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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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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Children of the 80's may remember the British Disco synth-pop group "Dead or Alive" who had a couple minor hits which live on indefinitely on classic rock stations featuring the 80's new-wave music. The lead singer of that group, Pete Burns, has been a walking billboard for what resembles body dysmorphic pathology (a psychiatric condition re. body image) for years having had dozens of procedures which have left him progressively less humanoid looking.

Mr. Burns is now in the news after horrible complications from lip augmentation, a picture of which is shown below. (from This is London):

In 2000 Burns went to Dr Maurizio Viel at the London Centre for Aesthetic Surgery to have a lip implant removed.

But instead of having the original implant taken out, he was injected with a filler called Evolution and then later with another called Outline.

Despite complications, Dr Viel persisted and injected more of the substance - only for the problems to escalate, causing swelling, blisters, discharge and lumps.

Eventually the singer was left so disfigured he could not eat normally, could only drink through a straw and did not leave his house for months. He said his career would have been at its peak if it were not for the botched surgery, as he was about to record with the Pet Shop Boys and pursue a number of solo projects as well as launch a greatest hits album.

Lip augmentation is tricky business. There are hundreds of celebrity pictures with the infamous "trout pout" from aggressive collagen injections in years gone by. Hyaluronic acid fillers like Restylene or Juvederm have largely replaced collagen and tend to last longer with fewer potential allergic reactions. Many patients continue to ask for longer term options and that means lip implants (silicone, Gore-tex), fat grafting, long-acting temporary fillers, or permanent fillers.

As Mr. Burns case points out, permanent fillers can go real bad, real quick and has tempered the enthusiasm of many of us for such products. The perfect filler hasn't been developed yet but we know what we want. Ideally we have a very long lived or permanent product with some way to dissolve it if we needed to. Unfortunately, the only fillers we can dissolve easily are the hyaluronic acid ones which only last a few months anyways.

You also have to question the judgment of any physician willing to continue to perform elective surgery or cosmetic treatments to someone like Mr. Burn who is clearly body dysmorphic. In the insane (no pun intended) legal environment of the United States there have even been doctors sued with failure to diagnose body dysmorphia as a cause of action by patients during malpractice suits.

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