Urologist Karen Elizabeth Boyle, M.D., F.A.C.S., says she started her reconstructive and aesthetic practice under the umbrella and support of the 80-plus physician urology group, Chesapeake Urology Associates in response to patient demand and her love of microsurgery and reconstruction.
More than a decade later, Dr. Boyle, founder of Chesapeake Aesthetic Surgery, says aesthetics found her. It wasn’t something that she tried to introduce to her practice.
“It … organically occurred and fit into my area of expertise,” Dr. Boyle tells The Aesthetic Channel. “I do think there are challenges for general urologists to just decide that they want to start providing more elective reconstructive or aesthetic procedures. I think that’s actually very difficult to do.”
Dr. Boyle, who has fellowship specialty training in reproductive medicine, microsurgery and reconstruction, and whose specialties include infertility, microsurgery, sexual health, genital reconstruction and aesthetics, shares her experiences and advice for offering aesthetics in today’s urology practice.
The Aesthetic Channel: What types of aesthetic challenges do you address?
Dr. Boyle: For women, I perform procedures like labiaplasty; clitoral hood reduction; clitoropexy or clitoroplasty; vaginoplasty; perineoplasty; reconfiguring the labia majora; vulvar beauty after baby—those kinds of procedures. I also perform hymenoplasty, or hymen reconstruction, for women — usually for cultural reasons, [to repair] the hymen, so they can get married within their culture.
Among the male procedures, there are some that are purely aesthetic, or elective, like correction of penis scrotal webbing, scrotal lift or scrotal reduction; then, there are some that border reconstruction and are not necessarily elective aesthetics, including correction of hidden penis or trapped penis; pubic lift; open lipectomy or liposuction.
For procedures that involve the pubic area and the abdomen, I partner with a plastic surgeon.
As a urologist who performs genital aesthetics, it is essential to recognize where my expertise ends and where a dedicated partnership with plastic surgery begins. Even if I’m comfortable in the suprabpubic space, if the patient would benefit from an abdominoplasty or liposuction, I involve plastics.
The Aesthetic Channel: Did you transition into aesthetics, where you might have referred more patients early on than you do now because you have more experience? How does that work?
Dr. Boyle: I did not wake up one day and decide I was going to perform labiaplasties. I had specific surgical interests with a dedicated focus on genital reconstruction from my surgical training. I feel so fortunate to have had an extremely strong training in pediatric urology — utilizing skills from that training that I now use daily in my adult aesthetic practice. I had what I consider exceptional general surgery and urological surgical training at Johns Hopkins. I had a personal interest in reconstruction, microsurgery and plastics. After leaving Johns Hopkins, I went to Baylor College of Medicine and trained in reproductive medicine and microsurgery. After my fellowship at Johns Hopkins, I started doing more genital reconstruction as a faculty member. Also, I helped out with the now adult (former pediatric) urology patients who needed genital revision procedures. I then joined Chesapeake Urology Associates 10 years ago under the leadership of Dr. Sanford Siegel, who shared my vision of Chesapeake Aesthetic Surgery and has given unwavering support of this practice.
My first labiaplasty patient years ago had been seeing me for sexual health concerns. I referred her to plastics, but she came back and said: I really want a female physician, and I really want a doctor who is sensitive to my concerns about sexual health.
So, the first few labiaplasties I did, I worked with plastics. I did extra training with genital aesthetic surgeons in California and gained experience. Even though I had that experience from training, doing aesthetics is a very, very different practice type.
Clearly from my perspective, it’s just something that naturally fit in to my practice structure because I perform mostly elective surgeries. I perform microsurgical vasectomy reversals; I do vasectomies; I do sexual health. I don’t take care of prostate cancer, bladder cancer or incontinence. So, I already had a large self-pay population of patients. My practice was already set up for and comfortable with dealing with young, healthy patients who desired ‘unnecessary’ elective surgeries.
The Aesthetic Channel: What are major and minor considerations for going into aesthetics as a urologist?
Dr. Boyle: Patients in an aesthetic practice are more like clients. Even though you are seeing them within a urology practice, they are not urology patients — they are plastic surgery patients and need to be treated differently. They have certain expectations about what they will encounter at your office, with your staff, and with you that are very different from your traditional patient. They research physicians on the internet. They’re calling around. They’re shopping price. They’re shopping experience. They’re looking at pre- and postoperative photos. A lot of our time is actually spent fielding calls and inquiries, doing evening phone calls to prospective patients to address their questions and concerns even before they decide to make a consultation. It’s very labor intensive.
These patients don’t need your services. They’re electing to come to you. And as a genital plastics patient… demand that kind of attention and service.
At Chesapeake Aesthetic Surgery, the office is separate and unique from the rest of our Chesapeake Urology practice — it has its own dedicated waiting room, it is quiet and tranquil and decorated differently. Even from a logistics standpoint, the way my office flow is and the focus of my team is very different than my partners’, because I often spend an hour with each patient. I don’t charge for a consultation for aesthetics. It’s complimentary because that’s what is done in the plastics community in our area.
I have a dedicated coordinator that spends another 30 to 60 minutes meeting with each patient. She does a lot of counseling and handholding, talking through each surgery, reviewing preop testing, fees, financial counseling, what services we offer. So, it’s a very concierge type practice. It’s difficult to mesh with a traditional practice, if you don’t protect that time and have an infrastructure and office setup to support it.
And these surgeries are not something, in my opinion, that surgeons should dabble in. If you’re not doing labiaplasties every week, you probably shouldn’t be doing labiaplasty.
I think the practicing urologist, who is already doing some genital aesthetics or is interested in increasing genital aesthetics, has to recognize the necessity of having an interdisciplinary team that includes a patient coordinator, as well as individuals in billing, advertising, interoffice communication and practice support, and referrals ….
It’s really a commitment on behalf of the practice to support this area of specialty. Without that support, I wouldn’t be able to provide this service.
The Aesthetic Channel: What are the biggest challenges of incorporating aesthetics and how do you address them?
Dr. Boyle: As a urologist, you simply don’t get the training within a traditional internship or residency on how to run any surgical practice or business, especially one that is fee for service. Plastic surgeons get a lot more hands-on experience and even mentorship on how to handle this particular patient type — not only from a communication standpoint in the office, but also from a billing, advertising, and patient experience standpoint.
Fortunately, here at Chesapeake, we have that leadership in Drs. Brad Lerner and Sanford Siegel. And we have strong non-physician leadership. We have an amazing, dedicated CFO, Mr. Steve Bass. And we have the infrastructure in human resources, advertising and marketing and billing. Without that infrastructure, I would not be able to have the unique practice type I do. I also have the support of my partners, who understand the different needs of this patient population, and support and refer to me whenever appropriate. I’m incredibly fortunate.
From the surgeon’s standpoint it’s all about patient selection and setting realistic expectations.
This is different. The outcomes are different. We’re taking somebody who is healthy, who doesn’t need the surgery but is choosing to have surgery, and you want to make them happy.
You need to be a therapist, as well a surgeon, to make sure the patient has realistic expectations about what you can and cannot achieve. You have to be comfortable with turning patients away — either because they’re not good physical candidates, or because they don’t have realistic expectations about what you can and can’t do for them.
I think it helps to spend time with plastic surgeons. I used to go to a plastic surgeon’s office and see his genital reconstruction patients, and being around that practice environment is very insightful. I still refer to and work with plastic surgeons in our community for things that are outside my areas of expertise. That collegial environment between subspecialties is essential.
The Aesthetic Channel: There are so many options in cosmetic surgery today, how do you decide whether to add a procedure or device into practice?
Dr. Boyle: You asked about all of the new laser devices available today. I do perform vaginal reconstruction — vaginoplasties. We have looked, over the years, at vaginal laser devices that are being used for incontinence and vaginal tightening, and we have not made a decision or commitment to invest in those, yet. We probably will. There are many options, and as a practice we are waiting and assessing the available technologies.
The pressure within the marketplace is to be the first on the block to offer something. My advice is: Don’t do it right away. Let it mature in the marketplace. Sometimes, it’s not as important to be the first on the block as it is to be the best on the block.
And you don’t have to do everything. There are so many people doing CoolSculpting, for instance. It’s amazing technology. But as a urologist, is that something you’re going to do? Plastic surgeons who offer CoolSculpting use it all over the body. Are you going to use it just in the pubic area, which is your area of interest? Or are you going to start expanding beyond your area of focus – should you be doing procedures on someone’s arm or thigh? I personally don’t think we should do that. [The doctors that do it] are also the doctors who refer to me. So, it’s also about being collegial.
I am a urologist, and, for that reason, I limit the areas I operate on to the genital and pubic region. You won’t see me offering therapies outside of my area of interest. You need to offer safe, high quality of care within your area of expertise and know your limitations. Just because you can do something, doesn’t mean you should do something.
The Aesthetic Channel: Would you do anything differently if you were to start aesthetics today?
Dr. Boyle: I’m an optimistic happy type person and try to live life, including my professional life, without regret.
I think the biggest thing I’ve considered over the years is whether I should have done a dedicated plastic surgery fellowship. I definitely considered it….But, if I had done that, I wouldn’t be doing what I’m doing now and I would have a totally different practice type. I love my practice here at Chesapeake, I love my patients and my specialty. I love doing microsurgery, vasectomy reversal, and helping couples with sexual health. I feel incredibly fortunate to be practicing at the leading urology practice in the country, Chesapeake Urology Associates.
The Aesthetic Channel: What advice would you have for urologists in all practice types, if they’re thinking about incorporating aesthetic services?
Dr. Boyle: I think it is most important, like anything, to incorporate aesthetic services for the right reasons. My interest in performing genital aesthetic procedures was purely patient driven. Don’t be enticed by the finances. It can be dangerous when you’re thinking financial rather than thinking patient quality of care. Although these procedures are self-pay, these patients are also incredibly time consuming. A genuine love and interest in this kind of reconstructive surgeries and a desire to serve this patient population must be the driving force.
Don’t look at this as an adjunct to your practice because you’re just looking for a new line of service to provide. I think [in a urology group] if somebody has a focus on reconstruction and aesthetics and it seems to make sense and fits well into their area of interest, then I would definitely encourage a fellow urologist to explore this sub-specialty. As a practice and partner, allow them to spend time with plastic surgery, and see if it’s something they can grow organically — rather than aggressively, in terms of trying to recruit patients. Then, get the support of your practice leadership and your partners because that’s where your referrals are going to come from.
Involve plastics early on, if this is something that you’re just learning how to do.
The Aesthetic Channel: How has adding aesthetics to the practice impacted your bottom line?
Dr. Boyle: When I look at our financials for the practice, I’m not the most profitable surgeon, and I don’t do this because of it being self-pay. Our patients are labor intensive and you cannot see the same number of patients in a session as you can with general urology. Your consult appointment is not billable. Your postop appointment is not billable. You will literally spend hours with a patient who will ultimately not schedule surgery with you. It can be profitable, but at its own cost.
It’s a hard thing to consider starting to perform aesthetics. I love it, and feel so fortunate to have the support of Chesapeake Urology to provide this service line. I don’t want to be discouraging to fellow urologists, but I think it’s something you definitely need to go into with eyes wide open.