What we talked about
Dr. Alex Roher, MD is a board certified anesthesiologist who reinvented his career after falling out of love with anesthesia and built SD Botox into a fast growing aesthetics business. He shares how he started in 2012 with only one procedure, renting a room from an esthetician, then learned business by doing it. He explains the turning point when he acquired a struggling practice that became his Pacific Beach location, and how the business expanded through organic growth and smart acquisitions, including rapid growth during the Covid era “Zoom Boom.” Today, SD Botox spans 11 locations across San Diego and Austin, built around four pillars: injectables, laser and energy based treatments, medical grade skincare, and esthetician services.
Show notes
Dr. Alex Roher describes doing a liquid rhinoplasty, using filler to reshape a nose in about ten minutes, and handing the patient a three-way mirror so they can see all their angles at once. There are tears sometimes. He calls it his favorite procedure because the transformation is immediate and undeniable, and it captures something he could never get from anesthesiology: he actually sees what happens to the patient after.
What we covered
- Roher started SD Botox in 2012 knowing only how to do Botox, no filler, no laser, no other procedures. He chose the name because SD is San Diego and Botox was the only thing he knew. The first months were empty. Growth came slowly, then accelerated when he acquired a struggling Pacific Beach practice for very little money and cleaned up its operations. During COVID, he describes swallowing up practices while the rest of the industry panicked, picking up three locations in a single year.
- The “Zoom Boom” was real and specific: people working from home were staring at themselves on video calls, noticing lines they had never focused on before, and booking appointments. The combination of government stimulus money, no travel spending, and remote work created a surge in aesthetic demand that Roher says was unlike anything before or after.
- GLP-1 drugs like Ozempic have meaningfully reshaped parts of his practice. The rapid weight loss they cause has created demand for new treatments, skin laxity procedures, facial re-volumization for what the industry calls “Ozempic face,” and body contouring for areas like the abdomen and postpartum skin. He is actively building this into a growth area.
- His wellness sister brand, Hormones and Wellness by SD Botox, treats perimenopause, testosterone replacement, and peptides, and is becoming a point of entry into preventive care for patients who would otherwise never see a doctor. He describes requiring lab work before prescribing GLP-1 medications and repeatedly discovering undiagnosed thyroid disease, kidney problems, or liver issues, conditions that had gone undetected simply because the patient had not been to a doctor in years.
- The FAA analogy is central to his critique of the current healthcare system: when a plane crashes, the FAA takes the black box and systematically redesigns the process to prevent recurrence. Medicine, he argues, does the opposite, it focuses on prolonging illness rather than preventing it, because the incentive structure rewards ongoing treatment over sustained health.
- Roher went on a surf trip with Laird Hamilton, who told the group he had fallen more times than most people had surfed. That framing, failure as the precondition for mastery, not the opposite of it, is how Roher processes his own mistakes, including a serious vascular occlusion during a nose filler procedure that he navigated while traveling. He came out of it having learned ultrasound guidance and having built a safer practice.
About Dr. Alex
Dr. Alex Roher is a board-certified anesthesiologist and the founder of SD Botox, which now operates 11 locations across San Diego and Austin, and Hormones and Wellness by SD Botox, a sister brand focused on hormone replacement, peptides, and preventive health. He has been practicing aesthetic medicine since 2012.
- LinkedIn: https://www.linkedin.com/in/dr-alex-roher-md-27624413b
- Website: http://www.sdbotox.com
Episode 123 of the PreVetted Podcast.
Full transcript
Federico Ramallo (00:00) Welcome back to the pre-Verede podcast where we spotlight extraordinary people and remarkable talent reshaping our world. Today we’re joined by Dr. Alex Roher. He’s a board certificate anesthesiologist and the owner of SD Botox. In 2012, he opened SD Botox to help people feel more confident through minimally invasive cosmetic procedures and micro treatments.
with a focus on natural looking results and a warm and relaxing experience. Dr. Rojas talks about pre-juvenization mindset of proactive preventive care plus a commitment to personalized treatment plans and clear reliable education in a industry that can be full of noise and misinformation. Alex, welcome to the show.
Alex Roher (00:50) yeah. Thank you for having me.
Federico Ramallo (00:52) I’m honored to have you here today. So tell us why did you decided to start your clinics back in 2012?
Alex Roher (00:54) Thank you.
Yeah, so I was kind of, as you mentioned, I was a board certified anesthesiologist, still am. Haven’t performed anesthesia in like five plus years at this point. So all I do now is this. And I will tell you, like, it wasn’t a love for aesthetics initially. It was really just a falling out of love with anesthesia. It’s just redundant. The hours you worked, you know, like never knowing what time you get to go home, working nights, weekends, et cetera, like.
You would ask the surgeon how much longer in the case and they would tell you a number and you have to take that number and multiply it by like two. That’s really like how much longer. Surgeons just aren’t there’s a lot of ego. They’re not the most fun to deal with. So that’s not all of them. That’s some of them. But enough that I just wasn’t happy. So I called the company SD Botox because SD is San Diego. That’s where I’m based. And Botox is
the only procedure I knew at the time, meaning, you know, I didn’t know how to do filler laser or any other stuff just yet. So it just called the SD Botox and it worked out. was like Botox is kind of a surrogate term for like all the procedures in this world is more of the household name. So yeah. And so no one came in for a couple of years, like a couple of months and then slowly started getting busier, had to learn business along the way. Cause
Like most doctors, just did not have a business background. It’s a different kind of brain, I think, like the medical side versus the business side. And so it’s opened one clinic, not too far from where I lived, you know, and slowly got busier. I just rented a room from a esthetician and then I got busier. then, yeah, and then another business doing similar stuff.
similar procedures. They were going out of business. they hail Mary, they kind of sold me their assets. And that was my second location. And that one was when it really exploded. And then because it came with the staff, they were doing a lot of things right, they were doing some things wrong. So I cleaned it up. And that became my Pacific Beach office. This was probably like 2017 2018. And I paid very little for that, because it was just kind of in shambles. And then it just exploded. And then, you know,
kind of kept growing organically, got to five, kind of in the early, during COVID, know, everyone, certain businesses did well during COVID, certain obviously did not, you know, and so my business, this business did great, like aesthetics, just because everyone had money, the government was giving them money, no one was traveling, everyone was starting to work remote, so it’s called the Zoom Boom, just like we’re right now, we’re talking, everyone’s like looking at themselves, and there’s this little line they’re not loving, they’re gonna go address.
So was just a great time. And it was like, everyone was panicking, like as if this business wasn’t gonna do well. So I was swallowing up practices. I think I got to five at that point, three that year. And then more recently, we’ve kind of just been super dialed in operationally and just opportunistic. And so we’ve tacked on another three. So we’re at eight in San Diego. And then I had a employee.
She was one of my cool sculptors. Cool sculpting is a procedure that freezes and kills fat. So if you have like a double chin or a love handle, we could target just that specific area. That part of the business got eaten up a little bit by all the GLP ones, so like those at BIC. But she ended up moving to Austin because her, employee moved to Austin because her boyfriend, now husband, they got a job there. And we ended up opening an office together there.
And that did so well that we then opened up two more in Austin. So I have total of 11 SD Botoxes. And SD Botox is just purely aesthetics. So it’s only, you know, it’s like Botox. There’s four pillars of what we do. There’s injectable, so Botox and filler. There’s laser and energy-based device, which is super important, resurfacing the skin, IPL, all that kind of stuff. And then there’s at home medical grade skincare.
And then there’s esthetician services like hydrofacial, peels, that kind of stuff. So that’s SD Votox. There’s currently 11 of those. And then me and my best friend, we got more into the wellness side of it all. So we have two offices, it’s called Hormones and Wellness by SD Votox. that is not, that’s like, so it’s, we deal with lot of like hormone replacement, men and women, men are just testosterone, women are.
perimenopause, they’ll do like estrogen, progesterone, testosterone. And then we’re super into the peptides, which are just having a moment right now. And that’s all done out of that office as well. And then we do recovery modalities. So we do like DEXA scans, lab work, and then we do like saunas, cold plunges, cryotherapy, I’m sorry, yeah, red light bed, hyperbaric oxygen, all the health and wellness side of this business. So it’s like they’re sister companies.
This is more aesthetics and this is more wellness.
Federico Ramallo (06:10) Right, right. And on wellness, can do more preventive care so people can have the options of whether they want to have a aesthetic operation or they want to prevent it, you know. ⁓
Alex Roher (06:22) Absolutely. Yeah.
that side, it’s the younger generation is prioritizing health above like all the material possessions and things that like the older generation spends money on. And so, you know, they’re, they’re drinking less. They’re, you know, they’re all wearing like a aura or a whoop or a Apple watch. So, you know, they see the effects of like say drinking on their body, you know, they get that instant feedback.
And they love all these, the health and wellness side. There’s a lot of them that are, know, they don’t like Botox somehow at some point became cool. You know, it’s the best thing. mean, I’m not complaining, but it’s like sometimes they come in at like 22 years old and they don’t even have a line on their face and they’re like, they want Botox. So we, the right thing to do is not to do it. And we, that’s what we do, but it is a changing cultural shift kind of towards the wellness and the aesthetic and taking care of yourself and.
spending, being willing to spend a bigger portion of your money on this type of, on bettering yourself, your skin, your health, et cetera. Kind of not waiting until you get sick. Yeah, yeah.
Federico Ramallo (07:28) Right, right. Yeah, I think it’s important because now you can provide both options, right? And coming from a world where, you you don’t hear anything about this type of operations until you hear, you know, a bad case like I remember Meg Ryan, she had a beautiful face and then she got a really bad operation, right? And everybody was kind of talking about that, right? At that time.
Alex Roher (07:46) Sorry.
Federico Ramallo (07:53) And, but nobody talks about the, the success, cases of plastic operations where you cannot see it, right? ⁓
Alex Roher (08:01) Exactly.
The goal is that you get something done and you look good, but no one knows that you had anything done. You don’t want it obvious. And in Meg Ryan’s case, like a lot of the celebrities that have, I think it’s just a matter of way too much filler. So filler, hyaluronic acid, you inject it, you can make lips bigger, cheeks, anywhere on jaws, chins, noses.
Etc. And sometimes celebrities and non celebrities will just go overboard with a filler and start looking kind of alienish and kind of gives a whole like their faces are billboard, you know, so we don’t you know, we tell people no all the time because a little bit of filler is great, but a lot of filler you’re going to look weird. And so it’s a little bit of what’s called filler fatigue. A lot of people are putting less hyaluronic acid filler in the face or doing more sculpture.
and other products, but we’re not making the weird looking people, you know, I’d like to think we never did at SC Botox, but you know, as a society and as an industry, I think we’re backing off of like overfilled cat lady looks.
Federico Ramallo (09:06) Right, right, yeah. And I’ve seen more on the women this idea of owning their age, right, rather than just trying to, you know, present themselves as young, even though they’re not.
Alex Roher (09:21) Yeah, absolutely. It’s not about looking younger necessarily, it’s just about looking your best. it’s, I mean there is a little bit when you certain procedures, the quality of the skin, the placement of the filler, et cetera, that you do achieve a little bit of a more youthful appearance, but it’s not really the North Star primary goal. It’s really just making you feel beautiful in your skin.
Federico Ramallo (09:44) Right. And what are the biggest reasons people come to see you?
Alex Roher (09:48) Um, so I would say Botox is still 65 % of what we do. Um, and I’m sure everyone’s pretty familiar with Botox, but Botox, say, classic drugs called the Neural Modulator, you inject into certain muscles that gets rid of, let’s say like you have those horizontal lines on your forehead from raising your eyebrows or that vertical line between your eyebrows from furrowing your brow or your furrowless feet from all that smiling, all that happiness. So we inject the Botox into that area and it
decreases the function of that muscle for four months and those lines fade. So Botox is number one, filler is number two, and then we have a lot of laser and energy-based devices. So we’re kind of talking about cool sculping. That’s kind of, like I said, on its way out a little bit, because all the new GLP-1 drugs are just so amazing that everyone’s losing weight like that. But we do a lot of like…
laser resurfacing, what’s called IPL or BBL broadband light. So it’s this removes the pigment, you know, when you have that like hyperpigmentation, the sun damage on your face or anything red vascular, it’s awesome for that. It’s just kind of like that’s, like the beauty side of this industry, you know, just really, you know, like dialing in your physical so that, you know, you look amazing. And then the other side is, so you, once you look amazing or
then you feel amazing once we get you on the right hormones or peptides or whatever it may be, all the healthy lifestyle changes.
Federico Ramallo (11:21) Yeah, because it’s not only looking good, it’s also feeling good, right? ⁓ And sometimes the external appearances reinforces the internal feeling, right? ⁓
Alex Roher (11:25) Absolutely.
Yeah,
know, humans are very visual creatures, you know, and what do they say that you judge someone within the first two seconds of meeting them? obviously, physical appearance is a big fact part of that.
Federico Ramallo (11:45) Right. Right. And what does a good result look to you?
Alex Roher (11:50) Kind of like I said earlier, it’s like you look great and no one knows what you did. Why you look great. Is it a laser? Is it a botox? it some well-placed filler? Whatever it may be. It’s subtle enough that no one knows what happened, but obvious enough where you look great, but not gonna get called out on by your family and friends and everyone else.
Federico Ramallo (12:16) Right, right. I’m sure that those patients, won’t feel comfortable referring, you know, patients to you because they don’t want to expose themselves as having, right?
Alex Roher (12:26) Yeah, it was a little bit. Yeah,
it’s true. We do have a referral program and it’s not used too often. It is used, but and there’s like two type of people, you know, there’s there are the gatekeepers that just secretly do all this stuff and don’t tell anyone. And then there’s the sing it from a mountaintop like, I to ST Botox. Look what I did. You know, going live on TikTok during the procedure itself, all the things. So obviously, that’s my preference, those people buy it.
Federico Ramallo (12:45) Ha
Alex Roher (12:52) I understand it’s a personal thing and it’s a medical procedure and it’s their right, know, just like anything, their patient privacy, if they don’t want to say anything to anyone about it, that’s, that’s perfectly fine too.
Federico Ramallo (13:04) Right, right. Yeah, but I can understand the, not frustration, but the situation where they won’t feel, if you do a great job, they won’t feel comfortable telling, know, right.
Alex Roher (13:15) Right. Yeah, no, I
just slept well. OK. Yeah, totally. Good sleep really does that, you know. Sometimes it would be like a group of friends and let’s say five friends and one of them realizes one day that the other four have been getting all these things done for like four years, five years. And they’re like, what? Not cool, guys.
Federico Ramallo (13:20) Right, of course.
Ha ha ha.
Right, right. They can refer from a friend. I have a friend, you know, that got an operation, now looks great. Right, right. Not that I have done that, but you That way they can keep face to their friends and you know.
Alex Roher (13:39) Right, yeah, exactly. I hear this stuff is amazing.
Yeah, exactly.
And I think a lot of that social
stigma is getting better. I think it used to be more secretive and I think now the general trend I would say is more just telling people what you did and where you did it and how much it costs and how much you love it and et cetera.
Federico Ramallo (14:07) Right, right. There’s less stigmas for sure. Yeah. And it’s hard because people, once the stigma goes out, then they can freely talk about it. And it creates a reinforcing feedback loop where people can realize that the outcome is not going to be the Meg Ryan’s of the world.
Alex Roher (14:27) Exactly. Well, the problem is that the Megarines of the world, like we noticed them. So even though that’s like, it makes up like 1 % of what total patients said.
You know people that dabble in this world, know that one person when other people see that that they just assume that’s what this world is because the other ones you don’t notice like, you know, you know, it’s the one woman with giant lips that should have quit putting filler in there like five syringes ago. But you don’t notice the let’s say the other 49 out of 50 that, you know, did it one time. It looks great. You’re doing. Oh, well, that’s a natural beauty.
Federico Ramallo (14:59) Right, right. And San Diego and all the area around LA, it’s kind of the, you have the highest percentage of women that have been through plastic surgery, right?
Alex Roher (15:09) Yeah, yeah, yeah. Southern California
is probably the Mecca for, you know, like San Diego, Orange County, LA. Definitely like we have that reputation for a reason, you know, like definitely there’s more med spas than Starbucks’s.
Federico Ramallo (15:14) Right.
Right.
Right, right. And do you see a difference in expectations compared to San Diego and Austin in terms of what they expect from the surgeries?
Alex Roher (15:39) I’d say between, I feel like San Diego does have, I’d like to think that when people think of San Diego, they just think of like, kind of like sun-kissed beach beauties, know, kind of not overdone. I think like the one that has that big stigma is LA. You know, the one where that tends to be where if you’re have too much of anything, it’s probably LA is somehow involved. Not to say that doesn’t happen everywhere, but definitely that does seem to be where.
Patients take it to the extreme and providers don’t tell them no and they probably should.
Federico Ramallo (16:14) Right, right, yeah. I like San Diego because it’s a much more balanced place compared to LA, for sure.
Alex Roher (16:24) Me too, yeah, yeah, yeah. I did my residency
in LA. The reason I lived in San Diego for 14 years now, it’s definitely. I like visiting LA. I’m not here bashing LA, LA’s a great place in its own way, but I mean, I agree with you. This is a better fit, and it just, I think even a lot of LA people might even say that, but LA’s great in its own way.
Federico Ramallo (16:31) Right, right.
Yeah, yeah, I I like LA to go and visit, but I’ve seen so many extremes, right? That I go there with a lot more caution, right? Yeah. So what do you enjoy most about this work?
Alex Roher (17:03) Yeah, absolutely.
I like the instant gratification of my favorite procedure at SD Botox. The aesthetic side is called a liquid rhinoplasty. And so on the nose, this is called a dorsal hump. This is called the radix, acetyl depression. And then oftentimes you will have ptosis or drooping of the tip or the surgeon took way too much when he did a surgical rhinoplasty. Then I like filling the nose with a product called Juven Voluma and Juven Volux.
And that instant gratification just as you see the results right away, you give the patient this cool like three-way mirror, kind of like when you’re getting a suit tailored. So you could see all the different angles and so they could see complete profile from both sides. And I mean, there’s tears sometimes, they’re just like, it’s just so fun to change someone’s life so dramatically in literally like 10 minutes. We use ultrasound, make sure we don’t have any vessels and then we do the procedure, give them the mirror and it’s just a fun.
patient interaction from beginning to end. I’m getting into, I started seeing patients over at Hormones and Wellness by SD Votox, two day, just two hours a week. And I enjoy that patient interaction too. I’m getting into that. Like I’ve been doing this so long that it’s like, I’m enjoying the newness of that. know, people come in and we talk about perimenopause. Sometimes patients will come to me for…
for Botox and it’s like 45 year old woman. I started asking her about sleep, energy, mood, sex drive, et cetera. And it’s like, my line is it’s like the Botox is like polishing the brass on the Titanic. You know, the ship’s going down. Like, let’s get you over to my other clinic. Let’s do some labs. Let’s get a DEXA scan. Let’s, you know, and, and based on symptoms and labs and everything else, we, could then get them started on hormone replacement and then even taking me even further with some peptides.
Then that patient comes back to me four months later for more Botox and you could just see the difference. know, you know, like my Botox patients typically don’t hug me, but my, you know, when someone’s going through menopause and you turn that around, my God, they’ll, they’ll hugs and, know, singing my name from the mountaintop for sure.
Federico Ramallo (19:20) Right, right, that’s amazing. And now you have more control over your hours, right?
Alex Roher (19:26) Yeah, exactly. I think if someone asked me not too long ago, there anything you miss about anesthesia? And I had to think a long time. I mean, I do enjoy some of those procedures, like putting in a central line or a peripheral nerve block under ultrasound guidance, but not really. I mean, I haven’t thought about anesthesia. If you’re going to surgery and I’m your anesthesiologist, don’t get the surgery because it’s been five years. You don’t want me putting you to sleep. And I don’t miss it. Honestly, like…
Federico Ramallo (19:53) you
Alex Roher (19:55) 99 % lifestyle is better. The work itself is better, you know, financially, everything is my life is just better now. I’m happy I went through a little bit of a period where I was less happy. would say I wouldn’t say depressed, I just anesthesia is an interesting gig. It’s good. It’s great. I’m not investing this one either, but it’s kind of, you know, you go to work every day, you know, and dies, you do good job. You go home, repeat the next day, next day. You know, it’s just like, there’s no longterm goals to it all.
And it’s cool owning a business and seeing it grow and the decisions you make like come to fruition and kind of like chipping away, grow, you know, making it more successful. I once read a book that everyone thinks about like their business. They always like think about like the three major things that changed the business, like three big decisions, like getting that Pacific Beach office, that second location, whatever. But really, it’s those like one percent incremental gains every week that add up. And that’s really where the magic is.
And that’s really like, so I was like two brains. It’s kind of like the medical side, which I love, and then the business side. And sometimes I’m very into this and sometimes I’m married to that. And I’ve got an awesome team. Now we have, uh, think almost a hundred employees, not quite maybe like 80 ish. Um, and just the relationships and the grow, you’re just developing the, like that side of the business, like, you know, like the market, like
developing the people themselves that then empower the business.
Federico Ramallo (21:25) Right, right. It seems that you enjoyed the technical difficulty of anesthesiology, but then you didn’t enjoy the coworkers, the hours, the lack of control over that, right? ⁓ But…
Alex Roher (21:36) Mm-hmm.
Yeah, and
I would even argue maybe just the work itself got old. You know, it’s very redundant. And also like, you know, surgeries are five hours. So it’s like, you know, like the surgeons having all the fun, the anesthesiologists in their rain down vitals and I don’t know. To be honest, like I actually wanted to be a surgeon. wrote after medical school, I wrote my personal statement was applying to surgical residencies. And I had this epiphany that the lifestyle was.
I just did not want it. And I mean, it’s so fun to operate, but that’s such a small percent of what they really even do. So it’s. So I scrambled, I rewrote the last paragraph of my personal statement applied to all the same programs, but for the anesthesia department instead of the surgery department. then about halfway through residency, I was like, I kind of, think I kind of like, what have I done? You know, like not like I wanted to be a surgeon, not like, but I almost didn’t want to be an anesthesiologist. And then a beautiful thing about life and.
medicine in particular is just so could pivot. And that’s what I did. I left one field for another and I don’t think people are supposed to have the same job for 40 years. I mean, that’s okay if that’s your thing, but I’d love the journey of like, we’re being open to new opportunities. And I’ve had failures along the way. Obviously I’ve had businesses closed down, et cetera. what kind of that journey and like just kind of like…
you that generation of like after World War II where you just go to the factory for 40 hours a week and you know, whatever that looks like and for 40 years, it’s like, like, you know, you just kind of put your head down and work until you can retire. Like, no, I think it’s like the joy is found along the way.
Federico Ramallo (23:19) Right, right. Yeah. Eventually you lost a purpose, right? Because you were repeating and repeating and you didn’t have any gratification for the work because it’s either no gratification, immediate gratification, neither long-term gratification, right? Because you don’t see the patients further on the road getting better and getting, you know, a feeling of accomplishment, right?
And with every high performing activity, you eventually end up making sacrifices on the personal side, right? ⁓ How many surgeons can have a good, a balanced work life, right? ⁓ It’s hard, right? The best ones are going to work harder and harder on the job, right?
Alex Roher (23:48) Yeah.
Peace.
Yeah, absolutely. Yeah, someone told me.
Right. Absolutely. Yeah. Like you were saying, like humans need three things. It’s like a purpose, something to look forward to and something, someone or something to love, you know, there’s another analogy someone had where it was like, it was like life is like these, like a gas stove, like four burners and like the four burners are like work, career, friends, family.
And,
Maybe fun, yeah, let’s go with that. And it’s just like, it’s hard to have all four burning at the same time. It’s easy to have like two, focus on like the career and the friends or whatever, but it’s hard to like really have all four of those going all the time. so something I I tucked away and I think about every once in a while, something like, am I doing enough of this? Am I doing too much of that kind of thing?
Federico Ramallo (24:43) Hahaha
Right, right, yeah. And now you can have a much balanced life. can see the impact on the people, not only on your patients, but also on your employees, right? Because now you’re responsible for their lives and seeing them grow, that also provides lot of gratification and happiness, right?
Alex Roher (25:25) Absolutely, yeah. You know, it is a little bit of a family. And then that makes it super difficult when you have to let someone go, because it’s like, as a company matures, it was kind of like, it was small and fun, and I could hang out with all my employees on go party, whatever it looks like, and how it’s at a point where it’s like a little more corporate. You know, it’s not a good luck when I have like 10 drinks with the staff, you know, like.
Federico Ramallo (25:31) Yes.
Alex Roher (25:49) We had to mature as a company and so I wouldn’t say we’re like corporate and boring, but I would say we’re just more mature and you know, cautious and probably better as a result of that all. So it’s like my baby, you know, it’s like, I joke, have a six and eight year old daughters and I consider S.D. Botox my 13 year old daughter. You know, it’s like, or maybe 14 now actually, but like, you know, it’s going through some…
Federico Ramallo (26:02) Right.
Alex Roher (26:17) 13, 14 year old is a difficult time in someone’s life. It’s got some challenges, puberty. So it definitely feels like that some days. This thing’s going through puberty. It’s maturing, but it’s also a lot of mood swings, a of ups, a of downs, all the things.
Federico Ramallo (26:32) Right, right. And then based on my experience, the next iteration of that is to be able to let the baby go, right? So can the company operate without you for a day, a week, a month, right?
Alex Roher (26:44) Yeah,
so when you yeah, absolutely. So when you start a business, you’re doing everything you’re wearing every hat, you’re juggling all the balls, you’re just and then as you as a company matures, you have experts in those particular fields are part of the business like finance operations, marketing, you know, medical, etc. Then you
Federico Ramallo (26:51) Yes.
Alex Roher (27:04) goals. But like, like, you know, I’ve just had people I surrounded myself with people that are so good at what they do that I didn’t have much to do. So it’s like, what am I the CEO? Am I? Because I my CEO was probably so strong that you could stand alone as a CEO. So I kind of went very lifestyle for a while. And that I was traveling, you know, maybe like 16 to 20 weeks a year. Like I’m a big skier. So winners are fun. I’m like wakeboarding. like golf, you know, I like
I went a little, the pendulum swung a little too much lifestyle and the business didn’t suffer too much, but I think it is better when I’m around more. So that was about the ski season. I’ve only gone done two trips. So it’s, could tell I’m, and I, you know, like maybe a total of 10 days. So it’s definitely. And I, I love, I like coming back. I like the phase that I’m in right now, but I also love, there’s a lot of value in, in those trips with the family, with friends, whatever. And I kind of.
take yourself out of the business, find inspiration from different places, think about a problem from a different angle. I think there’s a lot of to gain for the business itself, as well as your own mental happiness. But yeah, so I’m at a point now where I’m focusing on the things I like. I’m the marketing side of things. I’m spearheading some projects there, and I’m bringing on new medical procedures. We just got
Everyone’s losing all this weight on all of the GLP ones. So a lot of people have loose skin. we’re doing, as we’re addressing that problem, we’re putting filler, re-volumizing the face, because it’s called a zempic face. There’s also a zempic finger, like, you you’re having to your wedding ring resized because it’s fallen off because you lost 50 pounds. It’s called a zempic butt because, you know, people usually want some weight on their butt. And so we’re doing some cool new procedures for the laxity of the skin.
Federico Ramallo (28:56) interesting.
Alex Roher (28:58) you know, it’s Morpheus and Quantum and they’re the abdomen and you know, like even postpartum women, so women have a given birth, they’re thin but they have loose skin. So that’s, we’re getting very into that, those particular skin tightening procedures right now.
Federico Ramallo (29:15) Right, By detaching yourself from the operation, then you can focus on the innovation that nobody, no other employee will be able to do if they’re doing their jobs, right? So, but I think it’s interesting to have that duality of you know in the back of your mind that you can, the company can run without you and then…
Alex Roher (29:15) So it’s, yeah, yeah, yeah.
Federico Ramallo (29:40) you decide to get involved in the most challenging problems, the most innovative problems, because ⁓ that gives you the freedom that whatever you do, in those activities, even if you fail completely on trying to achieve a goal, you learn a lot, but it will not affect the reality of the company. You can take those additional risks. And that becomes much more gratifying for you.
Alex Roher (29:47) Yeah, absolutely.
Yeah, yeah, and I think someone said that success is just being able to fail well and that really it is, you know, you just have to. I think it’s fear of failure that prevents a lot of people from doing anything at all, and it’s just take that leap. You know, if you’re going to wait for everything to be perfect, you’re never going to do anything. So it’s like you have. I try to teach this to my six and eight year old daughters because you know one beats the other one in like Mario Kart or something that you learn more from your failures than from your successes, but.
It’s a little bit of a tricky, a little bit of a complicated, they’re not really grasping it just yet. But I’ll continue to hammer them and tell them that failure is part of life and it’s a blessing and all this kind of stuff. But maybe I should save that for when they’re a little older, but I’m trying to get that in the map.
Federico Ramallo (30:57) Right, right. Yeah, it’s hard. mean, the the best way I explained to my son, I have a 10 year old. The best way I explain this is the heroes. They they have courage because they’re afraid if they’re not afraid, like, you know, at one point, Superman was so, you know, perfect as a hero that didn’t have any weakness that they had to come up with kryptonite to kind of, you know.
make him vulnerable, right? So without fear, there is no, you know, courageousness, right? ⁓
Alex Roher (31:30) Yeah,
exactly. And then I think that’s the definition of being brave is being scared and doing it anyway.
Federico Ramallo (31:36) Right. Right. ⁓
Alex Roher (31:38) Yeah, no, I
was I went on a surf trip with Laird Hamilton. He’s like a big wave surfer. was like kind of like a hero of mine. I had his poster on my wall when I was a kid and this opportunity came up and he was Laird was telling us a story about how he caught a wave and fell. And this guy was like, I didn’t know Laird Hamilton fell, you know, and Laird is like, I’ve fallen more than you’ve surfed, you know, kind of thing, like meaning I’ve took a lot of failure for me to become this who I am. It’s like, you know, surf God. So.
Federico Ramallo (31:49) nice.
you
Alex Roher (32:07) I was just kind of a cool application. of exactly what we’re talking about, but just kind of I’m learning the sports world, which I thought, you know, it’s like makes it even cooler than, you know, I’d rather talk about, you know, way cooler than Botox. Let’s big wave surfing.
Federico Ramallo (32:20) right right yeah and it’s embracing failure and being able to just move forward with it
Alex Roher (32:26) Absolutely. Yeah. And that’s it. You have to remind yourself, though, because when you’re in the midst of failing, you forget. So it’s like, remember that failure is good.
Federico Ramallo (32:33) Yes.
Yes, yes, which brings me to the other topic, having a family that supports you. Because the way that I see it, know, my wife is my co-founder, you know, we work together a lot. But the way that I see it is no matter what happens in the world, you know, no matter how successful we are, how, you know, how unsuccessful we are, we have each other, we have our family. And that’s my rock. And that means that everything else, you know, kind of.
has is less important, right?
Alex Roher (33:06) Yeah, I agree it goes back to the burners, you know, and it’s like if work is going bad At least you have family, you know, it’s like if family’s going bad, whatever at least you have work. It’s like friends fun, you know, but it’s It’s tough when it’s like everything’s bad which happens every once in a while, you know your home life is hurting for whatever reason your work life is certain and It’s like one plus one is like six, you know, it’s like where do I turn?
You know, that’s so.
Federico Ramallo (33:34) Right, right, which leads you to make bigger risks, to make more innovation, to take more chances. And it’s a positive feedback loop that kind of fits to each other, Because now you have more resources, you can spoil a little bit more your family, take them to a nice place to dinner, to vacations, whatever. that, know, kind of, you know, each other kind of help each other, right?
Alex Roher (33:45) Yes.
Yeah, absolutely and Me and my wife have been together for I want to say like 20 years at this point You know, met my third year of medical school. So I was like Yeah, I’m 43 now so I was 23 or 24 then so like 20 years we’ve been together and it’s like You know, love you, baby. Hopefully you’re listening to this It’s been like, you know, it’s fun to go through life with someone like her
Federico Ramallo (34:28) Right, right. The way that I see it is like adding salt to the food, right? It enhances the flavors, right? Then when you’re successful, it makes that successful better because you have your life partners with you and your family with you that is supporting you, Yeah. ⁓
Alex Roher (34:44) Yeah, absolutely.
Federico Ramallo (34:49) So anyway, going back to the practice, what are the most common questions first time patients ask?
Alex Roher (34:55) I guess, kinda like we were talking about, everyone kind of lumps these overfilled, weird looking people into this field, so it’s kind of getting them over that fear. There’s the fear of pain. I mean, it is a needle, so it does hurt a little as it goes through the skin, but it’s not terrible. I think it’s like, fear of a complication too, Botox.
The biggest complication is you can get Botox in a muscle right in your eyelid and then you have like a ptosis or like a drooping of your eye like this, you know, and that it lasts like three months. It sucks. It’s not pleasant. Their eye drops at hell, but filler is scarier filler. You know, you can get what’s called an intravascular occlusion. So that means fillers, a thick viscous substance, like a gel. And if you inject it into an artery, you could have blocked that artery. And then whatever that artery is feeding blood to is no longer getting blood. So you can across, can, you can
you know, like kill someone’s, you know, skin, which is never pleasant. And there’s ways out of that too. So filler, hyaluronic acid, there’s an enzyme called hyaluronidase. So you inject that, hopefully under ultrasound guidance, but even just blindly. And you could reverse that. Lasers could be a little scary because if you don’t do the right settings, you could burn people. Also, if they’re on certain medications or an antibiotic, Accutane, definitely we don’t touch Accutane patients with lasers.
You know, peels could get out of hand, you know, like you could have a, so there’s, there’s legit, it is a medical practice. There are things that go wrong and you know, having done this 14 years, I mean, I’ve seen all of that. that’s almost what you want. You want the guy or the provider, to see that’s, that’s kind of had some crazy stuff happen and has gotten out of it and has learned, like we said, like a failure that you learned, you know, like I had a bad occlusion.
That’s that, where I was injecting someone’s nose. got into an artery. the nose started dying. was traveling at the time, which is crazy. And, you know, I was just like doing a guest thing somewhere like not in ST Botox and another clinic. And, I mean, as a result of that, I learned ultrasound. I learned how it applies to this. I bought an ultrasound. I like I bed better to my practice. I came out stronger as a result of it. The downside is of obviously that patients, you know,
went through some misery and so did I but but I mean she’s she’s fine now and mostly forgiven me so you know and and the practice is better as a result so so I mean if you want to make an omelet you got to crack some eggs not saying not calling her an egg or anything I’m just saying if you want to do anything great in life in general it’s like you you know like like rewarding things are tough and so
Federico Ramallo (37:08) Right.
Alex Roher (37:25) you have to self forgive and you have to make it right in some way when something does happen, you know, and you have to fix it, you know, and you have to learn and you have to then try to prevent it from the happening again. You know, I was like, I’m also interested in kind of medicine overall, like a nice, one nice analogy I like is that when a plane crashes, the FAA like gets that black box and they study it and they find like,
How do we prevent this from ever happening again? There’s systematic changes that are like something happens that, know, a new procedure, whatever, that they prevent future plane crashes. Whereas in medicine, it’s almost like the plane is crashing and our goal is to prolong the crash. You know, like instead of like falling to your death in eight minutes, you’re gonna fall to your death in 12 minutes. It’s like…
We’re just like you have diabetes and now we’re going to put you on all these medications. It’s like your quality of life won’t be like, why didn’t we put that same patient on medication before they cross some invisible line that we decided as the definition of diabetes? Why don’t we? So that’s really the big shift in medicine now that I think is happening largely with the younger people is they’re more preventative and they’re really prioritizing their health and going to places like hormones and wellness by ST Botox and like, you know, although and it’s the simple stuff too. It’s literally like, you know, the things that everyone talks about.
You know, exercise, daily movement, whatever it may be, you know, like you can geek out on different zones and, know, like heart rate, all that kind of stuff, but just moving, eating right, not drinking too much, you know, prioritizing sleep, you know, being, and then there’s things like just going outside, getting early morning sun, you know, like being in nature, feeling connected socially to other people. I mean, these things are all basically free and it just a matter of doing them so that you don’t
turn your plane crash from eight minutes to 12. You you’re, you’re preventing those diabetes, metabolic disease, cardiovascular disease, dementia, you know, like all the big cancer, all the things that kill people. So it’s really, I just, it’s a beautiful thing to watch as a doctor, kind of like almost like society’s maturation and, prioritizing health and not having a car full of garages, but having like, you know, a resting heart rate of 50. So the real flex.
Federico Ramallo (39:47) Right? The way that the FAA has been able to make flight safer and safer, right? And it’s safer than driving a car, right? And how many flights have they been able to do, right? Compared to how many people have died or have gone into accidents, right? And that’s a statement improvement hasn’t happened in health, right? There’s actually a general from…
Alex Roher (39:47) point.
Right.
Federico Ramallo (40:11) I don’t know if it’s the army or the Navy, but basically talking about that, you know, throughout the years, less and less people are qualified just to apply to the military, right? Because they don’t have the basic, you know, they cannot do the basic training because they have the minimum, right? They’re overweight, they don’t exercise, right? And they cannot pass the minimum, right? So…
And that’s the critique that I have for the healthcare insurance. It’s, you broke the car. Well, we figured out how much it costs to fix it, right? But there is no incentive for prevention, right, in that system, right?
Alex Roher (40:47) Exactly. And I
think health insurance is not fond of, no one’s fond of it. Honestly, terrible as sounds, it’s like a CEO was murdered down of UnitedHealthcare and the general sentiment was like…
Federico Ramallo (40:58) Yes.
Alex Roher (41:01) Well, sorry that happened, but you guys are pretty evil. know, like it wasn’t, you know, it was, was, it was funny to see society’s reaction to, to that. You know, was like, like, cause I, cause that is the general sentiment about health insurance. are incentivized, the deny claims they are, they’re not looking out for your health. They’re, you know, looking out for their bottom line, their shareholders, whatever. And it just, it’s a, it’s a broken system, you know, and everyone knows it and no one has the solution to it or someone probably does, but no one’s implemented it. But
You know, it’s fascinating. I bought a book. I haven’t read it yet, but it’s basically like it’s about, I don’t know, like 20 different countries and their health care system, you know, like Canada with it’s like free health care for all, but you can’t pay to cut the line in the United health care era. I’m sorry. United kingdom. Like it just kind of goes through. I think, I think the general conclusion was like Australia or New Zealand has an awesome health care system, but like I said, I haven’t read the book yet, so I don’t know what the, I don’t know how it ends.
Federico Ramallo (42:02) Right, right in in Argentina, I grew up in Argentina moved to Mexico 17 years ago and one of the things that they have is called prepaid medical care. So basically you pay a fee every month and then you get access to everything except aesthetics or anything that is non critical, right? Or so, you know, if you have a you need to get a tooth removed, right?
Unless it’s critical, they won’t do it, right? For the first, I don’t know, six months or whatever, right? So you have a cooling period. But if you have an emergency, they’re going to take care of you as if you were a patient for 20 years. And the money spent distributes throughout caring everybody. So it’s a different thing and they are incentivized to keep you healthy for longer. So…
They do yearly checkouts. They do, you know, a six month checkout on different things, right? Because they want to keep you healthy because, you know, it’s in their best interest, right? And then you have a copay from employees. an employer would pay some money, some of that money. So you pay a little bit and then you get copay for medicine. You don’t have the crazy prices as I’ve seen happening in the US.
Alex Roher (42:57) Yeah.
Federico Ramallo (43:16) They don’t have the crazy prices for medicine. So it becomes very cheap. It becomes very cheap to pay and very cheap to buy medicine, whatever you need it, right? And then that,
Alex Roher (43:26) Way to go, Argentina.
Federico Ramallo (43:27) yes, yes. It works really great, right? In Mexico, they have the healthcare insurance. So it’s a bit different, right? Yeah, but the…
Alex Roher (43:36) Yeah.
Federico Ramallo (43:37) they have a public healthcare system where basically you get treatment for free but for complex operations is great because they have the best doctors but then for everything else that is non-complex the system sucks because you have a lot of queues it’s hard to get allocated time whatever and that’s where you can
If you have both, then you can choose, right? You can have a private for one thing, but then they cap you off to a certain amount. And then if it goes up, you can switch to public, which is covered by your employer’s fee, right? And that’s better.
Alex Roher (44:04) Yeah.
Yeah, no, absolutely. Yeah, we like, like what you say, like we don’t prioritize preventative care in the United States. And I think a lot of that is because like the doctor experience is so miserable, like it takes a long time to be seen, like to get an appointment two months, you know, and then, you know, like doctors not going to be on time. He’s overwhelmed. He’s got seen too many patients systems kind of, you know, stacked against him when it’s finally your turn. It’s like rushed, you know, it’s like two minute thing. Here you go. Whatever. It’s like,
you know, and then having to go to the, so it’s interesting because we are a med spa. do primarily aesthetics. The only one procedure or one, I don’t know what you would call it. One service that we do at both SD Botox and hormones and wellness by SD Botox is, the GLP ones. like it was Zempic, Manjaro, et cetera. And, we,
We make patients get labs in order to start that procedure or that those medications and you would be shocked by how many times we picked up on, you know, thyroid disease or kidney or liver like pancreas, whatever. And it’s just because it’s like these people are not getting regular health care. This is the first time anyone’s looking at this. So it’s like, I don’t really care if you come to me because you know, you’re overweight and you want to change your physical appearance to feel better about yourself. Have to do that.
I don’t care. Or if you’re coming to me because you’re afraid of metabolic disease, you’re kind of going down that diabetes pathway. That’s, that’s great. Cause the truth is once you’re on these medications, you’re going to get the benefit of both. You know, you’re going to look better, you’re to feel better and you’re going to stave off some serious diseases that, you know, like have long-term sequelae. You know, like I remember when I was going through my general surgery internship, I was, there was a guy, was a Mexican guy. So he called me El Sarrucho, which I correct if I’m wrong. means like the butcher.
Because know, diabetes, like late-term diabetes, when you don’t take care of it, got blood sugars in the 400s on a regular basis. I mean, it’s terrible for your microvasculature. like, I mean, we were cutting off toes and we were transmeditarial half the foot, then like a low BKA below knee amputation. Then, I mean, we just kept like systematically, like, kept chopping this man down. And it’s like, you just, you know, it’s like one thing if you think, oh, I’m not gonna take care of my health because I’m just gonna die young. But it’s like, it’s not that simple. It’s like, oftentimes you’re like, you’re dying a death of like just…
Federico Ramallo (46:17) Wow.
Alex Roher (46:33) me cutting off like further and further up your leg. It’s just like, you know, it’s it’s and that really I remember when this class of drugs came out like GLP ones, it was a diabetic medication came out in like 2017. Then it was kind of like the Hollywood people figured it out. The Kardashians were on it, obviously less so for health and more for aesthetics. And they were saying like, there was a shortage because, know, like everyone was taking these medications to get thin and not
then the diabetics couldn’t get their own medication, which I understand. And we kind of did the compounding pharmacy. So we were trying not to touch the name brand that was for the diabetics. But I mean, don’t you think that same diabetic would have preferred to be on that medication 10 years before so that they never got diabetes and now they’re not having to be on insulin and like 12 other diabetic medications, including the JLPs, you know, wouldn’t it be great if that just never happened? So it’s like, I understand that
The shortage was like, look at these poor diabetics, but like at the same time, like look at all these people that aren’t going to be diabetic. Look at all the like, like they’ll that’s amazing. Like that that’s true medicine. It’s just that the problem is the incentive is kind of prolonging that plane crash. the not saying I don’t hate the pharmaceutical industry nearly as much as the as the insurance industry. But I will say.
You know, the incentive is for you to need to take a medication for a long time. You know, so that’s what they want. They want you, they actually want their incentivize for people to have a disease and then for that person to be on their medication, like high blood pressure medication for 30 years or whatever it may be. And that’s the system is not such that anyone is winning when you exercise and know, the pharmaceutical industry is winning when you don’t get a disease. So it’s like, you know, where there isn’t enough public health
push to really, I mean, there is some obviously, but there should be more of like truly preventative, like, don’t get sick care, not sick care, healthcare.
Federico Ramallo (48:36) Right, right. And I think you nail it when you said it’s, you know, when you were compelling the FAA that were doing systematic improvement and in the health care system, they’re not, right? And that’s a core issue, right? Because I think we all agree that getting, you know, having healthier people on society is better for everybody. It’s, you know, less medicine cost.
You know, people can have happier lives, can do more things, right? ⁓ So, you you have that. And then on the other hand, all the health care system is not incentivizing you to stay healthy. It actually, you know, kind of try to, you know, just make patches to keep people, you know, connected to, dependent of drugs or medical procedures, because those are the incentives they have, right?
Alex Roher (49:04) But. Okay.
Yeah, no, I’m that’s why I’m proud of my industry I mean, I think you could look at what I do and think very superficial you just kind of make it lips bigger No, I mean like I said we are this especially with the new branch. We’re really Like I’m the only doctor people will see you know, like it’s a lot of people, know Like they just they just don’t go to the doctor and so just that point of entry into the healthcare system of like, you know, maybe it was some vanity thing that brought you in but now
guess what you’re on a GLP one, like I said, it’s like you’re losing weight, you’re looking better, obviously, but like you’re also like not gonna get all the long term, you know, effects of over being overweight and all the health, metabolic, etc. So it’s, it’s it’s a nice, it’s a satisfying field to be in for a lot of reasons. Like I said, the big reveal with a nose, but it’s also just these people that like really your, your prior you’re explaining them the importance of health and what they can do, and how to not get sick and then
pointing them, getting the labs, getting the DEXA scan, which is a full body. We just got the DEXA, I love the DEXA. It’s like this, like you lay on this bed and it’s X-ray technology. It goes over your entire body and it tells you your body fat percent, your lean body mass, your visceral fat. So the fat inside the abdominal cavity that’s associated with metabolic disease, your bone density. then it’s like in business and it applies here in medicine. It’s like you don’t change
what you don’t measure. So it’s just great to have that data point. And then you go home and you whatever lifestyle change, you’re eating better, exercising more, drinking, whatever you do that. And then you would do the repeat, that’s and lab work. And you can see your lean body mass increase. You can see your visceral fat decrease. You can see there. I actually have low bone density. I’m like, I’m like a bird over here. I’m like the 25th percentile for my I’m saying I learned right before a ski trip, too. It’s like nice to have in the back of your mind. Like
Federico Ramallo (51:13) Wow
Alex Roher (51:18) So I’m like, from zero to 100, I’m like a 25 % for my age and bone density. So I’m starting to take vitamin D, you know, I’m starting to, you know, I was always exercising, but really prioritizing like strength because muscle, building muscle hypertrophy, making the muscle bigger actually strengthens the bone because it’s pulling, it’s tensile, positive feedback. You’re now laying down new bone. So I…
It’s like, but did I, was I ever diagnosed with like osteoporosis or something? No, I wasn’t. I just, did it early enough and I not found a problem before it was a problem.
Federico Ramallo (51:57) Right, right. And I think that there’s always room for improvement. I think that’s important that you can measure that, right? Because then you can work towards an improvement. And even though people come from vanity, I think that it’s important that you are meeting them where they are. That’s the initial motivation, but then you’re providing a holistic approach. It’s not only about how you…
how you look, it’s also about how you look and your health and how you feel.
Alex Roher (52:27) Absolutely. No, appreciate it. I am new to the podcast scene, so appreciate searching me out and putting me on here. Great to meet you, Frederico.
Federico Ramallo (52:29) Yeah. So Alex, we’re running out of time. I truly appreciated you being here today. I think we learned a lot. Any final remarks before we wrap it up?
Absolutely.
You did great. So thank you for being here today.
Alex Roher (52:51) All right, thank you.