Due to popular request, we are in the process of creating an advanced course for botox and fillers. Stay tuned for the announcement for the first course which will be in November 2016 !
Dr. Martin's Blog
July 7, 2016
The glabella has been recognized for years as an area of risk for filler, but now has become almost a “no-go” zone. Blood supply to this area is supplied from both sides, but the vessels are small and easily compressed or thrombosed. The supratrochlear and trochlear arteries are situated very close to the glabella. In addition, retrograde flow though the trochlear artery can cause blindness.The prevailing wisdom seems to be that the safest approach is by cannula if targeting SubQ or very superficially into the dermis.
Fillers | June 1, 2016
Question: Do you have a corporation for your aesthetic business? Is it a medical corporation? The answer to this question can have far reaching implications. Recently two situations have come up that illustrate the point.
Doctor A had a corporation (non-medical) for his aesthetic business. The business income was 750,000 with 100,000 income after expenses. He filed corporate taxes and paid the corporate rate – about 17% = $17000. When he was audited, it was ruled that his practice income had to be billed by a medical doctor, not the corporation. So, the CRA attributed the 100,000 income to him personally and taxed him at his personal rate of 40%. As a result, his bill was $40,000 instead of $17,000 which meant that he owed the CRA another $23,000 in addition to the $17,000 he had already paid. Nasty surprise.
Doctor B decided to create two corporations – one for the aesthetics business and one as a true medical professional corporation. Again, it was determined that the income had to be billed by the professional, which meant that the income itself had to go to the doctor’s, not the business. This meant alot of adjustments – first the doctor billed the client for botox, and billed the expenses, then paid the clinic it’s share.
Bottom line – Beware of billing medical procedures like botox through a non-medical corporation. You may not be allowed to do it and if you are investigated by the CRA, your tax bill could be much higher than you thought.
Best to seek out the advice of an excellent tax lawyer who has experience specifically with medical corporations.
Business of Medicine | October 17, 2015
Dysport is one of the “new kids” on the block in Canada. The brand is gaining popularity because it is very similar to Botox, but it is important to know that they are not the same.
Dysport is cheaper – costs about $300 a vial rather than $380CA. The vials are 300 units vs Botox 100 units. Since Dysport is diluted with three times the amount of normal saline, one unit of measurement on the diabetic syringe is the same for both.
At this time, the product monograph for Dysport limits its use to glabella, therefore you must explain to clients that use in any other area is “off label”. Botox has been present in Canada for longer and therefore it’s indications include all areas of the face.
There is some question in my mind about the range of effect and the appropriate dilution of Dysport. Although the manufacturers suggest that it has the same range as Botox – about 1cm, it has been my experience that it actually diffuses further, which is good news for crows feet and hyperhidrois, but one must use extra caution in glabella and forehead.
Botox is also officially indicated for hyperhydrosis. Dysport at this time is not “indicated” for hyperhidrosis. There is no question that it works well for HH – but technically it is still “off label”.
Xeomin has a lower molecular weight than either Botox or Dysport and, due to lower protein count, it has a theoretical lower risk of allergy or tolerance. In our experience, it is more similar to Botox in effect, but it has the price point of Dysport. At this point, the Canadian public is still not as aware of it, but I suspect that it will gain momentum over the next few years.
Botox, Neuromodulators | June 11, 2015
I had one of our past students call the other day and ask about Hyaluronidase. His problem was this: He had inadvertently administered some Juvederm ultraplus more superficially than intended. When the patient came back in 2 weeks, she had a superficial lump. He wanted to know how to fix it.
Hyaluronidase digests hyaluronic acid – both from temporary HA fillers and natural HA. As a result, be as specific as you can about where it is being injected. It comes in a vial of 150 IU/ml from any compounding pharmacy eg. Habers or York Downs in Toronto. I normally draw up between 0.3 and 1.0 ml into a 1cc syringe and inject it as directly as possible into the area of concern. In this case, 0.3 ml into the palpable filler will suffice.
Followup in another 2 weeks. It will take about that long for the hyaluronidase to take effect. If it is not yet flat, then inject another 0.3 ml.