Kate Dee, M.D., Exposes the Ugly Underbelly of Unregulated Medspa Mayhem

Exposing the unsavory underbelly of the medical spa world is no small task and not for the fainthearted. While medical aesthetics as a whole is moving away from allowing these kinds of practices that put patients’ health and even lives in danger, the public distancing and reproval of unsafe and shady medspa practices is a fairly recent development. Kate Dee, M.D., on the other hand, is one of the brave practitioners that decided to stand up in opposition to the unregulated world of medical spas and advocate for patient safety. Of course, like Dr. Dee, there are plenty of good medspas out there that provide excellent service and patient care, but it just takes a few bad apples to ruin things for everyone, the taint of their misdeeds overshadowing the dedication and achievements of the many upstanding medspas. Her thorough expose, “Med Spa Mayhem: The Good, the Bad, and the Ugly Secrets of the Aesthetics Industry,” seeks to help both consumers and practitioners better understand and navigate the very complex world of medical spas.  

From Breast Cancer to Aesthetics

Kate Dee, M.D.Photo courtesy of Kate Dee, M.D.After 16 years as a breast imaging specialist focused entirely on breast cancer, Dr. Dee learned about aesthetics from two retiring colleagues and spent a day with them in their clinic before they closed their office. She remembers, “It was the most fun I’d had in medicine ever.” It was then that she began taking outside courses, “Thus began my personal self-directed residency in aesthetic medicine.”

It was a toxic middle manager that began a campaign of harassment against Dr. Dee at the breast center in the hospital that finally pushed her to take the leap into aesthetics once and for all. After raising higher in the ranks at the hospital through cutthroat tactics that expanded her own power while destroying others’ careers, “pitting people against one another, fomenting distrust and anger, and getting people fired,” the woman began focusing on Dr. Dee when she began to pose a threat, manipulating others to get her in trouble on trumped up claims and making her professional life there miserable till she decided to hand in her resignation.

After that, she wanted to focus on creating the kind of practice in medical aesthetics that empowered and helped the lives of both the patients and staff. Dr. Dee explains, “It is about the whole experience and the outcomes. Hospitals are just way behind the rest of the economy when it comes to user experience and worker satisfaction. Starting my own business meant I could focus all of my energy on both of those things. All of our business decisions must make business and medical sense and improve the happiness of both our patients and our staff.”

She was able to create that, but along the way learned of the many flaws that also need to be addressed in the world of aesthetic medicine and the under-regulated world of medical spas. 

Medspas: The Wild West of Aesthetics

The inherent loopholes in medical spa regulations have allowed the kinds of risks now coming to light to persist for too long. The loopholes that exist aren’t always readily apparent to consumers or practitioners trying to navigate this complicated merging of medical aesthetics and the spa business, which was created by none other than investors and entrepreneurs wanting a piece of the aesthetics action despite not having any experience in the medical arena. That combination is a fairly good recipe for disaster, and as we’ve seen in recent years, disasters have ensued. Dr. Dee decided to step forward and “pull back the curtain on this industry, shining a spotlight on the hidden corners in the hope of guiding both consumers and practitioners to safer, more ethical shores.”

“When injectables first arose, plastic surgeons around the country learn how to inject the new toxins and fillers and trained their nurses and PAs to do the injections.” The same occurred with dermatologists learning how to use injectables on the job and training their nurses and PAs in lasers and injectables. No lucrative industry is going to pass the notice of Wall Street investors and those in business of making money when they discover they could also be getting a piece of the pie. So, in comes the entrepreneurs, who “founded a new creation called the medical spa. They hired the same mid-level practitioners from plastic surgeons and dermatologists…They were the first to offer spa treatments like facials and massage and medical treatments like laser hair removal and Botox under one lovely roof. The medical spa was all about the customer experience, and it took these procedures out of the sterile medical office setting.” These entrepreneurs got around the problem of not being a licensed doctor, by hiring a “medical director” for the spa. 

Thus began the era of the medical spa and the rising commodification of aesthetics, leading to the current problems with the lack of medspa regulations and the inevitable consequences that come with it. Dr. Dee points out the crux of the issue regarding the commodification of aesthetics, “In medical aesthetics, every treatment is elective and cash-pay. You don’t need to convince the government or insurance companies to pay for a service. You need to convince the consumer. This proves far to be a far easier task, as long as you have enough advertising dollars. Let that sink in: no one is in charge of deciding whether a treatment is effective – except the consumer. You have to trust that the person selling you the service is telling you the full truth.”

Not even counting the properly licensed but unqualified professionals one can encounter in the aesthetics space, Dr. Dee discusses the even greater issue of false claims of board certification and unlicensed individuals illegally entering the field. She explains, “Beware of people falsely claiming to be board-certified. If you see a credential that says ‘double board certified’ in any of the following categories, these are not recognized by the ABMS: integrative medicine, antiaging medicine, aesthetic medicine, cosmetic medicine, regenerative medicine, functional medicine.” Dr. Dee adds that these “are training courses, like many of us have taken. There is no legitimate board certification in aesthetic medicine. It doesn’t exist.”

Practitioners and patients also need to watch out for individuals with fake nursing degrees. “In 2023, a scandal broke where thousands of nurses were found to have purchased fake nursing degrees online. These nurses were working all over the United States, and they are still being weeded out of the system,” states Dr. Dee.

When forming her own medspa business, Dr. Dee came face to face with the “challenges of distinguishing a genuine expert from a pretender, the pitfalls of falling for surface-level charm.” Her own experience with finding the right staff, and wading through the pretenders led her to create “a ‘Successful Injector” checklist. And, I go over it with each new NP or PA at the ninety-day review.” This is just the tip of the iceberg, with numerous other pitfalls and dangers for practitioners and patients to navigate in the medspa world.

Financial Frauds Fueling the Medspa Mayhem"Med Spa Mayhem: The Good, The Bad, and The Ugly Secrets of the Aesthetic Industry" By Dr. Kate Dee.Image courtesy of Advantage Media Group

The Importance of Reviews & The Yelp Mafia

The hustle for reviews has left room for companies like Yelp to take significant advantage of medspa owners, with an algorithm designed to help those who fork over the cold hard cash. “When I was researching medical spas in my neighborhood, the only place that existed back then had some ugly reviews on Yelp. About six months later, that place started advertising on Yelp. Suddenly they had an almost five-star rating.” Dr. Dee experienced the full Yelp “mafia protection” scheme after opening her medspa and receiving a suspicious bad review that didn’t seem to have any relation to her business or mention of receiving services. While Yelp did take down this slanderous review from a clearly fake account after leaving it to affect her budding medspa’s reputation for 6 days, Dr. Dee notes, “Soon after, I got a call from Yelp asking me to advertise my business.” While she could hardly afford to advertise at that stage, and after asking numerous questions about how to handle these situations, what she should do and how she could get in contact with someone faster if this happened again, only to receive vague answers to the tune of promising help and relief from this problem if she advertised with Yelp, Dr. Dee admits, “I started paying up. That’s right. It is protection money.”

Dr. Dee is far from alone, with many of her colleagues who own medical spas relating similar stories. Unfortunately, while making sure to ask every patient to write a review, if “your patient has never written a review before, that review will be “not recommended” and get relegated to a hidden status. Yelp prioritizes reviews from Yelpers.” What’s more, “Many medspa owners report that the moment they started paying Yelp for advertising, they suddenly had those five-star reviews pop up as recommended,” says Dr. Dee, adding, “Every single business owner I know gets routine visits from these sales reps. They are there to convince you to pay some protection money. If you agree, you’re married to the mob. There’s no quitting.”

Consumers Cheating the System

Dr. Dee points out, “As the quest for eternal youth and beauty intensifies, so does the audacity of those willing to exploit the vulnerabilities of medical spas and clinics. These unscrupulous individuals seek to gain at the expense of unsuspecting practitioners.”

Botox Bandits: One widespread example of this you may have heard about are the “Botox Bandits.” Dr. Dee explains that these are, “individuals who seek high-end treatments but disappear without settling their bills. Across the country, headlines from recent years tell tales of thefts and frauds in medical spas.” This can include everything from people simply walking out without paying post-treatment to actual break-ins. Dr. Dee says these consumer crimes are “happening every day at med spas and aesthetics practices across the country. This is basically the cosmetic version of a dine and dash.”

She would know, as Dr. Dee was a victim of this very crime. One woman who came into her medspa, “had a $240 treatment. At the front desk while checking out, she exclaimed, ‘Oh, I left my wallet in my car. I’ll be right back!’ and ran out the door, never to be seen again…The police knew exactly who she was and where she lived. Nothing was done. The prosecutors did nothing.”

“Such instances not only expose the vulnerabilities of aesthetic clinics but also underline the growing obsession and lengths some individuals are willing to go for antiaging and beautifying treatments. Safeguarding against such incidents is important for practitioners and clinics alike,” relates Dr. Dee.

Extortion Through Malicious Fake Yelp Reviews: Dr. Dee relates another consumer scheme she experienced when a woman left a review claiming a treatment at her medspa had scarred her face. When Dr. Dee reached out to the woman by phone and then email asking for her to come in so she could see the damage and do what she could to address the issue, worried for the patient, she received a reply that stated, “If I gave her a refund, she would take down her review. She refused to speak to me on the phone or come in for a follow-up visit and pictures. She refused to send us an image showing the ‘scarring.’ This is really the perfect way to get free services!”

Medspa Money Making Schemes

The Groupon Bait and Switch: Dr. Dee discusses the tactic some medspas use to get patients in the door, offering a Groupon special that comes with a hidden agenda. She states, “When you see Botox priced at $8 per unit on Groupon, I can guarantee that the business is losing a lot of money on every person who walks in the door, assuming they are using real Botox.”

Now there are a few possibilities when it comes to the reason for a medspa offering such discounted rates on an expensive treatment. The first according to Dr. Dee is, “The spa could be purchasing illegal neurotoxin from the gray market. There are many websites selling “Botox” from Europe or China. Some are simply illegally importing real Botox from foreign countries. Others are illegally importing Chinese (or other countries’) fake Botox.”

Another possibility is, “The spa could be diluting Botox or other toxins with extra saline – watering it down.” In addition to this practice, certain medspas “could be using it as a ‘loss leader.’ This is when stores purposely offer a product at a loss, in order to upsell customers on more expensive items,” states Dr. Dee.

The Bait and Switch, however, is a more commonly used tactic when it comes to suspicious Groupons. Dr. Dee explains, “This is where the spa uses the coupon to get you in the door, and when you arrive, you find that the original product that you purchased is unavailable, but for more money, you can apply that coupon to something else that has a higher profit margin.”

She discusses one instance of this practice that she came across, involving a medspa known for their Juvederm Groupon specials that she discovered never actually ordered Juvederm. “When you walk into the Juvederm Groupon spa, there is a sign that says, ‘Why rent when you can buy?’ They convert every Juvederm Groupon into a downpayment on Bellafill. They never have to buy Juvederm,” says Dr. Dee. 

The Filler Fanatics: We have all seen those pictures of patients with overfilled lips. Thankfully the trend of overfilled lips is passing, but while a good aesthetics practitioner knows when to tell a patient enough filler is enough, there are many medspas that will use as much filler as the patient requests. Dr. Dee states, “Many spas will inject what you will pay for. The nurse injectors are often paid on productivity. They make less if you spend less. This is no incentive to talk you out of a procedure. It is extraordinarily shortsighted. Why? Because the patient will never trust you again. They will tell all their friends: never go to that place. And they will never believe you when you suggest something else that might actually be better for their skin.”

Prepaying for Treatments Sight Unseen: Another practice Dr. Dee came across as she navigated her entrance to the medspa world was business that asked patients to prepay a certain amount for treatments before even getting a medical consultation. She related the story of a patient that called her medspa asking about consultations for dermal fillers. “We told her that we have a nominal consultation fee that acts as a credit if any service is booked within 90 days. Then she asked if she had to prepay for fillers. We answered no; as a matter of fact, we would not even know what to charge without seeing you first. We have to do an assessment in person and have a discussion about your goals before making recommendations. We can’t even guarantee that you’ll even need fillers! The woman on the phone was floored,” says Dr. Dee.

The patient then told her about a virtual consultation she had for a spa, which was actually with a salesperson and not a nurse or doctor. In this consultation she was asked to prepay $1,500 to book the filler appointment before she even saw an actual medical provider. She ended up leaving before getting the treatment despite not being able to get a refund for her prepayment when she got a bad feeling about the spa and staff after arriving. When Dr. Dee mentioned this story at a medical conference, she was told by a colleague that the spa in question was known for this tactic. 

If Looks Could Kill: Lethal Liabilities in Medspas

There are far greater issues than the financial schemes explained above. Many of the loopholes in medspa regulation leave room for serious medical complications and even death from certain aesthetic procedures.

Ommitting Risks: One practice that can lead to major medical complications is the omitting of potential risks involved related to treatments, such as filler treatments. Dr. Dee had a patient walk in for a treatment after deciding not to go through with it at another medspa. When they went over the consent process, “including the (thankfully) rare possibility of vascular occlusion. Her eyes widened at this possibility. The other place simply omitted this from the verbal consent. No doubt, they have it in the written form you must sign to have the procedure. But unless you ask, you won’t hear about it from them. We have found that very few patients have ever heard of this before – even patients who have had filler many times in the past.”

Disfigurement Post-Treatment Due to Unqualified Staff: A particularly harrowing story involved a patient that wanted her jowls treated, which is an issue of skin laxity due to volume loss. This spa suggested the use of Kybella, a bile acid used to dissolve submental fat under the chin. Dr. Dee related, “In general, the jowls are not caused by focal accumulation of fat in this area. On the contrary, it is the loss of fat pads in your face over time that contributes to the overall droopiness.”

The patient told Dr. Dee of the excruciating pain she experienced during the treatment. This pain ended up being a serious warning of what the patient would experience post-treatment. “It happens that there is a nerve right there, where the jowls form. The first side hurt so much, she was practically jumping off the table. Within a month, she realized the disaster that was emerging on her face. She had two jagged linear divots extending from the corners of her mouth to the sides of her chin. She felt like she looked like an angry witch,” says Dr. Dee.

Felonies: You may recall the story we covered on the patients that contracted HIV after getting PRP treatments at a New Mexico spa. This is just one example of the illegal practice of aesthetic medicine and the dangers patients face from treatments being provided by unlicensed individuals. Dr. Dee explains, “To be clear: this salon owner did not have any type of license to practice medicine. It was a dangerous and dirty illegal operation.”

The issue of people illegally purchasing filler is also one that puts patients in serious danger and is all too common a practice, in the same vein as the purchase and use of fake Botox. “There is a gray market of direct sales of illegally-imported filler from other countries. So, just because someone is injecting, it does not mean that are doing so legally. According to the American Medical Spa Association (presented at a national conference in 2022): Nearly 15% of injections are performed by unlicensed people – aestheticians, medical assistants, etc. One-third of these providers don’t have a medical director at all,” warns Dr. Dee.

Aesthetic Device Growing Pains: As aesthetic devices have joined injectables as treatment tools in the aesthetics arena, as is the case with anything completely new being developed, there were some bumps in the road, to put it mildly. In 2015, this technology that the industry and consumers were understandably excited about, as it was the first fat-destroying device that worked, had been integrated into the businesses of so many aesthetic providers that millions of people were getting treatments…and experiencing complications afterward. These could be anything from uneven or wavy results to paradoxical adipose hyperplasia (PAH), which involves the fat growing instead of shrinking. Dr. Dee states, “With PAH, the new fat is rock hard and does not easily respond to traditional treatments (like liposuction) and often must be surgically excised.”

It wasn’t until recently, in 2021, however, that the treatment’s possible complications began to make headlines when Linda Evangelista claimed that CoolSculpting left her disfigured and filed a suit against the manufacturers, which was settled in 2022. “There is also at least one class-action lawsuit claiming the same issue that the supermodel is claiming: CoolSculpting Weight Loss Procedure Customers File Class Action Lawsuit Alleging Bodily Deformation. Meanwhile, the New York Times published an article on April 16, 2023, about how the rate of PAH is actually much higher than Allergan claims: A Beauty Treatment Promised to Zap Fat. For Some, It Brought Disfigurement. Then a week later on April 22, 2023, the Times published their investigation of how often PAH occurs. They contend it could be as much as 50 percent: Just How Rare Is a ‘Rare’ Side Effect of a Fat-Zapping Procedure?”

Mending Medspa Mistakes: Looking to the Future

While the picture Dr. Dee paints of the numerous issues the aesthetics industry currently faces with the lack of medspa regulation, she leaves us with a message of hope. There are groups and forces for good in this industry. In response to the death of Jennifer Cleveland on July 13, 2023, after receiving IV therapy at a medspa in Wotham, Texas, AMSPA, “put together a task force of stakeholders to design a set of legal guidelines for the industry. They published this set of guidelines to their members at the same time as launching an effort in the Texas legislature to introduce these guidelines into law. There was a massive mutiny among the members. Some members were excited to see the beginnings of self-regulation in the industry. We would like to create a uniform set of laws and standards so that patients know that there are standards that must be met in medical aesthetics. But there was a huge uproar among many spa owners that AMSPA was trying to put them out of business, and many of them left the association.”

She offers these two pieces of advice to practitioners:

1. Believe in Yourself & Remain Persistent in Your Pursuit of Your Dreams: “I was laughed at by my old radiology group when I proposed starting an aesthetic practice. Instead of being discouraged, I was energized. I took matters into my own hands, securing a location, insurance, and a domain for the business. Believe in yourself and your ideas, even when others may doubt you.”
2. Find the Right People: “My experience trying to find the right manager for my spa is a lesson for any business owner, about the need to have people who align with your business values and can help you achieve your vision.”

Dr. Dee leaves us with food for thought and a call to action, stating, “The best consumer is an informed one. I spend so much time with my patients explaining how everything works because I want them to fully understand the science and know that they want to pursue any treatment they might undergo…Why did I write this book? Many of us in the industry are dumbfounded that there is so much illegal activity in the aesthetics space. I’ve reached out to attorneys for the city, country, and state. They all say that it is not within their purview until a crime is committed, and even then, it has to be a major crime. Botox Bandits often get away with is. Bait and Switch is legal. But death and disfigurement – that’s where they draw the line. Well, I think that people need to be informed before that happens. Ask the right questions; do your homework. And keep the conversation going.”

References:

1. Dee, Kate. (2004). "Med Spa Mayhem: The Good, The Bad, and The Ugly Secrets of the Aesthetics Industry". Advantage Books.