Amy Andrade had been thinking about Botox for a while. So when she spotted a spa-like "cosmedical" clinic in the upscale Dallas mall she visits about once a month, she was immediately interested. When she learned the clinic was connected with one of Texas' leading medical institutions, she was sold. She had Botox injected into her 32-year-old forehead and near her eyes to smooth out infinitesimal wrinkles. "It was great. I felt like I was getting a facial," said the furniture showroom manager. She was hoping to look younger and knew about Botox because several of her friends have had the injections.
Medical spas like the one at Dallas' NorthPark Center are booming. The number in the United States has jumped from 50 in 2002, when Botox injections won federal approval, to about 2,500 this year, according to the International Medical Spa Association. Malls and other retail sites are the hot spot locations as companies and medical institutions move closer to their customers. Such spas offer minimally invasive cosmetic procedures like injections of Botox, which relaxes facial muscles to make lines fade, and fillers like Restylane, which add volume.
Not all medical spas have ties with a major medical institution like the Klinger Advanced Aesthetics Cosmedical Center, Spa and Salon at NorthPark, which has teamed up with the University of Texas Southwestern Medical Center. Some "cosmedical" clinics don't even require their practitioners to be plastic surgeons or dermatologists.
Those who specialize in the field say involvement by a plastic surgeon or dermatologist ensures consumer safety. Dr. Rod Rohrich, professor and chairman of the department of plastic surgery at the University of Texas Southwestern Medical Center, is one of two plastic surgeons who help oversee cosmetics procedures at the NorthPark operation.
"When you peel back 'Botox in the mall,' you have a top-notch medical facility in a mall setting," he said. "What you're doing is you're getting the best of the best in a place where people shop and you're doing it safely." The doctors are generally there just half a day a week - sometimes more. But they say they are always available for the nurse practitioner, who does most procedures.
Benjamin Akande, dean of Webster University School of Business and Technology in St. Louis, said that it's a business decision that makes sense. "The partnership with these legitimate entities gives them the kind of credibility that cannot be questioned," Akande said. "They're saying this is as good or better as you coming to your local plastic surgeon."
Moving such procedures closer to consumers also makes sense because "cosmetic surgery in the 21st century is not an anomaly," Akande said. "It's a daily fact of life." The Klinger spa in Dallas is located across from the Barneys New York store and near Neiman Marcus. It offers haircuts, massages and nail services along with its cosmedical procedures. Botox there starts at $400 for one area of the face, Restylane at $650.
Andrade, the 32-year-old who got the Botox treatment, said that she'd made a few phone calls to research the procedure before being drawn in by the sleekly designed spa, which is connected to the Sephora cosmetics store next door. Almost two weeks after her injections, she said she's been pleased with the results, which she described as a natural look. "I still have expression," she said, while getting rid of some creases between her eyes. "Nobody really notices it except me."
Aware that the results fade in three to five months, she said she'll decide then whether to do it again. She has gotten some compliments. "Some people say, 'Oh my God, your skin looks so beautiful.'" Her typical reply is that she's been using a new skin product. Her bottom line, though, is: "I like it, so I think that's what counts." Botox is the No. 1 minimally invasive cosmetic procedure, with 3.8 million treatments done last year, according to the American Society of Plastic Surgeons. The International Medical Spa Association estimates that by the end of the year revenue from medical spas will exceed $1 billion, said Hannelore Leavy, founder and executive director of the group.
The Dallas location is an example of a concept Klinger plans to market to other medical spas and doctor's offices, said Klinger chairman and chief executive officer Richard Rakowski. For a licensing fee, the Norwalk, Conn.-based company plans to put the Klinger name on other spas that adhere to its standards, which include supervision by board-certified plastic surgeons.
Klinger has another such flagship clinic in an affluent shopping area in Chevy Chase, Md., that is overseen by doctors from Johns Hopkins Medical. Leavy said each state has different qualifications rules for those who perform minimally invasive cosmetic procedures. Work done by those poorly trained can lead to "a lot of complications," she said.
In October, the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery drew up "guiding principles" for supervision of non-physician personnel in medical spas. Specialists in the field say the issue is who's running these spas and who's supervising. Dr. Richard A. D'Amico, president-elect of the American Society of Plastic Surgeons, said the concern is more about safety than location. He said that it's important that such procedures are at least overseen by a plastic surgeon or a dermatologist.
The procedures may look like simple injections, but serious complications could result if someone isn't properly trained. For example, an injection that paralyzes the muscle, like Botox, given in the wrong spot could cause an eyelid to droop, he said. Skinovative USA, a Tempe, Ariz.-based chain of medical spas that opened in 2001, does not demand that its medical directors be plastic surgeons or dermatologists.
Vin Wells, company founder and chief operations officer, said the chain's directors are doctors or nurse practitioners who get training at corporate headquarters. "It's really about the quality of training," he said. Skinovative has four mall-based medical spas and is adding two more in the coming months, including one in the Houston Galleria, Wells said.
Despite the accessibility of mall-based medical spas, those who run them say they screen patients to make sure that they understand the procedure and determine whether it's appropriate for them. "We don't want impulse buyers. We take a careful history - talk about pros and cons," said Dr. Jeff Kenkel, professor and vice chairman of the department of plastic surgery at UT Southwestern, who oversees the NorthPark spa along with Rohrich. "We want to make sure that that person is educated about what they're looking for."
Wells of Skinovative says his doctors almost never treat someone the same day. "People aren't psychologically ready for it," he said. Kate Parsons, director of the Center for Ethics at Webster University in St. Louis, said that she is worried that as such services become more widely available, people will be less inclined to examine why they feel the need to fill in winkles and look younger.
"I guess my concern is that we're not examining that as much as we could be," Parsons said. "It is becoming increasingly accepted as one more option among the array of cosmetics and fashion.
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