatment elsewhere. They also have a desperation detector. They can tell if you really need them to sign on to your treatment plan, and probably won’t. I have observed that they respond best when they are educated about their concerns and are able to calmly review options with no pressure. They seem to respond best when I present the plan personally and are able to go home and review their choices.

“I am optimistic for the future and will express my thanks to those who consult me and receive my treatment, letting them know that I value their trust and confidence. I will continue to give value and professionalism in the experience. Lastly, I have learned that this is a team effort with my employees, who have gone out of their way to make our practice look good through their positive attitudes, professionalism, continuing education, and commitment to positive patient care.”

Shannon Triplett Leade is a contributing writer for PSP. She can be reached at [email protected].

Catherine Maley, MBA, consults with physicians in private practice as well as industry vendors on how to grow an aesthetic practice using PR, advertising, and creative marketing strategies. She can be reached at (877) 339-8833.

Jeffrey Frentzen is the editor of PSP. He can be reached at [email protected].

What You Learned from the Recession

The following are insights into the process of coming to grips with a changing economy, and how some aesthetic practitioners on PSP’s editorial advisory board have dealt with adapting to new business models, new patient expectations, and how they have kept their heads above water.

PSP: How will you apply what you’ve learned to improve or enhance or change your business practice for the future?

Joseph Niamtu, DMD (Norfolk, Va): Doctors are traditionally sloppy businesspeople; and as long as things are going well, most pay little attention to the basic things that all other businesses look at under a microscope. When times get tough, surgeons have to all of a sudden become real businesspeople and pay more attention to such things as salaries, benefits, overhead, fixed costs, and ordering. In reality, we should all do that in the best economy, but we have surgical training, not accounting expertise.

No surgeon is happy about this sour economy, but it is an excellent time to learn to be a “real” businessman or woman. My partners and I have used this opportunity to hone our business policies. With the assistance of our accountant and managers, we have learned a lot of valuable things about tightening our belt and running a more efficient practice. It is the old adage that when life gives you lemons, make lemonade!

Jane Petro, MD (Great Neck, NY): When business gets slow, I have always used the extra time to get organized; work on projects that have been relegated to the back burner; and maybe even take a few extra hours for fun things, a movie, a book, dinner with a friend.

Part of the get-organized activity takes into account reviewing the practice, its strengths and weaknesses. Where do the patients come from who are still coming? Are my fees too high? Do a little competitor shopping to see what other pricing in the community is like. Review the staff, their job descriptions, and their work habits. Are we overstaffed? Sometimes when things slow down, you may even realize that you are understaffed, because everyone begins doing a better job.

Niamtu: Many docs will cut back their marketing in this economy, but in actuality it is a good time to turn up the heat. If the unemployment rate is 7%, then 93% of people still have income and are shopping more consciously for goods and services, including cosmetic surgery. Providing incentives during a sour economy can be effective. Value-added promotions such as buy two filler syringes and get the third one half price may be more effective than across-the-board discounts. This is also a ripe time to work you own patient base with specials, e-blasts, and Web-oriented marketing. The patients are out there. We simply have to dig harder.

Angelo Cuzalina, MD (Tulsa, Okla): We are fortunate to live in the Midwest where the economic downturn was not as severe as other areas of the country. Practicing exclusively cosmetic surgery in times of an economic downturn can make you reevaluate your practice. First, it is a great time to access your overhead and areas where wasteful spending can be trimmed. It makes no sense to throw money at advertising randomly without knowing exactly what each ad or promotion is truly doing for you—and if it is worth the time and money spent. We limit our advertising to what tends to be most cost effective based on results from tracking phone numbers that can give you data needed to make rational business decisions on fact rather than emotion.

Niamtu: Even though patients may not have extra money to spend, they still need “feel good” treats for their self-esteem and well-being. I have operated on numerous patients who lost their job but now have recovery time and want to look better to compete in their next venture. Also, I have seen several patients who were terminated with early retirement and they fully intend to reenter the workplace. They are investing in themselves with their severance package.

Patrick McMenamin, MD (Sacramento, Calif): I’ve been more creative when balancing the books. Since the trend has gone to less-expensive procedures, I’ve been doing more of the work I used to delegate to my ancillary staff. That has not yet led to a cut in staff hours and a 4-day workweek, but it is a consideration. My least-tenured employee has been with me 18 years. I have a wonderful team working together and I feel responsible for their livelihood, so I’m doing what I can to keep everyone employed and secure.

Petro: In our practice, we decided to open an accredited office operating room, and had the time to prepare all the policy and procedure manuals, staffing requirements, and stocking that needed to be done, and managed to get accredited in the first go-round. Most of all, we have recognized the value of diversity, both in staffing, patient flow, and the kinds of things we do. Our practice base is diversified geographically, economically, and socioculturally. Not all parts of the economy have taken a turn for the worse. While we have the spa, do the cosmetics, injectables, and other things that are the cornerstone of an aesthetic practice, we have a partnership with breast surgeons and do a lot of breast surgery. Especially in an economic downturn, having a necessary procedure as part of your practice provides a safety net.

Cuzalina: We did take the opportunity to focus on ways to stay busy in slower times by taking advantage of our current patient population. Sending reminders for nonsurgical procedures like fillers and Botox to current patients keeps them “in the loop” and creates a patient flow that ultimately leads to additional surgeries from previous patients who already trust you. It was a good time to utilize our patient software system to its maximum potential via group blast e-mails relaying various details about our practice and procedures. In general, I think the recession helps us become more efficient while still being focused on providing quality care.

— Shannon Triplett Leade