The U.S. economy is sputtering, Wall Street may be falling down and the price of gas remains high, but the current rough sledding in the overall financial health of the country appears to be having only a minor effect on the rate at which consumers are seeking cosmetic procedures from dermatologists and other cosmetic medicine physicians. Recent data from both the American Society for Dermatologic Surgeons (ASDS) and the American Society for Aesthetic Plastic Surgery (ASAPS) suggest that there’s been a slight downtick on some fronts — namely in numbers of major surgeries such as full face-lifts and procedures that require relatively more downtime than others. But overall, the center is holding.

In its most recent ASDS member survey, 63% of respondents reported a consistent volume of procedure appointments among their existing patients in the first half of 2008. Among them, 24% reported an increase in bookings, and 32% said that the number of new patients had risen by as much as 30%. The ASAPS’s annual statistics report of 2007 data found that the total number of cosmetic procedures — on which Americans spent a whopping $13.2 billion — was up 2% over 2006, and that 82% of those procedures were nonsurgical. (See sidebar on page 46.)

“People definitely are sensitive to the economy, and that’s a driver in the trends we’re seeing,” says New York dermatologic surgeon Darrell Rigel, MD, current president of ASDS. “I think that the reason procedures dermatologic surgeons do are increasing is because people are ‘downsizing’ on some of the bigger procedures such as face-lifts and instead going for Botox or fillers, knowing they’ll have less in results but pay a lot less money.”

Following are other key findings of the ASDS survey, published in June:

• 28% of dermatologic surgeons said that their use of fillers increased up to 30% in the first half of 2008; 48% reported the volume of such procedures to be unchanged.
• 40% reported an increase in use of injectable toxins, and 38% predicted a further increase — possibly up to 30% — between mid 2008 and year end.
• 37% of respondents reported an increase in laser-related procedures, and 36% predicted increasing volume before the end of 2008.

Notably, however, the survey found that, compared to last year, dermatologic surgeons’ patients are now spacing out their procedure visits, a likely result of the economic downturn. Nearly half (44%) reported that current patients were scheduling their cosmetic procedures farther apart but didn’t provide specific supporting trend figures.

For his part, Dr. Rigel said that he was surprised that procedures numbers hadn’t declined precipitously, in tandem with the economic slump, as he and other ASDS officials had expected. He was surprised, too, by the regional differences the survey uncovered. “In New York and Florida the [procedure] numbers were going up more, and in California they were dropping a little bit. That may be more economy dependent,” he explains, “because in New York there are a lot of international people coming in for procedures. That may affect those numbers.”

A Changing Patient Dynamic

ASAPS President Alan Gold, MD, a Great Neck, NY, plastic surgeon, concurs on the big-picture view that Dr. Rigel presents. But he attributes the general trend toward less invasive options to the ever-broadening range of both cosmetic procedures available and consumers who seek them.

“There are many new technologies, products and instrumentation — new concepts, too — that allow us to treat a wider range of people, sometimes at an earlier age,” Dr. Gold says. He cites the expansion in soft-tissue filler products as a key example of the expanding options. He explains that patients who might not have been ready for surgery or for whom there may not been appropriate treatments available to treat them are now coming in at younger ages.

“I don’t think that anyone who understands what’s involved thinks that these things will replace surgical modalities,” Dr. Gold contends. “They’re an adjunct.”

As an adjunct, those low- to no-downtime procedures are seeing impressive gains. In 2007, Botox injections topped the ASAPS list of nonsurgical procedures, at 2.7 million of the 11.7 million total, followed by hyaluronic acid treatments at 1.4 million.

“Certainly our patients are younger now, more conscious of the need to care for their skin, and more conscious of earlier aging-related changes,” Dr. Gold observes. Consumers aged 35 to 50 accounted for nearly half (46%) of cosmetic procedures in 2007, according to ASAPS data. Interestingly, men continue to seek cosmetic procedures at roughly the same rate as a few years ago, Dr. Gold adds. “It’s not much different percentage-wise. The numbers are increasing for both men and women, but the rate at which men are doing procedures (17% of the total) is not disproportionate to what it has been.”

North Carolina dermatologic surgeon Tamara Salam Housman, MD, lead author of a recent study that examined changes in types of medical specialties that perform outpatient cosmetic procedures, suspects, based on recent data and what she has heard, that Botox injections and soft-tissue fillers “are probably the bulk of dermatologists’ cosmetic practices.” She also thinks that numbers of such procedures are likely rising faster than recent reports, including her retrospective study published in the January 2008 issue of Dermatologic Surgery, would indicate.

That research, based on data from the National Ambulatory Medical Care Survey for the years 1995 to 2003, found that dermatologists and plastic surgeons performed 48% and 38%, respectively, of all cosmetic procedures. Chemical peels and fillers were the two most commonly performed ones. Each accounted for 16% of the total, followed by sclerotherapy at 15%.

Less Downtime, Perceived Low Risk Drive Nonsurgical-Procedure Increases

Those percentages are “probably far higher now,” says Dr. Housman, medical director of Raleigh Skin Surgery Center and a researcher at the Wake Forest University School of Medicine’s Center for Dermatology Research. She also thinks that convenience and presumed safety are major drivers.

“I think that consumers are getting fewer surgical procedures because there’s less downtime and less risk, as perceived by patients anyway, in the nonsurgical procedures,” says Dr. Housman, who is also a Mohs surgeon.

Dr. Rigel’s view is that the key deciding issue for consumers is not so much whether a procedure is invasive versus noninvasive, but rather the downtime factor Dr. Housman cites. “Basically, what people are looking for is either minimal or no downtime,” he says. “They want non-ablative procedures that are minimally invasive, and that’s most of what we do in cosmetic dermatologic surgery now.”

Some plastic surgeons who deal with a wide range of potential patients, as does Dr. Gold, have a slightly cynical “30,000-feet” view. “Our society wants a quick fix — they would like minimally invasive procedures to give them the same result as the maximally invasive ones, with the shortest possible downtime and the quickest return to work — at no cost,” Dr. Gold quips. “That’s what we deal with in cosmetic medicine.”

Dr. Housman thinks that other factors, some of which consumers probably wouldn’t articulate, are responsible for the shift away from “major” procedures and toward less invasive ones and nonsurgical procedures of all types. She cites two key factors: substantial experience gains and technique improvement among highly trained dermatologists and other specialists who perform the procedures. She maintains that the improvements in the products used in procedures may contribute to the perspective that nonsurgical procedures are preferable to surgical ones, but thinks it’s not a key reason consumers seek cosmetic procedures from dermatologists.

“The quality of the products may be better, but it’s really the quality of the dermatologists that’s making the difference now, I think,” Dr. Housman says. “They have more experience, and they are getting better at techniques.” In addition, many younger dermatologists who perform cosmetic procedures or focus their practices on cosmetic dermatology are better trained than their counterparts were in the past, simply because there are many more training options and fellowships available now than a decade ago.

“That’s a big factor,” she says, adding that patient reporting of their experiences and Internet-fueled word of mouth likely are also boosting cosmetic dermatologists’ procedure volumes.

Safety Concerns about Inadequately Trained Physicians Persist

The findings of the recent surveys and studies present a bright to partly cloudy forecast for rates of cosmetic procedures performed by dermatologists and other highly trained specialists. Still, the fact that a rising tide raises all boats — including those of physicians inadequately trained — and the proliferation of advertising that makes certain physicians and practices appear more experienced than they are, are contributing to specialists’ worries about consumer safety.

“We’re still concerned about the surgery by non-surgeons and people who aren’t adequately trained. But we are now increasingly concerned about the non-surgical treatments being administered either by inadequately trained surgeons or inadequately trained physicians in general or even non-physicians,” Dr. Gold observes. He specifically cites what he calls non-core cosmetic surgeons/physicians — those who aren’t plastic surgeons, dermatologists or ophthalmological plastic or facial plastic surgeons — but rather primary care physicians who are now expanding into cosmetic medicine, yet offering a limited menu of options.

“In many arenas, you have physicians who have no other modality to offer offering things to patients that might not be the best treatment for them. In other words, if all you have is a hammer, everything looks like a nail,” he says. “So that a physician who cannot offer the whole gamut of cosmetic treatments, ranging from non-invasive or minimally invasive to moderately invasive surgical procedures, only has that tool available — and they overfill faces with fillers or over-treat with lasers things that shouldn’t be treated with lasers. That’s the concern.”