Who’s Performing Cosmetic Procedures at MedSpas?

CARLSBAD, California — The level of training and supervision among individuals who perform cosmetic procedures at medical spas (MedSpas) varies widely, a trend that patients may not be aware of, according to Sara Hogan, MD.
“I’m not anti-MedSpa; I’m pro–patient safety,” Hogan, clinical assistant professor of dermatology at The George Washington University, Washington, DC, said at the Controversies & Conversations in Laser & Cosmetic Surgery symposium. “The MedSpa industry is booming; it brought in $17 billion last year. There are as many MedSpas in the United States as there are practicing dermatologists, and that number is set to exceed the number of dermatologists.”
According to industry data from the American Med Spa Association, 63% of member MedSpas have non-MD ownership. Among MedSpas owned by physicians, 80% are of a noncore specialty, meaning a specialty other than dermatology, plastic surgery, otorhinolaryngology, or ophthalmology. Of MedSpa medical directors, 69% are from noncore physician specialties. “There’s an increasing amount of data that shows a relatively higher incidence of complications from cosmetic procedures that are delivered at MedSpas,” Hogan said. “A 2020 study suggested that this is likely due to improper training, improper technique, and/or improper device settings.”
Hogan also cited adverse effects linked to counterfeit or mishandled botulinum toxin (Botox) injections that prompted the Centers for Disease Control and Prevention to issue an alert to clinicians in April 2024. Clusters of 22 people in 11 US states reported adverse effects after receiving injections with counterfeit Botox or injections administered by unlicensed or untrained individuals or in nonhealthcare settings, such as homes or spas.
To better understand who performs cosmetic procedures, provides medical supervision, and follows safety protocols at MedSpas, Hogan and colleagues conducted a “truth in advertising” study of 127 MedSpas in the greater Chicago area. They chose this geographic location because an analysis published in 2021 identified Chicago as having the third highest number of aesthetic physicians and the fifth highest number of MedSpas in the United States. The researchers enlisted help from “secret shoppers” who contacted the MedSpas by telephone to ask about the level of training, if patients underwent a review of medical history, the level of on-site physician supervision, and the protocol for complications.
The top five cosmetic procedures offered by the 127 surveyed MedSpas were facials (85.0%), hair removal (85.0%), Botox injections (83.5%), dermal fillers (82.7%), and chemical peels (76.4%). About two thirds of cosmetic procedures were performed by aestheticians (66.9%), followed by registered nurses or licensed practical nurses (52.8%), board-certified physicians (48.8%, mostly plastic and reconstructive surgeons), nurse practitioners (27.6%), and physician assistants (9.4%).
In the realm of supervision, 16.5% of MedSpas surveyed reported that a medical director or supervising physician is always on site. “If not located on site, when asked where the physicians are, the majority of the time they were at the physician’s primary practice, clinic, or hospital,” Hogan said. “Only 65% of the MedSpas surveyed stated that they informed the patient that the supervising physician is not on site. In addition, a patient’s medical history is reviewed at only 40% of the MedSpas. To give context, in Illinois, a physician can only deliver care after a physician-patient relationship has been established, meaning that a good faith exam has been performed. And if they are to delegate any type of service, they must always be on site to provide assistance.”
Hogan noted that there are no federal statutes or agencies that regulate or oversee MedSpas. “Regulation and oversight are often delegated to state licensing agencies that are overwhelmed and often stretched thin regarding personnel and budgets,” she said. To raise awareness of this issue, the American Society for Dermatologic Surgery Association (ASDSA) launched the Medical Spa Safety Coalition, which aims to promote model legislation for states known as the Medical Spa Safety Act. Highlights of the bill include clear definitions of medical spa and medical director, as well as the requirement of an on-site medical director who must be a physician trained in all procedures performed at the MedSpa. Coalition members include 16 state dermatology boards as well as the ASDSA, the American Academy of Dermatology Association, the American Society for Laser Medicine & Surgery, and the American Society of Plastic Surgeons.
The ASDSA provided funding to support the published study. Hogan reported having no financial disclosures.
 
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