In May 2001, when Terri Bowling, 42, walked into the Steliotes Dental-Medical Spa in McMurray, PA, for laser hair removal, she thought her husband had given her the perfect Mother's Day gift. "The technician wore a long white coat, had all these certificates on the wall, and said she'd been doing this for a while," recalls Bowling, who was looking forward to never having to shave her legs again. Once the procedure started, however, she began to worry.
"The pain was worse than childbirth," Bowling says. "Every time she zapped my legs, the skin would come off. I could see a purple checker pattern forming. By the time I got home, my legs were swollen to twice their size and covered with fluid-filled blisters."
The next day, an emergency room physician diagnosed Bowling with second-degree burns. Back at the spa, she discovered that the woman who had performed the procedure was a cosmetologist — and that the only doctor associated with the spa was a dentist, who'd used his license to purchase the laser.
Bowling filed a complaint with the Pennsylvania State Board of Medicine. The spa owner, Theodore Steliotes, DMD, was fined $1,000 for practicing medicine without a license, and Bowling received a small settlement from his malpractice insurance.
She was lucky compared with Shiri Berg. On December 28, 2004, the 22-year-old college student planned to head to Premier Body Laser and Skin Clinic in Raleigh, NC, for laser hair removal. At home, she covered herself with a numbing gel the clinic had sold her to prepare her skin. But as she drove to the spa, Berg had a seizure. She soon lapsed into a coma and died 8 days later.
An autopsy concluded that Berg had suffered lethal brain damage from an overdose of the numbing gel, a potent combination of lidocaine, tetracaine, and phenylephrine. Under North Carolina law, doctors are supposed to take a medical history or perform a physical exam before writing any prescriptions. Premier had no doctors on site, yet the staff routinely dispensed the gel, which is safe only on small patches of skin. The state medical board concluded that Premier's medical director, Ira David Uretzky, MD, had exhibited unprofessional conduct. His medical license was suspended for 6 months.
Birth of the medical spa
There's nothing wrong with medical spas in concept — or, in many cases, in practice. Dermatologist Bruce Katz, MD, who opened the first medical spa in 1999, says his patients had been asking for something like it for years. "A lot of our patients were telling us that they went to spas and got massages and facials but that they didn't get any lasting benefit from the treatments," says Katz, who is director of the Cosmetic Surgery & Laser Clinic at Mount Sinai Hospital in New York City, as well as medical director of Juva Skin & Laser Center. "We thought, 'Why can't we have a relaxing spa setting, but with a dermatologist doing things that really work?' "
The combination proved alluring. These hybrid facilities have become the fastest-growing segment of the $11 billion spa industry, according to the International Medical Spa Association. By 2004, there were approximately 400 medical spas, or medispas, across the country. Now there are about 2,000. The problem is that not all medispas deliver on both parts of the promise inherent in the name. Yes, you can get a facial and a pedicure at a medispa — along with a chemical peel for your crow's-feet, Botox for your wrinkles, and a laser treatment to whisk away sunspots and excess hair. The one thing you might not get is the attention of anyone with a medical license. And that can be dangerous.
"I don't think a lot of people think of themselves as patients when they walk into these places, but they should," says Michael McGuire, MD, communications chair of the American Society for Aesthetic Plastic Surgery. "It's not like going to a beauty parlor or the cosmetic counter. These are medical treatments."
They are indeed: Anything that affects the structure or function of the skin qualifies as a medical procedure, as defined by most state medical boards. That means it must be performed by a doctor or supervised by one. The catch is that states have very different rules about what supervision means. So in Louisiana, only a physician or dentist can wield a laser — while in Florida, a doctor can "supervise" the treatment from an office 75 miles away. A medispa must have a doctor as a medical director, but in many states, he or she may visit only periodically and may not be available in case of problems. Sometimes the medical director is a "ghost doctor" who never sets foot in the spa but simply leases the use of his name.
"In medispas, you can have untrained people doing procedures without proper supervision in unsafe settings," McGuire says. "I've seen some pretty god-awful-looking results."
The price of cut-rate beauty
The increase in medispas has been accompanied by a jump in reported problems. A 2003 survey of members of the American Society for Dermatologic Surgery showed a 41% increase since 2001 in the number of patients coming for help after a skin treatment botched by a nondoctor technician. Laser and light-based treatments seem to cause the most trouble (nerve damage and scarring in addition to burns), but chemical peels, microdermabrasion, and other treatments are not risk free. Researchers have reported some appalling cases. In a Northern California spa, an esthetician trying to remove a tattoo from a woman's ankle used a pumice stone and glycolic acid. When the woman's ankle became infected, the esthetician told her not to worry, but after 10 days the woman went to an urgent care facility. The doctor there said that if she'd waited much longer, he would have needed to amputate.
Medispas often offer low prices on popular treatments like Botox — a major lure for customers. But when you see the corners that can be cut, the deals don't look so good.
Allergan, the only maker of FDA-approved Botox, for example, sells every vial at the same undiscounted price: $505. Because a low-price spa can't economize on the Botox itself, it must find other ways to cut costs, says Susan C. Taylor, MD, a spokesperson for the American Academy of Dermatologists.
One solution: using workers who have minimal training and experience. If Botox isn't injected properly, eyelids may not open all the way or eyebrows may droop until the effects of the toxin wear off. Mistakes can occur even when a doctor does the injection, but, says Taylor, "there's a big difference between a physician-supervised, trained nurse practitioner and an inexperienced medical assistant who might be earning $13 per hour. You can lower your price if you're paying workers $13 an hour."
'Expensive water'
There can be another explanation for a suspiciously good deal. Allergan sells Botox as a powder, which should be mixed with 2 cc of sterile water before use. But some spas may stretch their supply by adding more water, says McGuire, who's had patients come in after a $99 medispa special, complaining that the Botox had no effect. "I always say that the patient is not getting cheap Botox, she's getting expensive water," says McGuire.
Does that mean that a medical school diploma on the wall provides perfect protection? Of course not: One of the most notorious of Botox counterfeiters was Idaho physician Ivyl Wells, MD, who was sentenced last December to 6 months in jail for using cut-rate botulinum toxin labeled not for human use. Criminals aside, though, doctors can prevent a multitude of mishaps.
He or she needn't actually be hands-on for the procedure, says dermatologist Katz, who heads the medical advisory board for the Medical Spa Society, a trade group. Technicians perform many of the treatments at Juva — but at that medispa and others like it, every customer sees a doctor first for a medical history and treatment plan. And a doctor is always at the spa when procedures take place.
That means prescription-strength medications can be used in pampering treatments: At Juva, the anti-aging facial sometimes includes fluorouracil, a drug that destroys precancerous cells (in higher doses, it's used in chemotherapy). Spa goers can get a full range of medical procedures, including laser treatment using whichever of several different kinds of lasers is best for their skin. Many less-reputable medispas have only a single laser, which may not be right for some customers. And with a physician down the hall, a technician can call one if, say, a suspicious-looking mole is noticed during a massage.
When problems arise
The doctor can also step in if a problem arises, says Patricia Farris, MD, a clinical assistant professor of dermatology at Tulane University. That can be critical, because no procedure is without risk. Take the skin "polishing" treatment known as microdermabrasion: It's widely used and generally safe, but Farris saw it go wrong in her office. As her technician treated one woman a few years ago, "every single place we touched turned into a giant hive," Farris says. The danger signal suggested an allergic reaction called angioedema, in which swelling can obstruct the throat and prevent breathing. "I had to give her emergency injections of antihistamine and cortisone," says Farris, who published a report of the case in Dermatologic Surgery.
Doctors have a breadth and depth of knowledge that can be sorely missed, as Jordan Miles, 52, found out. In October 2004, the stay-at-home mom visited a medical spa in Panama City, FL, to have some sunspots on her back removed by laser. The technician who sold her the treatment assured her that it would be relatively painless.
To the contrary, recalls Miles: "It felt like they were sticking a hot curling iron to my back. Within an hour of leaving the spa, I was in severe pain and throwing up. When I went to a doctor, he said I had second- and third-degree burns. About a week later, they started oozing and turned into sores."
The problem was actually quite simple and easily avoided by anyone with basic medical knowledge. Miles was tan. A laser works by zapping cells or unwanted hair with highly focused light; the light is absorbed by pigment in the targeted cells, which heat up so much they're destroyed. But when the patient is tanned, the surrounding skin can be badly burned, too. The treatment also presents special risks for African Americans, Hispanics, and people of many other ethnicities, even if their skin doesn't appear to be highly pigmented.
"It's not necessarily the fault of the device but how it's being used," says dermatologist Vic Narurkar, MD, an assistant clinical professor at the University of California, Davis, and past president of the American Society of Cosmetic Dermatology & Aesthetic Surgery. "And it's not only about technical ability. It's about knowing when to treat and when not to treat."
Making spas safer
It's a common complaint that laws change only after someone's been hurt. In the case of medispas, there have been plenty of injuries and at least one death, but the laws remain an inconsistent and threadbare patchwork. After the death of Shiri Berg in North Carolina, a state legislator in 2005 introduced a proposal that would have stiffened the training requirements for technicians providing laser treatment. It set off a firestorm among cosmetologists and other groups and was amended so many times that its sponsor finally withdrew it from consideration.
Something similar happened in California, where then-state Senator Liz Figueroa introduced one bill making it a misdemeanor for anyone but a physician, nurse, or physician's assistant to use a laser device, and a second bill requiring a doctor to be in the spa during any laser or other cosmetic medical procedure. But the law that was signed last year simply ordered the state medical board to review the issue and adopt new regulations by January 1, 2009.
The Medical Spa Society is developing voluntary standards for the industry, says Katz. The rules will compel spas to have a physician on site anytime a medical procedure is performed and will make it crystal clear that the term medical procedure applies to many of the treatments most commonly performed at medispas — laser hair removal or skin resurfacing and injections of Restylane or Botox, along with therapies like microdermabrasion.
But it's likely to take at least a decade for the regulatory kinks to be worked out. Until then, the responsibility for a good outcome rests on the shoulders of the consumer. "You have to know the people, the place, and the product," says McGuire. "That's the only way to ensure you have a good chance of getting the result you want and that you won't wind up with a catastrophe."
Nearly 3 years after Jordan Miles tried to have her sunspots removed, her back is still so severely scarred that she can't wear anything sleeveless or cut low in back. Terri Bowling's foray into a medispa in search of a bargain has permanently altered her lifestyle. Once an avid scuba diver, she had to give up the sport because she can no longer go in the sun. She hasn't worn a skirt, dress, or pair of shorts since 2001. And she still has to shave her legs.
Shiri Berg no longer has to do that.