Having A Little Work Done (at The Mall)

ANDREW RUDNICK snickered when he first saw a medical spa offering Botox and laser hair-removal services on a visit to a Las Vegas all in 2002. He laughed at the thought of someone - anyone - shopping for the latest fashions, grabbing a bite to eat and then, oh yeah, strolling in for a quick shot of Botox to zap out a nasty wrinkle.

"I couldn"�t understand why anybody in a mall would walk in and have their legs lasered, never mind Botox,"� he recalled. He parked himself on a bench near the spa and watched in amazement as shoppers strolled in. He owned a weight-loss and laser center in Boston at the time, and the sight was a revelation. "I counted the traffic in and out and saw the revenue, and said, "�Wow! This is a retail business."� "� Returning to Boston, he scouted retail locations. He dropped the weight-loss part of his business to focus on skin care and laser treatments, renamed the company and opened his first Sleek MedSpa that same year. He has since opened six more - near Boston and in New York and Florida, all in upscale malls or retail areas.

"It took off like a bat out of hell,"� he said. Thanks in part to television shows like "Extreme Makeover"� and "Nip/Tuck,"� the number of Americans seeking chemical peels, laser procedures, Botox shots and wrinkle-filler injections is soaring. According to the American Society for Aesthetic Plastic Surgery, such "noninvasive"� treatments have increased more than 700 percent since 1997. Botox received Food and Drug.A-~-n_i.&on approval in 2002. THE stampede of doctors and entrepreneurs rushing to fill that demand has left some doctors and plasticsurgery trade groups wondering about the expertise of some of the people providing these Services. For many Americans, price and convenience come first, with few questions about the experience and qualifications of the person injecting the treatments.

For its part, Sleek MedSpa says some of its outlets have on-site physicians while others have doctors as medical directors off-site, and nurse practitioners and physician's assistants who handle day-to-day treatments. If there were an emergency a nurse couldn"�t handle, the nurse would call gii, Mr. Rudnick said. He added that no such emergency had ever arisen. Kim Wanderley, 39, a stay-at-home mom from Parkland, Fla., said she thought it was "great"� when she spotted a Sleek MedSpa at the Town Center mall in Boca Raton in 2006. "If it had been in Ohio, people might have blinked twice, but this is South Florida,"� where vanity rules, she said. "People do not take aging lightly, without a fight, here."� While Sleek MedSpas lack the feng-shui ambience of a traditional beauty spa, they don"�t exude the sterile atmosphere of a doctor's office, either. The spa in Boca Raton is contemporary and sophisticated, Mrs. Wanderley said, with videos of cosmetic procedures streaming across a flat screen, skin-care products lining another wall and before-and-after picture brochures scattered around the waiting room.

And it's convenient. "I can be in and out in a half-hour,"� she said, and "it gives me an excuse to go to the mall afterward to do a little shopping."� If a procedure causes redness or bruising, the spa offers a convenient backdoor exit to the parking lot. Mrs. Wanderley acknowledges that 10 years ago, she would have thought this "way too excessive and ridiculous,"� she said. "But now I"�m one of the bozos on the bus."� She started out requesting microdermabrasion facial treatments and has since added Botox shots and Restylane filler injections to her medspa repertoire.

Mr. Rudnick estimates that 50 percent of his company's mall clients are walk-ins like Mrs. Wanderley. Sleek MedSpa7s revenue, which was $1.5 million in 2002, surged to more than $14 million in 2007, Mr. Rudnick says, and he expects that total to double this year. Profit margins are in the 20 to 25 percent range, he said, and over the next four years he expects to open 40 more locations in 25 cities.

Sleek MedSpa is among dozens of companies operating medical spas, often called medspas. Hannelore Leavy, founder and executive director of the International Medical Spa Association, estimates that there are 2,000 to 2,500 medspas nationwide, up from 25 in 2002. There has also been a surge in the number of nonsurgical cosmetic procedures. Of the 11.5 million cosmetic procedures performed in 2006, more than four in five were noninvasive treatments, according to the aesthetic plastic-surgery society. From 1997 to 2006, the number of surgical cosmetic procedures rose 98 percent, and noninvasive treatments jumped 747 percent.

Nonsurgical treatments "are effective, they"�re safe and they"�re affordable - and there's no down time,"� said Dr. Foad Nahai, a plastic surgeon in Atlanta and president of the society. Some doctors7 offices are joining in. In New York, Dr. Bruce K. Moskowitz, an ophthalmologist and oculofacial plastic surgeon, says demand on the cosmetic side of his business has skyrocketed, to 50 percent of his business, from 25 percent 15 years ago. To meet demand, he opened a medspa in his office; patients in the waiting room can read brochures about Botox and fillers when they come in for eye checkups.

Dr. Moskowitz7s qualifications for cosmetic procedures run long and deep, given that he had been using Botox for facial twitching disorders as far back as 1991, long before the F.D.A. approved it for cosmetic use. And his oculofacial expertise gave him insight into how facial muscles and nerves respond to filler injections and other cosmetic treatments.

Industry experts attribute the surge in cosmetic procedures to aging baby boomers as well as to television shows. Marian Salzman, author of more than a dozen books on cultural trends and current affairs, said she predicted 10 years ago in "Next: Trends for the Near Future"� that cosmetic procedures would become mainstream. Affordable and walk-in cosmetic surgeries were among the trends she had forecast, Ms. Salzman said. "I used to say they"�re going to be as prevalent as salons,"� she recalled, adding that "people used to roll their noses up at me and say it's obscene, it's ridiculous."� The youngest boomers, those born from 1955 to 1964, are driving the trend, she said. "They will do absolutely anything to prolong youthfulness to stay in the game,"� she said, "and if that means a filler here or Botox there or hair implant there, then so be it - they"�ll do it."� At the same time, television shows helped make cosmetic procedures appear safe and stylish. By the time the Motley Criie frontman Vince Neil went under the knife in 2005 before millions of viewers on "Remaking Vince Neil"� on VHi, cosmetic surgery had truly arrived in mainstream America.

"Virtually every office patient I see talks about the reality TV shows,"� says Dr. Paul Wigoda, a plastic surgeon who runs a cosmetic surgery business in Fort Lauderdale, Fla., owns the MeDaySpa in Miami Beach and is medical director of two Sleek MedSpas in Florida. After watching the shows, he says, patients feel more comfortable about the procedures. DR NAHAI and other plastic surgeons worry that shows like "Extreme Makeover"� gloss over the risks, and edit out the bruising and recovery. "I tell every patient - forget the word "�cosmetic,"� and remember the word 'surgery,"� "� he said. "And there's no such thing as surgery without risk."� Lou Gorfain, an executive producer of "Extreme Makeover,"� which was broadcast on ABC, dismissed such criticism, saying, "We did show the bruising and the pain and risky surgery that it is."� And Linda Klein, a producer and medical adviser of "Nip/Tuck"� on FX, said the series tries to show that surgery is "not a pretty sight"� - and emphasized that the show is fictional. The death of Emye West's mother in November, from complications following a tummy tuck and breast reduction surgery, pushed concerns about procedures into the spotlight.

Sometimes, surgical horror stories can make noninvasive procedures look more attractive. Still, even nonsurgical procedures, like Botox shots and laser treatments, have their own risks, especially if the person giving the treatment isn"�t fully trained, cautioned Dr. Richard D"�Amico, president of the American Society of Plastic Surgeons and chief of plastic surgery at the Englewood Hospital and Medical Center in Englewood, N.J. In the wrong hands, he said, lasers can burn and Botox can cause drooping eyelids or paralvsis until the toxin wears off in three to six months.

In the most dire case, if an injection gets into a blood vessel and the product gets into the retinal artery, a patient could be blinded, Dr. D"�Amico said. He said it was crucial that people check the credentials and experience of those who offer cosmetic treatments. Even the kind of doctor needs to be scrutinized, he said. In the past, cosmetic procedures were done solely by plastic surgeons, dermatologists and ocular plastic surgeons. Today, even podiatrists and dentists are moving into the field. No federal or state laws regulate what doctors can or cannot do once they have state licenses, according to the American Society of Plastic Surgeons. Some just take weekend courses on cosmetic procedures and then set up shop, Dr. Nahai said. Only those certified by the American Board of Plastic Surgeons have undergone formal training of at least six years in plastic surgery and passed an exam on the procedures, Dr. D"�Amico said. Taking a weekend course or watching someone on a DVD isn"�t enough, Dr. Nahai said. "If an airline told you the pilot had simply watched someone fly a plane as his only training, would you want him to take you up in the air?"� he asked.

Many people are attracted by the price, savoir-faire settings and convenience of medspas. Unlike doctors"� offices, most are open seven days a week. Kristen Salera, 24, from South Weymouth, Mass., started getting chemical peels after seeing a Sleek MedSpa in Braintree, Mass., last year. Troubled by acs, she had been curious about cosmetic procedures but had never consulted a plastic surgeon. After dropping into the medspa, she was impressed with the staff and the cost.

"Friends who went to a medical office paid double what I was paying,"� she said. Later, she signed up for mesotherapy, in which injections go into areas of fat, to dissolve hard-to-lose cellulite on her upper thighs. Many experts say medspas are in their infancy, with tremendous growth potential. Aging baby-boomers are driving much of the demand, with 12,000 Americans turning 50 every day, or one every eight seconds, according to AARP. "This is a huge market,"� said John Buckingham, chief executive of Solana MedSpas, a development and consulting company that helps doctors and entrepreneurs set up medspas. New drugs on the horizon may bring more price competition, thus attracting more consumers. The Medicis Pharmaceutical Corporation is awaiting F.D.A. approval of a Botox alternative, Reloin; it is expected to get the green light in 2008 and will compete head-to-head with Botox, from Allergan. Most of the youth-enhancing effects of Botox and cosmetic fillers wear off within three to nine months, making it necessary for patients to get repeat shots. This aspect makes industry experts view the business as largely recession-proof.

The treatments are also seen as a stepping stone to possible plastic surgery. "This is a gateway drug. I started with microdermabrasion and already I"�m doing Restylane as well,"� said Mrs. Wanderley, who doesn"�t rule out plastic surgery at some point. IN addition to Sleek MedSpa, the industry includes chains like Sona MedSpa International, Pure Med Spa, Dermacare Laser and Skin Care Clinics and American Laser Centers, which was recently sold to two private equity firms for about $230 million. Despite the boom, some other medspas have flopped. Skin Nuvo International, which operated 40 mallbased clinics, had problems with its hair-removal equipment and wound up filing for Chapter 11 bankruptcy protection in 2005. And HealthWest Inc. and SkinKlinic have closed shop. Mr. Rudnick is bullish on the sector's growth and is already planning a network of full-service cosmetic surgery facilities. The first opened adjacent to his New York medspa in October. "We know one thing for sure: people aren"�t getting any younger,"� he said. "We know another thing for sure: they all want to look younger."�

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