The use of social media services like Facebook and Twitter to promote your medical practice on the web has become common in recent years. For today's potential patients, if you don't have a web footprint then you might as well be invisible. A new wrinkle on this has been causing some concern that it might be both illegal and unethical when applied to medical services like laser hair removal, BOTOX injections, and other goods and services.

Services like Groupon offer heavily discounted goods and services to people who buy the "deal of the day" through Groupon. They then collect the money and keep a large percentage of the fee, passing the rest to the merchant. Groupon’s first daily deal in October 2008 was famously a half-price deal for a pizza restaurant located in its office building in Chicago. From that event, the service has exploded. This is now a big business, with such "deal of the day" businesses projected to exceed $6 billion in sales by 2015.

Is this good for anyone other then the principals of Groupon and the like? I don't think so. Like many of the so called "innovators" of silicone valley and the web (ie. Facebook), most ideas you see bubbling up merely seek to skim money off the top of transactions rather then creating a product of any kind of value. It's a giant long con that would seem to be creating another internet bubble for shareholders and investors in these companies.

Expect to see more signs like this from small businesses:

A blog post I found from earlier this year (see here) crystalizes the problem for Groupon noting,

"many businesses will still make the mistake of overestimating the value of the customers they are likely to get from them. The proportion of customers procured from Groupon who are likely to make a return visit/repeat purchase may be dramatically lower than average meaning that, especially when you also factor in the significant cut of the revenue that the retailers have to pay to Groupon, they could actually make a significant loss on the deal. It’s the same logic which has led many online retailers to shun voucher code sites which they see as catering only to bargain hunters as opposed to potentially loyal customers."

You're hearing more and more horror stories from merchants who are not realizing how insane participating with such budiness models is, particularly at the levels of revenue Groupon is skimming from them. In aesthetic medicine, we see more and more of such deals from Botox and laser treatments for hair removal, skin tightening, and body contouring. I see these offers and am boggled at what these clinics and spas are thinking. You cannot stay in business offering services for less then cost, and it is clear that patients who shop through Groupon will always be price shoppers rather then repeat clients. I recently saw a dermatologist lose almost $5000 on a special they did on one of these services not realizing how much they were actually promising to deliver after their cost of the Botox (which is almost $600/bottle).

A new wrinkle (no pun intended) has been the examination of such a relationship in the context of restrictions of what's known as "fee splitting". These types oflaws prohibit the offer, solicitation, payment or receipt of anything of value, direct or indirect, overt or covert, in cash or in kind, intended to induce referral of patient for items or services reimbursed. The language of such laws vary by state, but the spirit of most of them would seem to be at odds with the Groupon model. A number of experts are concluding that such programs, by virtue of their "per unit" fee model, violates such federal rules and many states medical board rules (see here and here) and are advising providers to tread carefully.

So, in summary we have an illogical business model that may or may not be legal for medical goods and services. What's not to like?

Rob

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One of my favorite shopping websites is Slickdeals (www.slickdeals.net) which is a user driven collection of random shopping deals around the internet. You can find some fantastic bargains on all kinds of things, and the site is updated throughout the day by users reporting sales and promotional items.

In honor of this, I'd like to point out the "slick deal" Allergan is offering on it's products thru July. Allergan is the world's largest breast implant manufacturer, but they also make BOTOX, the dermal filler Juvederm, and the eyelash growing solution Lastisse. Thru July they are offering a $50 rebate coupon on either BOTOX or Juvederm purchases when you try Latisse. Details are available here.

Rob

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Well, it appears that calmer heads (or at least calmer foreheads) are prevailing.

Yesterday it leaked that the Democratic caucus was considering taxing BOTOX & cosmetic surgery in their desperate search for revenue to provide a fig leaf of budget neutrality in the health care power grab. After much ridicule on the ludicrousness at the feasibility and effectiveness of it, they're backing off.

Presumably, house speaker Nancy Pelosi , she of frozen forehead, killed this :)

Rob

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Apparently, there is a rush on regional practices in the Washington D.C. area on politicians, celebs, high-society, and the media to get BOTOX done before next weeks inauguration.

From USA-Today:

Washington, D.C.-area cosmetic dermatologists, and skin experts in other major cities, say despite the sagging economy, requests for quickie cosmetic fixes, such as Botox and microdermabrasion, have picked up during the last few weeks as people pretty-up for inaugural fetes.

"We have been absolutely swamped since the election with people desiring rejuvenation procedures for the upcoming inauguration," says Washington, D.C., cosmetic dermatologist Tina Alster.

"My normal load for cosmetic procedures has doubled, except for hyaluronic acid fillers — Perlane and Restylane — which have almost tripled," reports cosmetic and laser surgeon Hema Sundaram, who runs two offices in the Washington, D.C., area.

I guess if you need you're skin cancer checked you're still SOL (see here for related post)in the beltway. So apparently, Democrats are not only more miserly in charitable contributions (see here), but they are more venal as well :)

Rob

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This past week the FDA had some hearings to discuss the issues of dermal fillers (like the popular Juvederm, Restylane, Sculptura, & Radiess) and BOTOX. The use of such products has exploded in recent years and we've seen some real complications reported. The majority of such problems are usually minor and transient as most of these products degrade or wear off. However, there are some products whose effects are permanent (like some of the micro-silicone injectables which aren't used in the US) or last up to several years (like Radiess or Sculptura).

The FDA presented data on over 800 patients who suffered reactions after injection with dermal fillers between 2003-2008. There have been no deaths reported to the FDA, but almost 80% of the patients required follow-up treatment of some sort. Most of these were minor swelling and redness (which isn't really a complication, but expected IMO). However, the FDA also received reports of "serious and unexpected" problems, including facial, lip and eye paralysis, disfigurement, vision complications and some severe allergic reactions.

Most troublesome complications of these fillers are those injected around the eye to fill the hollow "tear trough" that develops under the lower lid with aging. Injections in that area offer a solution that cannot be reliably fixed surgically as the changes are produced from a combination of atrophy of the cheek bone (malar complex), deflation of the fatty tissue of the orbit/cheek, and thinning of the skin rather then something descending and producing loose skin. The thin skin of the lower lid is unforgiving for imprecise injection of dermal fillers as it shows each and every irregularity. In addition, inadvertent injection into a blood vessel in this area has been associated with embolic phenomena to the eye which can produce blindness. Natasha Singer, the NY Times go to girl for cosmetic surgery articles wrote a nice summary up last week (see here).

Not directly addressed at this hearing was the hornet's nest of exactly who is actually doing these procedures, particularly those indications that are still "off label" for the injectable. (Natasha, if you're reading this BTW that subject is screaming for an feature by you....Rob) To this point, states have been reluctant to engage the issues about qualifications and credentialing for doctors performing aesthetic medicine or surgeries. It strains common sense to allow people who are un or undertrained to perform these types of procedures. IMO, if you're not trained in lower eyelid surgery (a la an opthomologist, plastic surgeon, or ENT surgeon) you don't have much business pushing injectables or fat grafting that area - it's that finicky! In many other states, physicians are not even required to do these procedures themselves but are free to delegate them to low level providers or nurses.

Rob

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You know you're a plastic surgeon when you watching the press conference tonite by the US Senate leadership about passing the $700 billion USD bailout bill and not being able to take your eye's off of Sen Mitch McConnell's BOTOX'd brow!




Sen. Mitch McConnell (R-KY)



Other pols who stand out for BOTOX

Hillary Clinton (D-NY)



Nancy Pelosi (D-CA)



Nancy Pelosi's Cat :)



Rob

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From my favorite New York Times columnist, Natasha Singer, comes the story "Botox Appointments Faster Than for Moles, Study Finds". This is similar to a story from MSNBC last year "The Dermatologist won't see you now."

Basically it highlights the September Journal of the American Academy of Dermatology article which published an "expose" on how it is easier to get a Dermatologist to return your call if they think you're going to schedule a BOTOX injection versus getting an appointment to have an irregular mole evaluated for skin cancer.

What was the difference?

More the three weeks delay on average (8 days versus 26 days).

Is this surprising?

Only in the sense that it only took 3 weeks to get in to a dermatologist for a mole to get looked at. Keep in mind that some other similar surveys have found much longer waits. For example almost 47 days in Syracuse, N.Y., 48 days in Phoenix and a whopping 73 days in Boston.

The amount of dermatologists being trained in the US has been artificially suppressed for many years. I saw reference somewhere to the fact that the number of dermatology residency training programs has remained stable for almost three decades with about 300 training positions. It's led to a significant backlog of people being able to be evaluated for cancers as the baby boom approaches AARP status, this volume of patients is expected to explode.

What's more, many of the medical students going into dermatology have no interest in general dermatology or treating skin cancers at all. It's been estimated that there's been almost a 50 percent shift in effort away from medical and pediatric dermatology. If you browse chat-rooms of medical students interested in derm, it's clear that many would like to set up clinics doing nothing but lasers, injectable skin fillers, and BOTOX. In a practice survey of dermatologists I found, younger women going into dermatology spent almost 20% less time seeing patient then male counterparts per week. As women make up increasing numbers of both medical students and dermatologists, this "contraction" of productivity is another factor likely affecting future access.

If you extrapolate that many (most) of these boomer patients will be Medicare beneficiaries, and that Medicare reimbursement could fall as much as 40% over the next few years, it seems likely that this bias towards BOTOX could become significantly larger. Expect to see some lobbying from Nurse Practitioners and Physician Assistant's for greater independent roles in the evaluation and management of skin lesions. For some related Medscape articles click here.

Rob

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Several recent scares with Boutulism food poisoning should be a reason to reexamine where BOTOX comes from. At right is a high magnification image of botulism spores.

Castleberry's Food Co. of Augusta,GA recalled more than 90 types of canned chili, beef stew, corned beef hash and other meat products. Cans of chili sauce made by the company were found in the homes of an Indiana couple and two children in Texas who had been hospitalized with botulism toxicity. All four are expected to survive. Botulism can be lethal by paralyzing the repiratory muscles when ingested in quantity.

Boulinum toxin is the product of the bacteria, Clostridium botulinum. A layman's description of how botulinum toxin works courtesy of Wikipedia:

Botulinum toxin blocks the release of acetylcholine from nerve endings thus arresting their function. The C. botulinum bacterium produce toxin in an anaerobic environment, and the toxin is unstable to heating, so poisoning generally occurs from the use of improperly bottled or canned foods.

BOTOX (the cosmetic) came from the observations of an opthamologist who was treating a patient for blepharospasm (BOTOX's initial clinical use) and noticed his patient's wrinkles got better in his forehead. Likewise BOTOX's use for treating migraines came from the observation of a Plastic Surgeron who was treating wrinkles (both surgically & with BOTOX) and kept being told his patients headache's were getting better. BOTOX is now used from everything to hyperhidrosis (extra sweating) in the palm or armpit, esophageal spasm, anal fissures, constipation, and 1001 other novel applications.

A competitor preparation of botulinum toxin called Reloxin is due to be introduced to the US later this year and will finally give some competition to lower the price for these kinds of medicines.

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I'm on vacation this week which is why I've been so productive with the blog.

I saw this on FOX-News, but it's been picked up by the DrudgeReport as well. Entrepreneurs in New York have come up with "drive-thru" clinics to give BOTOX to walk-in clients. While this is convenient, I think this is a somewhat troubling trend.

Allergan, the parent multi-national conglomerate, who owns BOTOX, the Lap-Band weight loss surgical device, Juvederm skin filler, and other products has taken a page from the pharmaceutical industry in how they market. Allergan bought Inamed Corp. in 2006 to also become the world's largest breast implant maker and are now arguably the world's premier cosmetic medicine complany.

To these corporations, Doctors are an inconvenient middleman in their product distribution systems. Big pharma realized this years ago by slashing their budget for detailing physicians & concentrating it on print and media ads directed at consumers. What they want is for people to show up asking for their drug by name when they go to the doctor.

Allergan has thrust out it's formidable marketing team with huge media pushes for BOTOX & Juvederm (their hyaluronic acid filler aimed at knocking off market-leader Restylane), with TV ads on Grey's Anatomy and other popular shows featuring actress Virginia Madsen (co-conspirator Tony Youn mentioned this here last month).

From the Orange County Register, in an article titled "Allergan rethinks marketing of Botox, implants."

In its new breast-implant campaign, for example, Allergan's marketers imply that implants are artful, like designer clothing. Even though implants are basically plastic bags filled with silicone or saline solution, Allergan portrays them as sources of power, freedom, individuality and self-confidence.

That's a big change from last year, when Allergan bought Santa Barbara-based Inamed and its breast implants for $3.2 billion. Then, the implants were labeled "Style 68," "Style 101," etc.

The old labels were cold and clinical, so Allergan is giving them a new identity that sounds natural, feminine and artful. In a new marketing campaign, they're the "Natrelle collection of breast implants."

Write this down: Expect to see lots of feisty press releases from the anti-breast implant crowd over this for the wrong reasons (ie. a non-demonstrable auto-immune disease risk). The underlying concept of direct-marketing this type of surgery makes me uncomfortable as it will further trivialize what is an operation and aftercare that is anything but simple.

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A Cleavland Plastic Surgeon, Bahman Guyuron, made an interesting observation a few years ago when he was told by several of his brow lift patients that their migraine headaches went away after surgery. Working from that feedback he hypothesized that surgical release of several muscles that are divided to improve forehead wrinkle line act as trigger points for migraines. Eventually this led to the therapeutic use of BOTOX cosmetic for treating migraines, which has become quite a big business for neurologists.



Ironically, there were a number of Neurologists who initially aggressively protested that it was impossible for BOTOX to have an affect because Neurology dogma had migraines originating from central brain triggers rather then peripheral ones. However, the studies that have been published since have been overwhelmingly compelling for how effective this type of therapy can be in selected patients.

The graphic below demonstrates the classic central forehead/nasal injection pattern for paralyzing the procerus and corregator muscle groups which are the muscles divided in some brow lift procedures.



For several years in the Plastic Surgery literature we've been trying to better quantify who would be candidates for planned surgical division of 3 or 4 muscles for treating migraines with surgery for a permanent cure. The anatomy and refinements of surgical techniques for this are being developed by an acquaintance of mine, Dr. Jeff Janis (seen in picture at right), at the University of Texas-Southwestern in Dallas,TX. Jeff's been featured in a bunch of stories on this recently (see here)which is great for such a bright guy.

I ran into Dr. Janis at the Dallas Rhinoplasty meeting last week where he was about to commence a marathon cadaver dissection to study the anatomy in dozens of fresh human cadaver heads that had been used as part of the rhinoplasty course. The work he's doing is really developing an area that has tremendous potential to help some patients suffering from this terrible condition.

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I saw a really interesting analysis of the stock prospects of several of the major cosmetic medicine & Plastic Surgery industry companies on The Street.com, specifically the heavy hitters Allergan-Inamed, Mentor, & Medicis are all spotlighted, each incidentally is up ~10% for this year.

There are a lot of competing products hitting the market as Allergan's new injectable filler, Juvederm tries to unseat the popular Restalyne (from Medicis). Likewise, Medacis' Reloxin (a drug similar to Botox) should hit the market in the US next year. Hopefully that will lower the price of some of these injectables.

Things are set to heat up in the US implant market with the recent silicone implant reintroduction. The article writes,

"Allergan and Mentor are the dominant players in this $500 million to $600 million global market segment. Most analysts expect 30% to 40% first-year conversion rates of the saline-implant market, but early gains may be greater, as a result of pent-up market demand. The anticipated switch to more profitable implants supports a strong revenue outlook and further margin upside for these two players in '07."

I personally think an estimate of 30-40% market share for silicone is on the low end talking to other surgeons. Meanwhile, my savvy Plastic Surgery stock-pick of Ivivi is now sitting a full 10% below it's IPO price. I guess my kids will be going to state instead of Princeton :)

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