By Polly Mosendz 

December 12, 2024  

Invasive procedures are being done by nurse practitioners. Should  liposuction be one of them? Influencers have a powerful effect on the  beauty business, and med spa nurses have become influencers within  their industry. Since 2021 the federal government has required  drugmakers and medical device manufacturers to disclose their  financial ties to nurse practitioners. Those payments rose to more than 

$135 million last year, up about 70% from two years earlier, as NPs  took on a wider role in US health care, a Bloomberg Businessweek  analysis of a Centers for Medicare & Medicaid Services database  shows. Much of that went from the aesthetics industry to NPs, some of  whom teach other NPs how to inject drugs like Botox.  This is the third installment of The Nurse Will See You Now, a series  documenting how the increasing reliance on nurse practitioners may  be imperiling US patients.  

The patient popped a painkiller, a Xanax, something for allergies,  another pill for nausea—a pharmaceutical cocktail meant to replace  general anesthesia. Thirty minutes later she was on an operating  table under the care of Karen Jean Anderson, a nurse practitioner  who’d trained for 40 hours with a medical device distributor in  performing liposuction. The patient was undergoing a breast  augmentation and fat removal, and she was wide awake.  

The pain was searing. She was handed a stress ball and a blindfold.  Anderson and the other employee in the room asked the patient if she  wanted them to stop, but she’d invested $10,000 in the procedures  and was midsurgery, so she decided to see it through.  

“We want to hear your breathing, not your voice,” one of the providers  told the patient, according to a Statement of Allegations filing from  Utah’s Division of Professional Licensing (DOPL), which investigated  Anderson. (The patient was not identified in the documentation from  the investigation.) In the filing, from May 2022, the division alleged  that Anderson violated a variety of health-care regulations. The state  Board of Nursing, which operates under the DOPL, conducted a two day hearing into the allegations, and recommended that Anderson be  cleared of the counts against her, with the exception of one pertaining  to her procedures in prescribing drugs. The director of the licensing  division disagreed. He filed an order of adjudication determining that  the nurse practitioner “unlawfully practiced medicine by performing  ablative cosmetic procedures.”

Med spas sometimes treat this light anesthetic regime as a  selling point, boasting of “awake lipo” and “twilight lipo”.  

In that order, Anderson was banned from performing the surgery,  fined $10,000 (later reduced to $5,000) and ordered to take a  continuing education class related to the drugs she’d prescribed. The  patient later sued both Anderson and the medical spa at which she  performed the procedure, Belle Medical, for malpractice. That suit was  settled in November, but that didn’t settle all the issues. Anderson has  sued the state of Utah, saying that the law does in fact allow her to  perform liposuction, as, she said in the suit, she has done safely more  than 1,100 times—and as nurse practitioners do at medical spas  nationwide. The case has been heard by the state’s Supreme Court,  which will likely issue a ruling next year. 

In an emailed statement, Belle Medical, which operates nine medical  spas in four states, said it is “committed to high-quality patient  outcomes, patient safety, and complying with all laws and regulations”  and that it “contracts with qualified and highly trained medical  professionals, including board certified surgeons and APRNs  [advanced practice registered nurses].” Anderson referred questions to  an attorney, who didn’t comment, citing the pending litigation. 

The Belle Medical patient is among the millions of Americans who’ve  sought treatment at medical spas, often called med spas. The name  refers generally to offices that sell cosmetic procedures. Some of their  services, such as body scrubs and chemical peels, aren’t medical in  nature. But plenty are—Botox injections, dermal fillers and weight loss injections, to name a few. Some med spas offer liposuction and fat  grafting. Some offer vampire facials, a procedure in which the  practitioner draws a small amount of blood from a patient and  separates out the plasma. The plasma is then injected into the  patient’s face, typically with microneedles. There’s not much evidence  this is effective, according to the American Academy of Dermatology  Association.

Today the med spa industry generates an estimated $17 billion  annually, according to the largest US industry group, the American  Med Spa Association, or AmSpa. More than 10,000 medical spas are  in business nationwide, according to AmSpa, and an additional 1,000  are expected to open next year. Some med spas are small shops with a  narrow specialty. Others are multisuite, multilocation operations that  offer a variety of services and branded merchandise and help set up  loans for clients who want especially costly care. 

Despite the size and rapid growth of the industry, it occupies a  regulatory gray area. Med spas rarely accept health insurance, so  they’re of no interest to insurance regulators. Surgical auditors don’t  have to accredit them, and the government regulators that oversee the  businesses vary from state to state. In effect, no one is watching. 

A minority of med spas offer liposuction, and those that do typically  advertise it without using the word. They favor the term “sculpting”  and describe the procedure as “minimally invasive.” Lipo can be costly  at a med spa—procedures can reach the low five figures—but is  generally less expensive than the version done by a plastic surgeon. At  Belle Medical, Anderson conducted what is called tumescent  liposuction. One of the six liposuction techniques recognized by  the American Society of Plastic Surgeons, this involves the infusion of  lidocaine and epinephrine into saline, which is injected under the skin  as fat is loosened and removed. Med spas sometimes treat this light  anesthetic regime as a selling point, boasting of “awake lipo” and  “twilight lipo.” In an outpatient surgical suite, by contrast, a plastic  surgeon usually opts to use general anesthesia, which incurs an  additional cost and involves another physician. 

Alex Thiersch, head of AmSpa, says his organization advises its 4,000  members against doing liposuction. “We typically exclude liposuction  from the list of services that med spas should be performing,” he says.  “This is more of an invasive procedure beyond what med spas do.  

Most of the med spas aren’t doing lipo.”

Liposuction at med spas is typically performed with what are called  power-assisted devices. The business end is a roughly footlong metal  wand called a cannula. Inserted beneath the skin, it vibrates at  thousands of strokes per minute to separate and remove fat. The  procedure usually lasts several hours. These devices have become  synonymous with treatments such as the “mommy makeover,” which  aims to break down stubborn belly fat, and “influencer arms,” where  fat in the upper arms is removed. Sometimes fat is redistributed into  another area, as in the Brazilian butt lift, or BBL. Liposuction tools are  expensive, at around $30,000 each, but they can pay for themselves  quickly. The US Food and Drug Administration approves such devices,  but it doesn’t police who uses them. 

“This treatment has been trivialized to the point that  patients no longer see it as health care”  

AmSpa said in a 2023 report that 43% of the businesses it surveyed  offer body contouring, a broad term covering both surgical and  nonsurgical procedures. The report said 17% of annual med spa  revenue among those surveyed came from energy-assisted devices, a  wide-ranging category that, in addition to body contouring devices,  includes lasers and services such as microneedling and tattoo removal. 

The med spa is a relatively new phenomenon, born out of a  combination of regulatory change, cultural acceptance and  entrepreneurial spirit. Over the past decade, cosmetic procedures have  become more normalized, in no small part because of the Kardashian  family and their televised chronicling of the many changes to their  bodies. At the same time, nurse practitioners have gained full practice  authority—the ability to practice, within the scope of their license,  without physician oversight or with limited oversight—in more and  more states. (There are now 27.) These health-care providers, many of  them young women—like the customer base of the med spa industry— saw a booming business opportunity and rushed to open their own  clinics.

“Fifteen years ago there weren’t really medical spas. There were these  services offered inside a dermatology practice or surgical practice,”  says Michael Byrd, a health-care lawyer who specializes in med spa  compliance. “There has always been a little bit of a perception issue  because of the retail elective nature of this. Expectations are more like  they’ve just gotten a spa treatment—unless something goes wrong, and  then that changes.” 

About two-thirds of medical spas have a single owner; among those,  about a third are operated by physicians. The rest of the single-owner  operations are run by nonphysician, nonsurgeon health-care  providers, such as nurse practitioners, physician assistants or  registered nurses, according to a 2023 AmSpa report on the industry. 

Doctors are becoming scarce in med spas. While other jobs in the  business have seen a boom in hiring, physician supervisors have fallen  out of favor, according to AmSpa. In 2021, the group found, 25% of  med spas had a supervising or collaborative physician on staff. Two  years later, only 16% had one. Doctors are expensive; they demand  higher salaries and have costlier malpractice coverage. 

AmSpa’s report found an average annual revenue of about $1.4 million  at med spas, and because insurers rarely cover cosmetic procedures,  it’s often a cash business. The average patient comes in repeatedly and  spends around $500 per visit, according to AmSpa’s market-research  report. Traffic is often driven by the social media hype cycle: More  clinics means more customers means more social media posts means  more customers means more clinics. Twice as many med spas have  social media managers as have doctors, according to AmSpa. Ninety five percent are on Instagram. 

Thomas Terranova, CEO of Quad A, a nonprofit, nongovernmental  surgical industry accreditor, says that in large part because of social  media, med spa clients tend to see themselves as customers and not  patients. “This treatment has been trivialized to the point that patients  no longer see it as health care,” he says. Quad A was born out of the 

early days of outpatient plastic surgery, in the late 1970s and ’80s,  during which some clinics ran wild while others wanted to  differentiate themselves as safer and thus more appealing to patients,  even at a higher price. They opted to have Quad A accredit their  practices, and today some state legislatures mandate this kind of  third-party review to allow cosmetic practices to operate. 

“The state of the industry is just wide open,” Terranova says. “I don’t  know when or how that trigger comes that says we need to get our  hands around it.” 

The majority of practitioners in a med spa haven’t formally studied the  services they’re providing. They aren’t able to—there are few programs  for this specialized training. The Dermatology Nurse Practitioner  Certification Board says only 37 NPs were certified in dermatology in  2023, out of the tens of thousands who graduated from NP programs.  Those 37 had to work with patients for 3,000 hours before they could  take the certification exam. Nurse practitioners in the med spa  industry are most often educated as family practitioners. 

The educational gap for NPs in med spas is filled by the cosmetic  industry itself, through training companies. For $10,000 the Los  Angeles-based American Association of Aesthetic Medicine and  Surgery will teach a nurse practitioner how to perform liposuction  over the course of three days. For $2,450 it offers a self-guided 6½- hour online class. Empire Medical Training Inc., based in Fort  Lauderdale, Florida, teaches courses in injectable buttock  enhancement to physicians, nurses and even dentists. The Elite Nurse  Practitioner offers a variety of online courses for cosmetic procedures,  taught by NPs to NPs, with no in-person option. None of these  businesses responded to requests for comment for this story. 

Influencers have a powerful effect on the beauty business, and med  spa nurses have become influencers within their industry. Since 2021  the federal government has required drugmakers and medical device  manufacturers to disclose their financial ties to nurse practitioners. 

Those payments rose to more than $135 million last year, up about  70% from two years earlier, as NPs took on a wider role in US health  care, a Bloomberg Businessweek analysis of a Centers for Medicare &  Medicaid Services database shows. Much of that went from the  aesthetics industry to NPs, some of whom teach other NPs how to  inject drugs like Botox. 

Leslie Fletcher, among the most prominent nurse-fluencers,  has received more than $1 million in payments from  pharmaceutical companies making aesthetics-related drugs,  according to the database. “#1 Allergan Trainer 2019-2024,”  she says in her Instagram bio, referring to Allergan Inc., the  maker of Botox and dermal fillers. “Pharma is definitely  going the non-MD route with the majority of their training,  more than likely due to the fact that 80-85% of all aesthetic  treatments are performed by non-MD’s and so nurses/PA’s  are their target customer,” Fletcher said in an email. Over  the past five years she’s trained more health-care  professionals for Allergan than anyone else in the country,  averaging 175 sessions annually. In a statement, Allergan  said it is “committed to providing world-class training and  education for licensed aesthetics professionals, including  nurse practitioners, who provide professional care to their  patients.” 

The standards and regulations that apply to med spas vary widely  from state to state. They can be hard to parse and are sometimes  challenged in court, as Anderson opted to do. Her suit contends that  the statutes do allow her to perform liposuction, and during the oral  argument before the state Supreme Court, both sides noted that  ablative cosmetic procedures are routinely performed by nurse  practitioners in Utah. Anderson’s attorneys also argued for the safety  of the procedure. “APRNs worldwide thus perform hundreds of  thousands of procedures with the Vibrasat Power each year, and the  procedures are highly successful,” they wrote in a brief.

A spokesperson for the Utah Department of Commerce said that the  fine has been stayed but that Anderson remains banned from  performing liposuction pending the court’s decision. In its statement,  Belle Medical said, “Anderson and Belle Medical have worked with  and complied with DOPL’s rulings throughout the entirety of this  process despite great financial costs which impair the company’s  ability to service its obligations.” 

Quad A plans to roll out accreditation rules for med spas next year. As  it tries to get the industry to take this effort seriously, the organization  has an ally: private equity, which has begun to buy med spa practices.  

There’s a strong business case for accreditation. It could decrease  malpractice costs, which could mean bigger and more reliable profits  for investment companies. 

The rollup is in its infancy: About 3% of med spas have been acquired  by private equity firms. But the deals that have been done are  attention-getting. Ever/Body, a New York-based chain with 10  locations, has raised more than $100 million since 2019, including an  investment from Tiger Global Management LLC. Princeton Medspa  Partners LLC, which operates 14 locations in 10 states, raised $120  million, with growth capital coming from BC Partners Credit. Skytale  Group, the health-care mergers-and-acquisitions advisory firm, has  dubbed med spas “healthcare’s hottest investor market.” 

Belle Medical gained a private equity backer in 2021, Peterson  Partners. The fund lauded the clinic chain for providing “non-invasive  cosmetic surgery, leveraging technology that is less aggressive on the  body and far safer than traditional liposuction.” That same year,  Anderson performed the procedure that led to her hearing. Peterson  Partners didn’t respond to requests for comment for this story. 

After the patient left Belle Medical, she said in her malpractice claim,  she experienced several months of hardness in her breasts. Alarmed,  she went to plastic surgeon Mark Jensen, who later testified at  Anderson’s hearing. He said he drained a baseball-size cyst from the 

patient’s breast, filling a bowl with the fluid, a photograph of which  was admitted as an exhibit. In his testimony, Jensen didn’t take issue  with the use of the liposuction device itself, but with everything  around it. He was concerned, based on photographs of the office  where the procedure was done, about sterility. (Anderson said the  office was sterile, according to the state’s order of adjudication.) There  was no access to emergency support for the patient. And the fat graft  itself was too large compared with the size of the patient’s body.  Jensen was also concerned about the credentials of the spa’s  employees. Liposuction, he said, is among the riskier procedures he  performs.  

Sara Nethercott says she didn’t understand the procedure she signed  up for was liposuction. Sara Nethercott, a patient of a Belle Medical  facility in Idaho Falls, Idaho, says she didn’t realize she’d signed up for  liposuction at all. “They just make it sound so much softer than what it  actually is,” she recalls of her February 2019 procedure, which she  underwent in an effort to slim her love handles. She’d seen a  promotion for “3D body contouring” and had been impressed with the  before-and-after photos the med spa showed of other patients. She  says she signed up using a credit card, got a prescription for some pain  medicine, and the next morning was back in the office to be sculpted.  Nethercott says that the day of the procedure, as she sat in an exam  room wearing paper undergarments, she was pitched additional  treatment on her upper back. The spa employees suggested she take  advantage of a sale and add it to her tab. Feeling self-conscious, and at  least somewhat affected by the painkiller she’d been prescribed,  Nethercott yielded to what she now feels was a high-pressure sales  tactic. After that, she was taken into another office suite to meet the  provider for the first time. She says she assumed she’d be meeting a  surgeon.  

The provider was a nurse practitioner, who performed the liposuction  across Nethercott’s sides and back while she, like the Utah patient, was fully awake. The health-care workers spoke with her, asking her to flip  so they could work on her other side. “That was the most pain I’ve ever  felt,” she says. 

After the procedure, she says, she  

developed an infection and visited an  

urgent-care facility, where she was  

informed that the 3D sculpting  

procedure she’d undergone was in fact  

liposuction. That was noted in one of  

the medical forms she signed in  

advance of surgery, but she says she  

didn’t see it. “They never said, ‘It’s not  

surgery,’” Nethercott says. “They didn’t  

have to—because they never mentioned  

it could be surgery! So it just seemed  

like a beauty procedure.”  

Citing patient privacy, Belle Medical  

said that it couldn’t comment on  

Nethercott’s account but that it complies with regulations and is  committed to patient safety. “The medical providers, both board  certified surgeons and mid-levels, use their medical training to decide  what to prescribe for each given case and patient,” the company said.  

The liposuction was about $6,500. Nethercott says she paid an  additional $3,500 toward IV antibiotics, administered twice a day for  two hours, to clear the infection from her system.  

“It looks like a bullet hole,” she says today, reflecting on her scars.  “Belle Medical. Medical—it sounds like you know what you’re doing.” 

With Caleb Melby and Noah Buhayar 

Photographer: Will Warasila for Bloomberg Businessweek