Facial disfigurement after botched cosmetic injections

This story might seem extreme. However, many cosmetic injections performed in prestigious medical offices are performed by untrained people who are not doctors.

Dermal filler correction of early aging in the male face

More and more, executives and non-celebrity men are desiring to maintain the edge at work provided by a youthful appearance. We previously discussed modern techniques for hair restoration. In this episode, plastic surgeon Dr. David Shafer discusses how HA-fillers, such as Juvederm and Restylane, can correct the signs of early aging in the male face.

Walter Unger, MD: Follicular unit hair transplantation

Most men develop early signs of male pattern baldness by the age of 40. However, few realize that modern hair transplant techniques can be extremely effective at halting the inevitable and more noticeable balding.

Dr. Walter Unger, Professor at Mt. Sinai School of Medicine in dermatology and full-time hair restoration expert discusses the modern technique called follicular unit hair transplantation. Older techniques that caused the infamous “doll’s head” look used large plugs of hair. He explains more in the video discussion below.

 

David Shafer, MD: Laser-assisted liposuction

Interviewed by Steven Greer, MD

David Shafer, MD, plastic surgery attending at the MEETH (Manhattan Eye, Ear and Throat Hospital) discusses the new technique of laser-assisted liposuction. Cynosure’s SmartLipo is demonstrated with before and after photos of some patients.

Bad cosmetic dermatology outcomes: Just the tip of the iceberg?

The Healthcare Channel, April 26, 2010

The NY Times recently reported that Hollywood now prefers to hire actors who are natural with no cosmetic surgery. Casting directors are rejecting the Barbie doll look, such as reality TV’s Heidi Montag.

There might be a bigger problem related to this. Backlash from Hollywood could be just the tip of the iceberg. Bad outcomes from cosmetic dermatology facial injections are expected to become more common now after years of repeated procedures on patients and the growing numbers of patients.

For the treatment of facial wrinkles, dermal filler injections and botulinum toxins like Botox have undergone a rapid adoption. Since the year 2000, the ASPS 2008 statistical database indicates that Botox procedures have grown 543%. In the 90’s, collagen filler utilization became popular but has declined over the last decade due to complaints of bad aesthetic outcomes and short-lasting results. The approval of alternative longer-lasting hyaluronic acid fillers has also contributed to the decline of collagen. Overall, usage of dermal fillers of any type has increased more than 100% since 2000, according to the FDA and ASPS.

Johnson and Johnson stopped selling its Evolence line of collagen dermal filler in November of 2009, shortly after acquiring the product in the ColBar LifeScience Ltd acquisition. According to Dr. Kevin Smith, a cosmetic dermatologist interviewed by The HCC, “Bovine collagen is essentially obsolete because of short duration of cosmetic benefit, and porcine collagen [Evolence] has been withdrawn from the market because of unsatisfactory aesthetic complications [areas of excess fullness, subcutaneous papules] in too many cases.” In an article by CBS subsidiary Bnet, consumer reviews in RealSelf.com were very bad.

Manhattan aesthetic plastic surgeon Alan Matarasso said, “Facial fillers have been a wonderful addition to the repertoire of plastic surgery. However, there can be adverse outcomes. These range from mini irregularities all the way to severe skin damage (loss of tissue).”

Dr. Smith attributes some of the poor outcomes to plastic surgeons (as opposed to dermatologists) who do not take the procedures seriously enough. “Another consideration could be that in many plastic surgery practices Botox/Dysport and fillers are a sideline, and the consults and treatments are not done by the physician. In dermatology and other practices, it is more common for the consult and the treatment to be done by the physician, who has a high level of skill, knowledge and ongoing training and is more likely to provide a satisfactory service than a physician extender in a plastic surgery practice.” However, many dermatology offices also delegate the injections to non-MD staff.

There are several other materials used to inject the face. Liquid silicone is more dangerous than collagen as a dermal filler. For many decades, plastic surgeons have known how the body treats injected silicone as a foreign body and creates encapsulated scars and granulomas in reaction.

Yet the practice of injecting silicone into the lips and face is still performed, and actually making a comeback, even though the long-term risks are not any less now than before. Lisa Marie Presley has significant facial disfigurement from silicone injected by a fraudulent doctor. Lisa Rinna, the actress best know for her soap opera roles and stint on Melrose Place, underwent repeated lip augmentations, and is now speaking about her lumpy scarring as a result.

In some cases, it takes years for scarring to develop as an adverse outcome from the repeated injections, and only a small portion of all patients develop scarring. Unsightly scarring of the lips and nasolabial fold will be the biggest problem. Because millions of patients have now received repeated dermal injections, we could see a much greater problem soon, according to a prominent Manhattan plastic surgeon who preferred to remain anonymous.

Botox is currently the most popular cosmetic injection, although it is not a filler. It reduces the appearance of dynamic wrinkles by paralyzing the underlying muscles connected to the skin. Over time, as the skin ages and becomes damages by the sun, these wrinkles become permanent. Botox is approved to treat dynamic wrinkles between the eyebrows.

One problem that has developed with Botox is the inappropriate injection of very young patients, aged 20 or younger, who have no dynamic wrinkles caused by ageing and sun damage. Many prominent board-certified dermatologists and plastic surgeons will inject young patients with Botox creating a fake “Barbie” look. Perversely, many teenagers desire this body dysmorphic outcome. It is a trend recently dubbed “Teen Toxing”.

A myth propagated by some in the cosmetic surgery and dermatology community to justify this profitable and controversial practice is that Botox in teens can prevent wrinkles later on. The HCC reviewed the literature on PubMed. No credible clinical studies were found to support this. Dr. Smith said, “If a teen is a chronic frowner, treatment with Botox would likely prevent frequent creasing of the skin [dynamic frown lines] from turning into permanent [static] frown lines, just the same way as Botox works in people who are in their 30’s and 40’s. I’m not aware of any studies on that point, but all of the available evidence suggests that Botox for that indication in that age group would be safe and effective.”

Medicis and Allergan, makers of botulinum toxins, declined to reply to our questions. The plastic surgery medical specialties also declined our request for an interview.

The problem of bad outcomes from dermal fillers and injections has received little attention for many reasons. A minor scar on the face of a willing cash-paying “customer” pales in comparison to more life-threatening problems that increase healthcare spending. Complications from vanity procedures elicit little sympathy.

The FDA convened an advisory meeting 18 months ago to discuss dermal filler safety. Recommendations were made to strengthen the science behind the dermal filler clinical trials, and to limit untrained staff from performing the injections. The HCC interviewed cosmetic dermatologist Jessie Cheung of NYU about the matter.

The FDA advisory meeting has resulted in very few significant changes to the way these products are administered. Doctors will openly discuss using Botox in young patients as if it is perfectly acceptable. The recent national meeting of aesthetic surgeons featured no large-auditorium discussions about the recommendations made by the FDA advisory committee in November 2008, or ethical usage of Botox in teens, according to the program. The President of the ASAPS, Dr. Saltz, did not reply to our questions.

Something more powerful than a regulatory agency will likely address the facial cosmetic dermatology bad outcomes problem: market demand. A critical mass of celebrity plastic surgery nightmares combined with more common disfigurements in American teens may cause a reduction in customer demand. Hollywood is a good indicator of trends, and the casting directors are saying that the Barbie face is no longer fashionable.

Jessie Cheung, MD: FDA scrutiny of dermal fillers

Jessie Cheung, MD, co-director of cosmetic dermatology ant New York University Medical Center, discusses the safety issues raised at the FDA advisory committee on cosmetic dermal fillers

Jessie Cheung, MD: Overview of treating face wrinkles with injections and fillers

December 23, 2008, 9:02 AM ET, Wall Street Journal

http://blogs.wsj.com/health/2008/12/23/economy-be-damned-im-getting-my-botox/tab/print/

Economy Be Damned: I’m Getting My Botox

Patients may be cutting back on some treatments amid the recession, but they’re not letting slimmer pocketbooks take their Botox away from them.

“It’s like comfort food,” says Maralyn Burr of Omaha, Neb., who in June lost her job as a district sales manager for Borders bookstores. With $140,000 in debt from her 22-year-old daughter’s musical education, Burr told the WSJ she’s slashed spending and all but stopped eating out. But she hasn’t given up her Restylane and Botox injections.

She’s not alone. Nearly three-quarters of plastic surgeons responding to a survey this fall said demand has increased or held steady for minimally invasive procedures, including the Botox anti-wrinkle drug, dermal fillers used to plump up lips and smile lines, and skin-smoothing chemical peels, according to the American Society of Plastic Surgeons. At the same time, the survey found a steep drop in demand for plastic surgeries such as breast augmentation and nose reshaping. (See this post from early this year, which took note of a similar pattern.)

Patients may be scrimping on big-ticket procedures but appear to be ponying up a few hundred dollars now and then for injections.

Even so, the companies that make these products aren’t brimming with confidence. Allergan, which makes Botox, cut its 2008 guidance for the product, citing overall “subdued demand,” and Medicis recently has been offering a $100 consumer rebate on its Restylane antiwrinkle products.

Botox Bonus: For more info on the non-surgical alternatives for improving the appearance of your face, see this video with NYU dermatologist Jessie Cheung.