Cheap Restylane & Botox: Are you buying it from Canada?

I've received a number of inquiries about buying Restylane, Botox, Juvederm, and other injectables from Canada, Ireland or even Bulgaria.

Here's are two threads from the Physician to Physician discussion area:

Purchasing Restylane from Canada: Legal or not?

Buying Restylan Cheaper Oversees.

There does seem to be a great deal of pricing disparity. The Canadian suppliers and pharmacies who are selling Restylane and Botox are certainly undercutting the pricing that doctors are charged in the US.

(There are often pharmacies offering Botox and Restylane for 75% off advertising on this site.) 

My own experience is that some of our physicians have and are currently buying all of these (Restylane, Botox, Juvederm, and whatever else they can find) from Canada or elsewhere. It brings up a number of questions for docs and problems for the companies. How can they exploit the market opportunity in the US which will generally accept higher prices while still selling into countries that won't? 

Botox Deaths

Botox Deaths via CNN.com

Botox is best known for minimizing wrinkles by paralyzing facial muscles -- but botulinum toxin also is widely used for a variety of muscle-spasm conditions, such as cervical dystonia or severe neck spasms.

The FDA said the deaths it is investigating so far all involve children, mostly cerebral palsy patients being treated for spasticity in their legs. The FDA has never formally approved that use for the drugs, but some other countries have.

However, the FDA warned that it also is probing reports of illnesses in people of all ages who used the drugs for a variety of conditions, including at least one hospitalization of a woman given Botox for forehead wrinkles.

Alergan Stock takes a dive. 

Smoothmed New York: Botox on the go.

Botox will now be available as a walk-in, no appointment necessary treatment in midtown Manhattan.

 

Smoothmed, a retail medicine concept started by two plastic surgeons, will be opening it's doors on East 59th Street. My guess? It'll do fairly well and may be the largest Botox account in the U.S.. Of course it could go the way of SkinKlinic.

 

 From the New York Times: The Little Botox Shop Around The Corner.

Smoothmed, scheduled to open next month, will offer only one procedure: Botox injections to smooth wrinkles around the forehead, eyes, lips or neck. Its owners said the idea is convenience, competitive pricing and standardized care.

“Botox-on-the-go is the way we like to think of it,” said Dr. Andrew I. Elkwood, an owner of Smoothmed. He and his business partner, Dr. Michael I. Rose, are plastic and reconstructive surgeons who practice in Manhattan and in Shrewsbury, N.J.

Botox Cosmetic, a diluted form of botulinum toxin, is used to temporarily paralyze the muscles underlying wrinkles. Dr. Rose said that making injections easily available would expand the market.

“It will appeal to people who took a few hours to shop at Bloomingdale’s, to secretaries on their lunch hours, to people who live and work in the neighborhood, and we will be getting visitors who think on a whim, ‘I wouldn’t normally do this at home, but we’re in New York, so let’s try it,’ ” Dr. Rose said.

Hollywood doc gets 18 months in prison: Was he injecting Silicon 1000?

 Doc gets 18 months in federal prison.

...for injections of substances consistent with industrial grade silicone used to lubricate auto parts, as well as medical grade silicone, which is used for some eye surgeries but is not approved as wrinkle filler, according to court papers.

Silicone Injections: Illegal 'pumping parties' can be life threatening.

Via Physorg

A study of individuals who underwent illegal silicone injections revealed a high fatality rate from pulmonary silicone embolism, or obstruction of the lungs. The study was presented today at the annual meeting of the Radiological Society of North America.

The U.S. Food and Drug Administration banned silicone injections in 1992, but people still seek them out because they are cheaper and easier to get than professional plastic surgery or hormone therapy and provide immediate results. In surgical clinics, transgender patients are often required to undergo psychological testing before receiving treatment.

Unfortunately, the illicit nature of the injections makes it hard to estimate how common they actually are. However, the increasing popularity of the "pumping party"—where a host will inject a number of people with silicone in the same sitting—indicates both the demand and the ready availability of the substance.

Lips and Silikon 1000...a good combination?

Grandma...is that you?

A good friend of mine recently confessed to me that she had seen one of my competitors and gotten Silikon 1000 in her lips.  I usually treat her for Restylane that we use judiciously in her nasolabial folds and her lips.  We also use a little Botox around her eyes.  She is 31 years old and has a beautiful face.  Her lips are full, but she wants "luscious!"  Her assistant had had it done with Dr. T and "she looked amazing."  And when my friend went to his office, his entire staff of young women all had gorgeous bee-stung lips. 

Now, for a moment, just forget all the stories of granuloma risk and inflammation.  Let us pretend that Silikon 1000 in the lips is 100% safe.  I actually do have Silikon 1000 in my office.  But I've only used it in a handful is situations.  One woman had been "butchered" (her term, not mine) by a oral surgeon and felt it left 2 divots in her lower lip.  I carefully filled these in.  Another woman's right upper lip dropped lower than her left from lingering Bell's palsy.  I used it to even out her lips. 

I have two patients who want to look like Angelina Jolie. I can't seem to put enough Restylane into their lips. One of them is from Texas and she said to me, "Honey, bigger is ALWAYS better!"  But the vast majority of my patients who want lip augmentation want only a slightly fuller look.  And so what happens when Angelina is no longer the superstar?  What happens when thin, straight, bead-like lips are in style?  Or what happens when all these young, beautiful woman with these mammoth sized lips get old and are grandmothers?  Their faces will continue to age in the normal, dynamic manner.  But those Silikon lips will be permanent!  I keep getting the visual of a faded tattoo on the side of  a wrinkled, sagging breast.   

The not-Botox deaths in Florida

JAMA has released an abstract showing that the doctor in Florida who injected himself and three others with botulism, may have used enough to kill himself 2857 times. They also state that "no cases of botulism with detectable serum toxin have previously been attributed to cosmetic or therapeutic botulinum toxin injections."

Results  Clinical characteristics of the 4 case-patients were consistent with those of naturally occurring botulism. All case-patients had been injected with a highly concentrated, unlicensed preparation of botulinum toxin A and may have received doses 2857 times the estimated human lethal dose by injection. Pretreatment serum toxin levels in 3 of the 4 case-patients were equivalent to 21 to 43 times the estimated human lethal dose; pretreatment serum from the fourth epidemiologically linked case-patient was not available. A 100-µg vial of toxin taken from the same manufacturer's lot as toxin administered to the case-patients contained a toxin amount sufficient to kill approximately 14 286 adults by injection if disseminated evenly.

Conclusions  These laboratory-confirmed cases of botulism demonstrate that clinical use of unlicensed botulinum toxin A can result in severe, life-threatening illness. Further education and regulation are needed to prevent the inappropriate marketing, sale, and clinical use of unlicensed botulinum toxin products.

They should have said: The more doctors do this, the fewer the doctors that will be doing this.

Black Market Botox....A Better Buy?

Botox for $50 a vial?

Thought that would grab your attention.  I've heard you can find Botox on the internet for that price.  I wouldn't recommend it.  Read further and find out why.

Occasionally a patient will ask me to explain why those people in Florida "died from Botox."  They are referring to a story that was widely publicized in early 2005 about some people in Florida who were sent to the hospital after receiving phony Botox injections and becoming paralyzed.  There was another story around the same time of a woman in California who died from Botox injections done by a hair stylist.  Hair stylist?  Yes, you read that right.  The very important distinction is that they didn't actually ever have Botox injected into them.  They were duped and actually had raw-grade Botulinum toxin type A used on them. 

Right about now you might be thinking, well that would certainly never happen to me.  My vials all say Botox and have the purple, red, orange colors on the box.  Matter of fact, I'm guessing that the guy in Florida thought his product was safe since he used it on himself.  I actually know a physician who had ordered, but never used, similar products.  They think they've found a better source to get the real thing at a cheaper price.  "It's from Canada, so it must be safe.  I'm just by-passing the expensive American pharmaceutical industry.  Plenty of people get their drugs from Canada.  It's the exact same product."

Botox is a trademarked name for a substance that is made by Allergan.  Anything else is phony and potentially very dangerous and most certainly not worth the savings that might be had.  This bootleg industry has become so prolific that I wanted to be sure everyone knew what to look for and what to avoid.  Fake Botox is frequently made in China or Korea, but it can come to the U.S. via Canada, Sweden, or any number of other countries.  Authentic Botox is made and distributed by Allergan and has a hologram indicating it's credibility.  To view the hologram:

1) Examine the vial under a desk lamp or fluorescent light source
2) Rotate the vial back and forth between your fingers; look for horizontal lines of rainbow color on the label
3) Confirm that the name "ALLERGAN" appears within the rainbow lines.

I'm guessing that this black market industry will soon learn how to counterfeit the hologram as well.

Filler Injections: The old and the new.

From a Wall Street Journal Article: Face Time: The new injectables.

On the Market Now

• Botox: A neurotoxin drug that is by far the most common injectable, with more than three million procedures reported last year. Botox temporarily paralyzes muscles with a series of tiny shots, smoothing frown lines between the eyebrows and crow's feet around the eyes. It is the only neurotoxin approved for cosmetic use in the U.S. Lasts three to four months. Average physician fee: $363. From Allergan Inc., Irvine, Calif.
 
• Restylane: The second-most-common injectable, with about 700,000 procedures in the U.S. last year, Restylane is a filler that plumps up creases under the skin and is mostly used on the lower face. It is made from hyaluronic acid, a natural sugar that binds to water, creating temporary volume. Lasts six months or longer. Average price for all hyaluronic acids: $557. From Medicis Pharmaceutical Corp. (A thicker version, Perlane, is awaiting FDA approval. Medicis is also developing other versions to complement its brand, including Lipp, Fine Lines and SubQ.)
 
• Juvéderm: A new hyaluronic acid in limited release that is going up against Restylane. Doctors like its ease of injection, but competition will focus on relative cost and duration. The cost to physicians is slightly more than Restylane, but retail pricing won't be clear until after Allergan officially launches Juvéderm in January. Allergan's older Hylaform and Captique products don't last as long as Juvéderm or Restylane.
 
• CosmoDerm: A collagen product that, unlike its 18-year-old predecessors, Zyderm and Zyplast, doesn't require an allergy skin test several weeks before treatment. Zyderm and Zyplast are harvested from cows, whereas CosmoDerm and its sister product CosmoPlast are made in a laboratory from human collagen, a natural component of the skin. CosmoPlast is used in deeper lines and furrows. Treatments are also popular in the lip border and fine lines above the mouth. Average fee for all collagen products: $390. Allergan.
 
• Radiesse: Made from tiny calcium particles that create a scaffold for the body's own collagen to grow. Approved for craniofacial surgery. In August, an FDA panel recommended approval for smile-line wrinkles, but the agency hasn't ruled yet. Some dermatologists who use it off-label for cosmetic applications caution that particles can migrate and cause nodules, especially in the lips. Some tests show it lasts perhaps a year or longer. Average fee: $914. From BioForm Medical Inc., San Mateo, Calif.
 
• Sculptra: A synthetic polymer that stimulates new collagen production. Approved in 2004 for treating facial fat loss in HIV patients, but used off-label by some cosmetic dermatologists. It is reported to last a year or more. There have been some reported incidences of delayed small bumps under the skin. Average physician fee: $876. From Dermik Laboratories, a unit of France's Sanofi Aventis.
 
• ArteFill: A permanent implant approved last month for treating smile lines. Early versions of the product, sold in Europe and Canada, caused reactions called granulomas in some patients. Many doctors won't use it, but advocates say it's especially good for acne scars. Results are reported to be very dependent on the medical practitioner's technique. Price hasn't been announced. Artes Medical Inc., San Diego.
 
• Silicone: A permanent, liquid injectable that is making a comeback. Many doctors stopped using it a decade ago, especially after silicone breast implants were taken off the market. It remains controversial, but some dermatologists are using a purified product sold by Alcon Inc. for eye surgery. Like ArteFill, it's an option for permanent filling of facial scars.
 

Coming Soon

• Evolence: A collagen product developed by the Israeli company, Colbar LifeSciences, that was recently purchased by pharmaceutical titan Johnson & Johnson. Evolence is reported to be in late-stage human tests in the U.S. Dermatologists are buzzing about its potential to last a year or more and supplant other collagens on the market.
 
• Puragen Plus: A hyaluronic acid filler, expected to last about six months, about the same duration as Restylane and Juvéderm. Mentor Corp. launched Puragen in Europe last year. Puragen Plus includes an anesthetic, lidocaine, that the company says make the injections less painful than those of other fillers. Mentor hopes to launch in the U.S. late next year.
 
• Laresse: A biomaterial used in spine surgery that has been developed as a filler, expected to last about six months. Launched in the U.K. this summer. Entering U.S. human tests soon, possibly on the market in 2008. FzioMed Inc., San Luis Obispo, Calif.
 
• Aquamid: A permanent filler made from a biomaterial used in contact lenses and other medical devices. Sold for cosmetic use throughout Europe. FDA human tests expected to begin in the U.S. soon. Contura International A/S, Denmark.
 
• Reloxin: A Botox-like drug undergoing human tests in the U.S. Expected launch in 2008. Physicians hope it will break Botox's monopoly and bring down prices. Sold in Europe under the brand name Dysport. At the Palm Desert meeting, preliminary data were presented by a U.K. physician indicating it might not last as long as Botox. Medicis has U.S. rights.
 
• Puretox: Another potential Botox rival. Technology licensed by Mentor from the University of Wisconsin. A researcher there decades ago helped develop the purification process for botulinum toxin that later became Botox.