Performance Max is the campaign Google recommends to almost everyone. You supply the goal, the budget, some text, images and video, and Google's automation decides where the ads appear across everything it owns.
For many businesses, that works well. For a plastic surgery practice, it comes with two limits that the recommendation never mentions. The images that sell surgery best mostly can't run where Performance Max spends most of its time. And the data that usually steers it, the practice's own patient and visitor lists, is off-limits for cosmetic surgery.
Neither limit makes Performance Max useless. Both change when you launch it, what you put in it and how tightly you fence it in. This chapter covers all three.
Most of Performance Max Is Pictures and Video
A single Performance Max campaign can show ads on Google Search, YouTube, the Display Network of websites and apps, the Discover feed, Gmail and Google Maps. Google decides the mix, based on where it expects conversions.
Only one of those places is a search results page made of text. The rest are visual: a banner on a news site, a video before a YouTube clip, an image card in the Discover feed on someone's phone. That is where Performance Max finds people who aren't searching yet, and it is also where a plastic surgery practice runs into Google's image rules.
For plastic surgery, that early reach has real value. Chapter 2 found that about three-quarters of Dallas plastic surgery searches came from people who weren't ready to book yet: researching a procedure, checking what it costs or looking at results. Many of them take months, sometimes years, to choose a surgeon. A practice they have seen a few times along the way has an advantage when they finally start comparing. Performance Max is one way to be seen during those months, if the campaign is built for what plastic surgery is allowed to show.
The Photos That Sell Surgery Can't Run There
Before-and-after photos are the most persuasive thing a plastic surgery practice owns. Patients go looking for them, study them and compare them surgeon by surgeon.
For breast and body procedures, most of those photos count as nudity under Google's sexual content policy. The policy covers "exposed intimate body parts, including representations that are blurred or censored," so a censor bar doesn't change the classification. And ads with sexual content can't run on the Display Network, YouTube or Gmail. Those are most of the places Performance Max would put an image.
Face results, such as a rhinoplasty or a facelift, aren't nudity. They can run, but they carry their own rules on patient consent and on implying results, which Chapter 14 covers in full.
So the images in a plastic surgery Performance Max campaign have to do a different job. Instead of showing results, they show the practice:
- The surgeon. A real portrait, not a stock photo of a stranger in scrubs.
- The consult room and the recovery suite. Nervous patients want to see where they will be.
- The team. Patients name coordinators and nurses in their reviews. Show them.
- A short video of the surgeon explaining a procedure. Google will generate a video from your other assets if you don't supply one, and a generated video rarely looks like a surgical practice. Even a simple, well-lit minute of the surgeon talking is better.
These aren't second-best images. Chapter 8 showed how much patients write about whether the surgeon listened. A face and a voice speak to that directly.
Your Patient List Can't Steer It Either
Every Performance Max asset group has a slot for audience signals, the starting clues its automation uses before it has learned much on its own. For most advertisers, the strongest hints are their own lists, such as people who visited the website or a list of past customers.
As Chapter 9 explained, Google's health rules take those away for cosmetic surgery ads. Remarketing lists and Customer Match uploads aren't allowed. Google's own in-market and affinity segments are allowed, because Google removes the sensitive signals from them first.
Custom segments are the gray area. Google's policy says that custom segments pointing to sensitive landing pages "will only serve with Display campaigns to non-sensitive audiences or contextually." It doesn't mention Performance Max at all. So don't count on a custom segment to steer a surgery campaign. Add Google's own segments as hints, and expect the real steering to come from two other places: the search themes below and the conversions your Search campaigns have already recorded.
Wait Until Search Has Taught It Something
That second source is why timing matters so much. Performance Max learns from conversions. If the account already has months of real consult requests, Performance Max has a picture of what a good patient looks like. If it doesn't, it has only a budget and a guess.
So Performance Max comes after the Isolation and Exploration campaigns from Chapter 6 are running well and producing a steady flow of consult requests. For a new plastic surgery account, that is usually around the sixth or seventh month.
At launch:
- Goal: conversions, meaning consult requests and qualified calls, the way Chapter 1 set them up.
- Bidding: Maximize Conversions with no target cost per conversion at first. Add a target once the campaign's own cost per consult settles, set from what it is actually paying.
- Location: the same areas and the same "Presence" setting as the Search campaigns from Chapter 9, including the places traveling patients come from.
The Search campaigns keep their ground. If a patient types exactly "tummy tuck dallas" and Isolation holds that exact keyword, Google's rules send the search to Isolation, not to Performance Max. The catch is budget. An Isolation campaign that has spent its day's budget by mid-afternoon isn't in the auction for the rest of the day, and Performance Max can step in. Keep Isolation funded, and the searches you built it for stay under your control.
One Asset Group per Procedure
An asset group is the set of headlines, descriptions, images, videos and search themes that Performance Max mixes together, with the page it sends people to. The simplest mistake is one asset group for the whole practice. Then a tummy tuck image can appear beside a rhinoplasty headline, sending someone to the home page.
Build asset groups the way Chapter 4 built pages: one per procedure family.
- Search themes. Performance Max has no keywords, but each asset group takes up to 50 search themes: phrases that describe what patients search for. Take them from the keyword lists in Chapter 5, procedure by procedure: "tummy tuck," "tummy tuck cost," "tummy tuck after pregnancy." Google treats them as hints and will go beyond them. If Google flags a personal health theme during review, remove it and keep the procedure-level themes.
- Headlines and descriptions. By month six, the Search campaigns know which headlines patients respond to. Move the proven ones from Chapter 8 into the matching asset group, then add the longer lines Performance Max allows. Skip Google's automatic asset generation at launch, for the same reason as in Search: every line should be one the practice wrote and can stand behind.
- The page. Each asset group points to its procedure page, not the home page.
Fence It Off From Your Brand and Your Med Spa
Left alone, Performance Max goes where conversions are easiest to find. In a plastic surgery practice, two places are easy and misleading.
Your own name. People searching your practice or your surgeons by name have already chosen you, and your brand campaign already reaches them cheaply. Without a fence, Performance Max can show up on those searches, collect those conversions and look far more effective than it is. Add brand exclusions for the practice name and every surgeon's name.
Your med spa. If the practice also offers Botox, filler or other injectables, their booking pages convert easily and often. A Performance Max campaign allowed to send traffic there will learn to chase injectable bookings and report them as wins, while the surgery it was built for gets less of the budget. Keep it off the med spa pages with URL exclusions, add negative keywords for injectable searches, and give those services their own campaign, as Chapter 15 explains.
Everything else. Performance Max now accepts negative keywords at the campaign level, and shared negative lists. Apply the list from Chapter 5, with other practices' names, other cities and medical tourism, and without the "job" negative that would block "nose job" and "boob job" searches.
Read Where It Spent the Money
Google now shows much more of what Performance Max does than it used to. Two reports matter most for a plastic surgery practice.
The search terms report shows which searches triggered your ads. In the first weeks, read it the way you read Exploration's in Chapter 6: anything that isn't a prospective surgery patient becomes a negative.
The channel performance report shows where the budget went: Search, YouTube, Display, Discover, Gmail or Maps, and what each produced. This is the report that tells you whether the visual channels are earning their share. If most of the spend is going to video and display and the consult requests are coming from Search, the campaign is paying for reach that isn't turning into patients, and the images and videos are the first thing to improve.
Then do what Chapters 3 and 7 set up for every campaign: compare the consult requests with the surgeries that followed, a month or two later. Performance Max should be judged on surgeries like everything else.
Next: Demand Gen and YouTube
Performance Max reaches people across Google's channels at once. Chapter 11 covers Demand Gen, the campaign Google built for YouTube, Discover and Gmail, and how a plastic surgery practice can use video to reach patients months before they search.
Every chapter is on the Google Ads for Plastic Surgeons home page.
Launching Performance Max late, with procedure-level asset groups and firm fences, is how our Google Ads management adds it to plastic surgery accounts. If you are adding it to your own, start with the channel report on day seven.
