When Jeffrey S. Yager, MD, opened his practice 13 years ago, he embraced a previously untapped Hispanic market in the New York City area. It was not just that he discovered a successful niche for his practice, he became "as close as what you can get to a community cosmetic surgeon, if there is such a thing," he says.

His community is the Hispanic patients of the New York area. "My dream was to set up a cutting-edge center that really catered to Spanish-speaking and, especially, Hispanic patients," he explains. "Currently, I would say that 90%—if not more—of my practice is Hispanic patients of cosmetic surgery. I think it’s just important to know that just because you do unnecessary surgery, it doesn’t mean that you can’t have a close personal relationship with your patients and really enjoy them coming back again and again. Eighty-five percent of my patients come from other patients. There’s nothing that makes you feel better than if one of your patients thinks so highly of you as to send another family member or friend to you."

A board-certified plastic surgeon, he is the founder of Yager Plastic Surgery in Washington Heights, NY. He completed his studies at Johns Hopkins and Columbia-Presbyterian.

"I did my undergraduate education at Johns Hopkins, because more doctors in the United States went to Johns Hopkins than to any other school in the country," he says. "I had always wanted to go to Columbia [Presbyterian] for medical school. I was fortunate enough to be admitted, and then doing my medical school training was really where I figured out which area in medicine I wanted to be in."

PRACTICE AT A GLANCE

Practice Name: Yager Esthetics

Name: Jeffrey S. Yager, MD

Location: Washington Heights, NY

Specialty: Cosmetic Plastic Surgery

Years in practice: 13

Patients seen per week: 100

New patients per year: 1,000

Days worked per week: 5

Days surgery performed per week: 2-3

Number of employees in practice: 13

Office square footage: 6,000

FINDING A NICHE

Yager first saw the need for a different kind of practice while training at Columbia-Presbyterian. "My patient profile is very different from most Manhattan-based plastic surgeons. In training at Columbia-Presbyterian, the patient population is highly Hispanic, specifically Dominican. Being a Spanish-speaking plastic surgeon was somewhat unique in the hospital. I really found that there was a need for a plastic surgeon within the Hispanic community who could speak Spanish, who could make the patients who were Spanish-speaking feel comfortable. If you were Hispanic and your English isn’t great and you go down to Park Avenue to have surgery done, even if there’s somebody in the office who speaks a little Spanish and can translate for the doctor, it’s just not the same. You sometimes feel a little uncomfortable when no one in the waiting room looks the same way that you do."

Yager designed his office around the needs of his clients. "The unique thing about it is, not only do I speak to every patient personally in Spanish and I’m fluent in Spanish, but every single member of my staff is bilingual in Spanish and English. Every brochure we have, all of our instruction sheets, even the magazines, videos, and TV programs are bilingual, so [patients] feel very comfortable."

It’s not just the administrative part of his practice that is designed for the Hispanic population, but his actual artistic style as a surgeon. "Cosmetic surgery on Hispanic patients and patients of color is different. You need to use different techniques, you need to do things differently, and there are sometimes different aesthetic ideals.

"I’m really very in tune with the Hispanic beauty ideals and the different ideals of the different countries, whether it’s Caribbean Spanish, South American Spanish, or European Spanish—they’re all a little different, the aesthetic ideals are a little different. That diversity within the Hispanic community is fascinating to me."

THE COMMUNITY VIEW

In order to successfully treat the Latino patient, Yager has learned much about the aesthetic taste of the culture. "The generalizations about the aesthetics for my patients, which hold true in my mind, are a lot of it is about curves. Curves are incredibly important in the Latin community. Everybody likes a narrow waist. Everybody likes a curvy hip. The things that are troublesome [for] most people are just a small bulge of fat that might be in the back or the waist area.

Yager treats each patient as though he or she was a family member.

"Dance is a very important part of the Hispanic culture, and the type of dance usually lends itself to terribly close-fitting clothing and a lot of hand-on-hip and back and side contact. The thing that mortifies a lot of the women is if they have a little roll of fat or bulge in those areas. In general, a curvier hip and fuller buttocks are sought after."

In terms of bust size, that’s where it really varies from culture to culture, Yager explains. "Some of the cultures prefer a very small, firm breast. Some of the cultures prefer a much fuller, rounder breast depending on where you’re from in South America or in the Caribbean. There are subtle differences between the cultures, but there are also some commonalities, such as the importance of curve and proportion and the importance of some of the social functions—such as dancing—which makes body shape very, very important."

Besides aesthetics, the technique of treating patients in this niche market takes some careful consideration as well—for example, how to treat the darker skin tones, Yager says. "Some of the lasers and other treatments can cause a lot of hyper-pigmentation and scarring that wouldn’t be as noticeable if you had the very light skin type. My patients have special needs. I have to be extra cautious as to a lot of the devices I bring in."

Yager’s "community view" extends to every area of his practice. "I always try to imagine myself or my family as a patient in my office. And I always try to think to myself, ‘How would I want to be treated? What would I do? How can I make it safer? How could I make it better?’ It is very real to me to think of each patient as a family member."

To that end, Yager explains that recently his wife was in his office for surgery. "There was absolutely nothing I did any different for her than I’ve done for any other patient. I’ve already done what I thought were the best possible safety measures for my regular patients anyway. There’s no special care that I have to give to VIPs because every patient is a VIP. They all get the same special level of care that I would give to anybody that would walk off the street."

THE LITTLE PRACTICE THAT COULD

Efficiency and reducing risk to patients are two concepts that Yager has taken to heart. His views on these ideas have helped his practice to not only cater to the Latino community of greater New York City, but also to integrate well with that community.

"There are several efficiencies that we have," he explains. "We have our own quad, a certified outpatient surgery center within our clinic. We have our own spa within our clinic. We’re located directly across from a hospital where [patients] can get all testing done in an expedited fashion."

Yager and every member of his staff is bilingual in Spanish and English.

Reducing risk to patients usually centers on how a procedure is performed and the intelligent use of anesthetics. "Depending on how long you take to do a procedure, your anesthesia options vary," Yager says. "So, if you’re able to be more efficient with performing a procedure, you can use more sedation techniques, regional techniques, and less general anesthesia techniques. The recovery process is much, much faster. In order to use these techniques, you have to be efficient with your surgery."

How does Yager cut down on time on different procedures? "In certain procedures—say, when I do breast-augmentation surgery—my average skin-to-skin time on a breast-augmentation procedure is 25 minutes. And because I can do the procedure in 25 minutes, I can just use TIVA [Total Intravenous Anesthesia], and it’s a much smoother, quicker process.

"I use different incisions based on the patient’s anatomy. It really doesn’t matter if I’m going through the nipple, under the arm, or under the breast—it always takes me the same amount of time to do the procedure. By carefully measuring, planning, and speaking with the patient ahead of time, it saves me time in the operating room."

Doing a procedure efficiently is not the same as speeding through an operation, Yager warns. "Surgeons like to brag about how quickly they can do procedures sometimes, but for a plastic surgeon who does cosmetic surgery it’s important not to equate doing a procedure efficiently with rushing through a procedure. I never rush. I never try to see how fast I can do surgery. It’s just that, over time, my process has evolved. When I opened my office in private practice in 1997, it used to take me about 2 to 2½ hours to do a standard full abdominoplasty. Since then, I’ve done more than 800 of them—about a hundred of them in my office in the last year alone—and now my average time to do that procedure is somewhere around 45 minutes. It is a tremendous improvement over the years, even within my own experience and my practice."

Each experience with patients leads the surgeon closer to determining the best possible way to do procedures, Yager says. "When you’re doing them all the time, you find out what’s important to do and what’s not important to do. After careful, evaluation of your results, your technique changes from patient to patient, depending on if it’s more of a muscular problem versus a skin problem versus a fat problem. The less time under anesthesia means less anesthesia complications, less nausea, and a superior experience for our patients."

For example, most of Yager’s current abdominoplasty patients are in and out of the OR in "about an hour," he says. "They’re in the recovery room for 1% to 2 hours, so by 3 hours from the time they walk in their surgery is done and they’re on their way home."

Yager is very in tune with the Hispanic beauty ideals and the different ideals of the different countries.

Around 10 years ago, Yager published a study documenting his experience with 50 of his outpatient abdominoplasty patients—colleagues criticized him for sending them home same day. "At that time, it was not a common procedure to do an abdominoplasty procedure and send the patient home the same day, but since then it’s become more of the standard of care— it happens in ambulatory surgical centers all around the country, commonly.

"But at the time I published the paper, I was criticized for doing such a quote unquote ‘large procedure’ as an outpatient. Nowadays, you’re hard pressed to find anybody who will keep a patient in the hospital after an abdominoplasty. It’s just an evolution of technique over time. I really think it’s not for everyone. If it takes you 3% hours to do the procedure, you definitely shouldn’t be offering epidural anesthesia or spinal anesthesia to do it. You should do it under general anesthesia, probably in a hospital setting, and maybe keep the patient overnight."

By keeping aesthetic procedures to under an hour, deep vein thrombosis and other complications are reduced, Yager says. "The American Academy of Chest Physicians states that risks go up with surgeries that last over an hour. If you can keep your surgeries shorter, you’re really decreasing your chances of that very important and dangerous complication to the lowest level possible."

BUILDING A "COMPASSIONATE PRACTICE"

The efficiency of Yager’s office allows him to consider the financial constraints of the majority of his patient base. "In general, [they] are not the high-society patients," he says. "I do have very powerful, famous people that are patients, but the vast majority of my patients are working class people—they’re teachers, they’re secretaries, they’re hospital workers, they’re even bus drivers. They come from all walks of life, and they work very, very hard for their money. It’s a sacrifice for them to do surgery. Every dollar means something to them.

Yager’s newly upgraded, 6,000-square-foot office space still retains a "community flavor".

"By keeping my anesthesia time shorter, it keeps my anesthesia costs down and I pass that along to the patients, in order to try to make sure that we can deliver a lot more than they pay for in terms of the fee for the surgery. We don’t change our fee based on what you do for a living or where you come from. Our fees are the same based on the amount of work it’s going to take. This is something that I feel strongly about, that everybody should be treated the same no matter what they do in life. Everybody deserves respect and the best possible work that I can do."

Building a community practice has taken a long time, Yager explains. "I grew up in the suburbs of New York City. I knew since I was about 4 years old that I wanted to be a doctor. My father was a podiatrist, and to make extra money early on in his career he used to work in a hospital in the New York area. When I was a little kid, I liked to go with him. He worked in the hematology lab.

"One day, when I was about 3 years old, he introduced me to the chief of pathology of the hospital. Sitting on his desk was a jar, and in the jar was his lung—it had to be removed from smoking. He was saying that he kept it on his desk to remind himself not to smoke. I was just captivated by that.

"When I was in nursery school, about 4 years old, the teacher went around the room asking everybody what they wanted to be. People would say a cowboy or an astronaut or a policeman. I said, ‘I wanted to be a pathologist,’ and they looked at me and they said, ‘Do you know what a pathologist is?’ I had somewhat of an understanding. I told them, ‘Yeah, it’s a doctor who tries to find out why people die.’ They called my parents because they were a little concerned."

When Yager started out, his practice was contained in a very small office in Washington Heights. "It was about 1,500 square feet when we opened. When I wanted to become an accredited ambulatory surgical center, I was able to expand it to about 2,100 square feet. We added another 3,800 square feet recently, which is just opening now. We’re at just about 6,000 square feet now."

Yager insists that the new expansion will further embrace the culture of the neighborhood. For example, the new office houses a gallery for local artists, which is separate from the treatment rooms. In addition, he supports neighborhood art walks. "I was always fascinated by medicine and science, but I was also always fairly creative," he says.

On The Web!

See also "Ethnic Rhinoplasty Pearls" by David W. Kim, MD, FACS, in the October 2009 issue of PSP.

"I’m very into all types of art, and I thought it was very important that the community have a space to show art, especially for emerging artists in the area. We’ve had a lot of Cuban and Dominican artists already give shows, and we’re trying to set it up in a more formal basis in the new space."

Yager’s love for art and the Hispanic culture extends to his love for film; collection of Art Nouveau; and exploratory trips to the Dominican Republic, Mexico, and several South American countries. This fall, a planned visit to Spain will include a visit to the architecture of Antonio Gaudi.

"It’s just part of the whole creative process," Yager says. "I love being around creative people because it just gets me more excited about what I do. As you can probably tell, I’m really passionate about what I do. I love what I do. Even though I’ve done how many thousands of procedures, I’m still tremendously excited about each case that comes to me."


Sarah Russel is a contributing writer for PSP. She can be reached at [email protected]