Dermatologists and plastic surgeons are divided on how — and even if — to approach procedures during the pandemic
It’s become a ubiquitous site during the coronavirus pandemic — the processions of vehicles stretched bumper-to-bumper; the PPE-clad figures, veritable carhops with clipboards, tending to their passengers. Three months in, we now recognize it instantly: drive-thru COVID-19 testing in progress.
If you live in Miami, however, there could be another reason for that packed parking lot: Botox.
Over Memorial Day weekend, Michael Salzhauer, aka “Dr. Miami” a board-certified plastic surgeon in Bay Harbor Islands, Florida, kicked off summer by introducing “Drive-Thru Botox”, a first-of-its-kind service he’s offering to patients on Sunday afternoons when he’s not in the operating room performing breast augmentations and Brazilian butt lifts.
The idea took root after he was tested in similar curbside style for COVID-19 antibodies: “I saw hundreds of people getting their blood drawn without leaving their cars,” he tells Allure. “It was very safe, professional, systematic, and organized. The scheduling, medical history, consent forms, and billing were all done online. And I thought, This would be perfect for Botox.”
At Salzhauer’s drive-thru, paperwork, payment of $300 per area (forehead, glabellar lines, and/or crow’s feet), and pre-procedure photos are handled digitally before each scheduled 15-minute injectable appointment. Patients arrive wearing a mask and roll down their window to submit to a contact-free temperature scan, upper-face assessment, and additional “before” pictures.
After they numb the skin with a disposable cold compress, Salzhauer (in full PPE and gloves) preps it with alcohol pads and injects brand-name Botox using a sterile syringe. He then has patients ice for 30 seconds, snaps “after” shots, and sends them off with follow-up instructions.
Since Dr. Miami began unabashedly promoting this to-go neurotoxin to his 1.4 million Instagram followers, his posts have been met with a mix of disbelief (“Are you serious?”) and delight (“This is amazing!”).
While he insists, “It’s very safe to administer Botox in [this] way, as long as the person doing the injecting is experienced and competent,” many of his colleagues vehemently disagree and have taken to social to speak out against what they see as a brash and unethical commodification of medicine.
“Drive-Thru Botox devalues and undermines every safety and care standard we strive to uphold in our sterile clinics,” board-certified Fort Lauderdale osteopathic dermatologist Shino Bay Aguilera wrote to his Instagram followers.
Janelle Vega, a board-certified dermatologist in nearby Coral Gables, echoed his sentiments in a post of her own: “Getting drive through #Botox or #fillers can be dangerous and undervalues the fact that you’re getting a medical procedure — not fast food.”
(For the record, Salzhauer is not offering fillers at his drive-thru clinic — although his fans are clamoring for it — because, as he says, fillers have a much greater risk of side effects, complications, and unfavorable results.)Cosmetic doctors are reimagining the in-office procedure
Salzhauer isn’t the only one getting creative with post-lockdown treatments. In New York, board-certified plastic surgeon Darren Smith is offering house calls to injectable patients — a service he’s dubbed Aesthetic Visit by Darren M. Smith M.D. Currently, those in Westchester, Long Island, and New York City are eligible.
“I [initially] decided to offer house calls for plastic surgery emergencies — dog bites, lacerations, burns — to help otherwise healthy patients stay out of emergency rooms and avoid exposure to the virus [while also] unburdening emergency rooms, so they could focus on treating critical COVID-19 patients,” he explains. “Given that we had developed a well-functioning workflow for these essential services, it seemed reasonable to adapt this experience to delivering something a little more fun once it was safe and responsible from a public-health perspective.”
Bringing Botox and fillers to patients in their own homes minimizes traffic at Smith’s Park Avenue practice at a time when physicians everywhere are implementing strict safety protocols and aiming to keep head counts low. Plus, he adds, “We’re finding that many folks would rather avoid going to public places, even as stay-at-home orders are relaxing.”
Board-certified New York City dermatologist Ellen Marmur is inviting patients to her new MM3 Bungalow — a private open-air dermatology space on the grounds of her Watermill home in the Hamptons, where she’s offering both medical and cosmetic services ranging from skin checks and hair-loss procedures to all manner of injectables, chemical peels, and devices, like Clear + Brilliant, Thermage, and CoolTone.
With New York City still reeling from the COVID-19 crisis, “Over 60 percent of our patients have relocated out east for the summer with no plans to return to the city until the fall,” Marmur says. So, she figured, why not bring the treatments to them? “This is a truly personal, concierge experience where you can relax, listen to music, have a mocktail, and even leave with the best sunscreens you’ll need for your summer.” She’s seeing just one patient per hour, Wednesdays through Fridays.
Having medical training in dermatologic surgery, she adds, allows her to “maintain elevated standards in an outdoor environment.”
Unlike Salzhauer, Smith and Marmur haven’t faced public scrutiny or outrage from peers on social media over their decisions to practice their craft in unconventional settings. And, certainly, the idea of an esteemed surgeon filling our lips in our living room, or an A-list derm zapping our trouble spots in a secret garden seems nothing short of inspired — downright dreamy, in fact. But one has to wonder: Is it truly safe to remove “in-office treatments” from their natural habitat?Can medical procedures be performed safely out of the office?
That depends who you ask, as doctors are split on this issue.
“Our new normal has blurred the line between our personal and professional spaces, so it comes as no surprise that medical visits have been crossing over from traditional clinical settings to more nonconformist scenarios,” says board-certified New York City dermatologist Shereene Idriss. “That being said, medical procedures…require attention to detail, from [patient] positioning to lighting to, most importantly, sterility and safety, as even a small oversight can have damaging long-term consequences.”
While Idriss acknowledges the need for the aesthetics community to evolve with the times, she maintains this should happen “within the clinical settings where we’ve been trained to practice.”
Vega shares her wariness: “As we collectively struggle through a global pandemic, I don’t see a compelling reason to offer elective medical procedures in uncontrolled high-touch environments,” she says. “It may be more convenient, but that convenience could come at the cost of subpar results or complications for the patient.”
Citing general concerns over sanitation, the risk of improper transportation of injectables, and a sheer lack of control in unfamiliar environments, Aguilera firmly believes, “It is never advisable for a physician to perform medical procedures outside of a clinical setting.” Other doctors see the house call and bungalow scenarios as more of a gray area than drive-thru Botox.
“It is a bit stickier, since [these treatments are] hopefully being performed in a one-on-one delivery with appropriate consultation, examination, and consent,” says Herluf Lund, a board-certified plastic surgeon in St. Louis and the president of The Aesthetic Society. “Any such home service should be prepared to manage potential complications just as a medical office would.”
The leaders of the out-of-office movement offer strong assurances that patient safety is absolutely paramount and stress that they’ve carefully considered every aspect of their pandemic-inspired pivots.
“There is simply no wiggle room when it comes to patient safety,” Smith says. “We only embark on a home visit if we know we can control the environment to ensure it meets our exacting standards for safety and sterility.” Before such a visit, the patient is screened by phone and receives a consultation virtually. During the actual appointment, office standards still apply, he says, including customized lighting, surface cleaning, and sterile draping.
In advance of outdoor sessions at MM3, Marmur also prescreens patients and conducts virtual consults. When treating patients in the flesh, “We wear N95 or K95 masks, gloves, scrubs, and adhere to all aspects of clean technique,” she says. “We’ve transported sterile drapes, gowns, cleaning solutions, and other equipment from the office to MM3 and have followed the local and professional guidelines to ensure legitimacy and safety. We even have a specialized air filter for the space.” The first patients to experience her outdoor clinic were physicians, she notes, who judged it to be “very reassuring and possibly even safer than in-office visits.”
Interestingly, Salzhauer makes a similar claim about his drive-thru service, calling it “potentially safer” than office-based appointments in the age of COVID-19.
Still, the notion of SUVs and hybrids pinch-hitting for exam rooms has some physicians uneasy. “There are over 700 bacteria in an average car as well as mold and viruses,” says Lund. “There are numerous reports in the medical literature of illnesses caused by vehicle-borne [pathogens], so having an injection performed in your car may increase your risk for complications.”
In response to Lund’s concerns, Salzhauer says, “It does not matter what bacteria you have living under your car seat — it matters what is on your skin, and [that] the area of the injection is cleaned with an alcohol wipe, just [as it would be] in an office.” He also makes the point that “hundreds of thousands of diabetics safely administer their own insulin shots every day in whatever environment they need to — home, office, or car.” And in his opinion, an insulin injection is far more dangerous than Botox.
While neuromodulators like Botox are generally considered lower-risk than fillers, Aguilera says he’s seen mycobacterium infections from Botox injections. He also worries about patients suffering unpredictable vasovagal reactions — fainting at the site of needles or blood — when behind the wheel.
Salzhauer notes in reply that while nothing in life is completely risk-free, “The likelihood of getting an infection from a Botox injection is close to zero,” and cites a retrospective review of cases published in 2007 in the Investigative Ophthalmology & Visual Science journal that found no significant effect on infection rate when the skin was not properly swabbed with isopropyl alcohol beforehand. As for vasovagal incidents, he insists that “they almost always happen immediately or within 60 seconds of the exposure.” If patients are prone to that “woozy feeling,” he asks them to wait a couple of minutes before driving off. “If this were a major issue, you would have heard about it from the drive-thru COVID-19 blood-draw testing centers,” he says.
Beyond the safety and ethical qualms being voiced by the court of public opinion over out-of-office treatments, there’s the obvious question of legality. According to Michael Byrd, a partner with national business and healthcare law firm ByrdAdatto, while each state may have rules as to where the practice of medicine may occur, these nontraditional settings are legally allowed in both New York and Florida.
He goes on to explain, “Doctors must follow the rules to establish a physician-patient relationship, perform an initial exam, and make sure the treatment is performed following OSHA [Occupational Safety and Health Administration] requirements.”
Marmur, for one, is very forthright about the permissions she sought before relocating. “This [move] is verified by many layers of professional approval: lawyers, medical insurance, local governance, and homeowners insurance,” she says.What’s the bottom line?
These are unprecedented times, in every sense of the phrase, and aesthetics doctors — many of whom were sidelined for months and are bracing for future closures — are thinking outside the box that is the standard exam room. “In these times, I’m working as hard as I can to keep my staff hired, and with benefits, even if we have another shutdown in October,” Marmur says.
Lund suggests asking a few key questions before committing to treatments in unorthodox outposts: How will the consultation and examination be performed? How will my treatments be administered, by whom, and what is their training? Are you prepared to manage any potential complications in this setting? For hyaluronic acid injectables, for instance, this means making sure the provider has ample hyaluronidase (an injectable dissolving) on hand to undo mistakes.
Ultimately, when deciding whether or not to partake in out-of-office procedures, you want to prioritize your relationship with the provider, their track record for safety, and their after-hours availability over some semblance of ease or Insta appeal. Trust: a doctor who shares their cellphone number is worth more than all the likes a drive-thru-Botox boom or poolside-Thermage post could possibly garner.
BY JOLENE EDGAR