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Dermatologists and plastic surgeons no longer have the corner on the aesthetics market. Shrinking reimbursement levels from traditional insurers have prompted health care providers ranging from gynecologists to ophthalmologists to add aesthetic services — a strategy that allows them to capture some of the cash flow that cosmetic procedures provide.

The baby boomers are making this specialty quite lucrative: More than 10,000 people turn 50 every day, and this portion of the population holds 75% of America's wealth.¹ Refreshing your appearance with a dermal filler injection or undergoing a laser procedure to rejuvenate your face has become much more affordable — and much more accepted.

Baby boomer interest in nonsurgical cosmetic treatments is not limited to our patients, however. The many NPs who fall in this age range are looking more closely at what aesthetics can do for them in terms of enhancing their practice revenue — as well as their appearance. And a growing number of NPs who were once employed by physicians to provide aesthetic services are now running their own businesses offering a range of minor cosmetic procedures. Surveys by ADVANCE for Nurse Practitioners show that 3% of NP-owned practices focus on aesthetics.

But not all practices reap the rewards of this growing specialty. The competition is fierce, and it seems to be growing each day. Therefore, it is imperative that you spend time and effort on research, education and training before adding aesthetic services to your practice. This article shares information about how to get started with these important steps.

Research and Regulations

Before adding any aesthetic procedure, investigate it thoroughly. Make sure you can provide the selected service in your state, and confirm that your insurance policy will cover you for it. For example, a malpractice insurance carrier may cover an NP for a variety of advanced procedures but exclude botulinum toxin type A (BoNTA; Botox) injections.

Regulations governing supervisory and training requirements for NPs who decide to incorporate aesthetic services vary widely among the states. After adequate training, NPs can safely administer BoNTA and dermal fillers and perform laser hair removal, cellulite reduction, body shaping, spider vein treatment and acne treatments. But not all states agree. Your state scope of practice may not allow anyone but a physician to perform certain aesthetic procedures. Or, it may require supervision by a licensed provider such as a dermatologist, plastic surgeon or another type of physician. In some states, you may be required to have an electrologist license to perform laser procedures (such as in Florida).

It is crucial to become informed and then stay abreast of regulatory changes affecting aesthetics practice. State regulations can be filled with ambiguity, and some outright contradictions among agencies have been documented. Do not count on anyone else to do the research: Check with your own board of nursing to determine what you are allowed and not allowed to do. Some physicians are not supportive of nurse practitioners performing aesthetic procedures, and several medical associations have issued position statements to this effect. Be prepared for negative attacks, and stand ready to defend the clinical quality of your care.

In addition to complying with relevant regulations and rules, it is important to adhere to the same clinical practice principles that apply in a traditional medical setting. Take a complete history that includes questions about herpes simplex virus type 1, seizures, current pregnancy status, immunodeficiency disorders and other conditions that might influence dermatologic response. Past cosmetic procedure history is also important. Find out when the patient last had a BoNTA or filler injection and what the results were. Establishing a good relationship with the patient plays a significant role in retaining her business and whether she will recommend you to her friends.

A careful evaluation of each patient is necessary, since not every patient can or should undergo minor cosmetic procedures. Table 1 outlines points to consider. Some patients may need to see a plastic surgeon or a dermatologist for something more extensive, such as a facelift or other surgical procedure. Other patients might be overzealous about their need for cosmetic procedures and require tactful redirection. Know when to refer, and be alert to unrealistic expectations. At every evaluation for an aesthetic procedure, carefully and thoroughly explain the realistic outcomes.

A skin analysis machine provides information about the condition of the skin's surface as well as underneath the visible outer layer. If you invest in one, use it at every consultation to highlight sun damage and note melasma. The results of skin analysis provide a guide to potential treatments for the patient to consider.

Dermal Filler and BoNTA Injection

The least expensive aesthetic procedure to start out with is dermal filler injection. This is also one of the simplest procedures to learn. Results are immediate or may become apparent in just a few days. Most results are temporary, meaning that patients are likely to seek repeat treatments.

After investing in training, your capital outlay will be for the products themselves. A vial of BoNTA costs around $550 for 100 units (amount used per patient depends on the site treated), and Juvederm and Restylane cost approximately $250 to $300 per 1-mL syringe. When determining how you will price procedures, factor in other consumables, such as gloves, needles, wipes and the cost of your training. Also consider that discounting your injection charges can often attract new patients, who may then return for the other services you offer.

The manufacturers who sell dermal fillers can provide educational materials, marketing tools and training opportunities. Videotaped presentations of the procedures (such as Elsevier's Procedures in Cosmetic Dermatology series of texts with DVDs) are available, but these should be supplementary to hands-on training. The levels of training available range from the basics to more advanced techniques. Web sites with useful training information, training videos and CME opportunities include www.thederm.org and www.aestheticenhance.org.

Specialized training at a local training facility or by nationally recognized trainers such as the Aesthetic Enhancement Institute (www.ae1400.com; owned by Barbara Jones, NP), the Esthetic Skin Institute (www.esiw.com; owned by Sasha Parker, RN) or Aesthetic Medical Educators Training (www.aestheticmedicaltraining.com) is an essential first step. We got started by attending seminars in our region, and we continue to attend advanced classes whenever possible. Other NPs learn on the job by working for a dermatologist or plastic surgeon who performs dermal filler and BoNTA injections.

Aesthetic practice requires knowledge of the underlying anatomy of the individual muscles in the face and how they interact, as well as understanding of individual patient characteristics, goals and expectations. Knowledge of material handling issues is also necessary, particularly with BoNTA. You must understand issues such as dilution, storage, risks, side effects, contraindications and uses in areas other than the face.

As with any new skill, practice will make you more comfortable. Start by practicing on your friends and family so you will not be as nervous when you perform the injections on paying patients. It is not difficult to find friends who will pay the cost of BoNTA injections or dermal fillers in return for being guinea pigs.

BoNTA relaxes muscles to give a more refreshed appearance and is the No. 1 nonsurgical cosmetic procedure in this country.² BoNTA is indicated for several medical conditions, from eye spasms (strabismus and blepharospams) to eyebrow furrows to hyperhidrosis (excessive sweating). Its official cosmetic indication is for temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator or procerus muscle activity in adults 65 or younger. Other common uses are off label and have not been approved by the FDA: treatment of crow's feet, forehead wrinkles (frontal lines), bunny lines (horizontal lines across the bridge of the nose) and wrinkles around the lips, neck or nose and to "lift" the eyebrows.³

BoNTA differs from dermal fillers because dermal fillers do more than just fill lines; they add volume to areas where it has been lost. Commonly used dermal fillers include Juvederm Ultra and Ultra Plus, Restylane (both nonanimal-based hyaluronic acid), Cosmoplast, Zyderm (human or bovine collagen), Radiesse (calcium hydroxyapatite microspheres) and Sculptra (microscopic particles of poly-L-lactic acid as a stimulatory filler).

Table 2 outlines facts about a few of the most common fillers available. The effects of these fillers can last from 3 months to 2 years. Results depend on technique, with minimal to no downtime.⁴

Before injecting BoNTA or a dermal filler, inform the patient about the potential side effects. The most common are redness, bruising or swelling at the injection site, and temporary lumpiness and unevenness where the product is injected. Also provide pretreatment and posttreatment instructions. Counseling the patient before any procedure is crucial. This is a perfect time to discuss sun avoidance and vigilant sunscreen use. Much of the wrinkles, spots and laxity we have are due to sun exposure that occurred in our youth. We can't take that damage back, but we can help correct it and prevent further damage.

At the start of your aesthetic specialty, begin with a temporary hyaluronic acid filler such as Juvederm or Restylane. Become comfortable with this before attempting some of the semipermament fillers, such as Radiesse or Sculptra. The effects of temporary fillers last a few months, and the effects of semipermanent fillers last up to 24 months.

Dermal fillers do not require skin testing prior to treatment. They are easy to administer and can be used in all areas of the face that would benefit from volume.⁵ Many dermal filler manufacturers offer advanced training classes, Web-based instructional videos and references to expert injectors in your area. These products are listed as medical devices, not medications, so you must determine whether you or a physician must order this product based on the law in your state.

Peels and Microdermabrasion

Chemical peels and microdermabrasion are commonly used to treat conditions including acne, melasma, rosacea and fine lines. They also may be performed to add moisture to the skin.

Peels and microdermabrasion are safe and fairly inexpensive, but careful assessment is needed to fit the procedure to the patient (Table 3). One such assessment requires a determination of skin type using the Fitzpatrick Classification Scale, which classifies complexion according to tolerance of sunlight, or the Glogau classification of photoaging. Each of these tools can assess the patient's skin and is a key component in determining the appropriate peel.⁶

Fair-skinned patients or patients whose skin is classified as Fitzpatrick type I or II can be safely treated with all types of chemical peels, while darker-skinned patients or patients with Fitzpatrick type III or IV skin can develop postinflammatory hyperpigmentation with medium-depth peels.6 Patients classified as Glogau type I (no wrinkles) benefit from a superficial peel, whereas patients classified as Glogau type IV (only wrinkles) would benefit from a deep peel.⁶ Superficial, very light peels reach to the level of the stratum spinosum, whereas deep peels reach to the midreticula dermis.⁶ Microdermarsion is safe for all skin types.

Chemical peels are a method of resurfacing the skin. They vary in intensity and effect from superficial sloughing to deep penetration.⁶ The depth of the peel determines healing time as well as possible complications.6 Chemical peels require adequate training to avoid adverse results such as prolonged healing time, infection, postinflammatory hyperpigmentation, postpeel hypopigmentation and, rarely, risk for renal and cardiac toxicity with the systemic absorption of 88% phenol. This substance is typically applied by a physician.

The cost of the chemical peel therapies depends on product choice and the peel you will offer. Types of peels include mixtures with hydroquinone, trichloroacetic acid, glycolic acid, retinol and salicylic acid. Prices range from a few hundred dollars for supericial, very light and light peels to thousands of dollars for deep peels, which are done by plastic surgeons. Patients who undergo peels may need local anesthesia, follow-up visits and multiple sessions, so remember this when setting pricing.

Microdermabrasion provides mechanical exfoliation. The provider sprays high-grade microcrystals across the skin's surface through a closed, pressurized stainless steel or glass wand. This procedure can improve many skin conditions, but it should be avoided in patients with rosacea because it is too irritating.⁷

Incorporating microdermabrasion into your practice requires the purchase of microdermabrasion equipment, whose price tag can range from $2,000 to as much as $20,000. Microdermabrasion creams range from $10 to $60 per jar and contain about 30 applications. The typical patient charge for a microdermabrasion treatment ranges from $100 to $250.

Vein Removal

Sclerotherapy involves the injection of an irritating solution to eliminate medium-sized veins. The solution causes the vein to collapse, and the body removes the vein naturally.⁷ Hypertonic saline and various detergents are used in sclerotherapy. The most common side effects of this procedure are bruising and temporary pigment changes in the treatment area.

An alternative to sclerotherapy is lasers, which can be used to treat spider veins and telangiectasias. Laser treatment for vein removal may be preferred by patients who are afraid of needles and thus are not good candidates for sclerotherapy.

Varicose veins are large veins that protrude from the legs and are unsightly. They can also cause leg pain. In many cases, varicose veins are most appropriately treated at a vein center. (See the article on varicose veins in this issue of ADVANCE for Nurse Practitioners.)

Laser Therapies

Lasers can be used safely and with great effectiveness in traditional medical offices as well as in medical aesthetics settings. They are a much more expensive investment than the tools discussed thus far. Table 4 provides information on a few of the lasers available for many types of cosmetic procedures. Only a fraction of the brands and types of lasers are mentioned; the list of choices is growing rapidly.

If you are interested in adding laser treatment to your practice, extensive homework and research are required. Talk to other NPs who have purchased lasers or used them in their employer's setting. Attend workshops or seminars that have a variety of lasers to view and use. Sign up for free webinars that provide information about the various lasers. If you decide to add laser services, start with a basic laser that can safely perform hair removal on various types of skin, and expand from there.

Laser hair removal. Lasers can remove or decrease body hair because the wavelength of light is attracted to the melanin chromophore in the growing hair follicle. Targeted delivery of laser light causes thermal damage to these follicles and decreases hair regrowth.

Various types of lasers and methods are used to damage the follicle, with minimal to no damage to overlying skin. Because the laser is only targeting the growing hair follicle, a series of treatments is needed to obtain optimal results. Laser hair removal will not provide 100% hair removal, and touch-ups may be necessary. Therefore, it is important to educate patients and set realistic expectations. Among the laser types used for hair removal are the 755 nm Alexandrite, the 1064 nm Nd:Yag and intense pulsed light (IPL) lasers.

Because it requires multiple treatments, laser hair removal is most often sold in packages. Remember that although you may attract more patients by offering discounts on packages, you will receive your payment at the start of the treatment course. You will then be treating the patient approximately every 6 weeks without receiving any additional payments. Plan accordingly.

Lasers are expensive. For example, Cynosure's Apogee Elite lists for approximately $120,000, with a leasing option of between $3,000 and $4,000 per month after a down payment. Informational charts on lasers, prices, continuing education and a method to receive more information from various companies can be found on The Aesthetic Guide Web site at www.miinews.com/index.php.

Intense pulsed light. IPL or photofacial therapy is a popular tool for skin rejuvenation. IPL lasers deliver multiple wavelengths of light to the skin. These wavelengths are attracted to the brown spots created by sun damage and the red areas of tiny broken capillaries. IPL lasers induce some heating of the deeper layers of the skin, encouraging collagen regeneration and providing some skin tightening. Other than a darkening of brown pigment and mild skin pinkness, the side effects associated with this treatment are minimal.

Skin rejuvenation. Fractionalized lasers emit thousands of tiny beams that reach some undamaged areas. This broader effect limits discomfort and downtime. Fractionalized lasers heat the deeper dermis and can treat a variety of cosmetic conditions, including fine lines and wrinkles, scars, brown spots and stretch marks.

When explaining the concept of skin rejuvenation to patients, we often talk about the 4 x 4 skin rejuvenation theory: Hitting someone in the face with a 4 x 4 enough times will cause injury to the dermis, eventually causing collagen stimulation and regrowth. But you'd be left with a lot of unpleasant bruising. Fractionalized lasers target the water in the dermis, heating it up to cause tissue injury that leads to collagen stimulation – without causing significant damage to the upper layers. These treatments work from the inside out, with minimal to no downtime. Ablative lasers such as CO2 and erbium YAG require longer recovery periods because the treatment removes layers of skin, dressings are sometimes required, and healing rates are variable.

Other laser approaches. In addition to skin rejuvenation, vein reduction and hair removal, lasers can be used to achieve the following results:

Laser Training Requirements

The training requirements for laser therapy vary widely. For example, to perform laser treatments in Arizona and Texas, providers must complete 40 hours of didactic instruction, pass a written test and observe 24 hours of laser procedures. They also must perform 10 hands-on laser procedures under the monitoring of a laser safety officer. Many other states have not developed laser training or practice requirements, but the growing interest in this modality is likely to prompt more of them to do so.

Numerous laser training facilities are available to provide instruction about laser safety, laser physics and the basic operation of lasers. Because there are so many types of lasers, hands-on training with the specific laser you will be using is imperative. Investigate with your board of nursing, radiation regulatory association or medical board to determine what your specific state licensing agency requires.

Lasers are safe and effective tools when handled appropriately and by someone who is properly trained. The Laser Institute of America is an international society focused on laser applications and laser safety. Visit www.laserinstitute.org to obtain information about training and to order the American National Standards Institute laser safety standards (ANSI Z136.3).⁸

The National Council of Laser Excellence (www.ncle.org) provides certifications for laser safety, and these are available to professionals who are not physicians. Certification should not be attempted until you have completed extensive laser training. Three of many training options are the National Laser Institute (www.nationallaserinstitute.com), the Cosmetic Medical Company Inc. (www.lasertraining.com) and Rockwell Laser Industries Inc. (www.rli.com). Again, this list only skims the surface of options available.

Certification and Professional Groups

National associations such as the Dermatology Nurses Association and the Association of Medical Esthetic Nurses (AMEN) have recognized nurse experts in aesthetics for years (www.dnanurse.org). A newer professional group recently formed within AMEN, the American Academy of Medical Esthetic Professionals (AAMEP). The AAMEP held its first certification exam in September 2007. Other organization choices include the Association of Aesthetic Professionals (www.aestheticprofessionals.org) and the American Association of Aesthetic Medicine and Surgery (www.theaaams.com). Investigate each organization before you decide to join. Like the field of aesthetics itself, the proliferation of organizations is rapid.

We urge anyone who plans to practice aesthetics to seek thorough education and to stay current with new developments in the therapies they provide. Earning credentials such as medical esthetics professional-certified (MEP-C) or medical esthetic-certified (ME-C) can enhance your credibility with patients as well as with your peers in the aesthetics field. These certifications are available through AAMEP (www.amen-usa.org).

Another option to enhance your knowledge of the aesthetics specialty is through small, focused groups such as the Nurse Practitioner Society of the Dermatology Nurses Association. If possible, work with an NP mentor in your geographic area.

We also recommend attending annual clinical conferences such as those offered by DNA, AMEN, the American Society for Laser Medicine and Surgery and other cosmetic or aesthetics associations. The Aesthetic Show, an annual program featuring clinical workshops and exhibitors, offers an opportunity to browse the offerings of laser companies, to network with others in the field, and to obtain valuable information on aesthetic procedures.

Subscribe to aesthetics or cosmetic journals to stay current with procedures, equipment and news in aesthetics. An example is ADVANCE for Healthy Aging, which provides free subscriptions to NPs in this specialty (visit www.healthy-aging.advanceweb.com).

As more types of providers add aesthetic procedures to existing services or open new facilities, many consumers, plastic surgeons and dermatologists are expressing concern about the quality of these newcomers. You must be aware of these concerns and be prepared to answer them by stating (and restating) your aesthetics training, your clinical experience and your NP education. Standardization of training for laser certification and for other procedures may be on the horizon, as evidenced in Texas and Arizona.

Malpractice Coverage

As you spend significant amounts of time preparing to add aesthetic services to your practice offerings, do not neglect the research required to make a sound choice about malpractice insurance coverage and personal liability. You will need to purchase coverage that is specific to aesthetics practice.

Before doing so, determine who will be performing the aesthetic procedures in your setting. Will it be you, a laser technician, a registered nurse or a physician? Liability policies for medical spa professionals can be arranged so that they extend to the services you perform for the spa or practice.9 Others require you to purchase a separate policy for this work.

For professional liability coverage, the typical liability limits are $1 million per occurrence and $3 million in aggregate.9 The amounts on your aesthetics coverage may vary depending on the insurance carrier and the state in which your practice operates. Multiple spas can be covered, but the premium increases with each site, and payment is usually required in advance. These policies typically are not all inclusive. For example, most policies do not provide coverage for services such as chemical peels, acupuncture and hormone therapy.⁹ Contact your medical malpractice insurer to confirm that you have coverage for services that fall outside the aesthetics policy.

Putting It Into Practice

Clearly, adding aesthetics services to your current practice can provide multiple benefits. Make the most of your investment by researching and preparing for the procedures you want to incorporate, carefully choosing your equipment purchases, hiring effective staff and purchasing adequate malpractice coverage. Remember that not every patient is a candidate for minimally invasive aesthetic treatments.

In this rapidly growing and competitive field, make sure you provide realistic expectations, thorough patient education and quality services at a good price. Meeting these goals will ensure patient satisfaction — and repeat business.

References

1. DeBias G. Building your Aesthetics Practice. Cynosure Webinar. Nov. 14, 2007.

2. Carruthers A, Carruthers J. Botulinum toxin. In: Procedures in Cosmetic Dermatology. Philadelphia, Pa.: Elsevier-Saunders; 2005.

3. Carruthers J, et al and the Botox Consensus Group. Consensus recommendations on the use of botulinum toxin type A in facial aesthetics. Plast Reconst Surg. 2004;114(6 suppl):15S-22S.

4. Association of Medical Esthetic Nurses. Study Guide for the Medical Esthetic Practitioner Certification Examination. 2nd ed. Ft. Lauderdale, Fla.: Association of Medical Esthetic Nurses; 2007.

5. Carruthers J, Carruthers A. Soft tissue augmentation. In: Procedures in Cosmetic Dermatology. Philadelphia, Pa.: Elsevier-Saunders; 2005.

6. Rubin M. Chemical Peels. Rubin M, et al, eds. Philadelphia, Pa.: Elsevier Saunders; 2006.

7. D'Angelo J, et al. Milady's Standard Comprehensive Training for Estheticians. Clifton Park, N.Y.: Thompson Learning Inc.; 2003.

8. American National Standard for Safe Use of Lasers in Health Care Facilities. Orlando, Fla.: Laser Institute of America; 2005. (ANSI Z136.3-2005).

9. Exploring professional liability insurance for medical aesthetics. Available at: http://www.insurancesalesman.com/professional-liability-insurance-for-medical-aesthetics.html. Accessed Jan. 15, 2008.

Sue Heck is a family nurse practitioner who is the clinical director for GreatSkin AZ in Scottsdale, Ariz. She also works part time in family practice.

Alma Celaya is a family nurse practitioner at Great Skin AZ in Chandler, Ariz., and works part time in a family practice setting. She is an adjunct faculty member at Rio Salado College.

For Further Reading

Esthetic Skin Institute, Inc. The Art and Science of Botox. Training Manual for Medical Professionals. Ft. Lauderdale, Fla.: Esthetic Skin Institute Inc.; 2006.

Esthetic Skin Institute, Inc.. The Art of Dermal Filler Implantation. Ft. Lauderdale, Fla.: Esthetic Skin Institute, Inc.; 2007.

Goldberg D. Vascular, pigmentation, scars, and medical applications. In: Laser and Lights, Vol. I. Rubin M, et al, eds. Philadelphia, Pa.: Elsevier Saunders; 2005.

Goldberg D. Rejuvenation, resurfacing, treatment of ethnic skin, and treatment of cellulite. In: Laser and Lights, Vol. II. Rubin M, et al, eds. Philadelphia: Elsevier Saunders; 2005.

Moretti M. Aesthetic Buyers Guide Primary Care Edition. Alisa Viejo, Calif.: Medical Insight, Inc; 2007.