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Adding Ancillaries: Botox injections


This is the seventh in a series of articles on specific ancillary services that can boost your bottom line and keep you and your practice busy in a competitive market.

One person's poison is another's passion and this is certainly true with Botox Cosmetic, a derivative of Clostritium botulinum that paralyzes muscles and keeps you from frowning or wrinkling. The craze may have started in Hollywood, and first become popular in New York and Los Angeles, but now millions of women (and some men) across the country are demanding-and getting-the smooth, young faces that Botox provides. In fact, Botox injections are the most popular cosmetic procedure performed in the US.

The number of minimally invasive cosmetic procedures such as Botox injections has risen dramatically, from 1.6 million injections in 2002-when Botox first received FDA approval for cosmetic use-to more than 2.9 million anatomic sites injected in 2004, according to the American Society of Plastic Surgeons. Although Botox is only approved for smoothing of the glabellar lines between the eyes, it's used off-label for multiple other cosmetic reasons such as crow's feet and laugh or frown lines.

Ob/gyn James Mirabile capitalized on the burgeoning popularity of Botox by incorporating it as an ancillary service and later opening MedCOSMETIC, a cosmetic services facility. Mirabile, who practices in Overland Park, KS, also leads educational seminars for doctors who are interested in adding Botox and other similar services to their practices. He's seen a growing number of primary care physicians reach beyond their traditional purview to include services like Botox and reap the rewards. One three-person FP group in Charlotte, NC, boosted its gross revenue by 16 percent just from Botox alone.

Botox must be purchased from Allergan, the exclusive manufacturer of botulinum toxin type A. The drug arrives packed on dry ice and must be kept frozen. Botox Cosmetic should be administered within four hours after the vial is removed from the freezer and reconstituted; during this four-hour period, the solution should be stored in the refrigerator. Since most offices already have a refrigerator with a small freezer section, you shouldn't need any additional equipment or materials, aside from disposable syringes and sterile saline to reconstitute the drug.


Extra exam rooms or storage space aren't required.


Allergan requests that anyone who gives injections be trained by someone with knowledge of neuromuscular and facial anatomy. "Many of the major dermatology and plastic surgery associations give courses around the country, teaching professionals how to administer Botox," says dermatologist Edward Lack of the American Academy of Cosmetic Surgery, in Chicago. The American Society of Dermatologic Surgery in Rolling Meadows, IL, for example, provides courses at its meetings, where registration runs in the vicinity of $650 to $1,000.

If you'd like your nurse practitioner or physician assistant to give injections, they, too, can take courses. But first, Mirabile advises, "Check with your state licensing boards regarding who can deliver the drug and if midlevel providers can perform the service under supervision of a licensed physician."


Each vial of Botox costs about $470. Syringes run about $20 per box, and a case of saline is only about $10. "Be careful of the cheaper, phony Botox sold on the black market by companies other than Allergan," Mirabile cautions. Botox is sold in 100-unit vials and when reconstituted has only a four-hour shelf life; by booking patients in large blocks of time, it's unlikely that any of the drug will go to waste. Even if you have some left over, Mirabile says, the solution should remain potent for about a week once the vial is opened, as long as it's refrigerated.

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Jennifer N. Lee, MD, FAAFP
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health