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The World of Spa

By Mary Bemis

Originally published in Massage Bodywork magazine, April/May 2005.
Copyright 2005. Associated Bodywork and Massage Professionals. All rights reserved.


I've followed the spa market since the late 1980s, when I wrote my first spa feature for a consumer fitness magazine. Since then, I think I've undergone every spa therapy available. I've had my body wrapped in chocolate, painted in paraffin, doused with a variety of liquids, and scrubbed with herb-infused salts and sugars. I've detoxed in traditional Mexican sweat lodges and sat in henna-infused sitz baths in Malaysia. I've had mud wraps in Italy, sipped the spa waters in Baden-Baden and Evian, and have had more facials than I can count. I've tested all kinds of pod-like pieces of equipment and a gazillion products -- and I've survived it all.

But this isn't a tale of survival, it's a story about growth. So before I delve into spa trends, I'd like to give you a brief overview of the industry. Ten years ago, the U.S. spa industry was just beginning to blossom. There were approximately 3,000 spa locations then, compared to nearly 12,000-plus locations today. According to the International Spa Association's (ISPA) 2004 Spa Industry Study, there was a 25 percent increase in spas from 2002.1 Day spas were popping up on every corner, driven largely by the full-service salon. Hotel and resort spas were few and far between, and destination spas such as the Golden Door and Canyon Ranch were luxurious getaways for the lucky few. When it came to treatments back then, the basic European facial and Swedish massage ruled. A handful of product lines were used at the majority of spas. Skin care was simpler then, in those pre-Botox and pre-microdermabrasion days. Times have certainly changed.

For starters, spa revenues in the United States are $11.1 billion, surpassing other leisure activities such as motion picture box office receipts.2 There are an estimated 281,000 people employed by the U.S. spa industry -- 51 percent of these are full-time, 34 percent are part-time, and 15 percent are on contract. Employee wages and salaries totaled approximately $4.9 billion in 2003. While day spas still lead in the United States (they represent three-quarters of all U.S. spas), resort/hotel spas have grown tremendously and account for the second largest spa group. This category has redefined the spa experience for today's consumer, as more people have traveled, whether for business or pleasure, and have experienced the many different spa and beauty treatments offered at these properties. (Club spas follow resort/ hotel spas with 6 percent of the industry, followed by medical spas at 4 percent, followed by mineral spring spas and destination spas.)

How stiff is the competition? Imagine this: In 2003, there were 136 million spa visits made in the United States (60 percent of those were to day spas and 27 percent to resort/hotel spas).

What does a typical spa-goer look like? For starters, 71 percent are female and 29 percent are male.3 The average age of a spa-goer is 41, and two out of five spa-goers are under 35; 87 percent are white, 5 percent are African-American, and 4 percent are of Asian descent.4 College graduates account for 55 percent of spa clientele, and the average annual income is $72,200. Eighty-two percent consider their health good, while 62 percent exercise at least twice a week. More than half of spa-goers purchase spa line products (facial care makes up 27 percent of these purchases, hair care another 27 percent, body care 22 percent, and foot care 18 percent).

Today's spa-goer is looking for experiences that deliver and treatments that show results. While one may go to a spa to be pampered, one also wants to walk out feeling transformed, be that more vibrant and energetic, or more relaxed and nourished. The following is a comprehensive overview of current offerings and what we can expect in the future.


Antiaging Facials to Custom Masks
Facials are the second most-purchased treatment, and facial care products actually account for 27 percent of spa purchases. Consumers are looking for antiaging and preventive skin care treatments and are spending money on high-tech medical spa treatments and pricey cosmeceuticals. They want effective treatments that either correct problems or have antiaging benefits. They're willing to pay top dollar for highly personalized treatments that are soothing and nurturing, as well as restorative. They want simplicity in all aspects, be it a spa experience or product. But most of all, they want results.

In my recent travels to day, destination, and resort spas, I've noticed a trend building in this area. Perhaps it's a backlash to all of the Botox, microdermabrasion, and other high-tech facials that have taken center stage -- but what I'm noticing is an increase in services calling themselves "manual face-lifts." The new massage techniques I came across are more intricate and advanced than ever in an attempt to firm and lift the skin naturally.

One of the most popular facials at the Gita Gabriel day spa in New York, for example, is the duo lift (90 minutes, $285). A two-part facial, this involves an intensive manual facial massage technique that uses distinct pinching movements for 20 minutes on each side of the face. (The first part of this facial uses a machine to gently twist and knead the skin, without electrical stimulation, mimicking what the esthetician does manually.)

It's also interesting to hear some of the horror stories from clients about the weird and wonderful pieces of equipment out there that are supposed to offer the miracle cure to aging skin. It is often these clients, with personal stories of skin care gone wrong, who turn to facials with a more hands-on approach.

Perhaps one of the most interesting facials I've recently experienced was the advanced concept lifting and firming facial at The Spa at the Mandarin Oriental in Miami. This facial combines body realignment work, energy work, acupressure, cold stones, and a firming facial massage in an 80-minute treatment.


Foot- and Hand-Care Trends
Certain body parts are receiving extra attention in the way of services. For example, foot and lower leg treatments are becoming more popular as spas go beyond the basic pedicure to offer all sorts of exotic foot rituals. This foot fetish, if you will, can be credited to the introduction of Asian-inspired therapies to the United States about seven years ago. Open a spa menu at any facility in the country and you're bound to find at least one elaborate foot treatment. Be it a luxurious pedicure, a soothing foot ritual, or a healing foot massage, the feet have shuffled forward.

Pedicures make up 53 percent of spa treatments ever purchased by women and 11 percent of spa treatments ever purchased by men.5 More spas are coming up with creative ways to coddle the feet. Foot treatments are becoming more sophisticated, more expensive, and lengthier. Today's foot rituals include elaborate foot soaks and gentle foot poundings, foot massages, and foot masks. A few spas are going so far as to introduce foot readings, similar to palm readings. Foot massages are now included in most body treatments and as add-ons to facials. Feet are being soaked, scrubbed, and moisturized with everything from green tea to soymilk, chocolate, eucalyptus oil, and sake.

Therapeutic medical spa pedicures are also on the rise, as is microdermabrasion of the feet and toe waxing. Many spas are offering foot rituals as a precursor to signature treatments. At the JW Marriott Desert Ridge Resort Spa in Phoenix, the wildflower foot bath is offered with two of the signature treatments. Large porcelain bowls are brought out to the client on a cedar tray in the relaxation room where the foot bath is enjoyed along with a cup of herbal tea, or the foot bath can be experienced in a private outdoor patio. In Seattle, the Gene Juarez Salon and Spa offers a ritual foot bath as a complimentary treatment before every service. The client chooses from a selection of aromas in this ritual, which includes a soaking segment, a massage, and an herbal tea.


Creative Scrubs, Wraps, and Massages
Body scrubs account for 25 percent of spa therapies ever purchased, while body wraps account for 17 percent. When it comes to the body, consumers are going for body wraps and scrubs that hydrate and smooth the skin, help reduce cellulite, firm the skin, exfoliate and detoxify, and reduce sun damage. I spent a lot of time recently in Los Angeles, checking out new spas and their treatments. While nature may not be the first thing that comes to mind when one mentions L.A., what I found in the spas there proved otherwise. I can't tell you how many of the treatments involved painting the body with honey and drenching it in warm milk. I had freshly crushed cucumber packs applied to my eyes and a freshly ground carrot concoction applied to my face. My feet were soaked in sake, and my hands were massaged with jasmine oil -- which brings me to a hot trend within body care now: that of organics, or going back to the basics. I've watched this back-to-nature trend grow for the past few years and attribute it not only to the consumer-driven interest in indigenous treatments, but especially to the rise in medical spa treatments. The latest statistics from the Organic Trade Association further validate this trend. According to the group's 2004 manufacturer survey, growth during 2003 for the personal care organics category was up 19 percent, totaling $170 million.6 Of that figure, skin care purchases made up $72 million (having grown 21 percent during 2003).

Natural and so-called organic treatments are popping up in spas nationwide. The Nob Hill Spa in San Francisco, for example, just introduced a lavender sugar scrub that uses organically grown lavender and sugar to smooth, soften, and moisten the skin. The price for this treatment is $100 for 50 minutes. The Spa du Soleil in Napa Valley has been creating its own seasonal spa treatments since opening in 2000. One of the more popular body treatments at this resort spa is the peaches and cream body mask ($200 for 90 minutes). One of the spa's therapists actually grows the organic peaches, which are combined with heavy cream and turned into a thick body mask. At the Aqua Beauty Bar, a day spa in New York City, owner Jamie Ahn teamed up with the chef of a trendy restaurant to create homemade body treatments, again from natural ingredients. Ahn has been creating her own body masks for a few years and offers a total of 10 different homemade body scrubs and eight different homemade facial masks. One of the more popular body scrubs at this spa is the brown sugar scrub, which combines cinnamon powder, vanilla, and aloe vera. Other popular ingredients in this category include avocado, grape seed, chamomile, mango, chocolate, coconut, lemongrass, maple sugar, soy, pomegranate, and fig.

Another body part claiming its own category on spa menus across the country is the back. A leading day spa in Pennsylvania offers a "bacial," which translates to a "back facial." Other back facials are called the back smoothing facial, the stress-relief back treatment, the ultimate back facial, the bare back treatment, and the apple-pumpkin intensive back treatment. In addition to back facials, there are deep heat treatments for back, neck, and shoulders.

It's important to note that the integration of world cultures is also having an effect on spa treatments. Take the stone massage, which many say originated with the American Indians, or the rhythmic lomi lomi massage with its soothing long strokes from Hawaii. There's also shiatsu massage from Japan and a plethora of ayurvedic treatments from India.


Baths are Back
I'm happy to report that hydrotherapy is on the rise and that today, two-thirds of spas offer wet treatments.7 I can't count the many spa owners and directors I've spoken with over the past 10 years who complained they had wasted their money by purchasing large, expensive hydrotherapy tubs that stood empty. A lot of that had to do with the fact that they didn't know how to market these pieces of equipment to a very new industry and an inexperienced spa-goer. Those who did do well marketed hydro treatments as underwater massage therapy, for example. Today, I believe the American spa-goer is finally ready to embrace hydrotherapy, which means that you as spa owners, therapists, and estheticians need to be educated enough to deliver a worthy and beneficial hydrotherapy experience -- be it in the form of a classic hydrotherapy tub, jacuzzi, soaking tub, or vichy shower.

Some hydrotherapy success stories I've come across include the Himalayan bath at Stone Spa in New York City. Owner Carla Ciuffo, whose dream was to offer Watsu (not so practical in New York where space is at a premium) had no idea how popular this would become with her clients. Her Himalayan bath room is nearly 400 square feet and houses a spacious tub with an air system that sanitizes itself before and after treatments. Ciuffo chose a tub large enough for two and found out in no time she had made a wise investment. Mothers and daughters, friends, and couples book this room regularly at a cost of $45 for 45 minutes and customize their baths with a variety of the spa's bath products.

At the Spa at Torrey Pines in La Jolla, Calif., spa director Darcie Debartelo was skeptical at the thought of installing a hydrotherapy tub when the spa first opened in 2002. The first year the spa was open, there were rarely bookings for baths. That changed dramatically, however, when the spa added the California grapeseed tea bath. The $120, 50-minute treatment includes a lavender-grapeseed infused bath, a special grapeseed tea blend to sip while soaking, and a 25-minute massage using a lavender-grapeseed oil. The hydrotherapy room at this spa is equipped with a tub featuring 125 different jets and color therapy lights.


Super-Personalized Treatments
Consumers visit spas for a variety of reasons, one being that the spa experience makes them feel special, allows them to take time out for themselves, and hopefully focus on what needs fixing. And what needs fixing varies from client to client. Whether a person steps into a spa to relax or renew, today she is looking for a much more personalized experience than ever before.

Customization is a huge trend right now. One reason is due to the fact that people are becoming more educated and are more comfortable asking for what they need from a spa. They want personalized service specific to their needs. Spas are responding to this by creating larger treatment spaces where guests remain for all of their customized treatments, often referred to as "spas within a spa," as opposed to moving from room to room with different therapists, and by allowing the guest to purchase a block of time versus a specific treatment. For example, at Simply Spa in New York, customers buy either the 60-minute slot or the 90-minute slot from the spa sampler. Sixty minutes buys a choice of three services (massage, facial, manicure or pedicure), while 90 minutes buys four services. The small day spa's six therapists are dually licensed estheticians and massage therapists.

The staff at the Mandarin Oriental was one of the first to recognize the trend, realizing that one person's needs and desires differ from another's. About three years ago, they created a super-customized treatment called the "time ritual." Instead of charging clients for preselected treatments, they charge for time spent (by the hour with a two-hour minimum) in one of the spa's beautifully appointed spa suites. When the client arrives, she tells the therapist her preferences, including how she would like to feel after the experience. The therapist then assesses what is best. (Each therapist receives three months of specialized training.) The treatment begins with an aromatic, petal-scattered foot ritual, and, at the same time, the client is given a smell test for preferred scents while she sips an herbal infusion of tea. The time ritual doesn't include makeup, nail care, or waxing services.

In the high-tech arena, the introduction of imaging systems that take digital photos of the skin and measure wrinkles, textures, pores, pigmentation, and bacteria are becoming more popular. One such machine gives you six images of your skin, assesses your personal skin condition, and then suggests a customized program of services, such as microdermabrasion.


Factoring in Men and Couples
Men have finally discovered and embraced what women have known since spa became a full-fledged industry in the United States: It makes you feel good and look good, and that's important in today's time-crunched, youth-conscious society. Today, the top spa services men are choosing are facials, manicures, and pedicures. According to the Wall Street Journal, American men spend $16 billion a year on their appearance.8 The American Society for Aesthetic Plastic Surgery reports that in 2002, men accounted for 25 percent of all cosmetic surgeries.9 The numbers of men going to spas is climbing, thanks to men who frequent resort/hotel spas where they are pampered in private surroundings. This has spawned a multitude of men-only spas. While destination spas such as the Golden Door in Escondido, Calif., have offered special men's weeks over the years, the sudden growth in men-only spas and private men's wings is evident in the day spa sector. John Allan's in New York City, The Grooming Lounge in Washington, D.C., and the newly opened Nickel in San Francisco are perfect examples.

The number of couples going to spas is also on the rise. Rooms that can accommodate two massage tables and tubs big enough for two are being built in record numbers. Not so long ago, the Wall Street Journal reported that couples who were about to have their first child were vacationing as never before, spawning (no pun intended) a new buzz word: the Babymooner.10 This trend, in turn, is helping to drive the trend of pregnancy treatments. Many resort and hotel spas are offering special two- and three-day packages for this group with names like "bundle of joy" and "mother-to-be."


Getting Hip to Teen Clients
While the industry has relied on baby boomers in the past, today we're taking a long hard look at the teenage market. This burgeoning new market has the potential to drive growth not only in the present day, but well into the future. Marketing to this age group is a viable method of building long-term clientele via a new generation of spa-goer. Take a look at these numbers:

- In 2003, the average American teenager spent $103 per week, according to a study by Teen Research Unlimited.11 The study also revealed that girls spend 15 percent of their total overall income on health and beauty products.

- 14 percent of spa-goers are in the 16 to 24 age bracket.

- 40 percent of spa-goers with children between the ages of 13 and 15 have taken their teens to a spa.12

Spas are targeting this growing market in a variety of ways. Canyon Ranch offers a three-week summer camp for teens. The Hyatt Regency Hill Country Spa in San Antonio, Texas, built an additional spa facility to cater to this group and sees 50 to 75 teens per week. Day spas are hosting "sweet 16" parties for groups of teens, who then learn about the importance of facials and proper skin care; many spas offer special teen rates; some properties are also creating special packages with mini versions of services for teens. The Tiffani Kim Spa in Chicago sees quite a few male teens who opt for treatments like the young man's manicure ($25, 30 minutes) and the young man's facial ($95, 60 minutes). This day spa even has a nutritionist on staff to offer its teen clients advice on healthy eating habits.

Two years ago, Seventeen Studio.Salon.Spa launched in Plano, Texas, with the goal to have two or three Seventeen Spas in the top 50 cities by the end of 2010. The Texas location has a wisely chosen staff made up of 20- and 30-something employees who see about 2,500 teens per month. The most popular services here are eyebrow waxing, facials, and nail services. Some cruise ship spas are also catering to the teen market. Lotus Spa, the Princess Cruises' spa brand, recently introduced teen-specific treatments such as the lotus youth facial. An interesting note here: Teens at Lotus Spa are required to wear a bathing suit during treatments.


Rx for Medical Spas
The medical spa trend is being fueled by the baby boomers' demand for effective and credible spa treatments, their desire for one-stop shopping, and their limited time availability. Back in the late 1980s, a handful of physicians were just beginning to employ paramedical estheticians in their practices, and day spas were partnering with plastic surgeons and dermatologists who were referring their pre- and postoperative patients to day spas for proper skin care, esthetic upkeep, and the benefits of human touch. The term "medical spa" was yet to be coined and "medi spa" yet to be trademarked by New York City-based Bruce Katz, M.D., owner of Juva Medi Spa. Medical spa treatments fall into two general groups: prevention/wellness, which includes everything from health physicals for executives to healthy lifestyle education; and esthetics/cosmetics, which includes everything from teeth whitening to Botox injections.

In 2002, there were 225 medical spas in the United States, accounting for $205 million in revenue annually with 2.8 million consumer visits.13 In fact, the medical spa segment is the fastest growing, in terms of locations, in the industry.14 The Medical Spa Association defines a medical spa as a facility with a medical program run under the strict supervision of a licensed healthcare professional, providing services that integrate both traditional and nontraditional medicine and spa treatments. One of the first and most successful medical spas is the Mezzanine Spa at Soho Integrative Health in New York City, where a blend of East and West is practiced. Services include cosmetic and general dermatology, laser surgery, obstetrics and gynecology, plastic surgery, Lasik eye surgery, podiatry, ayurvedic medicine, acupuncture, traditional Chinese medicine, chiropractic, fitness, and nutrition. The spa also offers a Rx menu, which closely ties in with each of the doctors on staff. For example, if a client is booked for liposuction, she visits the spa for a series of treatments specifically designed around the surgery, which may include cellulite reduction treatments, reiki for relaxation presurgery, and manual lymph drainage massage postsurgery to reduce fluid retention and accelerate healing.

More and more traditional spas (i.e., nonmedical spas) are benefiting from the medical spa boom by introducing pre- and postoperative treatments. For example, Elizabeth Arden recently launched its breast surgery massage, which it recommends as a series of six treatments. Each treatment lasts 50 minutes and costs $80. The more typical medical spa treatments include laser treatments; antiaging facials such as glycolic peels, photo facials, soft tissue injections such as Botox, Restylane, and collagen; microdermabrasion; cellulite treatments; and permanent cosmetics. The most common medical spa treatments offered are Botox, with 60 percent of spas offering; microdermabrasion, with 59 percent of spas offering; chemical peels, with 54 percent of spas offering; and laser hair removal, with 46 percent of spas offering.15

To further give you an idea of the types of treatments consumers are going for, consider this: There were more than 3 million non-surgical cosmetic procedures performed in the United States in 2003, according to the American Society of Plastic Surgeons,16 with Botox injections increasing by 157 percent from 2002 to 2003. The top three invasive procedures were liposuction, sclerotherapy, and breast augmentation, while face-lifts decreased by 5 percent.

These high-tech treatments are having an influence on consumer buying habits. Today, cosmeceuticals and clinical/spa brands are on the rise. This category has grown from a 2 percent dollar share of the market in 1998 to a 7 percent share in 2002, notes the NPD Group, a New York-based marketing information firm. Consumers are obviously willing to pay the high price of technologically advanced beauty products because they want to see verifiable results. I've spoken with dozens of dermatologists and cosmetic surgeons who, if not already running a medical spa, are contemplating entering the arena. This is obviously changing the spa industry as a whole. The spa consumer will still go to a conventional spa for pampering, relaxation, and skin maintenance, but is increasingly visiting medical spas to experience visible changes to her appearance. The medical spa trend is not going away anytime soon.

And we mustn't forget the dental spa. A growing number of cosmetic dental offices are seeking any which way to pamper patients waiting out their time while undergoing bleaching solutions, laser lights, or bonding materials. To combat this, some savvy dentists are simply turning the dental chair into a recreation center and offering their captive clientele such diversions as CDs and DVDs. Others are offering spa services such as paraffin hand and foot treatments and aromatherapy. Also of note: Teeth whitening is right up there in popularity with such other lunchtime favorites as the glycolic acid peel and Botox. According to the American Academy of Cosmetic Dentistry, teeth bleaching procedures have increased by more than 300 percent in the past five years.17


An Openness to Additional Therapies
It wasn't so long ago that spas were actually removing services such as craniosacral and reiki from their menus, as client demand or interest was simply not there. Times have changed. As the consumer's quest for mind and body balance grows, all sorts of alternative therapies are making their way onto spa menus. This spa trend is taking form with the dramatic increase in fitness class offerings such as Pilates and yoga, as well as an increase in energy work such as reiki and polarity therapy and treatments that incorporate color therapy. According to the latest study by ISPA, the spa offerings expected to make the biggest gains in future years are yoga (18 percent of spas plan to add it), posture and realignment (15 percent of spas plan on adding this), and spiritual or mind and body programs (14 percent of spas plan on adding this to their menus).18

At Ceiba del Mar, a holistic spa in Puerto Morelos, Mexico, I recently had my vital energy level read by a contraption called the Bio-Tensor. A sort of wand-like device, it wiggles around and swings back and forth, depending on one's vital energy. Spa director Gloria Guerrero begins each spa treatment by testing which aromatherapy oils' energies suit the client best. At The Spa at Wyndham Martineau Bay on the wonderfully unspoiled island of Vieques, one can opt for craniosacral, polarity therapy, acupressure, and reiki, along with the more traditional spa services.

Says Nicolay Kriedler, spa director and reiki practitioner, "'Alternative' for me is more a state of being than a procedure or a technique. The technique is the meditation that client and practitioner consciously choose. Ultimately, it does not matter what the technique is, whether it is reiki, massage, or a scrub. The deepness of the meditation is key to the depth of healing."


What Does Wellness Mean?
Webster's dictionary defines wellness -- a word that originated in 1654 -- as "the quality or state of being in good health, especially as an actively sought goal."19 It is my worry that in today's spa world we have misappropriated the word and strayed from its true meaning. The word "wellness" has become a buzzword of sorts and is being bandied about and attached to businesses and treatments that are anything but. We owe it to today's spa-goer to keep the definition clear and to help them in their quest for true wellness.

While it is important to stay atop of today's spa trends, it is of utmost importance to give your clients a true and meaningful spa experience that is worth their money and time. Before you take on any of today's trends, know exactly just who your client is, know what your strongest traits are (that is, what treatments you do best and why), and make sure your service and spa facility deliver.

Mary Bemis is a leading spa critic and writer who lectures regularly on spa trends. She lives in New York City and is the spa adviser to Shape magazine, the contributing editor of Home Spa Design for Luxury, SpaFinder magazine, and pens a monthly spa treatment and trends column for Skin Inc. magazine. Reach her at marybemis@insidersguidetospas.com.

References
1 International Spa Association 2004 Spa Industry Study, conducted by the Association
Resource Centre Inc.
2 Ibid.
3 Ibid.
4 International Spa Association 2003 Spa-Goer Study, conducted and prepared by NFO Plog Research.
5 Ibid.
6 Organic Trade Association 2004 Manufacturer Survey.
7 International Spa Association 2004 Spa Industry Study.
8 According to the Wall Street Journal ("New Market for Men's Cosmetics Gives Beauty-Product Sales a Lift," April 7, 2004), American men spend $16 billion a year on their appearance.
9 The American Society for Aesthetic Plastic Surgery reports that in 2002, men accounted for 25 percent of all cosmetic surgeries.
10 Not so long ago, the Wall Street Journal ("A New Parenting Ritual: The Last Hurrah," July 7, 2004) reported that couples who were about to have their first child were vacationing as never before.
11 According to the most recent study by Teenage Research Unlimited (TRU), teenagers aged 12 to 19 spent an average of $91 per week in 2004. That figure is actually down somewhat from the $103 reported in 2003. Michael Wood, vice president of TRU, believes this is due
to the weakened economy, as part-time jobs are not as readily available to the teen market as they once were. In spite of this year's decline, TRU reports that teenager spending has increased an average of 5 percent per year over the past seven years.
12 Forty percent of spa-goers with children between the ages of 13 and 15 have taken their teens to a spa, according to the ISPA 2003 Spa-Goer Study.
13 International Spa Association 2002 Spa Industry Study.
14 International Spa Association 2004 Spa Industry Study.
15 Ibid.
16 In 2003, consumer demand rose 41 percent for minimally invasive plastic surgery, exceeding more than 6.9 million procedures, according the American Society of Plastic Surgeons (press release of March 8, 2004). The most popular procedures include Botox (up 157 percent from 2002 to 2003) and collagen injections (up 30 percent).
17 According to the American Academy of Cosmetic Dentistry (AACD), teeth bleaching procedures have increased by more than 300 percent in the past five years. (May 2004 AACD press release "Tremendous Growth Seen In Cosmetic Dentistry: Patients Want Smile Transformations.")
18 According to the 2004 ISPA study, the spa offerings expected to make the biggest gains in future years are yoga (18 percent of spas plan to add it), posture and realignment (15
percent of spas plan on adding this), and spiritual or mind and body programs (14 percent
of spas plan on adding this to their menus).
19 Merriam Webster's Collegiate Dictionary. 2003 Eleventh Edition. 1421.






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