Letter from America| Volume 65, ISSUE 8, P1138-1140, August 2012
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# Facts not fiction: Fake Botox®, omega-3 fatty acids are good for you and the “Toxic Tush” syndrome

Carl Hiaasen is a best selling fiction author and columnist for The Miami Herald. He was once asked how he created his novels' bizarre yet humorous plots. He responded that it did not require much imagination on his part; rather that he based his novels upon facts gleaned from local news that appeared in The Miami Herald.
When asked why Florida, Hiaasen said, “The most common answer that people give is if you took the continental United States and you tilted it a little bit, all the sludge would drip all the way down the peninsula, all the way down this highway … right past my house.”
aWhen asked why Florida, Hiaasen said, “The most common answer that people give is if you took the continental United States and you tilted it a little bit, all the sludge would drip all the way down the peninsula, all the way down this highway … right past my house.”
“Borrowing a page” from Hiaasen, here are recent plastic surgery tales from South Florida that have not yet been transformed from fact to fiction.

## We're number one!

I do not think that our local chamber of commerce would lay claim to or take pride in the fact that when it comes to bizarre stories about injections, but pride of place belongs to South Florida. This is neither an idle boast nor a new claim based upon our moving up in the league tables. We have been number one for years if not decades. This is why we lead.

## Fake Botox®

The fact that we are first has been certified by none other than that august scientific agency known for its rigid standards for determining the validity of scientific claims — the United States Food and Drug Administration (FDA). The FDA has been ferreting out fake Botox® which has resulted in fines and prison terms for physicians and others involved in the product's use on patients. The problem that first brought the fake Botox® to the FDA's attention was not that fake Botox® did not work as well as the real drug, it worked too well. Where did the FDA first learn of fake Botox®? According to its own database, the location was South Florida. An osteopathic physician gave the drug to his girlfriend, himself and another couple. All four people developed paralysis, had to be hospitalized on respirators for weeks if not months and had continued complications.

United States of America v. McComb. (11th Cir 2007) No. 06-11093. http://www.ca11.uscourts.gov/unpub/ops/200611093.pdf; [accessed 26.04.12].

The osteopath obtained the fake Botox® from Toxin Research International, a company in Arizona, whose representative said that the drug was only sold, “to doctors and PhD students for research”.
• Goddard J.
Doctor and patients fight for life after anti-wrinkle jabs.
Apparently, the company considered the osteopath to be a doctor, notwithstanding the fact that he previously had lost his medical license for over-prescribing pain medications. The osteopath was sentenced to 3 years in prison. The naturopath who owned the company pleaded guilty to fraud and misbranding a drug. He was sentenced to 9 years in prison ordered to make restitution of $345,567 and to forfeit$882,565.2

## Toxic Tush syndrome

This underground injection phenomenon recently has reached epic proportions both literally and figuratively. A number of transgendered individuals sought to have buttock augmentation performed by what they believed to be silicone injections. Some of the patients developed cellulitis and even sepsis that required hospitalization. Rather than having received silicone injections, the lay practitioner is alleged to have injected the patients with a combination of ingredients including a product used to repair flat tires.
• Emmanuel L.O.
Possible victims come forward in bad butt injections case: officials. Lab results determined that household and automotive products were injected into the victim.
The police photo of the practitioner, which has been widely distributed on the internet, demonstrates the quantity if not quality of the results. (Figure 2a,b) Currently, (s)he is awaiting trial for the unlicensed practice of medicine.

## Plus ça change, plus c'est la même chose

Two common threads run through these tales. First, that the patients did not know what chemicals had been injected, and, second, that they suffered serious harm. Although some of these stories were “news”, the threads are not new. Years ago a plastic resident, I would sometimes see patients who had the misfortune to have received “silicone” injections from unknown practitioners. The patients would arrive at the resident clinic with a host of problems including infection, draining sinuses and migration of the material to regions that were south of the intended site. My teachers and I could but speculate about who had given the injections and what had been injected; we had no satisfactory solutions for these patients' problems.
One would hope that a mark of progress would be that with time both plastic surgeons and the public would become more knowledgeable. Sadly, that is not the case. Papers describing complications continue to demonstrate no proof that patients were accurate in their statements about what substances had been injected.
• Freshwater M.F.
Complications of hyaluronic acid injections or something else?.
• Freshwater M.F.
Artecoll injections or something else?.
Indeed, a recent paper showed that only 6 of 58 patients knew the correct material that had been injected into their breasts when the substances were analyzed with NMR spectroscopy.
• Okuda T.
• Hirakawa K.
• Orbay H.
• et al.
The use of NMR spectroscopy for identifying unknown foreign materials after aesthetic procedures.
Although there is no continuing education credit for getting the correct answer, read the following paragraph and select the best word that results in the paragraph making sense:The technique for the injection of _____ is simple and the injections can be given, after a little practice, by anyone who is able to purchase the equipment. The immediate results, when none of the untoward happenings occur, are at first very gratifying to the patient. Nevertheless, the _____ frequently shifts its position, and gradually trickles down the tissue planes, or the infiltrated tissues may thicken and cause deformities which are infinitely worse than the original defect.
• a.
Silicone
• b.
Macrolane®
• c.
Artecoll®
• d.
Aquamid®
• e.
Paraffin
The answer is e; the paragraph was written by John Staige Davis in 1919.

Davis JS. Plastic surgery its principles and practice. Philadelphia: P. Blackiston's Sons, http://archive.org/stream/plasticsurgeryit00davi#page/46/mode/2up; 1919, p. 47. [accessed 26.04.12].

Plus ça change, plus c'est la même chose — the more things change, the more they stay the same.

None.

None.

## References

1. FDA law enforcers crack down on illegal botox scammers. U.S. Food and Drug Administration, October 2009 ([accessed 26.04.12])
2. United States of America v. McComb. (11th Cir 2007) No. 06-11093. http://www.ca11.uscourts.gov/unpub/ops/200611093.pdf; [accessed 26.04.12].

• Goddard J.
Doctor and patients fight for life after anti-wrinkle jabs.
The Telegraph. December 5, 2004; ([accessed 26.04.12])
• Emmanuel L.O.
Possible victims come forward in bad butt injections case: officials. Lab results determined that household and automotive products were injected into the victim.
November 22, 2011 ([accessed 26.04.12])
3. http://tinyurl.com/toxic-tush; [accessed 26.04.12].

• Freshwater M.F.
Complications of hyaluronic acid injections or something else?.
J Plast Reconstr Aesthet Surg. 2011; 64: 896
• Freshwater M.F.
Artecoll injections or something else?.
J Hand Surg. 2011; 36: 1564
• Okuda T.
• Hirakawa K.
• Orbay H.
• et al.
The use of NMR spectroscopy for identifying unknown foreign materials after aesthetic procedures.
J Plast Reconstr Aesthet Surg. 2012; 65 ([Epub 2011 Oct 28]): 692-694
4. Davis JS. Plastic surgery its principles and practice. Philadelphia: P. Blackiston's Sons, http://archive.org/stream/plasticsurgeryit00davi#page/46/mode/2up; 1919, p. 47. [accessed 26.04.12].