The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

forward to welcoming him or her. Automated appointment reminders may save
you time and money, but they are impersonal and uninviting. It would be bet-
ter to text or email the patient than to do this. (See Chapter 1 for more infor-
mation on interpersonal communication and telephone etiquette.)
 Email: Email is an effective means of communication when it is welcomed, in-
formative, and personal. Email that is overused will be ignored. When your
office emails people for multiple purposes, be certain you have a distinct send-
ing address for personal patient email, one for general messages and one for
business. Email may be quick, but it need not be impersonal, and it must not
be impolite. Sensitive information or information specific to an individual’s
course of treatment should not be conveyed in emails; it is better left to a tele-
phone conversation for privacy.
Today email is best used for administrative tasks, such as collecting and
sharing information or documents. It is effective for appoint reminders or for
delivering instructions. Email is also an excellent method for sending targeted
messages from your practice, such as an invitation to a special event, a new
product in stock, or simply to fill appointment slots that are open.
 Voice mail: If you must leave a message, ask that the intended recipient return
your call; never offer detail, because you cannot know who will listen to the
message. Avoid an exchange of voice mail questions and answers. Set up a con-
venient time for a phone conversation or an in-person appointment. If it be-
comes too difficult for patients to connect with you, they might just discon-
nect the relationship. Define a policy for the office’s voice mail; require that it
be checked regularly and ensure that every call is answered the same day.
 Text and instant messaging: Although text messaging has become popular
and many use it in the same manner as email, do not view it as equivalent to
email. If your patient or those you are communicating with have indicated that
they are open to accepting text messages, keep these communications short
and simple, such as appointment reminders.
 Print: Printed materials remain an essential part of any practice. A print doc-
ument may be easier to view; it can be transferred electronically as a PDF or
by hand. A handwritten note is still the most gracious way to say “thank you.”
Some communications, such as congratulating a patient on an exciting life
event or achievement or expressing sympathy at a loss, should only be sent as
a handwritten personal note. Such courtesies should not be lost in the rush of
daily communications; the personal touch will have deep meaning for the re-
cipient. This is a part of building and maintaining an ongoing relationship
with a valued patient.
 Computer: PowerPoint, computer animation programs, and other automated
functions can be used to educate and communicate with patients. These may
support or enhance interpersonal communication and education, but they can-
not replace them, nor are they the primary means of communicating. You are
in a personal services industry, so it is vital to keep it personal.
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 Multimedia: Whether you use computer messages or play video messages of
interest in your office, don’t allow multimedia to dominate the environment
or replace the personal connection, or you will simply lose your connection
with your patients.
 Display: Various items will be displayed in your office, such as skin care sam-
ples, tabletop posters, even the syringe tray setup on the examination room
counter. Carefully consider which items to display and where to place them.
Avoid clutter—too many diverse or unrelated displays are distracting to pa-
tients.
Connections With Your Patients
There are specific kinds of connections that only you (or you in association with key
staff members) will make with your patients. These include the consultation, physi-
cal examination, patient evaluation, discussion of treatment options, treatment plan-
ning, education about treatments, photography, patient instructions, and patient
consents. How you conduct these basic functions will have a direct impact on the
success of future interactions with your patients and your ability to convert them or
retain them.
Treatments and follow-up functions can seem routine, but they are an important
means of relating to your patients.
 Treatment: Until your patient accepts treatment, you will make numerous con-
nections for multiple reasons, all culminating in treatment. Whether the process
takes a few moments, several visits, several weeks, or even months of consid-
eration and time, treatment is the goal. All of the basics for connecting in your
practice—environment, greeting, function, administration, and closure—must
be conveyed with the same care throughout the patient’s experience. Your goal
is not to make the connection for this treatment alone; you are striving to sat-
isfy the patient’s desires and make the entire experience satisfactory.
 Follow-up: After treatment, three things seem to happen: (1) patients follow
procedures for a necessary visit, such as suture removal, or (2) they return
when something just isn’t right, and (3) sometimes they revisit the practice
when they desire additional treatment. Some practices suggest a follow-up
timetable, but they don’t insist on it or schedule it—they wait to hear from pa-
tients. Proactive practices employ one of the many communication tools avail-
able to stay in contact with patients and to follow up regularly. Whatever your
method of maintaining contact, follow-up must not simply be a rote post-
treatment necessity or a means of addressing complications. Meaningful, pro-
ductive follow-up is a matter of good practice.
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Managing or exceeding expectations does not result from a single marketing strat-
egy or any single connection you make with your patient; it results from the nu-
merous connections you make inside your office, using multiple communication ve-
hicles to achieve a satisfied and loyal patient.
Connections With Referral Sources
Within your practice, it is essential to connect with the people who are your sources
for referral and help you to grow your practice. Patients who refer others to you will
also return as patients themselves or will accompany their friends. You may see them
on social occasions hosted by your practice, or you may reach out to them regularly
to express gratitude and personally acknowledge their importance to your practice.
Other physicians, service providers, or your direct peers who refer patients to you
may connect with your office to refer, confer, learn, or observe. Invite them in, keep
them connected, and in turn they will continue to connect others to you. There are
important strategies for managing your referral sources, and keeping them connected
inside your practice.
 Remain personally connected: Remind others that you appreciate them as in-
dividuals, that they are important to you and are not just referral sources.
Greetings on the anniversary date of a major procedure, annual follow-up calls,
or a personal note any time will be welcomed.
 Remain clinically connected: Keep your sources abreast of new developments
in your practice or specialty regarding what is relevant to them or to the pa-
tients they refer to you. Rather than simply putting this in writing, invite them
in for a luncheon, seminar, treatment, or to observe. Keep them educated, and
they will keep others educated about you.
 Show gratitude: The most common reason for a disconnect with your sources,
next to arrogance, is failure to show your appreciation. If you cannot say thank
you, don’t expect future referrals.
Referral sources grow your practice from the inside-out, so keep them inside in as
many unobtrusive, personal, and appropriate ways that you can, manage your rela-
tionship with them, and the expectations you have for that relationship.
Business-to-Business Connections
Inside your practice you need to connect with and manage relationships and expec-
tations with sales, service, and patient resources—those whose businesses or products
support your practice or who want your support in their endeavors. These business-
to-business resources can be the most overlooked connections inside the office, sim-
ply because they are more often viewed as “selling” rather than “servicing.” When

connecting with resources, you certainly don’t want to tax your valuable time, nor
do you want to miss out on valuable opportunities:
 Screen and team: Screen all visits and functions for resources carefully before
agreeing to a meeting; make certain the time is well spent for both sides. As-
sign a team member to manage the relationship, review new products, data,
research, procedures, or services, and provide you with the most pertinent in-
formation so that you can make a reasoned decision.
 Pay attention: If you have only 10 minutes to meet, give that resource person
your full attention during that time. If you are not willing to devote time to
this individual, have a team member screen and report back to you; be sure
that team member follows up with the resource, because you never know when
you might need the one person you’ve been avoiding.
 Ask for data and analysis: Resources often come to you with an opportunity.
Expect and request data and analysis that show whether that opportunity
would be attractive to your practice. In doing so, your resource has the op-
portunity to connect, and you have the opportunity and the information to
make an objective judgment.
Outside-In
The most commonly identified marketing strategies are those that reach individuals
outside your practice and bring them in. Connecting from the outside-in is a more
complex process today than ever before. As author David Shenk noted in Data Smog,
a marketing publication, the average American encountered 560 daily advertising
messages in 1971, which rose to more than 3000 messages per day by 1997. Today
various groups, from Nielsen to the Magazine Publishers of America, report that the
average American may now be receiving as many as 6000 daily commercial mes-
sages—a truly overwhelming number. As a result, your marketing strategies must be
more targeted than ever. Four distinct strategies—advertising, outreach, directories
and media relations–must be engaged to create and maintain visibility, generate traf-
fic, educate others, and invite those on the outside to come in.
Advertising
Advertising is a form of communication that maintains your visibility to an outside
audience. This is a controlled communication that is an extension of your practice
in which you have total command of the goals, message, tone, and call to action to
be conveyed. Advertising messages can be disseminated through a number of vehi-
cles, ranging from print (billboards, newspaper, magazines, directories, and direct
mail) to electronic media (radio, television, the Internet, and other electronic delivery
channels).
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Advertising can be general and serve the simplest and most far-reaching goal: visi-
bility. It can also deliver a targeted message to an audience that is potentially inter-
ested in and responsive to your services. Knowing your audience and its potential
response is of primary importance when choosing the right vehicle to deliver your
message. This vehicle must be based on the demographic segment it targets and the
potential effectiveness of this message once conveyed. The need for creating and de-
livering paid messages and for measuring their impact on your practice is funda-
mental. Every advertising plan should be monitored and evaluated continuously
throughout its execution. Strategies that do not work can be modified. If you fail to
reach your intended audience, reexamine their demographic viability and interest
and reevaluate the vehicles used. Messages that miss the mark must be redefined.
Advertising Essentials
Advertising is the marketing strategy that most succinctly characterizes you and your
practice to the people with whom you have the least personal connection. Any suc-
cessful advertisement must:
 Address a specific goal: visibility, announcement, solicitation, education, news,
novelty, or compliance. Pressure tactics and price do not belong in advertise-
ments for medical services. Define your goals so that you can measure the suc-
cess of this connection.
 Call attention by making a visual and/or verbal connection to the audience
(headline). Who does this message need to positively attract?
 Clearly communicate your purpose, which may be as simple as visibility, or
as complex as announcing a new service (body). Use a tone that is attractive,
inviting, and familiar (words, images, colors). What is your message designed
to convey or accomplish, and to whom is it directed?
 Directly and clearly issue a call to action related to your purpose (how, where,
and why others should reply). Determine how you want others to respond to
this message.
 Tie all elements together concisely and consistently.
Whether you develop ads on your own, hire a professional agency, or allow the chan-
nel through which you advertise to craft your message, you must micromanage how
you, your practice, and your message are represented:
 Any paid message must be detailed and precise in its imagery and language.
To someone who does not know you, this introduction should convey profes-
sionalism. To those who do know you, it should be consistent with the pro-
fessionalism they have grown to expect.
 No aesthetic surgeon should allow any paid message to be disseminated with-
out personally reviewing the message first and feeling fully confident that it is
representative of his or her image and practice. Trust your intuition and judg-
ment if you do not feel comfortable with this message. You have worked hard
to build your image, and it is crucial that the message be true to your mission.
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Outreach
Outreach is any event or opportunity that allows you or a representative of your
practice to deliver a message of purpose. For an aesthetic surgery practice, outreach
creates visibility for you and your practice at a defined time when you or your rep-
resentative can personally extend your message. Through outreach, much like ad-
vertising, your practice must directly convey who you are and a concise message to
a target audience. Unlike advertising, where a message is concise and controlled,
through outreach, your audience and the vehicle or partner you rely on may take
control of the effort. The vehicles for your outreach strategies are among the most
varied, from traditional means such as holding an event to the rapidly growing out-
reach of social media.
Like advertising, outreach can put you in touch with prospective and existing pa-
tients. Outreach strategies individualized to your practice and focused on a specific
audience are often overlooked, despite the immense value they have to your practice
for renewing communications with inactive patients to remind them about your ser -
vices, or for referrals, or to maintain visibility. You have to reach out beyond your
practice to keep people coming in. Who better to reach out to than those who al-
ready have an established relationship with you? Some outreach efforts can be golden
opportunities to put you in the spotlight for individuals who are interested in your
services but are not yet ready to make an appointment for a consultation.
Beware of participating passively in an outreach effort that is shared or driven by
another group; make certain your image and message can be delivered in a predictable
manner with a set agenda. Participate in planning and carrying out these forms of
outreach, and make certain that you know the other participants and their expec-
tations and contributions as well as your audience’s expectations. Many aesthetic
surgery practices are hesitant to engage in live or social outreach because of the un-
predictable return on investment and lost time away from productive practice. How-
ever, most successful practitioners recognize that if you do not reach out to those in-
terested in your field of expertise and those in your geographic or professional
community, you cannot expect that they will reach in to engage you.
You may have discounted the value of some of the new social networking channels
of communication as too gimmicky for your taste, but online networking is here to
stay, and your practice can capitalize on the growth of these social media. The gen-
eration who will be your target population in a few years is extremely Internet savvy,
and you must be, too.

Twelve Outreach Tactics
No matter which of the many outreach strategies you employ, successful manage-
ment requires that you define goals and a call to action that will bring patients into
your practice.
1. Seminars/lectures: Seminars and lectures must be of interest to the intended
audience. Individuals must walk away having learned something beneficial to
them personally or professionally. Make certain you have a clearly defined
agenda and goals for your seminar, with an organized presentation, no mat-
ter who or how many are in the audience.
2. Treatment events: Treatment events may be as intimate as prebridal party
preparation, or an event that draws complete strangers to experience some-
thing new. Seminars are often combined with treatment events. Be sure that
the attendees are willing to participate and that all appropriate procedures
are followed, including screening of candidates, patient education, and in-
formed consent. Before anyone is treated, regardless of the procedure, con-
firm that you have consent to treat and that the individual is comfortable ac-
cepting treatment in the group. I personally don’t like treatment events that
go beyond aesthetician services, skin care, and cosmetics. Anything more is a
truly personal endeavor and should be provided in private.
3. Expos and trade shows: Trade shows and expositions can be hosted by any
number of businesses, or they can be a collaborative effort arranged by a mar-
keting company to bring together similar businesses. Expos and trade shows
take time, preparation, and the right staff to interact with and educate visi-
tors, and such events can be unpredictable. You may find yourself standing
idle or be very busy interacting with attendees. It is important to know who is
hosting the event, the audience who is attending, and the past history for this
event. Then you can gauge your time and investment accordingly. Do not hand
out samples of products unless you anticipate you will have enough and they
will be appreciated; bring ample, high-quality, branded information about
your practice and try to make beneficial connections. Offering things such as
complimentary skin analysis will draw people who ordinarily would not par-
take of your services—but you must understand that it is unlikely you will
ever see those people again.
4. Social occasions: Social occasions offer an excellent opportunity for net-
working, whether you are the host or a guest. Don’t arrive at your neighbor’s
cocktail party and hand out business cards, but don’t be shy about asking
people what they do so you can share what you do. Even among people you
know, social occasions are an important time to network. Put others at ease
in your company so that when they need your services or want to refer some-
one to you, they will not hesitate.
5. Philanthropic events: Philanthropic events are an important way for a physi-
cian to give back to the community and to create goodwill. You may find the
audience is not of the demographic you would ordinarily attract, but giving
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of your skill and time is recognized and appreciated. Make the most of it, us-
ing these occasions for media relations, announcements, and demonstrating for
your existing patients and referral sources that you selflessly give to others.
6. Viral marketing: Viral marketing is “the buzz.” It’s what you do to get every-
one talking, sharing, forwarding, listening, and engaged in your message for
reasons that sometimes have little to do with you. Although it may originate
as advertising, viral marketing is a ploy designed to be so intriguing, so in-
fectious that people share it.
7. Social networks: Social networks range from Facebook, Twitter, and MySpace
to LinkedIn and Yelp. There are general social networks for making friends,
and specific social networks. The premise of these networks is that you es-
tablish yourself with a profile (information about you), and then you network
with others on the site through blogs, chatrooms, email, and instant messag-
ing. These virtual communities have rules, but that does not prevent people
from acting dishonestly or maliciously. Social networks are for social discus-
sion and connection; they are not a place to give advice or solicit patients.
Even if you don’t engage in social networks, you should know what they are
and monitor them, because your patients may just be talking about you.
8. Sharing: Sharing is a means to post videos, images, and stories on YouTube,
Flikr, or a multitude of other sites. The reality is that although these sites are
affordable (no cost) and accessible, they are not an effective means to reach
out to a prospective patient or a wider audience. Such sites are generally un-
monitored and somewhat unrestricted, and you may find that your well-
intended message has morphed into something damaging to your image.
9. Blogs: A blog (the term is derived from Web  log) is an online “diary” on
which people post commentary, share experiences, ask questions, and engage
in conversations. Blogs are often read by those who don’t participate. Like so-
cial networks, blogs have rules, but sometimes it is unclear who is monitor-
ing to make certain participants follow the rules. Some physicians choose to
start their own blogs on their own website or intranet for patients to ask ques-
tions and discuss topics of interest. This may be beneficial to your audience,
but if you start a blog, you need to keep it fresh and moving. Much like so-
cial media, although you might not want to spend the time on blogs, you
should know what they are and monitor them carefully.
10. Reviews: Reviews of physicians, medical procedures, and beauty products are
available online. You may be the subject of a review and not know it; multi-
ple sites crop up that offer patients the opportunity to anonymously review
your practice and your services. The best way to know where you are reviewed
or discussed is to regularly search for your name and brand through a search
engine and see what listings come up. Contact the webmaster of any site that
has incorrect information about you. They will likely try to sell you enhanced
profiles; however, they must either correct erroneous information at no charge
or remove your information from their site.
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11. Wikis: Wikis (the term is derived from the Hawaiian word for “hurry quick”)
are sites with collections of Internet content that are interlinked and can be
accessed by anyone to add content. Wikis are for public education purposes,
not for posting about oneself.
12. Directories: Paid or unpaid, this is so large a category that although it was
once simply known as “yellow pages,” now it is an outreach strategy all its own.
Directories
Directories come in print, electronic, and Internet-based formats; they can be very
narrow (all the physicians on staff at your local hospital) or broad (the national di-
rectory of all members in your specialty society).
Measuring response with directories is essential to managing the expectations you
have for your effort. Exposure is the first consideration; who will see you, and how
will they find you? Then it is a question of what communication vehicle specifically
prompted an individual to act and contact you. Electronic directories have the added
advantage of built-in tracking mechanisms. However, such systems measure num-
bers, not the quality of connections. The most reliable method for measuring re-
sponse to any communication strategy you employ is to simply ask those who en-
gage your practice these questions and track the responses:
 Who or what referred you to our practice?
 Where were you exposed to a message about our practice?
 Where did you obtain the information you used to contact us?
Media Relations
Media relations include interviews, press releases, and story placement (publicity):
they provide opportunities for you and your practice to be a source for public in-
formation on the subject of your profession and practice. There are two ways to en-
gage national and major market media relations to garner publicity:
1. If you are a strong enough presence and personality who has significantly
greater value or standing than your professional peers, you can drive your
own media relations efforts.
2. If you are a strong, dedicated, and articulate personality who is active in re-
search or teaching in your specialty; in the local, regional, national and inter -
national professional organizations you belong to; and with companies who
manufacture or supply the treatments you administer or sell, you will have
value to a media outlet. You can garner media relations through your contri-
bution to these groups, either by driving your own media relations efforts, by
partnering, or by acting as a spokesperson for the group you represent.
You must accept how media relations efforts are driven and realize that if you want
reputable media coverage through channels that have value to your target popula-
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tions, you must adhere to the principles of ethical media relations, and to your own
principles.
Once you understand the principles of media relations, determine how you wish to
communicate with media, whether you want to direct your own efforts or engage
others, and the results you expect. Know who to contact to regularly update your
contacts. For your message to be effective, it must be placed directly in the hands of
the journalist who can most effectively use it to fulfill the interests of viewers, lis-
teners, or readers.
Essentials of Media Relations
Whether you engage the media or you are approached by a media outlet, there are
some media training basics to adhere to, regardless of how well you know or trust
a journalist:
 Make certain the journalist or media outlet has integrity and that your mes-
sage will be fairly and accurately transmitted.
 Prepare carefully for any meeting or interview. Ask for the specific focus and
your expected contribution to any comment or interview as well as an agenda
so you may prepare accordingly. Practice the dialog you expect to provide with
any journalist. When this conversation does take place, have any supporting
information you may wish to provide at hand for easy referral.
 Ask to review any portion of your contribution to a media effort for clinical
accuracy. This is fact-checking to ensure that you are not misquoted; it is not ed-
itorial control. Do not make the mistake of telling a journalist how to present
his or her story, or you will never again be a source for media relations.
 Protect patient privacy when media are present on your premises or when
speaking with media. Certainly the best story is a personal story; involve your
patients in a general way when possible and be candid about the effort. If a
patient agrees to participate in your media relations efforts, you must obtain
a release from the patient for his or her participation, whether this is to be in
person or through photographs, even if the patient is not readily identifiable
in the photographs. This cannot be a quid pro quo arrangement (in exchange
for free service) unless that service is nominal and unattached to the effort at
hand.
 Communicate effectively and consistently with any media organization. Pro-
vide supporting data, follow up all questions with supplemental information,
and be sure that you know when your contributions will be broadcast or
printed so your office staff will be ready to field any phone calls or inquiries
that result.
 Maintain the media relationships you develop with verbal and written ex-
pressions of appreciation, similar to what you do to maintain your relation-
ships with patients through correspondence related to patient care and inno-
vation.
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Advertising/Editorial Hybrids
Paid advertising today is often not limited to an ad; in many cases short articles, pro-
files, and even full-length feature stories can be bought in publications or on radio
or television. You may even participate in a special advertising section on a specific
theme in a local publication. Meant to look like unbiased editorial content, these hy-
brid pay-for-play efforts are commonly referred to as advertorials (advertisement 
editorial). These hybrids contain artwork and editorial content and are disseminated
or published for a fee. An advertorial can be placed in a defined section within a pub-
lication that is labeled as advertising, or it can be supplied content included in a lo-
cal publication. All hybrids, whether simple advertorials or paid programming, must
be contracted as advertising, and you must carefully review the fine print.
 Advertorial: Most ethical and credible publications will state clearly that ad-
vertorials formatted to look like articles are advertisements. A quality publi-
cation will distinguish any paid messages from editorial content that is re-
searched, attributed, and vetted as factually correct and balanced. Such a
publication does not want to lose its reputation for objectivity or confuse or
mislead its readers. They do not want to appear to recommend, feature, or
present a product or service that has not been researched and reviewed through
appropriate channels. If you are not willing to have the advertisement labeled
as such, then your intention is to deceive. If the publication allows an adver-
torial without labeling it as advertising, its policies and format should be clear
to readers so they can easily distinguish between paid and unpaid content.
 Special advertising section: Regional and metropolitan publications often in-
clude special advertising sections on a specific theme that allow a templated
advertisement (a photograph and a set number of words), or a mix of adver-
tising and content at special rates. If you know the context of the special sec-
tion and all the other businesses, products, or providers featured, and are com-
fortable being showcased among this group, a special advertising section can
be a positive method for reaching a focused audience. If the section is unlimited
in how many providers like you are included, or undefined in the selection
process of those features in the special advertising, it is best not to be lost in
a sea of unqualified providers or diverse and unrelated products and services.
 Paid programming: There have been many instances of television or radio pro-
grams that appeared and disappeared for which a physician was offered the
opportunity to be featured in a documentary, or to star in his or her own pro-
gram if he or she raised sponsorship dollars or paid a fee. The results of these
programs are questionable. What you spend on paid programming is better in-
vested both in time and money on efforts to connect with serious prospective
patients rather than those who randomly connect with your radio spot or tele -
vision debut.
 Pay-to-play: In pay-to-play, a medium offers to mention you in an editorial
context in exchange for your advertising. Although publications and programs
should support their advertisers, they should never be so brazen as to offer
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pay-for-play, nor should you demand such a deceptive practice. If you have an
established relationship with the medium, use it as a resource, and their rep-
resentatives will reach out to you with questions about your practice or up-
coming story ideas. If you cannot truly claim to be an expert on a topic, pay-
ing to be recognized as one will not yield positive results.
 Paid features: An interesting phenomenon has emerged that combines several
articles or program segments featuring various topics or physicians to create
a full publication or program. These paid features are just that: the opportu-
nity to pay and have a well-trained editorial team shape an article or a seg-
ment about you or feature you as the expert on a topic of interest, such as an-
tiaging treatments. Look carefully at the publication, the program, and all the
other topics and providers featured. In most cases, no matter how straightfor-
ward the professional intent, these are easily identified by your audience as
paid efforts.
ONLINE MARKETING TOOLS
ANDREW R. BERGER
Today one of the most important means of promoting your practice is through on-
line marketing tools. Your website creates a picture of you, your credentials, your
practice, and the menu of services you offer. Various communication tools can help
spread the word about what’s new with your practice, upcoming events, cutting-edge
procedures, and results. Newsletters, social networking, and blogs, among others,
are all part of the new media that are helping to define the current online commu-
nications that doctors and their practices need to understand and implement if they
want to grow their practices.
Your Website
A well-designed website that has been optimized for Internet search engines is also an
important and effective marketing tool, and if planned effectively, does not have to be
a drain on the practice’s resources. Rather, it can provide a positive source of new
patients and revenue and serve as an educational tool for your patients.
Design
Your visitors’ first online impression of your practice depends on your website’s de-
sign; therefore it should be both aesthetic and professional in appearance and easy
to navigate. Many visitors judge the quality of content within the website by the or-
ganization and design of the overall site. Your company’s logo and colors should be
used throughout the site, creating a consistent look and feel. Slight variations in de-

sign between different sections can enhance your website if used appropriately, but
drastic shifts in appearance can leave your visitors disoriented. It is essential that
your website’s design be unique to distinguish your practice from the myriad sites
offering similar services.
Content
Your website’s design invites visitors into your site; the content of your website should
hold their attention. Content is the core of your website. Even the most aesthetically
pleasing site will attract few users if it is not informative. Well-thought-out content
not only educates your visitors about your practice but also encourages repeat vis-
its. Furthermore, having relevant content plays a pivotal role in search engine place-
ment and greatly increases link popularity to your site.
Search Engine Optimization and Submission
Every day search engines (programs that search for and list Internet documents con-
taining keywords or keyword phrases) direct millions of Internet users to their on-
line destinations. It is likely that your website will receive more than half of its visi-
tors from these search engines. Therefore your website should be developed in such
a way that major search engines and indexes can easily catalog and search your con-
tent. Depending on the search engine, it can take anywhere from hours to months
for your site to be listed. Once optimized and cataloged properly, your site will gain
visitors who type in keywords relevant to your practice.
The various search engines frequently change their algorithms to ensure that they
get a variety of relevant results. There are a number of techniques you can use to
achieve more prominent search engine placement. None of these techniques will guar-
antee you the top spot in all of the search engines; however, following these principles
will significantly improve your website’s search engine placement.
Selecting relevant keyword phrases (not just keywords) proves exceedingly impor-
tant. For instance, in addition to selecting “plastic surgery” as your keywords, choose
“plastic surgery in Boston” or “Botox in Boston” as well. Be as specific as possible.
These keyword phrases should persist throughout the following elements of your
website: website title, uniform resource locator (URL; your website’s “address”),
meta tags, and content. Although sprinkling relevant keyword phrases throughout
your web design will improve your search engine placement, flooding your web pages
with keywords may have a negative impact. Many search engines may ban you for
overusing keywords, and your visitors will show little interest in content that is so
compromised by keyword phrases.
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An abundance of relevant text content is as valuable to search engines as it is to your
readers. Search engines catalog all the text information from each of your web pages.
The more text content information you have cataloged in the search engines, the
greater the chance search engine users will find your website in their query results.
Link Exchange
Link exchange is one of the most effective ways of attracting targeted visitors to your
website. Aside from search engines, most users find new web pages through other re-
lated websites. In a link exchange, the owners of two websites agree to place each
other’s links on their sites, usually for free. Understanding how to make the most of
link exchanges is crucial to increasing your site’s traffic.
Link exchange has a direct effect on your site’s link popularity, which is the number
of links that point to your website as measured by the search engines. Since the ob-
jective of search engines is to serve those sites that are recommended by many other
sites, most incorporate popularity factors into their ranking algorithm. The quality
of the sites linking to you, however, is being closely examined as well. Therefore it is
important to get links from popular websites whose content closely relates to yours.
Getting only a few links from popular websites will be more useful than getting sev-
eral links from less-popular websites.
The easiest way to look for link partners is through the search engines. Enter your
keywords to find out which sites get listed first, and then contact each site owner to
suggest a link exchange. If most sites listed are your direct competitors, come up with
related keywords instead. For instance, if your area of specialty is rhinoplasty, look
for sites that deal with other types of facial plastic surgery. You may also be able to
exchange links with related publications or professional associations. If you have an
online newsletter, submit its link to online directories that are reserved exclusively
for newsletters.
Visit a site before asking its owner for a link exchange. Try to personalize your link
request email instead of sending an automated message to every site. In your email,
always suggest a title and short description of your site that may be displayed on the
link partner’s website. Your main keywords should appear somewhere within the ti-
tle, the description, or both.
Aside from link exchanges, offering quality content on your website is an indirect
way to increase your link popularity. People generally link to websites that offer
unique and useful information and will do so without being asked. Another way to
promote your site is to allow other websites to display your site’s content in exchange
for a link back to you. In summary, the more links your site has from quality web-
sites, the more traffic your site will likely receive.
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Online Advertising
Aside from search engine submissions, you can market your site through pay-per
click or pay-per-impression programs. A pay-per-click program typically places a text
link or a banner ad to your website and charges you a flat fee each time a visitor
clicks that link to visit your site. Although a pay-per-impression program also places
a text link or a banner ad to your website, it charges a fee based on the number of
visits (impressions) to the web page your link resides on. When considering these
programs, select only programs that place ads on sites that attract visitors within
your target market. Generally, pay-per-click programs and text links have been shown
to be more cost effective than pay-per-impression and banner ads, respectively.
How Many People Visit My Website?
To effectively run an online marketing campaign, it is important to determine not
only your initial level of website traffic (the number of visitors to your website), but
also any changes to these traffic levels in response to your marketing activities. This
will help you assess the effectiveness of your marketing campaigns as well as the ac-
tivities of outside consultants or services you might hire to assist you. The web server,
which is a computer where your website resides, likely already has installed website
statistics software for tracking website traffic. You can communicate with your web-
site hosting company to determine whether you currently have one of these programs
available to you. If not, they can usually be added to the web server for about $100
to $300 a year.
eNewsletters
Newsletters are effective marketing tools that serve a dual function: educating your
patients and promoting your practice. With the growing popularity of medical
newsletters and the enormous interest in aesthetic surgery, it is only natural that a
well-constructed newsletter will provide an effective vehicle for communicating your
message to current and prospective patients. Although traditional newsletters can
still be effective marketing tools, eNewsletters provide some distinct advantages over
their print counterparts, both in efficiency and economy.
eNewsletters are a relatively inexpensive way to communicate with patients. Profes-
sional email marketing services can cost as little as $25 to $50 per month for an
email list of approximately 2500 emails and allow unlimited email marketing cam-
paigns to your list. By comparison, one traditional newsletter with print, design, and
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postage costs could amount to more than a year’s worth of email marketing service.
Keep in mind that most of these services require that your email lists are “opt-in,”
which means the emails within the list have been voluntarily given to you by your
current or prospective patients and have not been purchased. Although initially this
requires some additional effort to acquire and build your email list, your growing
list will lead to increasingly effective direct marketing campaigns.
Today creating an online campaign through an eNewsletter service is an easy process
and does not require technical training. These services provide you with simple tem-
plates and a wide variety of design formats. All you need to do is fill in your mes-
sage. Keep your message focused, and provide embedded links throughout the email
to various pages within your website, such as announcements of new services, hon-
ors received, new developments in plastic surgery, and office contact information.
Distribution is instantaneous through a click of the mouse and can be scheduled for
launch at any time.
A variety of features within these services will greatly aid in growing your eNewslet-
ter community while allowing you to efficiently run your campaign and track its ef-
fectiveness. Simple link features such as “Forward to a Friend,” “Update Profile/Email
Address,” and “Unsubscribe” will help you easily manage your eNewsletter sub-
scriptions. Consider selecting a provider that offers statistical information on the
number of subscribers opening the newsletter and visiting your website through em-
bedded links in your email campaign. These statistics can help you fine-tune your
newsletter based on your subscribers’ actions.
You can promote your eNewsletter by featuring it in brochures and other printed
materials and on your website. Choose a service provider that supplies a referral but-
ton within each newsletter for readers to forward the information to friends and rel-
atives and a sign-up button for these new contacts to join your subscription group.
Newsletters provide an inexpensive means for maintaining regular contact and build-
ing relationships with your current patients, as well as capturing and educating
prospective patients.
Getting Help
Admittedly, most surgeons don’t have time to personally develop their online mar-
keting program and will hire a company to handle the details. The descriptions pre-
sented here outline factors that are important in a successful online marketing ef-
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Part II  Business Basics
fort. The following are some important considerations for your online marketing
campaign:
 Purchase your own domain name: Make certain you purchase your own do-
main name and that it is on an automatic renewal system for annual registra-
tion fees. Domain names can be purchased for about $10 per year from a do-
main registration company.
 Use a website statistics package: To assess the effectiveness of your online mar-
keting campaigns, it is essential to determine not only your initial level of web-
site traffic, but also any changes that result from your marketing activities.
 Create a pleasing website design with relevant content: Develop a website
that is aesthetically pleasing to your visitors while educating them on the proce -
dures and services you provide. Websites full of relevant content are more eas-
ily “seen” by the search engines and are more likely to result in return visitors.
 Use eNewsletters as cost-effective marketing tools: These campaigns can help
you to promote your practice economically and efficiently while assessing the
potential interests of prospective patients by tracking clicks on embedded links
in your email campaigns.
 Establish link exchanges: Building large link exchange networks with related
websites can greatly assist in search engine placement. Remember that the qual-
ity of the incoming link is usually more important than the quantity.
 Enhance your potential for search engine optimization/submission: Keyword
phrases should persist throughout your website design: website title, uniform
resource locator (URL; your website’s “address”), meta tags, and content. Al-
though sprinkling relevant keyword phrases throughout your web design will
improve your search engine placement, flooding your web pages with key-
words may have a negative impact.
Concluding Thoughts
FOAD NAHAI
It is extremely challenging to develop and maintain a successful aesthetic surgery
practice, and not without significant financial risk. It requires hard work, planning,
and perseverance. Before setting any goals, the surgeon must assess his or her strengths
and weaknesses. We all have areas of interest, procedures that we excel in and oth-
ers that we don’t do as well. The practice should be built around the strengths of the
surgeon or surgeons, taking into account competing practices. For example, if there
are several surgeons in your community who excel in breast augmentation but there
are none who perform rhinoplasty, provided you have the skills and interest, your
practice should focus on rhinoplasty where you have an opportunity to gain signifi-
cant market share with little competition. A successful cosmetic medicine/aesthetic
surgery practice is built around patients and their needs. Surround yourself with
qualified, motivated staff members who share your vision and commitment to pa-
tient safety and customer service.

Clinical Caveats
 The practice model directly affects the surgeon’s working environment, control of
everyday decisions, financial independence, and flexibility of schedule.
 The total patient experience, including his or her encounters with all aspects of
the practice, is just as important as the quality of the result of a procedure.
 To run a successful practice, a surgeon must have a basic understanding of the
business aspects of daily operations and a budget and plan for reaching the goals
that will drive the practice.
 Regularly scheduled staff meetings nurture a sense of teamwork and emphasize
the important role everyone plays in the success of the practice.
 One of the best ways to attract patients is to become involved and to make your-
self available as a speaker and educator, as a source of information for possible
referring surgeons, as an advisor to support groups, and as a local authority.
 The patient coordinator serves as a vital link between the surgeon and the patient,
and must be able to connect with patients on a personal level and to instill in them
trust and confidence in the surgeon and the practice.
 Computer imaging helps to establish better communication with patients to de-
fine goals, develop an appropriate treatment plan, and effectively communicate
expectations by demonstrating what is and is not possible to achieve through sur-
gery and adjunctive treatments.
 A well-designed and optimized website is an essential tool in today’s aesthetic sur-
gery practice.
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Annotated Bibliography
Baum N. Marketing Your Clinical Practice: Ethically, Effectively, Economically. Sudbury,
Mass: Jones & Bartlett, 2000.
This easy-to-read practice management book provides helpful information on marketing
approaches to promote practice enhancement.
Beckham DJ. Marketing Your Practice—A Practical Guide for Physicians. Arlington Heights,
IL: ASPS Health Market, 1986.
This plastic surgery guide provides useful practice management advice in a loose-leaf
format.
Brown S, Nelson AM, Branhesh S, Wood S. Patient Satisfaction Pays. Gaithersburg, MD: As-
pen Publications.
This is a must-read book for anyone considering practice enhancement. It provides im-
portant information on strategies and practical approaches for dealing with patients.

Kuechel M. Aesthetic Medicine: Growing Your Practice. St Louis: Quality Medical Publishing,
2009.
This book provides an overview of the issues to consider in running an aesthetic sur-
gery practice with numerous practical suggestions throughout.
Nelson AM, Wood S, Brown S, Branhesh S. Improving Patient Satisfaction. Gaithersburg,
MD: Aspen Publications.
This publication provides helpful information on patient relations.
Starr P. The Social Transformation of American Medicine. New York: Basic Books, 1984.
This book provides an evolutionary account of American medicine since its inception.
It supplies an excellent background of the social factors that have influenced and con-
tinue to influence American medicine and insight into how American medicine has meta-
morphosed into a megamarketing industry today.
Suggested Readings
Albrecht K, Zemke R. Service America—Doing Business in the New Economy. Homewood,
IL: Dow Jones-Irwin, 1990.
American Society for Aesthetic Plastic Surgery (ASAPS) website for medical tourism infor-
mation. Available at
Antin HB, Antin A. The Entrepreneur’s Guide to Common Sense Marketing. Beaverton, OR:
The Antin Marketing Group Press, 1999.
Brown SW, Morley AP Jr. Marketing Strategies for Physicians: A Guide to Practice Growth.
Oradell, NJ: Medical Economics Books, 1986.
Hillestad SG, Berkowitz EN. Health Care Marketing Plans: From Strategy to Action. Gaithers-
burg, MD: Aspen, 1991.
Jeevan R, Armstrong A. Cosmetic tourism and the burden on the NHS. J Plast Reconstr Aes-
thet Surg 61:1423-1424, 2008.
LeBoeuf M. How to Get and Keep the Customer for Life. New York: Putnam, 1987.
McCormack MH. What They Don’t Teach You at Harvard Business School: Notes From a
Street-Smart Executive. New York: Bantam Books, 1986.
Naisbitt J. Megatrends: Ten New Directions Transforming Our Lives. New York: Warner
Books, 1984.
Poppe F. 50 Rules to Keep a Client Happy. New York: Harper & Row, 1987.
Portnoy S, Stromberg E, Newbold PA. Acquiring and Enhancing Physicians’ Practices.
Chicago: American Hospital Publishing, 1988.
Quick J. A Short Book on the Subject of Speaking. New York: McGraw-Hill, 1978.
Sach L. Do-It-Yourself Marketing for the Professional Practice. Englewood Cliffs, NJ: Prentice-
Hall, 1986.
Saltz R. Cosmetic Medicine and Aesthetic Surgery: Strategies for Success. St Louis: Quality
Medical Publishing, 2009.
Schenk D. Data Smog: Surviving the Information Glut. New York: HarperCollins, 1997.
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The Practice:
Staffing, Services, and Financial Planning

MARIE CZENKO KUECHEL
CHAPTER 7

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Part II  Business Basics
T
here was a time when an aesthetic practice was all about outcomes—the phys-
ical improvement that resulted from aesthetic surgery. Today, managing your
aesthetic surgery practice involves a combination of inextricably linked factors, in-
cluding producing good outcomes, interacting with patients, empowering staff mem-
bers who excel, providing services that meet patient needs and are priced affordably
yet profitably, marketing to promote treatments, and communicating to educate your
patients.
This combination is essential for achieving patient goals and managing a lucrative
aesthetic surgery practice in a competitive environment in which other providers
and multiple options vie for consumer dollars. Whether to invest in surgery or a lux-
ury vacation, a car, or even a piece of jewelry is a decision your prospective patient
must make; the answer depends on the physical desire and outcome, but also on the
experience. Although your outcomes and interactions with patients may be your re-
sponsibility and under your control, your staffing, services, financial considerations,
and marketing rely heavily on the efforts of others and on variables that may be out
of your control.
Managing your aesthetic surgery practice begins with staffing and services and in-
cludes your financial model and marketing strategies (which are discussed in depth
in Chapter 6). One might call these the core factors for aesthetic surgery practice
management.
Staffing
The staff members you employ will interact with your aesthetic patients. In most
cases these individuals are the first and last point of patient contact, perhaps even
the primary contact. They are your messengers, gatekeepers, spokespersons, and ad-
vocates. Before you consider whom to recruit and what qualities your team should
have, consider the diverse skills that staff must possess to work collaboratively. Ide-
ally, your staff should include four functions—service, clinical support, patient man-
agement, and administration—that are integral to managing your practice and achiev-
ing patient expectations. Whether employees or contractors, staff are part of your
team and essential to your daily operation.

Service Providers
Today’s aesthetic practice commonly requires more than a surgeon providing ser -
vices intended to achieve specific aesthetic outcomes. Physician extenders (physician
assistants or registered nurses) and, in many practices, aestheticians provide services
to complement aesthetic surgery or to achieve specific aesthetic goals that may not
require surgery. Fundamental to managing these individuals is the understanding
that this is your practice, these patients belong to your practice, and these providers
are an extension of you. They may be permitted or required to act autonomously
based on their individual expertise and on patient needs, but how, when, and to what
extent can only be defined by you, within the parameters defined by state law and
your profession.
Clinical Support
Whether exclusively supporting you in the operating room or fulfilling a dual role
of providing aesthetic services to your patients and clinical support to you and other
team members, clinical support staff are essential; no one can function alone. The
individuals who provide clinical support are essential for managing patient expec-
tations; they may be the ones who allay patient anxieties before surgery, administer
anesthesia, or provide assurance and comfort immediately after surgery. Or they
may be invisible to your patient, such as the scrub nurse who rarely ventures out-
side the operating suite or interacts with conscious patients. Those who come in con-
tact with your patients must accept the demands of managing expectations at all
times. Because of this intricate interrelationship among support and provider roles,
it is vital that the scope of service and clinical support functions be clearly defined
in job descriptions, be well communicated among the team members, and be appro-
priately scheduled.
Patient Management
The term patient coordinator has been coined to describe the role of the individual re -
sponsible for patient management. In some practices this function is performed by a
nurse or another clinical support person. Titles are less important than are the dedi -
cation and skills of the individual who fulfills the patient management function. This
professional is a vital contributor to your team and is responsible for managing the
entire patient experience, including all the documentation and related communica-
tions. The patient coordinator is the pulse-point for your patient. This is not a po-
sition to entrust to a commissioned, contract, or consulting individual; patient man-
agement must be a vested function in your practice. For an aesthetic surgeon who
is strong on clinical skills but short on interpersonal skills, the patient coordinator
is not merely a vital contributor; he or she is the most important member of your
team, because without this person, you may not have patients who will accept your
services. (See Chapter 6 for a detailed discussion of the patient coordinator’s role.)
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Administration
Office manager and receptionist are common administrative roles in the practice.
Most often these are full-time employees, but these functions can also be supplied
by office management consulting firms that assume responsibility for the business
aspects of your practice. Effective data management is essential to successful admin-
istration; this will take the least amount of effort if it is conducted in a timely, sys-
tematic, and well-organized fashion. Administrative roles may be very focused, or
broad based to include financial and operations management, property and facility
management, and human resources management. I don’t believe in hiring someone
whose only function is to serve as a receptionist; every person in the office must be
capable of and responsible for answering the phone and greeting visitors.
Your team may be lean, efficient, and diverse in their duties, or may include multi-
ple individuals and layers for providing service and administrative support. There is
no one model that characterizes all aesthetic surgery practices or a single operational
skill set held by all surgeons or business owners. It is important to recognize that
the number of providers, the pace of your practice (number of procedures performed),
and the mix that exists in your service model will all factor into determining the
right number of people to employ. In addition, your surgical team, whether provided
by the hospital or surgery center where you operate, or employees or contractors at
your own office-based or ambulatory surgicenter, will also influence the ultimate
number of team members you require. Your own surgical staff can multitask to per-
form preoperative and postoperative functions and even provide such services as in-
jections, making your team more diverse in talent, although more limited in num-
bers. An outside surgical team can free your in-office clinical staff to provide
appropriate nonsurgical services while you are in surgery, creating an added revenue
stream, or may carry out essential patient management functions. There is no single
model. What is more important than the number of people on your team is their
contributions and loyalty to the practice and to your patients.
Every person on your team must be loyal to you and to the practice. All team mem-
bers must thoroughly understand your specialty, as they should in any medical prac-
tice or business. In addition, they must be willing to continuously learn and keep
current with the advances in your specialty, even if that includes services you do not
provide. An aesthetic practice requires individuals who fully understand the unique-
ness of providing elective services and are willing to meet the expectations of pa-
tients who have very specific physical and experiential needs. They must be discreet,
warm, compassionate people who also know when and where to draw the line, be-
cause they will regularly become involved in the most intimate details of your pa-
tients’ lives, bodies, and choices.
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Recruiting
Throughout your practice career you will either need to hire more staff or to replace
those who leave, from the natural process of turnover or because they are dismissed.
In recruiting staff, two questions need to be addressed:
1. Where do I recruit quality staff?
2. Should I hire based on skills or personality?
Your staff, particularly those with direct contact with clients and patients, must be
chosen based not only on skill, but also on personality and presence. An individual
with the wrong personality or image for the position does not easily change, but
with the right foundation, skills can be honed or acquired. Personality is the critical
variable. Staff members represent your practice as much as you do. in fact, in almost
every case, they are the first in-person impression a patient receives of your practice.
They do not need to be a physical model of aesthetic perfection or a mirror of your
finest work. They do need to be articulate, kind, patient individuals who understand
that appearance is an important personal issue for the patient.
Where to Recruit?
When the need arises to fill a position, the best place to start is always from within—
to nurture current team members with the potential to fill the role, or to engage them
in helping you recruit other talented individuals with whom they will have to work
as part of your team. When you don’t find the right candidates among this internal
network, you should look outward, but slowly. Look to similar (not necessarily the
same) businesses or practices for the right basic skills and the essential personality
traits. You can train and educate a capable individual, but you cannot overcome per-
sonal or service deficiencies that will be obstacles to your patients’ having a consis-
tently excellent experience.
Screening
Recruitment only begins with finding appropriate candidates for the job. Critical to
recruitment is screening. Interviews should be conducted not once, not twice, but at
least three times and should include the following components:
 Email correspondence beyond the presentation of resume and credentials
 Telephone conversation for a set period at a set time
 Face-to-face meetings with other team members and with the physician on
one or more occasions
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Before or during the interviewing process, you must check the candidate’s references,
understand his or her salary expectations, and explain the need for drug testing, a
credit report, or other screening requirements before the individual may be hired.
As you get closer to identifying the right candidate for a position, two things are es-
sential: a demonstration of skills, and shadowing. Invite the candidate to spend a
few hours or a day within the practice to get a feel for the pace, position, responsi-
bilities, and office environment.
Once you have found the right candidate and have screened appropriately, you can
make the decision to add this individual to your team. But remember, this is a team—
so include other staff members in the decision-making process, because they will be
working together in managing and meeting expectations in your practice.
Qualities to Hire in Your Aesthetic Practice
Competencies and personality are obvious factors in determining whom you will
hire. From the front office staff to the scrub nurse, those on your team should also
possess the following qualities.
PRIDE
Taking pride in oneself, in one’s appearance and actions, in one’s work, in the
team, in your business, and the services it provides is essential in a service-oriented
business that is inextricably tied to appearance and self-esteem. Pride indicates a
sense of self-worth; this is very different from being arrogant with a sense of superi-
ority. It is important to recognize the difference and hire those who understand and
strive for excellence in all aspects of their professional and personal endeavors.
RESPECT
Respect is not simply reflected as deference given to the surgeon: every
team member must possess an appreciation of patients, vendors, housekeepers, other
staff members, and certainly the surgeon. Respect must also be paid to procedures,
systems, protocols, and patient privacy. Although you may not perform life-saving
procedures in your practice, they are life-changing for many, and they also carry the
potential for risk; staff must understand and respect these potential risks and the
impact these procedures have on patients.
A THIRST FOR KNOWLEDGE
Those you hire must want to both learn and teach on
a regular basis. Exceeding expectations in the aesthetic surgery practice requires a
strong and empowering connection between your staff and patients to educate them
beforehand about the possibilities, responsibilities, and limitations involved with
surgical procedures. In that process questions can arise. An educated staff with a
thirst for knowledge will always seek the answers they don’t have, confirm the va-
lidity of those answers, and convey these facts. You will also need to continually up-
grade your own skills, keeping pace with technology, techniques, and best practices,
and differentiating between valuable learning and overhyped training.
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HUMOR
The ability to laugh is essential in the work environment. It is also, in
good taste, a means to allay anxiety, to establish a connection, and to deal with stress.
Staff with a sense of humor and good taste have the ability to keep the team or a
patient at ease and engaged.
PATIENCE
A service business as intimate as aesthetic surgery requires people who
exhibit patience for the client, the process, and all associated emotions, details, and
potential complications. Efficiency is important, but not when it forces others to be
hurried, or to overlook details, or when impatience becomes obvious and affects
team cohesion. We all have moments when a patient or situation has taxed our tol-
erance; it is important to respond by regrouping, or revisiting the situation at a time
when everyone has a fresh perspective and the ability to focus again on the impor-
tance of the situation. Decisions or actions made impatiently are not confident de-
cisions or actions.
Training
Specific training was once thought to be an essential prerequisite to working in an
aesthetic practice. Today, however, we recognize that training is an ongoing process
in a service-oriented business. Although the foundation of the practice may remain
constant, the service mix may change to adapt to the introduction of new treatments,
technologies, and techniques. As much as your credibility is the core of a successful
practice, so also is the credibility of those who work with you. Clinical staff have a
duty not only to keep abreast of new information, but also to remain current on
skills and training. Encourage this, reward this, display the certificates, and commu-
nicate your staff’s level of knowledge and training to your patients. Recognition of
individuals’ growth in the performance of roles contributes substantially to their job
satisfaction and ultimately to employee retention. Administrative staff have a duty
to keep abreast of market, operational, and business knowledge. This should be re-
warded, and the value of advancement should be communicated to the entire staff,
because it will inevitably benefit everyone in the practice when administrators can
improve the skills that make the practice succeed.
Training Essentials
The aesthetic world is changing rapidly. It is essential that new skills, technologies,
and treatment protocols that add value to your service mix be thoroughly investi-
gated and honed before adding them to the service menu. Without training, whether
from a book, a seminar, a webinar, or other professional resource, you and your staff
cannot progress.
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Respond to trends. Learning about the trends and procedures you will not offer is
as essential as mastering new skills. Today’s patients are well educated and have ac-
cess to an overwhelming amount of information, both credible and of dubious value.
To respond intelligently to questions about the treatments and services you do not
offer, you need to first understand what those procedures are and be able to state
succinctly why you have decided that these do not have value for your practice and
your patients.
The aesthetic practice faces daily service and clinical challenges, but what is often
lacking is a long-range goal that challenges the individual to progress and grow. It
is important to seek new learning opportunities and to promote training that allows
you and your team to be stimulated by new, positive, and potentially lucrative op-
portunities.
Managing
Nurturing and growing your staff as well as managing them is critical to maintain-
ing a strong team. The human resources function is essential, no matter how small
your practice or how successfully and harmoniously your team members work to-
gether. Management basics include the responsibilities of hiring, payroll, benefits,
and policy. You may personally manage your team, or you may choose to empower
someone on staff to manage and make final decisions. You may choose to outsource
the payroll, benefits, and other human resources functions; you should outsource
drug testing or competency tests. Internally, there must be a decision-maker and
manager you can rely on to manage compensation, which includes all things pro-
vided to your staff in exchange for services: salary, bonuses, or commissions, insur-
ance, and even perks such as treatments. Forms of compensation should not be cho-
sen lightly; they should be researched and defined in your practice policy. The process
of reviewing staff contributions, goals, and growth is the most often overlooked ba-
sic component of a staff cycle in any small business, and it is inextricably tied to
compensation.
You must review performance annually as well as oversee the day-to-day methods
and competence with which your staff addresses your patients’ needs. We have all
seen the difficult patient, the one with unreasonable expectations. We have also seen
what happens when a staff member, innocently or during a moment of pressure, con-
tributes to a service failure or implies an unrealistic or unattainable outcome. It is
the manager who must resolve these problems for the patient and the team. Can the
team member be retrained, or must he or she be terminated?

There will be times when an employee must be terminated, whether for perfor -
mance issues, in response to economic pressures, or for other reasons. Whether it is
you or your manager who carries out the termination, this is stressful. Terminating
any individual requires adherence to guidelines defined by law. Acting within the
confines of your practice, you must progress with your remaining team, answer the
inquiries of patients, and carry out all the functions necessary to continue to serve
your patients.
Essentials of Staff Management
ENCOURAGE RELATIONSHIPS
Staff members should be encouraged to forge appro-
priate relationships with their coworkers, the aesthetic surgeon, vendors, and your
patients. Clearly state your expectations for the relationships within your practice,
and define your expectations for relationships outside your practice, whether fam-
ily, friends, or acquaintances of your staff. For example, value the patients who come
to you for services as a result of a personal or professional relationship with your
staff members, and define how you might—or whether you will—offer special pric-
ing, services, or perks to those individuals.
DEFINE BOUNDARIES
Some actions are simply not acceptable, such as when an em-
ployee contacts patients outside the office. An individual’s one-to-one contact for
reasons other than the professional needs of your practice is unacceptable. Other
boundaries include behaviors such as dress, manners, language use, and even the use
of office equipment or conducting personal business on office time. An employment
manual that defines everything from dress code to personal calls, Internet usage, and
personal use of office supplies is essential to defining and maintaining boundaries.
KEEP AN OPEN DOOR
It is essential that you maintain open communication with
your team about minor daily events or major concerns and about practice or per-
sonal issues that may affect an individual’s performance in your practice. Don’t dis-
miss a matter out of hand that seems trivial; listen, put it in perspective, and move
the conversation to important matters. Although you should not get involved in per-
sonal staff issues, knowing that a member of your team is going through a divorce,
the illness of a parent or child, or other problems that may hinder his or her ability
to work is essential to your leadership. An open door will help you remain apprised
of matters that affect the morale and pace of your office and will establish a level of
trust between you and your team.
MAINTAIN RECORDS
Human resource records include employment applications,
verification of eligibility to work in the country of residence, bonding, drug testing,
salary, raises, bonuses, benefits, and performance reviews, performance infractions
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and warnings, emergency contact information, certificates and licensure, added skills
(such as fluency in a second language), and essential health records (for example,
TB test results). These records are all essential to the business health of your prac-
tice. You may not wish to be the keeper of these vital records; appoint a trusted and
appropriately trained leader to manage this function on behalf of the practice.
LEAD BY EXAMPLE
If you expect a staff of timely, top-notch, talented individuals,
you too must present that standard. A surgeon who consistently walks in the office
moments after the first patient for the day has arrived but first addresses emails, mes-
sages, and other business sends the message that patients can wait. We all have bad
days, but you must consistently set a tone of mutual respect that demonstrates what
is acceptable behavior and what is not, and a tempo that is efficient and professional.
Team-Building
Recruiting and hiring staff requires immense effort; a weakness or void in a staff po-
sition is taxing for everyone. Loyalty among your staff, motivation for your team,
and rewards that recognize staff accomplishments are critical to staff contributions
and retention and help to maintain consistency and continuity in your practice.
Employees’ loyalty must be to the team, the patients, and the surgeon. The different
providers, functions, and personalities involved in managing your patients’ needs
and expectations are not mutually exclusive; success happens as a result of the team’s
efforts. Recognize that you are the team leader; your actions, decisions, interactions,
and transgressions will have an exponentially higher effect on the team than those
of any other individual. Set the bar high, and recognize that loyalty must be earned
daily; it is not intrinsic to your role as the surgeon.
Rewards are essential to motivation; various motivating factors spur different indi-
viduals. For some it is money; for others it is praise. Some are motivated by advance-
ment; others are inspired by the fulfillment and satisfaction they receive from ac-
complishing daily tasks and specific goals; and others are gratified by their role in
helping patients to achieve their desired outcomes. Motivate in a manner that is val-
ued by the individual and beneficial to the team. Motivate team members daily when
things work well, or when conflict is managed. Encouraging words and leadership
are essential in difficult times; without them morale and subsequent enthusiasm and
desire to meet challenging expectations will wane.
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Services
The outcomes you achieve from the services you offer are the basis for your rela-
tionship with patients. A service model in your practice consists of more than the
surgical procedures you provide; today it must include a multitude of nonsurgical
treatments that complement or are preparatory to surgery, refine surgical outcomes,
or stand alone as important services to fulfill your patients’ appearance-related goals.
Your service model is defined further by the menu, setting, and time in which you
or staff members provide these treatments. It includes the amenities you offer your
patients or the convenience and access to these services. It also includes the manner
in which you address what you don’t offer.
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Five Essential Teams in Your Practice
You may have a staff of three or 30; regardless, the following teams are essential to
collaborate on a number of functions within your practice.
 Clinical: Whether in the office or the operating room, those who provide service
or maintain records of service to patients must work together and meet as a team to
review everything from individual cases to processes, and even preferences in supplies
and scheduling. This team will also review and critically evaluate data on new proce-
dures, techniques, drugs, devices, protocols to determine what can and should be
added to the service offering, and what falls outside your scope of practice or stan-
dards for excellence.
 Operational: The people who keep patient traffic moving into and through the office
are a team that includes both providers and administrative staff. Everything from
waiting times for appointments, waiting times at appointments, patient data, payment,
and even difficult patient situations must be on the radar of this team, whose principal
goals are efficiency, attention to detail, and service.
 Administrative: Those who handle calls, questions, accounts receivable, and accounts
payable need to work in synergy and set the pace of the office. Information that is not
communicated, payments that are not made or received in a timely fashion, and data
backups and records that are not up-to-the-minute and secure all pose a serious threat
of failure within your office. This team must consistently stay on top of details.
 Patient services/marketing: Your service menu, amenities, pricing, patient expectations,
website, consultation materials, community efforts, and all the things that are essential
to attracting and servicing your patients fall under the purview of this team, who reg -
ularly check to see that correct, consistent, and timely messages, services, prices, poli-
cies, and other pertinent information are operational. Don’t discount this team if you
are a referral-based practice; their job is to also find and implement the most effective
means for maintaining contact with your existing patient base and referral sources.
 Quality improvement: A team of individuals who combine all of the key areas and
monitor safety, accreditations, and other vital compliance issues serve as the critical
eyes and ears of your practice. Their role is not nitpicking; it is quality improvement
and the motivation for all to continuously do their best.

The box lists the general models that shape a large portion of your practice, although
these options will not wholly define your practice. The interest in and demand for
innovations in nonsurgical procedures and treatments are burgeoning, but you will
not limit your model to one category; you are a surgeon. Purely surgical practices
are rare today; these are generally highly specialized and limited in the range of sur-
gical procedures performed. The addition of nonsurgical services to a practice often
begins with injections or skin care and may evolve to include energy, laser, and light-
based technologies. Nonsurgical procedures are outnumbering surgical procedures
nearly 4.5:1, according to the 2008 annual statistics of the American Society for Aes-
thetic Plastic Surgery (ASAPS). The increase in the popularity of and demand for
nonsurgical procedures and the nature of their delivery has created a need and de-
mand for physician extenders: licensed physician assistants, nurse practitioners, or
registered nurses and aestheticians who administer treatment prescribed by the physi-
cian. However, according to a 2008 survey by the Physicians Coalition for Injectable
Safety, 69% of aesthetic surgeons (board-certified plastic, facial plastic, or oculo-
plastic surgeons) perform injections themselves in their practices.
Essential Elements of Service
Managing expectations in a personal service–oriented business such as aesthetic sur-
gery requires looking at service as more than simply the treatments you provide.
SERVICE MENU
Service in an aesthetic surgery practice can be viewed in one of
two ways: as a diverse menu of items including surgery, nonsurgical treatments, and
retail products for sale; and as a focused grouping of interrelated services that stem
from your primary expertise—surgery. This includes skin preparation and rejuvena-
tion to accompany facial aesthetic surgery, or hair removal to refine a newly sculpted
leg or abdomen. It involves treating scars that have resulted from skin disease or sur-
gery. Your service menu may promote other services, such as a patient who has re-
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Service Models for an Aesthetic Surgery Practice
 Cosmetic: Medical services that are elected to improve, enhance, or change personal
appearance. You are dedicated to medical solutions that address the physical and emo-
tional needs of your patients.
– Surgical: A portion of your services is dedicated to surgical solutions in your accred-
ited on-site facility, an ambulatory center, or a hospital.
– Nonsurgical: Patients are treated medically, not with scalpels or by making inci-
sions.
 Retail: Products that are required or that enhance or extend your services are sold to
your patients.
 Spa: Services are provided in a luxurious and pampering environment. However, you
don’t need to call your practice a spa to surround your patients with warmth, comfort,
and a relaxing environment.

ceived injections of fillers and who now desires the more extensive and permanent
results of a face lift. It may extend to a hair removal patient who likes her leg ap-
pearance and decides that she also wants her saddlebags improved for a total sculpted
look. The service menu must be up-to-date: procedures, products, pricing, and pack-
ages. It is important to review data regularly to identify trends and measure produc-
tivity and profitability.
SERVICE SETTING
Your practice setting is anywhere you offer services or meet and
engage your prospective and current patients—your office, a surgicenter, a medical
spa, or a satellite location. If you have more than one site, the atmosphere, appoint-
ments, privacy, and amenities offered should be consistent at all locations. There
should be a connection, where one setting is an extension of another and all loca-
tions work together in concert.
TIMES OF SERVICE
There are two approaches to the times you provide service to
your patients—the times you designate that you will be available, and those times
you make yourself available to meet patient needs. In a truly service-oriented prac-
tice, patients who request or require evening or weekend appointments get them.
Surgery schedules are not defined by the physician alone; they are scheduled accord-
ing to availability and the patient’s recovery needs. Because you cannot be there for
all types of services at all times, you must provide for supervision as appropriate and
for physician extenders to respond to patient needs.
SERVICE PROVIDERS
If your practice is to manage expectations and create an ex-
perience that is consistent in service and outcomes, all team members must be ser -
vice providers, and their titles and goals should reflect that focus. The patient expe-
rience is shaped not only by the results achieved through an aesthetic treatment, but
also by the connections he or she makes with each service provider.
The Operational Trilogy
An aesthetic surgery practice must focus on three distinct service entities: medical
services, personal services, and retail. Each aspect has a distinct function, individual
goals in fulfilling patient needs, and a unique contribution to revenue. Although each
can stand alone, it is the synergy among the three operational segments that has the
greatest value.
Medical Services
The medical treatment a practice provides, who the providers are, and where treat-
ment is provided define medical services. Your skill and care and that of your clini-
cal staff and supporting administrative staff represent the character of your clinical
operations. The office, surgical facility, and postoperative care provided represent
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the comfort of your operations. In an aesthetic practice the focus of care rests on
ability, plus the basics of character and comfort:
 How and where do you conduct consultations?
 Who is your patient support advocate?
 Where are diagnostic tests performed, and how?
 What is the consent protocol?
 What is the preoperative protocol?
 Where is the operating room? How does it function?
 Who provides anesthesia and preoperative, surgical, recovery, and postoper-
ative care?
The process by which you provide services to each patient builds an expectation that
you must meet or exceed for every occasion in which this patient is treated. Aes-
thetic surgery today is not a linear equation, one where the relationship begins when
the patient comes to you for desired treatment and ends with a positive clinical out-
come. The relationship is cyclical for two very distinct reasons:
 Nonsurgical treatments, commonly referred to as cosmetic medicine, are ther-
apies that must be repeated, intensified, or changed to produce or maintain
results. These may serve as a springboard to surgery as an individual continues
in the patient cycle. If you cannot fulfill or maintain the treatment cycle, you
have broken the cycle and lost the patient.
 Happy patients are your best source of success and growth. Keeping happy
patients in an active cycle maintains your visibility with them and reminds
them of the value of your services. This will bring them back to you for dif-
ferent or added services, or they will refer others to you.
Personal Services
The services you provide are highly personal in nature. Whatever the extent or range
of your service menu, the principles employed by the personal service industries are
essential to your patients’ experience and overall satisfaction. Personal services are
reflected in the way you deliver treatment: by using clinical means to arrive at a phys-
ical outcome without the experience feeling medical; by practicing medicine with a
team of talented, dedicated individuals who provide medical service while applying
the principles of personal service; and by delivering an experience that is wholly
based on personal fulfillment for the patient.
Some aesthetic surgery practices not only apply personal service principles to med-
ical practice, but they also enhance the medical practice by adding true nonmedical
services. Many practices thrive without them, some offer personal services but don’t
emphasize them, and still others call special attention to the personal services pro-
vided. Some of these personal services may be seen as nonessential, such as cosmet-
ics, massage therapy, concierge services, and a car that delivers your patients home
after a procedure.
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Definitions of medical services, personal services, or retail within your aesthetic sur-
gery practice are straightforward. They intersect in the manner in which you pro-
vide them and in the outcomes, safety, ethics, and privacy that characterizes their
delivery. Although treatment may create temporary pain, stress, and even fear, a suc-
cessful aesthetic practice will create a positive, encouraging environment that does
not discount these real conditions. Meeting or exceeding patient expectations re-
quires the personal services of providing comfort, individual attention, and positive
support.
Concierge Services
A concierge is often defined as a professional who assists guests in a hotel or mem-
bers of a specific community, such as a condominium complex or a country club. In
an aesthetic surgery practice, the term concierge encompasses the evolving concept
of concierge services. It implies the ultimate in personal service to assist your pa-
tients in every aspect of the aesthetic experience. In reality, concierge services sim-
ply reflect common sense and common courtesy.
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The Potential Impact of Personal Services on Your Practice
Personal services may have the following effects:
 Generate revenues or add expenses: They may produce revenue or increase your cost
of operations or your investment in inventory. They may occupy space and require
utilities, insurance, marketing, or other essential expenses.
 Enhance your mission: Cosmetics were introduced in medical practices to help pa-
tients disguise birthmarks, scars, and acne, or telltale posttreatment signs such as red-
ness, or bruising. They have evolved with science and improved formulations to
become an integral part of the aesthetic practice, not only for correction and camou-
flage and for completing the full aesthetic experience for your patient, but also for
maintaining results, protecting the patient’s rejuvenated, youthful appearance, and
nurturing the skin.
 Create opportunity: Whether to improve your patients’ experience, your ability to
serve them, or to invite a new audience to your service business, nonmedical services
must create opportunities for you to grow without having a negative impact on your
resources or image, or your patients’ experience.
 Nurture ongoing relationships: Whatever the service, whether it is brow waxing or
biofeedback, personal services that by their nature will be repeated by a happy cus-
tomer keep your core services continually visible to that client/patient, thus creating
a greater opportunity for your single greatest source for clients: referrals.

You may feel that concierge practices are excessive for most of your patients or are
not right for your service model. Nevertheless, don’t overlook the special needs some
patients may have, and weigh the value of such services to your practice. Keep in-
formation on file for a concierge service that is willing to learn your business, un-
derstand your expectations, and serve your patients.
Retail
The goods that your practice sells must complement your services, but they also have
some independent characteristics. Retail requires appropriate accounting and inven-
tory, including the collection of sales tax. In some practices, retail goods are the only
sale on which commissions can ethically be paid. They require an investment in in-
ventory, typically carry a 100% markup, and necessitate close monitoring of inven-
tory (as any retail function does) so that stock can be maintained appropriately for
patient-client demand and be accounted for. Sales of retail products are enhanced
by effective displays, but such items also attract theft. Products can also be sampled
or tested, unlike the surgical procedures and services you provide.
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Components of Concierge Service
 Attention: Your patients and their needs should always be the central focus of atten-
tion. A concierge in the very best hotel would never keep a guest waiting long for an
answer; likewise, you should not keep your patients waiting.
 Service: Concierges arrange service, where and when you want it. Likewise, in your
aesthetic surgery practice, house calls or preoperative in-person checks on your pa-
tients who recover at home are appropriate, especially when patients may not want
to be seen in public or have limited means to travel.
 Accommodation: A concierge makes travel plans and helps travelers who are in unfa-
miliar territory. Patients may travel significant distances to see you, whether you are
the closest geographic choice, are practicing in a choice destination, or are the pre-
ferred choice. Patients deserve assistance with travel arrangements for getting to, stay-
ing at, and enjoying your location. It is hospitable to do so.
 Comfort: A concierge is the person to call with your special personal needs for com-
fort when traveling. Coordinating postoperative needs, whether these are for skin care,
garments, amenities, or a place to recover, is good practice. It is inappropriate to per-
form a laser treatment on a client’s skin, then send that person home with instructions
stating, “Apply baking soda compresses and a coating of petroleum jelly for 4 days.”
Either provide the instructions far in advance so the patient can plan accordingly,
or send the client home with the items he or she will need.

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Once clients use and are satisfied with retail items, the expectation is that they will
continue to purchase them from you. This creates an ongoing revenue stream and
brings the client back to your business regularly to purchase more. These repeat vis-
its represent opportunities for maintaining the visibility of your other services.
Retailing in an aesthetic practice entails more than a patient’s choosing a product;
it requires that the physician or physician extender recommend the proper product
to treat or prevent skin conditions, promote healing or healthy skin, prevent or reverse
the effects of aging, and encourage renewal. Today even products sold in the drugstore
tout these benefits and more. If you choose to carry retail items to satisfy your pa-
tients’ needs, you should not sell a product unless you can confidently say that it is
effective. If it is sold in a nearby drugstore or department store, make certain you
can compete for dollars before you invest in inventory.
Retail can be a vital service complement and business component in an aesthetic
practice, but for staff who sell or recommend products to patients, training is criti-
cal. Designate specific personnel to staff your retail operations; in some cases they
will fulfill the retail function in addition to other roles. For the retail function to suc-
ceed, you must insist on staff training in product knowledge and sales technique.
Putting products on the shelf and expecting that the client will ask about them is in-
effective. Practitioners must find opportunities to recommend products. Sales sup-
port staff must expand on this recommendation and further recommend comple-
mentary products.
Skin Care
Your skin care choices must not be random selections; they must offer a reliable
complement to your practice and its service menu.
Choose products based on the quality of their ingredients, packaging, texture, smell,
and ability to stay fresh. Look for unique properties, clinically proven benefits, ease
of use, safety, and established brand reputation with vendor support.
Critical Elements of Skin Care
 Exclusivity: Products must be those that can only be purchased through a physician.
 Expectation: Products you sell must provide a distinctly better or different result from
that of products purchased elsewhere.
 Science: The research behind the product is consistent with medical research stan-
dards, testing, and approval.

Rules of Retailing
Retailing skin care or other products that support your aesthetic surgery services is
not as simple as stocking the shelves. Skin care, cosmetics, and at-home mechanical
or light-based devices are valuable extensions to your practice, but they cannot sell
themselves, and if they are misused or misguide your patients, they tarnish your im-
age rather than creating value. Heed these caveats for in-house retail operations, a
satellite medical spa, or an e-tailing operation:
 Do not sell prescription-strength products unless you have a patient record,
an in-office visit, and a prescription on file for the patient.
 Do not sell products you are not familiar with or would not recommend to
patients to treat a specific condition.
 Do highlight products by problem and solution and by product type and brand,
and do list complementary and conflicting products. There is no use selling
someone something that results in distress instead of solutions.
 Do highlight brands. Consumers look for recognized, well-known names.
 Do collect data on those who purchase products from you. You’ll want to
know not only what they are buying from you, but also from other sources,
with what frequency, and how they choose to mix and match. Most of all,
you’ll want to know when they stop buying, what they stop buying, and what
they are asking for that you may not presently provide.
Financial Management
Financial planning and management are essential to any practice. These involve pro-
jecting income based on goals, related direct expenses, and overhead costs. Finan-
cial management of your practice requires understanding some core elements of fi-
nance: income and expenses. Income and expense decisions all factor in managing
expectations that, on the most basic level, include your business’s profitability, your
personal income, the income and benefits you expect to provide to your staff (which
may not be the same as what they expect to receive), and the service benefits your
patients expect in exchange for what they are willing to pay.
Whether you are in an established, lucrative practice or one that is just beginning
and is heavily leveraged, you must comprehend and participate in your financial
planning. A plan in which you project, allocate, expense, adjust, and use all of these
variables to set reasonable goals is the only means to control the practice’s financial
operations. To keep these details up-to-date and consistent with expectations, you
will need an internal bookkeeper and outside advisors who may include an accoun -
tant, a banker, and an investment professional. Although you may trust your ac-
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countant to tell you whether you can afford to invest in a new piece of equipment
or a new facility, it is ultimately your decision, and you must understand the basic
concepts of financial management.
ASSETS
Your greatest asset—aside from your surgical training, skills, and certifica -
tion—is the data you have on your patients and the relationship you have with those
patients. Unfortunately, it’s rare that one can put a monetary figure on this asset.
Most often assets are measured as tangibles that have worth; assets in your practice
equate to property, equipment, and inventory (retail, drugs, and devices), your cash
on hand, and the financial investments of the practice, such as retirement plans. Prop-
erty, equipment, and inventory can all be financed, and they all can serve as collateral
(used as security for financing these specific items or other endeavors). Assets in gen-
eral can appreciate, as a retirement account would grow with interest income in a
healthy economy. They can also depreciate, both for tax purposes and in terms of
true worth. Technologies often depreciate quickly as they are replaced by newer and
more powerful technologies. Tangible assets and your expectations for them are
clearly defined on the balance sheet. But recognize too that you must manage your
intangible assets—your clients and patients, referral relationships, and your image.
While these don’t carry a dollar value that you can leverage, they do carry immense
value that is essential to your success. Nurture and monitor your patient flow as
carefully as you monitor your tangible assets.
CASH FLOW
Cash flow is the amount of money you have on hand based on the in-
come from services and what you must spend to stay in business on a daily basis. A
healthy practice makes effective use of cash so you are never out of it, but also so
you don’t have large amounts of cash on hand uninvested in your practice or in other
lucrative ways.
DEBT
Debt comprises the total of what you owe in principal, interest, penalties,
on your line of credit, on credit cards, and even in utility bills and property taxes.
Debt, like financing, may be short or long term.
LEVERAGING
The concept of leveraging is simple: you borrow money to fund your
practice or practice growth, planning that what the business makes will cover your
investment and interest. Taking it one step further, leveraging also means that the
cash you generate will also be enough to fund new endeavors, technologies, proce-
dures, practices, or facilities in the ever-advancing world of cosmetic medicine. Short-
term borrowing is for things with a low cost, potentially a short life, but a high cash
return. Long-term borrowing is for things with a high cost, a long life, and a pre-
dictable return. Leasing is for things with a high cost, a short life, and a predictable
return.
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Part II  Business Basics
PROJECTIONS
Generally tied to your tax cycle, projections are used to forecast
what you might earn and spend in operating your practice. But projecting requires
more than predicting your future based on the past year’s taxes, or planning for the
year ahead based on the outcomes of financial reports associated with your taxes.
Projections must take into account your strategic plans for growth and what you
must borrow, any necessary expense consolidation, economic cycles, risks, and new
trends and opportunities. Projections are a forecast based on multiple factors, in-
cluding the past, your knowledge of your patient base, and long-range adjustments
in overhead.
Attempting to operate a practice in which nothing is predictable, with no plan or
projections, will result not only in expectations that are unachievable, but also in a
business that is unmanageable. Even if you practice simply for the love of what you
do, you need to stay solvent.
Tracking income and expenses is more than an accounting function—the empirical
characteristic of financial matters allows you to make some important business de-
cisions about how you practice. The accounting function also provides a basis on
which to develop and revise policy, procedures, or pricing; identify losses and gains;
and make valid business decisions.
The Importance of Planning
FOAD NAHAI
Despite our love of medicine and the challenge of surgery, operating an aesthetic surgery
practice is a business, and issues of solvency, cash flow, and profitability must be ad-
dressed. You cannot operate a business that continuously loses money. Without a plan,
you will likely find yourself with cash shortfalls and an inexplicable balance sheet, un-
able to succeed in focusing on what you do best: serving the needs of your patients.
All of this planning may seem a burden, and it is, but what is more burdensome is
failing to plan and then looking for a reason to explain unmet goals. If history is docu-
mented as it is made, it is more factual, more effective, and more flexible. Fortunately,
you don’t have to be a financial wizard to do this, and you don’t have to do it yourself.
You and your partners can work together to define your tactical and fiscal goals and
then work with a trusted accountant or financial advisor who can put it all together.
As I have learned, the best way I can contribute to my practice is by maximizing my time
providing service so the practice can succeed. Your reputation and that of your practice
is built on the premise of your service, and you are an integral part of that “brand” and
must help sustain it.

Income
Income goals require that you understand how you make money, and how that
money is used within your practice to pay for the items necessary to operate the
business and to make your practice function. Patients will pay you by one or more
of the means described next.
CASH
Most staff are trustworthy and few actually steal, but the easiest thing to
take without being noticed is cash. It’s easy for an employee to avoid recording a
transaction when a patient pays cash, or to hide cash paid for services with a low
cost of treatment, such as procedures outside the operating room that need no clin-
ical support, such as skin peels, microdermabrasion, waxing, and massage. Cash be-
comes an even greater liability when it is used to pay for skin care or cosmetics; if
the employee pockets the money, you lose out on revenue as well as the value of
your inventory. However, you cannot banish cash from your practice. Patients some-
times want to pay with cash for convenience, to avoid debt, or to avoid any trace of
the transaction. If you recognize more or fewer transactions or an erratic cash flow
over time, start looking for the cause.
CHECKS
Personal checks are still a means of doing business, although they repre-
sent a much smaller portion of transactions today. The advantage of personal checks
is that electronic banking now allows immediate deposit of funds into your account.
The disadvantage is that if funds are not available in the patient’s account, you will
need to collect. This absorbs staff time, and it will cost you money while you wait
to get paid or if you must go to collection. Establish a clear policy that fees are to
be paid at the time of service and that deposits for surgery must clear days before
the procedure. Define a collection policy for returned checks, or do not accept per-
sonal checks in your practice.
CREDIT AND DEBIT CARDS
Convenience, rewards, travel miles, and financing are
among the reasons a patient may use a credit card. These transactions add security
for you as well as your customer, but they also come with a cost of doing business
(fees to the credit card company).
Accepting payment by credit and debit cards is not foolproof. A too common situa-
tion, unfortunately, is that of an unhappy or debt-ridden patient who has been known
to dispute charges in an effort to avoid paying. While this is in resolution, you don’t
get paid. With credit and debit cards, disputed charges represent a loss to your busi-
ness. The easiest way to avoid disputes is to have a contract for services. But in aes-
thetic surgery, defining “return” procedures is not something you want to interject
in managing your patient’s experience. Enact security practices with credit cards: in-
struct your staff to discreetly pay attention to the name on the credit card, and match
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signatures. Make certain all servers and connections where credit card and other
personal information is stored are secure. It is naïve to think that there is no risk
with credit and debit cards: identity theft is rampant, and your business may suffer
if a scammer obtains your patients’ personal credit card or private health care in-
formation. No matter how blameless you may be, a con artist who accesses a pa-
tient’s or your private information will severely damage the patient’s experience with
your practice.
GIFT CERTIFICATES
Selling gift certificates is big business. It allows either a non-
surgical service or a specific dollar amount to be given. Laws regarding gift certifi-
cates or gift cards and their expiration vary from state to state. Never allow gift cer-
tificates to be issued for surgical procedures, and never limit gift certificates to a
specific procedure—the recipient may not be interested or may not be an appropri-
ate candidate, and as a result you will be viewed as restrictive, and the gift-giver will
feel unappreciated.
PATIENT FINANCING
Options in patient finance abound, and practices regularly
offer financing programs to patients on high-ticket items such as surgery. But given
the cost of doing business, administrative time, and fees paid, there is a value judg-
ment to make in offering patient financing for fees in the hundreds rather than thou-
sands of dollars. Surgeons who offer financing on relatively low-priced services are
taking a big chunk out of their compensation; you should establish a minimum
amount for financing. Set a limit or define a policy on when patient financing is of-
fered and what it can be used for in your practice.
BARTER
Quid pro quo is the oldest principle in business. You provide my skin care
services, and I’ll refer patients to you or promote your spa in my salon—there are
many permutations of this. The question becomes: Does barter benefit the practice
or the provider? Barter can be beneficial, because without collecting cash you are
reducing taxable income. Although barter is easy, don’t diminish the value of your
services—barter for what they are worth. Set rules for barter so that each party is
mutually benefiting, not one party benefiting at the other’s expense. Proper account-
ing for barter is essential, or any analysis of your model will be flawed.
You must account daily for any income collected by the practice. A daily closing not
only maintains balance, but also provides important tracking data. With daily clos-
ings you’ll notice discrepancies sooner, such as cash transactions that are rapidly
falling off. From daily closings you can chart the trend of your most productive days
in procedures and product sales. From this you can also plan staffing more produc-
tively. And if you look closely, you might even determine whether busier days can
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be attributed to more productive staff, or the trends in time your patients like to
schedule services or make purchases.
Projecting income is essential to managing your practice. Unfortunately, although
expenses can generally be detailed, budgeted, and allocated in a very defined man-
ner, planning income is frequently overlooked and is not always easy to predict.
Commonly, practices use a historical basis and apply a reasonable increase based on
economic factors or projected growth to arrive at projected and budgeted income.
Rarely is income budgeted and broken down in an aesthetic surgery practice as specif-
ically as in other business segments. Why? It is not that this is unreasonable; it is just
that it is not easy. You must project income based on the following:
 Clinical service fees: Fees are broken down by reimbursed or insurance work,
aesthetic surgery and aesthetic medicine, by service and provider. Surgery and
anesthesia fees, if collected by your practice, should not be accounted with
your practice’s clinical service fees. These are facility and anesthesia fees, even
if the anesthesiologist is an employee. Revenue generated by anesthesia is an ad-
junct, not direct revenue to your clinical fees.
 Personal service fees: Aesthetician and other nonphysician, non–surgically gen-
erated revenue is broken down by service and by provider.
 Retail: Retail income is budgeted by each brand and product.
Why is so much detail required? Before even applying direct expenses to each in-
come line item, you will have an easy indicator of your greatest source of gross rev-
enue. Then, once you apply direct expenses, you will have an indicator of all net rev-
enue. Compare the two and see whether your highest gross revenue is also your
highest net revenue producer. If not, you must review the direct expenses attached
to that revenue producer to find out why a disparity exists. You can also use these
factors to do the following:
 Build growth on your greatest source of net income, your cash cows (this is
easy logic).
 Develop or retool those services where income and direct expense can improve
(translate to cash cows).
 Retool or eliminate services for which income and related direct expense re-
sult in a low net income. Retooling is valid if you can reasonably improve net
income or if you cannot eliminate a service. Elimination of any service that
yields a poor net income may mean a reduction of revenue, but it also allows
an increase in productivity. In turn, this allows an increase in time commit-
ment to the services that result in a better return.
In addition, budgeting income in such detail allows you to plan your direct expenses
accordingly and maintain appropriate inventory.
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Expenses
Expenses come in two specific streams: direct expenses and overhead. Direct ex-
penses are relative to income. An increase in income or service may carry an increase
in the expenses directly tied to providing service. For example, if you perform a
breast augmentation, you will need the appropriate implants in inventory; the more
breast augmentations you perform, the more implants you will need to purchase for
inventory, which will increase your expenses. In a less direct equation, if you increase
the income projections from personal services, such as clinical skin care, you must
also account for the increase in related expenses, including all additional staff, sup-
plies, and even the additional communication that will be necessary to grow that
segment of your business. In greater detail, direct expenses include the following.
COST OF TREATMENT
The cost of treatment includes single-use items for the cost
of treatment such as breast or other implants, units of Botulinum toxin, syringes of
dermal filler, and single-use packaged chemicals for peels; these are easy to allocate
to each procedure performed. Technologic devices must also be considered a cost of
treatment; however, how you allocate that cost is something only you can define
based on the cost paid for the technology, the cost to operate it, and its depreciation.
GENERAL SUPPLIES
General supplies include gauze, needles, cold packs, alcohol,
gloves, and other disposables. It’s difficult and time consuming to directly assign
these costs to a treatment, so an estimate should be used to define a global supply
cost to assign to treatments.
BACK BAR
Back bar products include cleansers, volume chemicals, masques, mas-
sage oils, and skin care products used for treatments. These items cost you money
and may be a source of waste or an easy target for theft, so it is essential to main-
tain an inventory and account for the use of all products. Either estimate a global
cost to apply to each treatment, estimate a specific cost depending on the type of
treatment, or include this as part of overhead, but in any case, attribute it to cos-
metic medicine and keep an inventory.
COMPLIMENTARY TREATMENTS
Whether testing a new treatment, providing treat-
ments for staff, or as a thank-you or a touchup, complimentary treatments cost you
something. Record this and compare what complimentary treatments cost you to
the value they bring you. Complimentary treatments are an important part of demon-
strating the value of treatments, creating walking billboards for treatments, testing
new treatments, and showing goodwill or reward. I favor complimentary treatments
far more than discounts for adding value.
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DISCOUNTS
Procedures must always be recorded for their full price; discounts must
be recorded as an expense. You must have a measure of how much discounts truly cost
your practice to determine whether they have value, such as generating increased sales.
Expenses also include what you pay providers and staff. There are multiple models
of compensation, and combinations among the models.
HOURLY WAGES
Wages are paid for time spent on-site, whether the individual is
productively engaged in treatment or not. This is most often the least expensive
model, but also the most likely to result in nonproductive time when disruptions to
scheduling occur. If you pay hourly wages to providers of cosmetic medicine, make
certain their job description includes duties to be undertaken when they are not ac-
tively performing treatments.
COMMISSIONS
Commissions can be paid on product sales. It is unethical to pay a
commission to someone who converts a patient to accept treatment. By doing so
you would make a medical treatment a commodity; this is not a car, a stock sale, or
a real estate transaction. Therefore you must not commission booking procedures.
Higher commissions are typically paid for commission-only models; lower commis-
sions are commonly coupled with hourly wages. Commissions can be individual or
can be team based. Commissions can drive people to sell, to compete for sales, and
to up-sell; that is, sell more than the patient was originally willing to buy. Carefully
consider the relationship of commissions to your image and your client base and de-
termine whether commissions create incentive and value, or pressure.
DIRECT PERCENTAGE OR SET FEES
Direct percentage or set fees are more common
with contractors than with employees. The provider receives a direct percentage of
the revenues collected, or a set fee for specific treatments provided. Or the contrac-
tor may actually make the collections and pay you a direct percentage or a set fee.
OVERHEAD
Overhead expenses are those incurred regardless of the pace of your
business or income projections. These can be variable for many reasons. For instance:
 Rent or mortgage is easily defined and likely unchanging in a yearly fiscal plan
(unless you refinance or default on a payment and incur penalties).
 Compensation of salaried employees and benefits to those employees are also
easily defined and likely unchanging, although a rehire at a different compen-
sation level or change in benefit plans could result in changes to overhead.
 Insurance and utilities are easily defined and unchanging, unless you have a
claim, the cost of utilities dramatically changes, or your utility consumption
changes.
 Taxes and interest expense are also defined as overhead, but they are not un-
changing. Income changes, tax law changes, your write-offs change, the prin-
cipal of your debt is paid down, you refinance, or you acquire more debt, and
these all influence your overhead.
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There are countless examples of just how easily defined overhead expenses in an an-
nual cycle can be variable, and how all of the variables tied to your business oper-
ations require a solid, detailed fiscal plan, including appropriate projections. So even
though changes in direct expenses are theoretically relative to income and overhead
is static, in reality, none of this is entirely predictable.
Limitations
Although few of us like to admit to limitations, we all have a maximum capacity as
to what we can reasonably accomplish. Limitations include:
 Physical limitations to what you as a provider can physically accomplish
 Fiscal limitations to what you as a businessperson can economically manage
 Legal limitations defining requirements and limitations for you as a physician
and businessperson
It is essential to your success and personal well-being that you recognize and accept
the limiting factors that are outside your control while setting personal practice-
defined limits that are within your control.
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Projections and Overhead: Finding the Right Balance
FOAD NAHAI
Obviously, projections and your budget cannot always cover every contingency; there
are always surprises that will be encountered in any practice. (Who could have imagined
the breast implant crisis of 1992 or the recession of 2008/2009 and the impact these
events had on plastic surgery practices?) However, a comprehensive set of projections
taking the big picture into account will help you to weather unexpected blips in your
forecasts.
Although one receptionist may be sufficient, a surgeon may choose to have an extra
receptionist to provide better service and minimize telephone hold time. Similarly, a sur-
geon may choose to have a second nurse in the clinic to provide greater coverage when
he or she is seeing patients. These extras are not essential but undoubtedly enhance the
patient experience and make life easier for the surgeon. These “luxuries” come with a
price, and the surgeon who is not aware of the finances of the practice can easily drive
overhead to unacceptable heights. Similarly, an office-based surgicenter owned by the
practice may also be looked at as a very expensive luxury. During a downturn, staff can
be cut and operating rooms closed, but the tax, mortgage, or rent on the facilities re-
mains unchanged. Although cutting staff may reduce costs, patient safety and the patient
experience on which your practice has been built must not suffer.

Financial Limits
In any business there are always financial limits to consider. Even a seemingly “un-
limited” cash flow has limits. Why spend something that will not generate a positive
return for your practice? If your answer is merely because you want to and you have
not done the groundwork to ensure that this contemplated expenditure will yield a
benefit to your practice, then that purchase is not for the benefit or success of your
practice; it is for your own personal benefit or pleasure.
A financial limit is simply the maximum a provider is able to or willing to spend on
a given item. It is not how one overcomes financial limits that is essential to manag-
ing your practice; what influences your ability to succeed is how you approach fi-
nancial limits, including allocations or adjustments of expenditures, or the demands
you place on productivity or operations to maximize your return on those expendi-
tures, and the adjustment of goals and objectives. In business there are three options
for managing financial limits: borrowing, decreasing expenses, or increasing revenue.
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Physical Limitations
FOAD NAHAI
We all have physical limitations, even though our busy schedules would sometimes
suggest otherwise. Few of us can deny the reality of what we feel after a day filled with
surgery and seeing patients has concluded and we are still reviewing charts, writing
chapters, preparing talks, working with PowerPoint, and planning our early-morning
flight to present at a meeting in a remote location. Although it may seem glamorous, it
can be exhausting.
Clearly, there are limits to what can be accomplished in any given period in provid-
ing service, managing the practice, meeting patient expectations, and fulfilling profes-
sional, educational, and organizational obligations. The goal is to expand the limits to be
able to grow the practice without overtaxing your ability to manage this growth. This is
best accomplished by finding other ways to add to growth and income that do not incur
additional time commitments on your part and may even afford you some extra time to
see more patients. These include adding support staff, adding services that expand your
treatment options, hiring providers that complement your specialty (such as an aesthe -
tician or dermatologist), and modifying facilities to provide more room for expanded
services and activities.

BORROWING
Will borrowing directly contribute to your success? Hardly. It will
have an impact on your bottom line by requiring interest payments on debt. Al-
though that is straightforward, borrowing will contribute to your success only if it
includes well-reasoned related approaches to either decreasing expenses or increas-
ing revenue through enhanced services, operations, image, or all of these things.
DECREASING EXPENSES
How aesthetic plastic surgeons responded to the economic
downturn that hit hard at the end of the past decade is proof that a practice can de-
crease expenses without affecting the patient experience. Decreasing expenses must
be done in such a way that it does not damage outcomes. You can trim little bits all
around, such as finding a more cost-effective supplier and rethinking utilities
providers, insurance, or even your communications budget. The sum of a little can re-
sult in a lot of savings, but only if it does not diminish services, jeopardize the qual-
ity of care, or lead you to fall short of your goals. If you must take future steps, con-
sider what is nonessential, or what is not fundamental to providing the services that
produce your practice revenue.
Often the reaction is to find larger cuts rather than trim a little. For example, you
may find a staff member or two who are paid more than the average for their posi-
tions. However, before you consider replacing one individual with someone else with
a lower compensation range, consider the current employee’s loyalty and the con-
tributions he or she makes to serving the interests of patients. Can you risk the over-
all patient experience by bringing in an unknown person? What you reduce or what
you spend must all be equated in value. If there is real value in an expense to your
practice and trimming or cutting that expense will have a negative impact on your
practice, you must make a value judgment. Manage your expectations with those of
your patients; decreasing expenses to meet your needs, but falling short on meeting
your patients’ needs, may cost you far more than you ultimately could expect to save.
INCREASING REVENUE
The third option for addressing financial limits is increas-
ing revenue. Will a slight increase in fees affect services or traffic? Can productivity
be enhanced to make more time for billable service, and if so, how might this affect
quality of care? Can conversion or retention be improved? Can traffic be increased?
What will any of these things cost to accomplish? Increasing revenue should reflect
the success of your practice, but only when it is relative to the effort and expense
necessary to do so, and when it does not have an impact on what your patients ex-
pect of you.
When you determine how you will approach your financial limitations, you need to
adjust your goals and strategic, financial, and applied plans. Define what you will
do to address and resolve your financial limitations in your strategic plan. Revise
your budgets and projections accordingly. Track all that you do along the way and
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the resulting impact on your practice. Unless you do this, you will not know if your
approach was correct or where it may have faltered or failed you. Make adjustments
and corrections, and continue to manage the situation.
Concluding Thoughts
Managing a practice is a challenging but rewarding endeavor. Effective staff man-
agement and careful fiscal planning are key to producing a well-run and profitable
practice. Obviously, the surgeon’s skill and reputation is the foundation of any prac-
tice, but this must be supplemented and complemented by a staff that is well trained,
loyal, responsive to patient needs and expectations, and attuned to quality. With the
right systems in place, a carefully thought out menu of services, a trained and re-
sponsive staff, and the appropriate fiscal controls, a practice can respond to chang-
ing trends and provide a solid platform for future growth.
Clinical Caveats
 Managing expectations is key to managing your practice. Managing the patient
experience comes first; but your expectations, the expectations of those you employ
and even of your community, along with the very real expectations of your fam-
ily all must be managed, every day. The principles, practices, and strategies of man-
aging, staff, services, and finances are essential to managing your operation. But
to truly succeed, you need to do more than simply follow the path where the aes-
thetic surgery and service industry meet; you must navigate that path daily, im-
plementing these essential concepts:
– Goals: Short or long term, narrow or broad, you need goals. Goals for revenue
are fundamental, goals for your time, your staff, efficiencies, patient satisfac-
tion or retention, growth, continuing education, even goals for self-enrichment
give you a target on which to set your sights and attain. At a minimum, pen a set
of goals and review and revise them annually. At an optimum, each day define
a new goal, or revisit and refine just one of the goals on your agenda.
– Quality: Perfection is an absolute: once you attain perfection you can only
plateau, or, as the world around you moves and changes, potentially you may
slide. Strive for quality—giving your best, being the best, expecting the best,
and encouraging it. Quality does not always require great expense, but it does
require attention to detail, care, and respect.
Continued
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Part II  Business Basics
Clinical Caveats—cont’d
– Consistency: Every day is a new day, every patient a new case, every challenge
a new opportunity to succeed. The variables and people within your practice
are diverse. So that you do not lose site of your goals or jeopardize quality, your
approach and expectations must be consistent. Define who you are, what your
patients and you expect, and be unswerving in how you go about delivering
your service.
– Flexibility: Rigid people, practices, and policies have no room to “give.” In a
dynamic world, you must be flexible and sensible. However, stretching has its
limits; reach too far and you risk injury. Set policies, rules, and boundaries, and
within them, allow for the flexibility necessary to achieve your goals while main-
taining quality and consistency.
– Balance: In your aesthetic practice, strive for harmony in more than the results
of your surgical skill. Your practice may be the dominant force in your life, but
it is not and must not be the only thing that rules your world. Find balance be-
tween your practice and your life outside your practice. Family, friends, interests,
and passion for someone or something other than your patients will help you
to appreciate the goals you have set for yourself, the quality exemplified within
your practice, and the rewards it brings you in income and satisfaction.
Suggested Readings
Gladwell M. Blink: The Power of Thinking Without Thinking. Boston: Little Brown, 2005.
Gladwell M. The Tipping Point, How Little Things Can Make a Big Difference. Boston: Back
Bay Books, 2002.
Harvard Business Essentials. Performance Management: Measure and Improve the Perfor -
mance of your Employees, Watertown: Harvard Business Press, 2006.
Kapferer JN, Bastien V. The Luxury Strategy: Break the Rules of Marketing to Build Lux-
ury Brands. London: Kogan Page, 2009.
Kuechel M. Aesthetic Medicine: Growing Your Practice. St Louis: Quality Medical Publish-
ing, 2009.
Saltz R. Cosmetic Medicine and Aesthetic Surgery: Strategies for Success. St Louis: Quality
Medical Publishing, 2009.
Sarkar D. Lean for Service Organizations and Offices: A Holistic Approach for Achieving
Operational Excellence and Improvements. Milwaukee: ASQ Quality Press, 2007.