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In the medical aesthetics industry, the path from clinical practitioner to CEO is rarely a straight line. It requires a fundamental shift in identity, a willingness to take calculated risks, and an ability to navigate the complex intersection of medicine and business.
On this episode of the Med Spa Success Strategies podcast, we sat down with Dr. Alex Roher, a board-certified anesthesiologist and the founder of SD Botox. Since opening his doors in 2012, Dr. Roher has grown SD Botox from a small “side hustle” into a groundbreaking endeavor with over 20 providers and multiple locations across San Diego and Texas.
Dr. Roher’s story is a blueprint for growth. We cover everything from his “Warren Buffett” approach to acquisitions and the nuances of unbranding yourself, to the specific operational metrics that keep his business profitable.
The Origin Story: From the OR to the Injector Chair
Dr. Roher’s background is traditional medicine. He completed his undergrad and medical school at the University of Arizona, followed by an anesthesiology residency at Loma Linda. After moving to San Diego over a decade ago, he practiced full-time anesthesia for about seven years.
However, the entrepreneurial itch started early. He launched SD Botox as a side hustle while still working at a community hospital.
“I called it SD Botox just because it was my little side hustle,” Dr. Roher explains. “All I knew how to do was Botox. I didn’t know how to do filler. I didn’t know anything about lasers and wellness. I learned all that as I went along. I didn’t have any business background.”
The beginning was slow. For the first couple of months, no one came in. It took about two years to truly ramp up. The catalyst for his explosion into a major brand came from an unexpected opportunity involving a competitor.
The First Acquisition
There was another Med Spa nearby that had racked up a massive bill with Allergan and was subsequently cut off from purchasing product. Being neighborly, Dr. Roher started selling them Botox—not to make money, but just to help them out.
Eventually, the owners approached him. They were underwater and asked if he would buy them out.
“I never really thought about a second office acquisition,” Dr. Roher admits. “I went and looked at it, met the staff, everything felt right, and I got a great deal on it. So I bought it, and that’s the one that really exploded.”
The Mindset Shift: Sick Care vs. Optimization
Six months after that acquisition, Dr. Roher had a pivotal conversation with his wife. He realized that when his mind went idle, he wasn’t thinking about putting patients to sleep or epidurals; he was thinking about aesthetics and business strategy.
He realized he preferred the aesthetics model over the traditional medical model. In the hospital, the cycle is: You are sick, we try to get you healthy. In aesthetics, the goal is optimization.
“Here, we’re just optimizing people, be it aesthetically or wellness,” he says. “Everyone is so happy to be there. It’s fee-for-service… I really started to love this business at that point.”
The “Warren Buffett” Approach to Expansion
Dr. Roher’s expansion strategy can be summed up by a quote he attributes to Warren Buffett: “When others panic, I buy.”
When COVID hit, uncertainty paralyzed the industry. Dr. Roher used that time to acquire three or four new practices for incredible deals. While he notes that the influx of Venture Capital and Private Equity has made finding those “steals” harder today, his strategy of opportunistic growth remains.
Currently, SD Botox has scaled to:
- Seven offices in San Diego.
- Two offices in Texas (Austin and Killeen).
Building an Ecosystem: Spin-Offs and Cross-Selling
Dr. Roher hasn’t just scaled his footprint; he has scaled his service offerings by creating spin-off businesses, specifically in hormone replacement, weight loss, and hair transplants.
The Structural Strategy
Interestingly, Dr. Roher found that these businesses perform better when they are freestanding, rather than hybrid models jammed inside an existing aesthetic clinic.
- SD Botox: The main brand. Focuses on pure aesthetics. They do allow GLP-1s (weight management) here because it bridges the gap between looking good and metabolic health, but they generally avoid IVs and heavy wellness services in these locations.
- Hormones and Wellness by SD Botox: A separate entity and physical location. This brand specializes in hormone replacement therapy (HRT) for men and perimenopausal women.
“Polishing the Brass on the Titanic”
Dr. Roher views the aesthetic side as a gateway to holistic health. He uses a vivid analogy to explain the relationship between the two businesses.
“I say it’s like polishing the brass on the Titanic. It’s like, the ship is going down. Let’s definitely do the Botox… but let’s see if we can’t help you further.”
A 45-year-old woman might come in for Botox. During the consult, Dr. Roher asks about her sleep, body composition, mood, and energy. This conversation often leads to a referral to the wellness office for lab work and hormone optimization. The patient returns months later, not just looking better, but feeling like her life has changed.
Converting the Client
While they have some “superstar” providers who are great at referring patients across brands, Dr. Roher doesn’t rely on hard sales tactics. Instead, he fosters a culture of cross-pollination.
- Employee Pricing: Staff gets great pricing at both companies.
- Shared Events: Company events include both the aesthetic and wellness teams.
- Genuine Belief: Providers use the saunas, cold plunges, and hormones themselves. They refer patients because they believe in the results, not because of a commission.
Unbranding the Founder: Escaping the “Dr.” Trap
One of the most common bottlenecks in scaling a medical practice is the “Star Doctor” syndrome—where every patient insists on seeing the owner.
Dr. Roher faced this head-on. “I had to purposely, consciously… unbrand Dr. Roher and brand SD Botox.”
The “Halo Effect” Strategy
Now that the brand is established, Dr. Roher is re-introducing his face to create a “halo effect” of credibility, but he manages his schedule strictly to avoid becoming the fulfillment engine.
- See New Patients: He tries to see many new patients to establish trust and branding early on.
- Specialization: He only does injectables (specifically liquid nose jobs).
- The Handoff: He actively recommends services he doesn’t do, forcing the patient to build a relationship with other providers in the practice.
- Availability: Because he is booked weeks out, patients naturally gravitate toward other providers for speed and convenience.
A Counter-Intuitive Insight: Many owners give new patients to the newest, least experienced injector to fill their books. Dr. Roher does the opposite. He wants the highest-trust figures (himself or top providers) to handle the first touchpoint. This solidifies the patient’s confidence in the brand, making them more comfortable seeing other providers later.
The Call Center’s Role
To ensure patients end up with the right provider, the call center staff spends a day once a month shadowing different providers. They learn the providers’ personalities and styles, allowing them to better “matchmake” patients on the phone rather than just filling a slot.
The Business of Medicine: Education and Operations
Transitioning from a clinician to a CEO requires a new toolkit. Dr. Roher notes that physicians are often risk-averse because their traditional career path is safe and linear. Entrepreneurship is the opposite.
To bridge the gap, Dr. Roher leaned on resources:
- Books: Traction by Gino Wickman (for structure) and Atomic Habits (for incremental gains).
- Peer Groups: He progressed through EO (Entrepreneurs’ Organization), Vistage, and now YPO (Young Presidents’ Organization). These forums provide a space to discuss the “top 5% and bottom 5%” of business and personal life.
Managing the Schedule
To wear multiple hats effectively, Dr. Roher adheres to a strict weekly structure:
- Mondays: Admin days. Stocked with meetings (Marketing, Ops, Finance).
- Tuesdays/Wednesdays: Clinical days.
- Thursdays: “Outside Interest” days (Spin-off businesses).
- Fridays: Personal days (Golf, boating).
- Weekends: Dedicated to his kids.
The COO and Labor Ratios
Scaling to 7+ locations required hiring a strong COO to handle the day-to-day. However, scaling adds “fat.”
Dr. Roher tracks a critical metric: The ratio of payroll for revenue-generating positions vs. admin positions.
“We were close to 50/50 at one point, and that was troubling,” he notes. While you sometimes have to hire ahead of growth (hiring for the company you want to be), keeping this ratio in check is vital for profitability.
Cultivating a Growth Mindset
Dr. Roher attributes his success to a constant “growth mindset”—the willingness to fail and the ability to find ideas anywhere.
The Exterminator Idea: Dr. Roher once had an exterminator leave a hanger on his door saying, “If the service was great, let us know and we’ll bonus this guy.” He immediately implemented this at SD Botox. If a patient leaves a review on Google or Yelp, the provider gets a bonus. It’s a simple, low-cost way to drive reputation.
The Reality of “Lifestyle” Business
Dr. Roher is honest about the myth of passive income. He travels frequently—including a recent 35-day family trip to Africa (complete with malaria pills and his 6-year-old daughter deciding halfway through that she hated pink and only liked blue).
However, he emphasizes that you cannot travel if the business is on fire. “There is no such thing as passive income… I could be on a boat in the Mediterranean, but if I’m thinking about work all day, that’s not a vacation.”
Managing Provider Performance: Autonomy vs. Standardization
When acquiring failed med spas—whether from overwhelmed solo nurses or failed Private Equity ventures—Dr. Roher often sees operational messes.
To maintain quality at scale, SD Botox tracks everything:
- Retention (returning within 4 months).
- Average ticket spend.
- Revenue per hour.
- Botox waste.
The Power of Autonomy
Unlike some corporate chains that enforce a strict “script” or flow for consults, Dr. Roher allows his 21 providers autonomy.
“I like places where people feel free to do it how they want,” he says.
This autonomy acts as a massive A/B testing ground.
- If one provider has retention rates 16% higher than the average, they investigate why.
- If another sells skincare at a 13% clip (vs. the company average), they ask her to present her strategy.
At their quarterly provider meetings, these top performers give talks on their specific methods (“talk tracks”). This peer-to-peer learning raises the bar for the entire organization without stifling individual creativity.
Resources and Contact
Dr. Roher’s journey proves that with the right mindset, systems, and willingness to learn, medical professionals can build thriving business empires.
To learn more about Dr. Alex Roher and his businesses:
- Website: sdbotox.com
- Social Media: Follow him for liquid nose job content at @DrAlexNoseBest (Instagram & TikTok).
Training: For nurses and providers looking to break into the industry, visit AestheticTrainingAcademy.com. They offer a comprehensive 4-week online / 1-week in-person course including job placement assistance.
