When her moms gynecologist mailed a postcard announcing she was adding cosmetic procedures to her practice, Kristen Cortland* didnt hesitate to see her about the prominent bags under her eyes. “Shes a really good gynecologist, so I assumed shed be good at anything she did,” says the 29-year-old Chicago-based realtor.

Right after being injected with something called a “natural fat burner” (it was actually a substance called Lipodissolve that has not been approved by the Food and Drug Administration) by her moms OB-GYN, Cortland felt unbearable pressure in her eyes. “Before I left her office, my eyes blew up really big,” she says. “At home, my face got so puffy that, in profile, you couldnt see my nose.” Cortland kept calling the docs office, and kept being told that there was no need for a follow-up visit. “Honestly, I dont think she knew what to tell me,” she says.

Six weeks later, when her features finally reemerged, Cortland still had the original problem, plus a new one: a prominent indentation between her lower eyelid and cheek that will need to be surgically corrected. Still, she was one of the lucky ones, says her new physician, Julius Few, MD, associate professor of plastic and reconstructive surgery at Northwestern Universitys Feinberg School of Medicine in Chicago: “She could have gone blind.”

If your doc hasnt gone cosmetic yet, it may just be a matter of time. As the cosmetic business booms (noninvasive procedures—including microdermabrasion, lasering, injectables, and chemical peels—are up 747 percent since 1997), more and more OB-GYNs and general practitioners (GPs) are branching out into aesthetic procedures. In fact, so many OB-GYNs have added lipo, Botox, and the like to their offerings, that theyve even created a society: the four-year-old International Society of Cosmetogynecology.

This trend could mean easy one-stop shopping for you, or it could mean a really bad, even disfiguring, experience like the one Cortland had. Heres what you need to know to face this new in-thing safely.

Next Page: The cosmetic revolution [ pagebreak ]The cosmetic revolution
Whats fueling this boom in noninvasive cosmetic surgery—and the rise in MDs working outside their fields of training? Two things. One, were a nation obsessed with looking as good and as young as possible. Cosmetic surgery without going under the knife is appealing to many—so many, in fact, that 9.1 million minimally invasive treatments were performed in 2006 (the most recent year for which we have statistics). The other: money. Botox Cosmetic (the leading cosmetic procedure) brought in around a half-billion dollars in revenue for its maker Allergan last year.

This new trend means quick loot for docs, too. When a patient comes in for wrinkle-smoothing rather than a urinary tract infection, not only does she pay a higher fee, but she pays for it on the spot. This means that the doctor isnt stuck chasing down an insurance check, says Mitchell Chasin, MD, medical director of Reflections Center for Skin and Body medispas in Livingston and Bridgewater, New Jersey. “Many physicians are doing it because of the effect of managed care on their practices, and all the hassle factor—theyre running to where they think the grass is greener.” In fact, an article on the American Academy of Family Physicians Web site encourages members to add cosmetic services. The title? “Better Your Bottom Line: Aesthetic Cosmetic Procedures Can Be Boon to FPs.”

Could they miss cancer?
Some happy customers see this as the ultimate in one-stop medical shopping (“Women want to go to one place where they can do it all,” says Beverly Hills, California, gynecologist and cosmetic surgeon Delores Kent, MD.) But as the number of hybrid practices has grown, so have the problems, according to alarming new research. An August 2007 study by the Physicians Coalition for Injectable Safety found that 38 percent of its plastic surgeon members have seen complications due to injectables administered by poorly trained providers.

Another recent report, this one by the American Society for Dermatologic Surgery (ASDS), found that 59 percent of its members (derms who do surgery) have seen an increase in the last two years in complications caused by physicians who were not dermatologists performing dermatologic procedures. The number-one problem they have encountered? Misdiagnosis of skin cancer as age spots (one in four of the derms has seen this screwup). “The nondermatologists think its an age spot. And, unfortunately, theyre not trained enough to know its a cancerous legion, so theyll remove it,” says an ASDS spokesman. The only problem: You cant laser off skin cancer, so it returns, generally at a more advanced stage.

This boon for physicians, then, may be a bust for patients, says Kathryn Hinsch, founder of the Womens Bioethics Project, a public-policy think tank in Seattle. “A big problem is that any doctor with very minimal training can perform these procedures, so the potential safety issues are high,” she says.

Brent Moelleken, MD, a plastic surgeon in Beverly Hills, California, adds, “If patients heard about a plastic surgeon expanding his practice to include Pap smears and hysterectomies, they would be horrified. But they think little of having laser procedures or liposuction done by a gynecologist. And there is no law against either.”

The scary truth is, many generalists who add aesthetic procedures may actually be winging it. They often have just one day of training—if that, says Omaha dermatologist Joel Schlessinger, MD, president of the American Society of Cosmetic Dermatology and Aesthetic Surgery (ASCDAS). He gets requests almost every day from docs: “They want to watch me work for one day and then start doing cosmetic procedures.”

The classes themselves are multiplying, too. At this years American Academy of Family Physicians meeting, how-to courses on lasers and fillers were offered alongside diabetes management and colonoscopy training.

Next Page: Moonlighting mishaps [ pagebreak ]Moonlighting mishaps
One of the biggest problems with quickie courses is they dont teach what to do when something goes wrong. So a barely trained doctor may not be aware of simple fixes, says Krista Ramonas, MD, a San Francisco–based ophthalmologist who sees medical and aesthetic patients, including more and more women who come in with droopy lids from bad Botox jobs they received from nonspecialists. “We have eyedrops that can lift the lid after an improper injection,” temporarily fixing the problem so that the Botox wears off evenly, she says. “But many doctors dont even know these drops exist.”

What continues to surprise Ramonas is the number of her medical colleagues who are willing to take a crack at someones face without knowing facial anatomy 101. “My mothers OB-GYN recently told her hes doing Botox. He said, ‘We have the patient population—women in their 40s. But they dont have the experience! In ophthalmology, we have a saying: We dont go below the clavicle. Well, OB-GYNs shouldnt go above the breast.”

“Complications can happen with a dermatologist, too,” acknowledges Flor Mayoral, MD, a Miami-based derm. But thats where years of study and experience come into play, she says. A dermatologist, plastic surgeon, or ophthalmologist has completed at least two or three years of surgical training and has learned how to manage complications. But a nonspecialist who doesnt know how to spot a red flag could forge on with horrific results—and Amy Sanders* has the scars to prove it.

Sanders, a 35-year-old woman from Omaha, Nebraska, went to a medispa owned by a “skin-care specialist” for hair removal. The spas medical director was an MD and a specialist, but not in skin care; he was an emergency room doc. Sanders never saw him, anyway, because a layperson manned the laser. “She was in terrible pain during the procedure, and she said so, which should have been the tip-off to stop,” Schlessinger says. As a result, Amy suffered second- and third-degree burns on her legs and stomach. And this isnt a rarity. In many cases, the so-called trained doctor isnt the one injecting your face or operating the laser machine, Schlessinger explains. “That doctor trains staff members, and, while hes busy seeing patients for coughs and colds, the secretarial person is busy administering the Botox.” There are derms and plastic surgeons guilty of handing off tweaks to support staff (which is perfectly legal in many states), but theyre less likely than generalists to do so because their reputations rest on you looking great, Schlessinger says.

Next Page: I just want a checkup! [ pagebreak ]I just want a checkup!
Bad cosmetic surgery aside, where does this trend leave the woman who just wants to see a dedicated MD? “Part of the fundamental trust between a patient and doctor is the idea that the doctor has the patients best interest at heart, and that there is no financial incentive for the doctor to perform any procedure,” Hinsch says. “When doctors start adding cosmetic procedures, which theyre adding because theyre big moneymakers, theres a corruption of that basic trust.” Many physicians sidestep this ethical quagmire by never directly hawking their fat-blasting, wrinkle-smoothing, and hair-removal services. But even a stack of brochures in the waiting room, Hinsch insists, sends the message to patients that looking younger is a matter of good health.

Even if you arent swayed by the literature, that stack of pamphlets may make you wonder: Am I still a priority around here? If your internist gets $20 co-pays from you and $500 cash from the patient he treats with Restylane, whose call will he return first? Who will he spend the most time with during appointments?

Some docs avoid becoming “jacks of all trades, masters of none” by slashing their patient loads or opting out of their original fields, which causes another problem. Its a brain drain that could have major reverberations throughout womens health care, Hinsch says. “Theres already a huge crisis in the shortage of obstetricians.” (Many OB-GYNs stopped delivering babies in the past 10 years, unable to keep up with sky-high medical-malpractice-insurance premiums.) Now, as the rejuvenation business surges, obstetricians may soon become more of an endangered species.

James Fairfield, MD, a derm in Lansdale, Pennsylvania, teaches newbies how to use lasers and fillers—and he counts gynecologists among his best customers. “The cost of malpractice-insurance premiums causes them to look elsewhere for money,” Fairfield says. “They drop the OB portion of their practices, buy a laser, and start doing Botox and fillers.”

(Health contacted the American College of Obstetrics and Gynecology (ACOG), but the organization declined to comment for this story. In their only statement on OB-GYNs doing cosmetic procedures, the group takes no position: “Because they are not considered gynecological procedures, it is inappropriate for the college to establish guidelines.”)

Should you trust your doc?
So, lets say your doctor is hopping on the beautification bandwagon. Should you find a new doc? It comes down to a gut feeling. Do you sense that shes focused on you—or that her head is somewhere else, say, on her burgeoning medispa down the hall? Heres a big red flag: Your MD tells you she could do something about those bags under your eyes, turning your medical appointment into a beauty consultation. That may be a signal to change doctors.

If you are considering a cosmetic tweak your doc offers, remember, “Its buyer beware,” says Northwesterns Julius Few, MD, a leader of the Physicians Coalition for Injectable Safety. “If you go outside the classic specialty group, there is no guarantee that youll get someone who has any experience,” he says.

Yes, there are GPs whove done hundreds of cosmetic procedures and do high-quality work, Fairfield says, “just as there are plastic surgeons and derms who dont take enough care and produce bad results.” But unless you find that rare primary care provider who is truly a subspecialist in aesthetics, youre taking a risk.

Thats a gamble that Cortland—the woman who received Lipodissolve from a highly regarded OB-GYN—will never take again. “I wouldnt go to my dentist for a gynecological exam,” she says now. “From now on, whatever a doctor specializes in is the only thing Ill see her for.”