Beware the Bargain Botox


The Botox price wars have begun, only two months after the wrinkle treatment won federal approval.

Advertisements touting the injections for $95 and $100 have begun appearing in magazines and direct-mail fliers in Los Angeles and Orange counties, sharply undercutting the standard $350 to $500 per facial area and raising questions about the quality of the bargain treatments.

But while some doctors objecting to bargain Botox prices may be unhappy to see competitors (particularly newcomers to the business who are not specifically trained in skin care) siphon off patients, others say they worry that low prices may reflect inferior treatment.

Few people are aware that the strength of the Botox solution can vary widely among doctors, says Dr. Brian Kinney, a Los Angeles plastic surgeon and spokesman for the American Society of Plastic Surgeons.

Overly diluted injections, which can lower a doctor’s costs, can be ineffective and raise the risk of complications, such as having a droopy eyelid.


“There is a lot of sophistication and subtlety to this,” Kinney says. “It’s not just taking a needle and poking it into someone’s face and pushing the plunger.”

Botox , which has other medical uses, is sold to doctors by Allergan Inc. for about $400 per vial; the U.S. Food and Drug Administration approved its use as a wrinkle treatment in April. Each tiny vial contains freeze-dried botulinum toxin type A, which, when injected, can temporarily paralyze certain facial muscles to smooth creases. But the dried toxin must be mixed with saline solution before it’s loaded into a syringe and injected.

Most doctors mix the toxin with 2.5 cubic centimeters of saline, producing enough Botox to treat three to four facial areas, says Dr. Alan Matarasso, a New York City surgeon and spokesman for the American Society for Aesthetic Plastic Surgery.

“We can get three to four sites, at the most, out of one bottle,” he says. “Simple arithmetic says charging $99 per site, you haven’t covered the cost of the bottle.”

But doctors offering the low fees say they aren’t looking for big profits from Botox.

At $100 per area, “we still make money,” says Dr. Kambiz Youabian, an internist who operates the Cosmetic Laser Center of Los Angeles. The main reason for the price cuts, he says, is to “get people into the office and acquaint them with our other procedures.”

Dr. Kamran Hakimian of the Laser Cosmetic Clinic in Beverly Hills and Costa Mesa says his high-volume practice allows him to price Botox at $95 per area.

“If you have two clients a day and some leftover Botox, you are going to lose money,” he says. “I have volume, and I don’t have as much left over.” Once mixed, Botox should be used within four hours or discarded, according to Allergan. Consumers have no way of knowing, however, if a doctor is diluting the treatments, says Matarasso.

Mixing the toxin with too much saline increases the risk of complications because a dilute solution is more likely to migrate into other muscle areas, he says, causing problems like a droopy eyelid, double vision or a droopy lip.

And a watered-down injection isn’t as likely to hold up. Botox treatments typically last for about four months.

“I’m worried that in a year or two people will say, ‘Don’t bother with Botox; it doesn’t work’ because [they] got an overdiluted dose,” says Matarasso.

Most Botox prices are quoted per muscle group. This usually means one of four major areas: the frown lines between the eyes, the forehead muscles, crow’s feet at the sides of the eyes and the cords in the neck. Consumers should make sure that doctors define how much of the face will be treated.

For example, says Kinney, “One ‘area’ may mean a very small area, a corner of your eye, not all of your eye.”

Also, in recent weeks, several doctors’ groups, insurance groups and even Allergan have warned consumers to avoid Botox parties, where discounted treatments are given at private homes, gyms or spas.

The Doctors’ Company, a leading malpractice insurance business in California, has recommended that Botox only be provided in a doctor’s office by doctors trained in facial anatomy.

To avoid potential malpractice lawsuits, the company also suggested its doctors take a patient’s medical history before a Botox treatment and ask the patient to sign an informed consent document describing the treatment and possible side effects, such as headache, nausea, respiratory infection, facial pain, skin redness and muscle weakness from migration.

Botox should not be given to pregnant or nursing women, the Doctor’s Company advised, because it is not known whether the toxin could harm a fetus or be secreted into breast milk.

Medical histories and informed-consent procedures may be bypassed when Botox is delivered in nonmedical settings, says Matarasso.

“If you go to a gym for a discounted treatment and have a complication, who do you call?” he says. “Do you call the gym and say, ‘When is the doctor coming back to the gym?’ ”

Allergan also recently issued a statement on possible abuses of Botox. The company says it will only market the treatment to aesthetic specialty doctors including dermatologists, plastic surgeons, facial plastic surgeons, oculoplastic surgeons, ophthalmologists and maxillofacial surgeons.

Allergan spokeswoman Christine Cassiano noted that the company cannot control doctors’ pricing.

But, she says, “The odds are that a doctor who is more qualified and has hands-on experience will charge more than someone who is less qualified.”