For the Botox set, a financial wrinkle

Special to The Times

From Santa Monica to Silver Lake, they’re complaining about the “silent treatment.” No, this isn’t an issue for a marriage counselor, but instead a complaint about the relationship patients have with their dermatologist or cosmetic surgeon.

These patients’ gripes are directed at their doctors, who they believe are reluctant to discuss their fees for popular wrinkle- reduction procedures such as Botox and Restylane.

These are elective procedures that even the best medical insurance won’t cover. That means patients must foot the bill themselves for treatments that typically cost anywhere from a few hundred dollars to well over $1,000. And there seems to be no shortage of Angelenos who are willing to fork over the cash.

In certain upscale restaurants in West Los Angeles, it sometimes seems difficult to find a diner over age 40 with a noticeable line in his or her face. And the proliferation of TV reality shows about cosmetic surgery is helping to fuel demand for these procedures.


While a patient going in for a surgical face-lift or nose job likely knows what the final bill will be, the privileged set who visit the dermatologist hoping to see their worry lines or crow’s-feet smoothed with an injection of Restylane often don’t know the exact price beforehand.

A typical experience might be the patient who excitedly sees one facial line disappear and keeps asking for another treatment, while the doctor, who makes more money with each injection, keeps filling and treating each wrinkle.

Dr. Stuart Kaplan, a Beverly Hills dermatologist, likens the process to having your house painted. “You know how much a bucket of paint costs, but you don’t know how much paint you’ll need until you finish painting the house,” he says.

Not knowing exactly how much treatment you’ll need until you’re in the middle of the procedure is only part of the problem. Patients and doctors acknowledge that there is also a kind of unspoken attitude: If you can’t afford it, or you have to ask how much, you shouldn’t be there.

The final bill may temporarily turn people off, but it doesn’t seem to be turning them away. A number of high-profile Beverly Hills physicians have six-week waiting lists.

After waiting so long for an appointment, some patients are so happy to finally see the doctor that they are hesitant to ask about price. Actress Mackenzie Phillips has had that experience. “I just get embarrassed to ask. I would maybe ask the staff, but I wouldn’t ask the doctor.”

Combine that with patients who will do just about anything to look younger, and who may be prone to impulsiveness, and expenses can get out of hand.

Beverly Hills plastic surgeon Steven Svehlak acknowledges that some doctors can take advantage of the situation. “Patients can get caught up in the excitement, and before they know it they’re getting all these injections, around their eyes, forehead and lips,” Svehlak says. “And then as they’re walking out the door they’re handed a bill for $3,500.”


Phillips has been down that road. “I would come in for Botox and they’d say, ‘Oh, you really could use a whole series of microdermabrasion appointments,’ or ‘You know we talked about you not being ready for a face-lift, but it’s starting to look like you might be,’ ” she says.

Kaplan, the Beverly Hills dermatologist, agrees that some doctors may have dual agendas.

Clearly proud of his high-profile clients -- a number of their gold and platinum records hang framed on his walls -- Kaplan says the medical world must play by a different set of rules.

“In every other business, if you take advantage of a situation you’re considered a great businessman,” he says. “In medicine we have to walk a very thin line because we still have to pay our bills and meet our overhead.”


For their part, patients need to realize that the meter is running with every injection. Collagen and Restylane are measured by volume, with a syringe filled with 1 cc (cubic centimeter) typically costing anywhere from $300 to $500 or more. Botox comes in a powder form, and it’s up to the doctor to decide the proper strength and price for each area injected.

“I can count both crow’s-feet as one area,” Kaplan says, “but there are doctors who give low prices and count each crow’s-feet as a separate area.”

Kaplan discusses the price of such procedures as Botox and skin peels directly with his clients. When a patient has buyer’s remorse, he says, it just hurts the doctor in the long run. And cosmetic surgeons don’t want unhappy patients: After all, some patients may come in for Botox or Restylane treatments two or three times a year because the effectiveness of the treatments diminishes with time.

Doctors acknowledge that haggling with patients over price isn’t the best part of the job. That may be why many doctors leave money matters to their front office staff. “I think it takes the professionalism out of medicine when you have to start bargaining with the patients,” Svehlak says.


Because beauty treatments aren’t covered by insurance, it’s understandable that patients might be more concerned about the cost. What is less understandable is why they are often so reluctant to ask, “How much?”

Kaplan has observed two kinds of clients: one who grills him about cost, and another who says nothing.

“Very often the wealthy are very cost conscious and will inquire about price,” he says. “And people who are less affluent are almost embarrassed to ask about the price because they feel they are going to be insulting the doctor.”

Then there are clients like Liza Schrage, a 38-year-old mother of three who recently saw a Westwood dermatologist for $1,200 worth of Botox and Restylane treatments. Schrage, who got the treatments before traveling to Mill Valley, Calif., for her 20-year high school reunion, says she was only concerned with results -- not the price.


“Once you see how good it looks, you just want to go back,” she says. “You don’t care how much it hurt or cost once those wrinkles between the eyebrows are gone.

“I wanted to feel like I was 17 again, or as close to 17 as I can get,” Schrage says with a laugh.