The Future of Cosmetic Surgery — with Erik J. Nuveen, MD, DMD (Ep.205)

The Future of Cosmetic Surgery — with Erik J. Nuveen, MD, DMD

Catherine Maley, MBA: Hello, and welcome to Beauty and a Biz where we talk about the business and marketing side of plastic surgery and the future of cosmetic surgery. I’m your host, Catherine Maley, author of “Your Aesthetic Practice, what your patients are saying”, as well as consultant to plastic surgeons to get them more patients and more profits. I have a really special guest today.

His name is Dr. Erik Nuveen. Now, he’s a cosmetic surgeon, who is embracing the future of cosmetic surgery, in a multi-surgeon, 10,000 square foot private practice called Cosmetic Surgery Affiliates, and it’s located in Oklahoma City, Oklahoma, which I’ve actually had a chance to visit this year for the first time in my life, and it was really nice.

So, this eight- figure, practice, which is embracing the future of cosmetic surgery, includes face, breast, and body surgical procedures performed by four surgeons in their two onsite operating rooms, which are fully accredited and AAAHC certified. Now, they also offer a plethora of nonsurgical treatments performed by many ancillary staff in their med spa, as well as online store that carries their own skincare line.

Now Dr. Nuveen and I crossed paths very recently. We were at the American Academy of Cosmetic Surgeons annual meeting in San Diego and Dr. Nuveen we were in the practice management session and after I spoke, then I listened to Dr. Nuveen’s talk and his was entitled, “The Future of Cosmetic and Plastic Surgery: Consolidation and Success”. So, this happens to be a really hot topic lately, so, I wanted to get his take on it because he’s very immersed in it and like I said, he’s embracing the future of cosmetic surgery.

So, Dr. Nuveen, thank you so, much for coming on to Beauty and the Biz.

Erik J. Nuveen, MD, DMD: Oh, you’re welcome. Thank you for having me. I appreciate it. It’s an honor, it’s always I don’t know, may, maybe it’s a point of retrospect and, and life, but to, to hear the things that I’ve done is kind of weird to listen. It just you know, I started off when I was six and always wanted to do surgery.

My father was an orthodontist and oh, He straightened teeth, and that was wonderful to change the perspective and often the self-esteem of o often adolescences. But at the end of that, I was always frustrated with my dad because he couldn’t fix their nose or their chin. Oh. And that’s really where it started.

And you know, today after finishing, you know, 14 years after college and. And eight, nine years of residency and fellowships. And then 21 years of clinical practice, it’s like a blink of an eye. And I, I know I, I sound like a broken record for us that are adding up some years, but what I think what’s been kind of special about my situation is when I finished up a full formal fellowship and face end body cosmetic surgery in Salt Lake City, Utah.

I had also finished a year of cranial facial surgery at Toronto Sick Children’s Hospital. So, I had a pretty unique bunch of skills and also medical and dental degree. Prior to, I did a total of two years of general surgery. So, it was interesting because I, I had also along the way had taken a little time to fly some airplanes and so, I figured, well, gosh, how can I involve myself with a hobby with a skill to help others and to improve the standard of care throughout the country?

And I, I, I take that statement very seriously. That was my objective and it still is to this day to try to improve each and every day. And I hope when I do exit. That it will be at the top of the game and, and I’m always looking forward to that because each day seems to be a better day. Oh. Yeah. Yeah. So, I, I finished my fellowship and I came to Oklahoma City.

I picked Oklahoma City because the cost of living here was very low. And the opportunity to start off day one in a 10,000 square foot facility that I purchased was not Something I could do in downtown Manhattan, right? Or other major metropolitan areas. So, I live about eight minutes from my office and 12 acres and nice countryside and quiet with coyotes and hawks and owls.

And it takes me 10 minutes to commute to see patients, and it’s just been a fantastic choice. It is the middle of the country, so, fortunately I get to use my airplane and go and visit the ocean often. And so, the practice really started there in Oklahoma City and I took over a preexisting doctor’s practice.

He was 71 and did exclusively breast surgery. And I saw an opportunity to expand that practice. And fortunately, God willing it did. And so, I purchased that practice from an individual, kind of the old school method, a handshake, a, a gratitude, and pat on the back and. And there I started and did —

Catherine Maley, MBA: Wait, were you in a different building? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yes. Yeah. From the, from, so, he was in a smaller facility and shared with an ophthalmologist oculoplastic eye. Mm-hmm. And that relationship couldn’t have lasted too long. Cause I really needed to grow and I needed multiple operating rooms to do what I had set my heart to do. So, my, my plan from day one was to come into the community meet all the other surgeons that did similar things and.

And opened the door for growth. And ultimately, I, I set the bar high. I want it to be the most dominant practice in this region of the country. And I, I think statistically we’ve been able to achieve that. I do. About, can, can I ask you something? Yeah. Mm-hmm.

Catherine Maley, MBA: Out of curiosity, what exactly did you buy? How did this affect your understanding about the future of cosmetic surgery?

Because, what did he have that you wanted of value? Was that a shortcut to get into the community or what? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. Yeah, it’s a great question. So, you know, there’s an exchange in life, right? You know, you, you ask for, you have communication, you hope for a response. And in the relationship with the physician was this gentleman wanted to exit and I wanted to come in.

Mm-hmm. And he had a patient flow volume of about 750 patients a year. He did a very high volume of breast augmentation and he was very consistent year in, year out. He didn’t offer almost any other procedures. So, I saw an opportunity there just in the patient flow volume to expand, and it did. So, we sent out letters to 6,500 pre previous patients and inform them of our expanded services and an opportunity to meet with me and.

So, the first month I was in practice I did 57 major surgeries and I’ve never slowed down.

Catherine Maley, MBA: Nice. And did you two, like were you feeding off of his credibility? Did he have to stay put for, for a while for the patients to get used to the transition or how did that work? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah, that’s, that’s a really variable answer if you’re speaking to the general public on that topic because it’s all about personality will determination.

Effort and I hope good counsel.  I think that’s an often-overlooked commentary is you, you need to, don’t, don’t do things foolishly because you think it’s the right thing to do. There’s been other people there before you and you really should ask some good questions and don’t be afraid to hear constructive criticism.

It’s, it’s very common to think that doctors have done very well in school and that that translates into financial or good decision making, and it doesn’t always. So, we have to admit that first and foremost, have the insight that the others have been there and let’s get some good advice. So, for, in my situation, I was taking over a gentleman’s practice who.

Had done almost 20 years of exclusively breast surgery. So, we had a very long proven statistical track record, and I’m very data driven. So, I did a lot of spreadsheets and demographics, co, you know, cost of living, cost of employment, and the goals that I set for myself and my business, and kind of predicted in a business plan exactly what I thought would happen.

And it’s actually remarkable how close I was over a 20-year period to exactly what I predicted. It’s actually freaky weird. I was off by less than a hundred thousand dollars in, in, in all the categories, which is pretty, pretty amazing actually.

Catherine Maley, MBA: But did he stay put like did you two work together or did he pretty much exit and you entered? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah, I made a very thought-out contract. There were some issues related to his history that I needed to insulate myself from and isolate myself from. So, I did that legally. And he worked about two hours. And then he was released from that obligation. And then I took it from there. And at that point, I had come down two times during my fellowship met patients, knew I was on good, solid ground of communication and I was willing to take that gamble.

So, he exited immediately and I took it over from there.

Catherine Maley, MBA: So, again, out of curiosity because these are the kinds of things people want to know about. Yeah. If you’re taking over somebody’s practice who might have some reputation issues or maybe some bad reviews, do you, how do you handle that? Do you just change the name and hope nobody notices, or what do you do? How did this affect your understanding about the future of cosmetic surgery?

Yeah. Well, you over his website with his SEO of 20 years of rankings, or how does that work? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. You know, today’s a different era. Yeah. You know, it’s 21 years down the, down the road since then. But at that point we did surveys. We sent out surveys to patients. We asked local doctors, because I did communicate with every other plastic surgeon here in Oklahoma City.

Not always to the most welcome response, but they gave me enough ammunition, fuel, and, and energy to try to approach. The challenges and also received the benefit. And the benefit was just a phone number and a website and that. Statistical demographic that was reaching out was very consistent.

And even though there were negatives and I, I have yet to meet a doctor in the country that didn’t have a negative of some sort. Right, right. There are risks and sometimes we take those calculated risks and I, I think if we’re, we’re a wise person, we’re going to really investigate background checks histories, people, they’re cavorting with their associations, their friends.

It was, my situation was abundantly clear. There were some significant challenges, and I have to say, if I asked 10 of my colleagues, they might have questioned my judgment, but I just looked at the demographics. There was, there was such strong patient flow and opportunity in that patient flow that I, I went for it and, and it was a good choice.

But how does that translate to other doctors? Excellent background. Listen to others, get experts, get lawyers, get accountants. You need to surround yourself by people you trust to the end. I mean, like people you’d give your kidney to if they needed it. You, you really have to have that level of faith because these people are giving guidance about your career.

And to take it lightly is a fool’s errand for sure.

Catherine Maley, MBA: What would you say is one of the biggest mistakes made that now you look at back at now and say, gosh, I wish I had avoided that one. How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Hmm. Well, I got to be honest with you, maybe I’m, maybe I’m just blissfully happy, but I can’t think of a single significant mistake that I made at all.

I mean, it, I really, it, it has been an unbelievable career. Unbelievable. And. Sure there are things I’d, I’d regret taking on too. Challenging a case at too earliest stage in my career. Mm-hmm. I’m definitely guilty of that and thinking that maybe sometimes I have more answers to a problem than I. I rightfully should have.

Mm-hmm. And those can bite you. But you know, it’s experience just leads you to those types of mature answers and inexperience leads you to immature answers.

Catherine Maley, MBA: So, how long were you in practice before you bought that 10,000 square foot building? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Oh, I actually bought it before I started, so, I, I, I had made some pretty savvy investments during residency and I saved up a great deal of money.

So, I had no debt. I paid off all my student loans and I had enough money to go in and, and pursue loans. And this was a different time. I mean, gosh forbid a person leaves a residency now with four or $500,000 of debt. I mean, they’ve got a doctor, doctor at a, at, you know, after their name and that used to buy you, you know, a million-dollar loan just for the handshake and a signature.

Those days are long gone. And it’s really an interesting time, which really leads us to the issues of consolidation. For sure.

Catherine Maley, MBA: How did you know that you, were you, so, you knew you were trying to build an empire, like you weren’t getting around like you, or were you thinking about renting it out to others? How did this affect your understanding about the future of cosmetic surgery?

Did you know you were going to fill that building up? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah, well, you know, my mom says things to that I’ll quote often, and I know she’ll listen to this podcast, so, she’ll probably get a little teared in her eye. But when I was a little kid, my, my mom always said he’s full of grandiose ideas. We’ll see what happens.

Catherine Maley, MBA: Famous last words, huh? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. Yeah. So, I, I’ve heard over and over from people and I surveyed as many people as I could find. I went all over the United States, never spared a vacation to, to go to a surgeon and spend time with them. I mean, I missed, I. Almost 10 years of vacation because every vacation was used to advance myself and my career for my patient’s benefit.

So, I I had a lot of information, a lot of experts out there, very famous people. I could just run-down a, a lengthy list. And they, the con the con consensus was a few things. No matter how big the space you get, you’ll fill it. Just watch, it’ll happen. And so, I took that to heart and came to Oklahoma where things were a little bit cheaper and started day one at, with 10,000 square feet.

And, and now we have another facility in Jacksonville, Florida that’s going to arrival at, so.

Catherine Maley, MBA: Wow. And then when did you start adding other surgeons? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Hmm. Well, I was in practice for three years before I took our first fellow, and so, I would. Count that as my first experiment with having another full-time doctor with me.

And that was a great experience. And so, I’ve had. 15 fellows. Now we have one every six months now. Those fellows are all over the country from Seattle to Scottsdale to Park City and down in Florida. And so, that’s been a great journey. I, I would say that is a really nice way to bridge the gap from independent practice to developing physician relation skills.

When you’re isolated in a practice, there are some strengths that come from that autonomy, but also some weaknesses that develop and that dictatorial unilateral approach to decision making can be a very challenging problem in, in various social arenas. So, I would attribute that first step of growth to fellowship training and devoting oneself to the education and betterment of someone else is, is a, is a really true altruistic art.

Mm-hmm. So, I would say there, now my first associate was 2007. So, I was in practice four years and took on a gentleman for two years. We knew his pathway was to leave, but we were fortunate to have him for two years, and that gave me another stepping stone towards longer term relationships. And I, I’m still learning to this day.

I don’t have all the answers. I. But I will say that there, I think there’s three categories of doctors you work with. There’s a doctor who’s very skilled, very capable, and very good, and is just trying to bridge that gap of independent practice from residency, for example. And they’re strong enough and good enough that they’re going to try to fight it and do it, do it themselves.

Some of those doctors will see value in associating with another doctor and others will not because they’re so, capable and skilled. That’s one type of doctor and they take a different approach and a different mentality and a different communication style. The next doctor is a doc. Our doctor is a doctor, is completely on the other end of the spectrum, and that’s a doctor who doesn’t want to own anything, doesn’t want to run anything, and just wants to show up.

And they literally don’t want to manage. Even the thought of management is, is just makes them almost sick to their stomach. And those doctors are really interesting because you can almost plug and play. You can have a system do consultations, plug in the doctor, minimize their interaction. Quite honestly, because often they’re not the most robust in their skillset and succeed very well because if they show up and are happy to do two or three surgeries a day, I mean, they’re thrilled to go home.

And maybe that, that term that sometimes confuses me work-life balance, which I don’t have. That, that’s the third type of doctor. The intermediate doctor is the doctor that I really strive for. But I’ll take anybody, I mean, I, I’m not going to say that we have a specific type of doctor that we’re looking for because honestly, all of them can work well.

It just. Listening to them, understanding them and respecting their skillset and their what they’re really looking for in their lives. So, that intermediate doctor is a doctor that wants their input heard. They want to be respected. They want to add to the quality of the practice or the contribution factor they want to contribute.

Yet they don’t want to overly be involved with the bills. And negotiating contracts with anesthesia departments, it’s just not what they want to do. So, those are the three kinds of broad-based categories of doctors I deal with, and all of them can be appreciated and all of them fit into a system. You just have to respect their differences.

Catherine Maley, MBA: And, acknowledge them. Because I think a lot of doctors aren’t aware of which box, they fit in. Mm-hmm. Because some of the doctors actually, some of the I’ll just generally speaking, yeah. The younger patients don’t, or the younger doctors don’t know anything about business and they’ve never had to come up with patients in a marketing plan and paying bills and being at risk. How did this affect your understanding about the future of cosmetic surgery?

Yeah. So, they come on a little strong and not be naively, you know, and then there’s the older doctor who might be burned out. But, but not willing to relinquish control so, that there’s nothing easy about that. I’m sure you take your time, you know vetting these people, right? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. Yeah. It, it’s, it’s really interesting.

It, it’s a, it has to be thought of, in my opinion much more fragile than a marriage. I know there’s analogies often made, but. I mean, it’s pretty easy to get out of a business situation, and it’s, it’s much more financially challenging to exit a marriage having been there. So, I, I, I would say that identifying egos who needs to be praised?

What, you know, what are their love languages? I mean, it’s truly a tort of force of intellectual psychological assessment and appreciation on both sides. I mean, we have to respect each other. We have to show that respect, but constructively, we have to give guidance. I mean, it’s really awesome. I mean, talk about fulfilling.

I mean, this type of, of business relationship is just amazing.

Catherine Maley, MBA: Well, I’ve seen some practices that are a true democracy. Mm-hmm. They meet, but they meet every week. They have the same values. They have honed this. Mm-hmm. I know a practice who has kind of like a coach and the coach keeps everyone on task. How did this affect your understanding about the future of cosmetic surgery?

Mm-hmm. Just in case things, they don’t want any big problems that are factoring and they’re not talking to each other, so, they really take it seriously. And, and they have a beautiful, profitable practice. Mm-hmm. And then others are just a dictatorship. They just, they. They hire some surgeons and they say, I’m running the show. How did this affect your understanding about the future of cosmetic surgery?

You just show up and, and appreciate that, and that’s it. How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Right. Right. Yeah. And, and yet there is room for all. I mean, there’s enough to go around. Mm-hmm. And the greediness and, and the you know, to, to think that you’re the only one to do it. The only way is just foolish.

Catherine Maley, MBA: So, I’ve been doing this for a long time and I’ve never heard the same story twice. How did this affect your understanding about the future of cosmetic surgery?

You know, there’s no one way to do this. That is for sure. I’m just loving all the creativity that is coming about, that’s evolving and that’s why we’re talking about this. But yeah, if I’m not mistaken though, when I was listening to you speak, do you have 39 staff people? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. Let’s see this week. And that’s a, that’s a, a laugh, but also the truth.

It does vary quite a bit. We have. We have one person two people kind of exiting. We have three coming on. That’s normal. That’s a normal week. So, we have a very open-door policy. I say the same thing every year at a Christmas party. I say, listen guys, whenever you want to leave, it’s perfectly fine with us.

Don’t ever feel like you got to be the last one in the, in the building. I just thank you for coming. Thank you for being a part of our employment. And just have a good time and leave whenever you feel darn good and ready. Don’t, don’t feel bad. And I kind of keep that same philosophy in the office. We tell people when they’re hired, listen, we’re, we’re here in this life for a certain amount of time.

You may be here for a long time; you might be here a very short time. Don’t ever feel bad about it. Always address things up with honesty and forthrightness. And if things aren’t going well or you’re seeing things differently, we need to hear about it. Let’s just be open about this. Immature adults. And so, we do have a fair amount of turnover in our office, which is both financially challenging and functionally challenging.

So, we’ve chosen kind of a redundancy and an overlap in employment that allows kind of a rotational cycle of employees. So, I have a set of employees that I work with primarily. Of course, I like to call them “The A-Team”, but. They’re really just a group that, that has piled around with me, knows my habits, knows my mannerisms, and we work really well together.

So, we work together three days a week. We, we typically do 12 hours a day, three days a week. And we start at six 30 and yeah, usually finish around 7 30, 8 o’clock at night and no, I take no lunch. So, talking about work-life balance. Yeah. I’m not the model of that. I love my work, love my work. I make no excuses about it.

I am no balance whatsoever. Work, work, work. Because I love work and I figure I want to work. And if I die at work, that’s okay with me.

Catherine Maley, MBA: Okay. Good attitude. Do you, hopefully you give them lunch, right? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yes, yes. As what’s required. But I, it’s so, funny because you know, people of personality types, they tend to congregate.

We like to hang around with each other and you know, we have a certain type of humor and we have a certain type of music we listen to. And it tends to be that these young ladies work their living butts off. Cause they love that I do. Nice. So, we’re all, it’s like a bunch of pigs and mud. I mean, we all love rolling around in it.

So, they take very little launch, often don’t take lunch, they’ll snack on something. They kind of mop about it, but they also are kind of proud about it and mm-hmm. So, my little set team is they’re amazing and I’m very happy for, but we’re just one small part of the big group. We have a, we have a big administrative group.

We have a very big IT division, which. I mean, I, I could just talk for hours about just our 13 different IT groups that we work with. It’s craziness.

Catherine Maley, MBA: And are you planning, do you go for patients all over Oklahoma? All over the nation? All over the world? Well, where, where are you going with that? How did this affect your understanding about the future of cosmetic surgery?

Where are you? I mean, are all these, like the, those breast dogs, was he getting all those just in Oklahoma City? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. Yeah. The so, the, my predecessor, the person I purchased the practice from was, was a, a, a very unique individual. He decided to basically do the Walmart service, so, he did, it was $2,800 cash breast augs saline only, cash only.

And he did four a day, five days a week. So, that’s not a bad business model. No, no. He did very well financially. Mm-hmm. You know, there, there were some unscrupulous issues and there were some, some financial misappropriations that occurred.

Catherine Maley, MBA: Well, the cats only probably was a hint there. How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah, yeah, yeah, yeah. So, Anyway, but we don’t run our, our business like that. So, our, our business is, you know, absolutely to a t run properly. And, and so. What is our recruitment? Honestly, we try to focus on the central Midcentral United States. We do get patients, word of mouth, friends, et cetera, that come from all over the country.

We have a very large military presence here in Oklahoma, so, we have a lot of people that relocate to Japan, Germany, Italy those are the big ones, and all over the United States on a different military basis. So, that has been a big area of contribution to the practice success. But really, I, I think it’s been 21 years of, of tremendous service and being available to the patients.

I, so, 21 years ago I made my own website. Mm-hmm. I did it over Thanksgiving. Weekend it cost me 25 cents. Nice. And I started something I’d never heard of and I did, made an online form entry and completely, there was no HIPAA and so, they just sent me pictures. And so, I was getting, you know, pictures of people, body parts from all over the country all the time.

And I was inundated. So, I had never heard of anybody ever doing this before. And you know, of course things have advanced to all the encryption and HIPAA policies and now almost everybody has an online form entry system. Mm-hmm. But you know, 21 years ago it was unheard of. I certainly never heard of it.

Catherine Maley, MBA: Oh, that was a big deal 21 years ago. Good for you. How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Oh yeah, we were doing 20, 25 cases a month purely from, without ever visiting with a patient. The patient would come in from out of town, we’d see him the day before, we’d do the consultation, then we’d do the surgery the next day. So, yeah, it was just I have to say that that concept came from a, another doctor who I met in Connecticut, and he was doing that for wisdom teeth removal.

And just inundated. And I thought, hell, why not try that in our business? And sure enough, it was a, a tremendous boost.

Catherine Maley, MBA: That’s how I’ve grown my own business. I always looked at all the other industries and I said, how can I adapt that to our industry here? And it’s all y all you have to do is be a little creative and say, how could we do that here? How did this affect your understanding about the future of cosmetic surgery?

And yeah. Now you also have an online store, a skincare line. You have your own skincare line with an online store where they can shop. I’m always curious about that. Is it a good profit center? Is it a pain in the neck? Who’s doing the fulfillment? You know, I never, I, I’m not a fan, but, but does it work? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: I mean, yeah. Well, first of all, I, I think you have to have a passion for whatever element of the practice your endeavor might be. So, for me, I’m a surgeon. I do surgery morning, noon, and night. I hire people that have passions for things that I don’t have a passion for. So, I have an aesthetician that does all the aesthetic services.

I have two nurse practitioners. That primarily do non-surgical things and supervise my clinics. I have a skincare person that deals with most of the retail services. Is it a profit center? Sure. It makes a profit. You know, I mean, it’s probably 50% margins on everything we sell, but, you know, as far as a comparative, I mean, just to use real numbers and I hope that’s okay.

I’m always very transparent about, about the practice. You know, selling $10,000 a month of skincare products is, you know, that’s $5,000 a profit. That’s pretty darn good for buying hamburgers and shoes for your kids.

Catherine Maley, MBA: I’m okay with that. As long as you don’t lose focus on the big-ticket items. I find that the vendors or sta like estheticians take it very seriously, but I just, I watch the balance of how many are, how much of your resources are going into that when it becomes only one or 2% of your overall revenues good. How did this affect your understanding about the future of cosmetic surgery?

That money have been made. Easier or elsewhere, or that, that’s my only comment there. How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: You have. Yeah. Yeah. It’s a very, it’s a very good point. And you know, some of the consulting services will focus on the quote, the, the money left on the table, right? Yes. That’s the common statement. Well, you’re leaving money on the table, right?

I mean, that’s a term that I just want to choke people out for. Because you’re absolutely right. If you have no passion for it, if you have no business doing it, please don’t do it. Yeah, you’re going to waste energy, time, frustration, managerial nightmares, legal liability. I mean, I could go on and on. If you are really good at something, I think you should do it all the time.

Because you’re going to make much more money at it. You’re going to enjoy your life. And I don’t worry one bit about my skincare related services, because I’ve got a young lady who loves it. So, there you have, yeah.

Catherine Maley, MBA: I mean, I practices try to train everyone on how to sell skincare and I just think I don’t get that. How did this affect your understanding about the future of cosmetic surgery?

I just, I think there’s a better use of your time. Regarding, you’re doing a lot of non-cervical as well. You have a full-blown med spa, right? Because isn’t your, is your philosophy more patient for life or one and done? Or where are you at with that? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. Yeah. God, you know, so, right now I, my practice and I as 90 plus, 90% of the overall surgical volume, I do about 2,240 procedures a year.

So, it’s almost mind boggling. But I did surgery. Yeah. And so, I, my focus is all there. So, but what would be ideal? If I were to step back and walk into this office as a businessman, which I like to do mentally. I would look at the colors, I would look at the smells. I would look at how I’m greeted. I would see what, what the door presentation is.

I would want to hear the music on the speakers and you know, is there a TV on and what’s playing on it and what’s being presented. Are there menus of services? What are the services that this offers mm-hmm. That this office. Offers, how is it displayed? Is it displayed on the wall? Is it displayed electronically?

All of these things that would go through my mind if I walk to the office. And it’s interesting because even though I, I suppose I’m in the position of c e o, I don’t fulfill all of those. Things that I’ve just told you, there’s always room for improvement. There’s, and that’s undyingly interesting to me, that there’s always room for a person’s improvement and the practice improvement.

Now, if I were to say in a more ideal situation for, so, I do about 90 major faceless and facial restorations a year in, if I could ideally, Play out for you. What I’d like to have, I’d like to have an introduction. I’d like to have a credentialing period. I’d like to discuss their goals. I’d like to hear from them for 10 or 15 minutes.

I’d like to a, evaluate them and like to give recommendations based on their goals. Now a quote is rendered, but I’d also like them to meet with an aesthetician because as part of the comprehensive care of this patient is not only. Pre-operative preparation for it in many cases, like laser skin reserving, but the post-operative maintenance, it, it is a really important, integral part of, of ideal patient care.

So, it’s not just a surgeon comes in, cuts, walks out of the room and never sees the patient again. That would be the, the most cur method of maybe managing the patient. But really ideally that’s what I’d like to have. Do I fulfill that each and every day? No, I don’t. I, I think if I were to walk in as a consultant, I would say, boy, you really need to kind of systematize that process each and every day to have that integration that I think is more ideal.

Catherine Maley, MBA: Well, as a, coming from a perspective of the cosmetic patient, once they’ve invested in themselves on one body part, they will move on to another body part. And especially if you help them with that. So, I think you, you, you have a patient there for life psychologically, you know? Yes. Once you get that bug to look good or feel good and all of that. How did this affect your understanding about the future of cosmetic surgery?

Yeah, usually it’s not a one-time thing for the patients and nor should it be for the practice, you know? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. The loyalty of patients within the cosmetic surgical field has been well documented. I mean, the average patient is like five procedures over a lifetime. If you can maintain them for a lifetime.

I wish only at five. Yeah, that’s, yeah. Way over that. If you look at you know, lifetime income from that, you know, our average price point per procedure is just about $11,400. And so, I mean, that’s not something we should shy away from. And we also know that the cost of acquisition of new clients is much more expensive than the preexisting ones.

So, it just, in every way it makes sense to establish and maintain an ideal relationship. But it really starts from. From the moment you meet them, being very direct, very honest, very, very open, and also expressing limitations. Just being a human. I mean, sometimes patients forget that just because you went to school for a long time, you don’t have all the answers.

And reminding them that, that humbly, I think, is really important. Have you noticed a

Catherine Maley, MBA: change in cosmetic patients from even, I guess maybe pre-social media to now or pre-internet to now? Like, how do you see them now? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Hmm. Well, I, I, I’d say I’m a little bit biased by my current position in maturity of practice.

Probably 55, 60% of my patients, maybe even slightly higher are previous patients. Nice. So, that’s, that’s advises me because they already know me. They already trust me. They, you know, their daughter, their aunt, and their grandma came. And so, that’s a, that’s a no-brainer. You should seal that deal. That should be pretty easy.

It’s the new clients, the new acquisitions that are, are Our, our have changed, evolved quite a bit of course during free money time and low interest rates. And, and COVID was, you know, the heyday for cosmetic surgery. I, I’ve rarely met a practice that didn’t show a significant increase because of time available for recovery, but also Liquidity was very high.

Yep. And so, that period is, is certainly changing right now. And we see, seen a macroeconomic tightening throughout the country and all the practices that I deal with. And, you know, you, but it, it’s a want and not a need. And thank goodness for that because having weathered housing crisis 2001 bombings there’s a, you know, little dips that you take, but.

People want what they want and they’ll put off their needs. They will not put off their wants too long. Mm-hmm.

Catherine Maley, MBA: I agree. So, I want to switch gears a little bit because Sure. You’ve grown this incredible empire. And then I want to talk about the talk that you gave about the future of cosmetic and plastic surgery and the consolidation. How did this affect your understanding about the future of cosmetic surgery?

So, can you go ahead and, and can you just like a brief talk of what your thought was? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Sure. Well, thank, thank you for, for listening to the talk. I appreciate it. Okay, so, five years ago. I sat down and I thought, you know, I’m not getting any younger. My practice has become a, a behemoth and it would be very difficult to sell the practice to an individual for what it’s valued or what I’m told its value is I.

And so, I was really struggling with that. So, I thought, well, maybe I could fractionate it, break it down to shares, and maybe five doctors could split it up, and that would bring me some revenue towards an exit. But honestly, it still wasn’t anywhere near what the actual cash flow and ongoing value of the practice was.

So, I got really frustrated with that and I, I can I Spoken, met with a lot of people from many different industries, auto industries tech industries all over as many people as would listen to me. And so, my, my grandma always said, if you want to want to learn something, just call. And so, I called CEOs from every website I could find.

It’s amazing how many of them were interested to spend just five minutes with me and tell me about you know, it was like I was a kid in, in high school asking on a school project. And so, I learned and learned and learned, and I realized that where the value in the future of our field, in my opinion, is in reducing redundancy.

That was really the central theme. If you think about every garage, you drive by in the United States and it’s open in the summer, you’d see a weed whacker and a lawnmower and a trimmer, and gosh forbid they’re sitting there like 98% of the time not doing anything. What a waste of money when one community could very well buy a set of lawn, a lawnmower, a tremor, and rotate it throughout the community.

Catherine Maley, MBA: There you go. Perfect. That’s a great idea. How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. Yeah. I think of it that way and. Yeah. And in our business, that’s exactly what we do. Almost every small boutique type practice has an office manager, maybe a person in charge of, so, social media, front desk girl, and an accountant. And, you know, maybe that’s the size that they’re, they’re comfortable with.

But my practice had grown so, big that I had, I have, you know, five departments. I’ve got department heads in each department and ins, subordinates within those departments. And we have department meetings and, you know, it’s all very corporatized and just everything was just going that way. So, the more information I got, the more I realized that I, I could very.

Quite honestly, I could very easily just go to a private equity consolidated group and just sell my practice. But what I did was I looked at all the available options and there were very few, and still are, very few actually that have gotten to a point of consolidation. And I realized there were a few significant weaknesses and I spent, I.

Almost 2000 hours. That’s no exaggeration by the way. 2000 hours. I documented all of it. I, during residency, I was very obsessive, so, I documented every hour I ever did during residency. And so, I have that all written down. So, I figured, you know, I’ve got to keep this up. So, I documented all the time, I spent on the phone, at conferences, at meetings with private equity groups.

And I learned a great deal and what I learned was the private equity groups often contributing some form of financing. So, they consistently wanted to take. Plastic elective surgery and Shoe Hornet into the models that they knew. And those models were gastroenterology, ophthalmology, dermatology, insurance-based accounts receivable.

Their due diligence process was very foreign into a cash-based system. They didn’t even understand that we were prepaid for surgery, you know, a month in advance. It was just, Whoa. Where’s your accounts receivable?

Catherine Maley, MBA: And there’s no accounts receivable. How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. None ever. So, I had, I was really like walking into these people that I felt I was the ignorant one, but they had absolutely no understanding of what I was talking about.

So, it was actually, I saw that as a great opportunity to, I mean, I always love somebody who’s willing to listen to me, so, I had a great. Time kind of going through so, many different groups, speaking to different levels, all the way up to CEOs of these private equity companies, and just hearing what was pleasing to them and what they were scared of.

Hmm. What. Oh my gosh. I mean, the list could be very long. Key operator dependency issues. You know, if there’s only one doctor in a practice, how can you show me on a, on a cash-based system that your 90 day and one 20-day revenues are going to be there when I’m used to waiting for accounts receivable for 120 days?

So, they, they want security.

Catherine Maley, MBA: You know, and this, and they want predictable revenues and how you say that in our industry, you know? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: That’s right. And all you can do is say, well, I’ve been in businesses 21 years and it’s gone pretty well. Yeah, right. So, I just kept on telling them that, listen, look at the books, look at the data, look at the, the, the cash system is, you know, a 40 to 60% profit margin.

You guys are arguing over 13 to 17% in dentistry. I mean, it makes no sense to me at all that you’re wasting all this time with dentistry when you’ve got a cash cow right down the street. I mean it just over and over again. And then one day I got a call back from one of the CEOs and I was in the Atlanta airport at the time, returning from a, a meeting with another private equity group, and he said, Erik, We like what you’ve been saying, we’ve been really talking about it, and we want to meet with you and your group.

So, that was, I mean, I, I almost cried. I’ve been telling you my hair stood up in my arms. I was like, yes. And finally, it took me four years to hear that type of response that I was hoping for. And, you know, speed ahead and the tides are turning. There’s certainly a tipping point. Of familiarity, understanding, and acceptance.

And the world of cosmetic elected plastic surgery is filled with people that make a great deal of money compared to the average person, and they’re very autonomous. And this is a tide that’s going to take a long time. But that’s okay. The, we’re, we’re in this for the long haul. This is a 10-year project.

This is not a one-year project. This is a 10-year project, and I really came up with that idea with a lot of my buddies in construction. And when they look at a thousand-acre plot, they’re not thinking about, you know, one year, they’re thinking about 10 years in building schools, community parks restaurants, everything.

That’s a part of urban development. And I just thought that’s, that’s the kind of approach I want to have in this industry is a 10-year plan. I. So, really that led me to some partners with some colleagues I’ve known for 25 plus years. All of them that are surgeons. Were business people. Yeah. These are all other surgeons that have been extremely, you’d know all their names if I mentioned them, but I won’t mention them because they didn’t give me an approval to do so, but they’re very well-known people that you would know immediately.

And people that after conversations, just like we’re having, came to the realization that the future is very strong when you consolidate. Mm-hmm. The strength, and this really comes from the relationship I’ve had with my wife and my. Fellows and my partners are that we are always stronger together than you are separately.

Always, always. And once people get that mentality shift accepted, they go, ah, I get it. So, we can have one accountant for the entire system. That’s one cost. We have one c e o, one procurement expert, one person that’s saving us 20% on. Allergan or Galderma just 20% right there of negotiating power. When you’ve got a 50 million a year cash flow company and you sign exclusive contracts, you’re going to get tremendous buying power, strength, and it, it’s just over and over again.

I could go on and on, but I, I hope that’s exciting for the viewership.

Catherine Maley, MBA: And are you consolidating the HR, the hiring, the managing? Because I find absolutely the surgeons, the number one challenges staff. Mm-hmm. They, they are. So, especially after post covid, they’re so, done with staff. Like they’re, yeah. How did this affect your understanding about the future of cosmetic surgery?

You know, is, does it include that? Because I can see a lot of practices thinking, oh my God, if I could get this off my plate and get back to doing what I like to do, which is surgery. Yeah. I’d be a happy clam right now. And I’m, and they’re, I’m not. How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah, yeah, that’s exactly the type of person that we’re looking for.

And you know, to kind of make this segue a little bit the goal is to have 50 practices that are like-minded, utilizing a centralized call center, centralized HR, centralized procurement. The buying power of, you know, 150 million a year company is just puts you into a totally different league, right?

We want doctors to maintain autonomy if they want to. So, we offer a number of different avenues to try to become partners, and it has to be a partnership. There are people that just want an exit plan and we provide that exit plan. There are people that want administrative roles and responsibilities.

There are people that want equity in a growing and very rapidly growing corporation that pays dividends. And so, we have avenues for all those different types of people, and we have avenues for people that just want to show up and work. I have a couple people right now that, so, we’re constantly interviewing.

We’re constantly evaluating practices, and you always learn something from that. Those, those communications.

Catherine Maley, MBA: Are you involving private equity or is this a physician led consolidation? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. Actually, the answer is yes and yes. Okay. Ultimately in order to fund the growth if you study almost every other industry, there’s a reason that loans exist.

Yes. I mean, why, why not just put it on your shoulders? Well, because honestly, there’s a point of growth that you need acceleration and you need to get through a, a bridge, a gap that costs money. And it’s, it can be a pretty substantial amount. So, the initial phase of development is a minority partnership with private equity where we maintain 80 plus percent of ownership and all decision-making rights exclusive of a few constraints with utilization of funds.

That are appropriate to any financial term, to any company. And but it is a board run by through and about physicians.

Catherine Maley, MBA: So, the board is made up of decision-making powers by physicians and the business people are also on that board? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yes. They have one seat at the board, at the table. They do have some.

Again, you know, lots of details, but ultimately decision-making powers of specific hiring roles. Veto powers do exist, but they’re extremely limited due to the minority position.

Catherine Maley, MBA: Gotcha. I’m doing, it’s a miracle though. I’ve worked with, I mean, when I get in when there are more than three surgeons in a room, we have a tough time making a decision, so, Yeah. How did this affect your understanding about the future of cosmetic surgery?

You know. Good, good for you, because I can’t imagine all of them coming. How does that work? Can you get a decision made? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. Yeah. Yeah. Well, I, I think, again, it all goes back to what I tried to form formally kind of describe, you have to have this mental shift. It’s not about me anymore. Yeah. It’s about the entity.

It’s about growth. It’s about the quality of consistency of quality of care. Mm. Mm-hmm. And I think those words play very strongly amongst even egocentric physicians. Mm-hmm. So, but getting that shift from me, me, me, Now I have a two-year-old and he’s constantly saying, mine, mine, mine. And I just, I got to take a video of it because it reminds me so, much of the first time I meet with a doctor who’s got been a very successful doctor in there.

They’ve got these barriers that are so, visible. I mean, you can just palpate and trying to get through that to, to a level of, of greater understanding that this is a societal shift. Hmm. You can either sit back and wait, or you can be a part of it. If you join early, you’re going to be in a position of more directorial involvement, right?

You’re going to have a higher equity value. And what happens if you look at the math and its pretty simple stuff. I’m, I’m the, not the smartest guy in the world, but I do work hard. So, if you look at the math, it’s really simple stuff. When you add practices to a group, it becomes stronger. When you exit, meaning when you sell it to a larger fish.

So, a small fish is eaten by a bigger fish, and that’s the principle at hand here, is that a private equity group comes along and says, this is a prosperous company. They’re running very efficiently. They do good business. I want to buy them now before they get too big and too expensive. And then there’s an equity transition.

And then that doctor can consider, do I want to cash in my equity or do I want to stay on for the next? Bigger fish that comes along and it’s just a pretty simple process, but you have to buy into it mentally. You have to understand that ultimately, it’s not about the individual practice anymore. It’s about the opportunity to take best practices from each location and formulate the best practice.

Mm-hmm. Because I can tell you, after spending so, many years and so, much time with all these other practices, there are some things that fall way outside the standard of care. And it’s readily available, and I’m very research oriented. I, I’m constantly studying and I don’t really do much else except fly airplanes.

So, for me I, I love trying to find out, you know, what is the enhanced recovery after surgery, what is the fastest way to get a patient home? What is the most efficient way? What is the safest way to reduce DBTs and blood clot formation and complications after surgery? That is just thrilling to me, and having that energy and enthusiasm and being able to transfer to multiple practices.

I mean, I, I mean, I don’t know what to say. This is the greatest life ever. Okay. I would love to have that. So, when I can find people with similar, like-minded ideas, then we, we blend pretty well. And the decision making is always about what’s best for the patient because the financial returns will come, they will come as a result of running the business properly, running it ethically, morally, keeping track of every dime appropriately and, and always best practice for the patient.

Catherine Maley, MBA: So, because this is a business and marketing podcast, I have to ask about the marketing. Yeah, sure. Is the branding now a big name, like your name is Olympus Cosmetic Surgery, is it now like Dr. Smith Plastic Surgery by Olympus? Mm-hmm. Or how does that work? And then who does, who does the patient attraction now? How did this affect your understanding about the future of cosmetic surgery?

Does everyone have a big ad budget and the, the front office handles all the, how does that work out the advertisement? How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah. Well, it, it’s always evolving. The current situation is that all the practices are independent, but we’re consolidating our services. Gotcha. Now, I, I do view in that 10-year time plan that I’ve told you that there will be a central theme, a central title AEN, a central logo.

We have our subgroup; we have our website related to Olympus cosmetic surgery group. Brett’s really in the stages. For information for future acquisitions or partners to find us. So, it’s not a centralized advertising platform. It will be there’s no question that’s inevitable, but right now, in each individual location, we’re trying to find the most successful practices, and they’re successful for a reason.

Mm-hmm. Because they’ve proven their methods successful in their region. So, if they’re dominating, we don’t want to rock the boat and dislodge that, that dominance from that area, just because we think we know better.

Catherine Maley, MBA: Right. Yeah. Okay, that’s a good idea. You know what, I want to wrap it up. Now. I normally, I’m afraid to ask, you know, because I like, I usually like to ask tell us something we don’t know about you. How did this affect your understanding about the future of cosmetic surgery?

So, if you can’t say that you fly planes, because we already know that. What, what’s another one? Cause I’m, you are a very interesting person. How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Well, I don’t know. I appreciate that. Well, gosh. I would say if I were to, to say the thing that, that you know, I, I, I say it all the time. I’m not, not the smartest guy in the world, but I do work my ass off, and I mean that at a much deeper level than I’m, I’m, I’m admitting I, I think that the.

Interest and the passion that I have for studying humanity is, is unparalleled. I absolutely love every moment of this life, and when I go, it’ll be just fine with me because I’ve lived a full and complete one. But just the, the interactions between highly intelligent people, investment bankers, a private equity group, leaders, I mean, These people, if I were a little kid and somebody said, someday you’re going to be hanging out with all these people that went to the best schools in the country, and were top of their class in every way, and you’re hanging out with them and you’re doing pretty well.

I’d say no way. You know, so, it just, the, the passion has is there for me. And I, I would just say if, if I could surround myself with people with equal or similar passion as I know you have in your field. I mean, gosh, I’ve, I’ve known you for like 25 years I think so, yeah.

Catherine Maley, MBA: So, I needed to be in this field to hang in there.

Erik J. Nuveen, MD, DMD: Yeah, yeah, yeah. And so, you have to have that undying, never say die, never quit. Passion that is, is, is, is palpable. So, other know, others know it and, and I somehow have been blessed with that gift. So, thank you for allowing me to say that.

Catherine Maley, MBA: Congratulations, and thank you for your father for being an orthodontist. How did this affect your understanding about the future of cosmetic surgery?

I had braces a million years ago, and I’m so, grateful it was a life changer. Looking back now, if I hadn’t had braces. Oh my gosh. That would be a different story, you know? Yeah. So, Dr. Nuveen, how can people get ahold of you? I’m sure there’s plenty of surgeons who are interested in your business model. How did this affect your understanding about the future of cosmetic surgery?

It’s very unique and I, and I find it’s very multifaceted. It seems like it, you don’t have a, a process in ink right now. It’s a multiple flexible fluid process because you’re evolving right. How did this affect your understanding about the future of cosmetic surgery?

Erik J. Nuveen, MD, DMD: Yeah, that’s a good way to look at it. There are some rigid elements that you can’t hear from due to the relationships.

Mm-hmm. But we’re always learning and we got to have that attitude. I mean, if you look at some of the other groups that have attempted to go down this pathway, they’ve really had some terrible problems. And, and, and actually it’s been a wonderful lesson because you look at what they’ve done and you’re like, well of course that wasn’t going to work.

You know, lifestyle lift. I mean, I could go down the road. There’s, there’s been probably 10. That are examples of just poor business practice or lack of transparency, or a lack of partnering. True partnering, it’s an overused term. It’s one that you really have to focus on is it’s got to be a partnership and people have to see eye to eye in the relationship.

So, yeah, we’ll continue to learn and evolve with the people that want to join us. My, my contact is probably best just as I give to my patients each and every day. Gimme a call. Give me an email. My email is [email protected]. fxfaces@ yahoo.com or call my cell phone. But also, you can Google, you can get me there as well.

My, my telephone number’s openly published. It’s (405) 550-7522.

Catherine Maley, MBA: All right. Well, it has been a pleasure having you on Beauty and the Biz. I really appreciate it. I’ll see you again at a conference coming up. Looks like you’re traveling. Everyone’s traveling again.

Erik J. Nuveen, MD, DMD: That’s fantastic. Yeah. Yeah.

Well, yeah, I’ll tell you any, anytime if there’s another in interesting issue you’d like to discuss. I, I do lots of other things un unrelated to this topic, but other business things with many different startups and techs and stuff, so, I’m always interested.

Catherine Maley, MBA: Thanks so, much.

Everybody that’s going to wrap it up for us today, a Beauty and the Biz and this episode on how Dr. Nuveen understands the future of cosmetic surgery.

If you’ve got any questions or feedback for Dr. Nuveen, you can reach out to his website at, csaok.com.

A big thanks to Dr. Nuveen for sharing his vision on the future of cosmetic surgery.

And if you have any questions or feedback for me, you can go ahead and leave them at my website at www.CatherineMaley.com, or you can certainly DM me on Instagram @CatherineMaleyMBA.

If you’ve enjoyed this episode on Beauty and the Biz, please head over to Apple Podcasts and give me a review and subscribe to Beauty and the Biz so, you don’t miss any episodes. And of course, please share this with your staff and colleagues.

And we will talk to you again soon. Take care.

The fastest way to success is to model other successful surgeons who have what you want, but you can only see their results, not the path they took to get there.

So, you continue to jump from one thing to another, hoping to find something that will work for you too, but it rarely does. So, try this shortcut instead. It’s guaranteed to move you forward. I compiled my intellectual property to grow cosmetic revenues, everything I’ve gleaned over the years into one playbook of the most successful practices and what they do to win.

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-End transcript for “The Future of Cosmetic Surgery — with Erik J. Nuveen, MD, DMD”.