The Pandemic's Unusual Business Ventures: Mirror Care's DIY Neurotoxin Injections
The pandemic presented a critical juncture for companies and individuals to demonstrate their resilience, agility, and creativity in challenging circumstances. Clothing brands promptly produced masks in their popular dress prints; New York bars initiated the sale of $1 slices of bread to circumvent Gov. Cuomo’s food-purchase mandate; and an enterprising Illinois family chose to introduce a DIY neurotoxin injection service – presumably capitalizing on the fact that we were all confined at home, fixated on our appearances on Zoom.
The company providing consumers with no medical training the means to self-administer neurotoxin is named Mirror Care (somewhere, a Black Mirror writer might be regretting not coming up with this storyline). The medical and legal experts we consulted describe it as perilous, insane, improper, highly dubious, thoroughly unethical, and extremely perplexing, but Mirror Care’s president and co-founder, Stanley Kovak, holds a different perspective.
“There has been opposition from the medical community, but we believe those concerns focus on patient well-being, and we share the same concerns,” says Kovak. “There’s no doubt that this is novel, but that doesn’t imply it’s unethical or hazardous.” Let’s explore further.
How Mirror Care Operates
Who Are Mirror Care’s Affiliated Physicians?
Interested consumers commence by arranging a telehealth consultation with a Mirror Care affiliated physician. According to Kovak, these providers are MDs and DOs, but he has declined to disclose any additional details regarding their specific areas of medical training or qualifications. Instead, Kovak clarifies that Mirror Care’s physician qualifications are based on the providers’ “years of experience injecting neurotoxin” and are verified by the company’s insurance provider and approved by Mirror Care’s chief medical officer and co-founder, his father, Dr. Stanley Kovak. In essence, there’s no straightforward method to determine the type of doctor supervising your “care” – it could be a dentist or an OB/GYN. Dr. Kovak himself is solely board-certified as an ER doctor, as per Mirror Care and his namesake cosmetics practice. However, we were unable to confirm this certification through any third-party source.
It is also unknown how many physicians are currently associated with Mirror Care – and Kovak has refused to provide the number. The service, though, is currently accessible only to consumers in Illinois, where Dr. Kovak practices. The company asserts that the affiliated physicians need to be licensed in the state where their patients are situated and confirmed that Dr. Kovak is one of the providers guiding the self-administered neurotoxin injections.
How Do Consumers Utilize Mirror Care?
Before the initial consultation, the patient is obligated to watch a sequence of training videos and complete quizzes covering topics such as the injection process, treatable areas, and correct injection techniques – steps that Kovak cites as some of the company’s safety measures. Mirror Care declined to provide us with examples of these videos and quizzes, citing proprietary content.
During the consultation, the physician decides if the patient is a suitable candidate for neurotoxin injections and, if so, how many units are required. It is then the physician’s responsibility to acquire and prefill syringes with the neurotoxin of their choice and ship them to the patient. The patient is required to watch more videos and complete more quizzes before self-administering the injections during another telehealth appointment with the same physician. “These are not DIY injections – they’re all guided by a physician in real-time,” says Kovak, who also emphasizes that Mirror Care is not engaged in medical practice and that only the physicians determine the appropriate treatment for the patients.
Is Using Mirror Care Safe?
However, Mirror Care’s self-proclaimed safety measures did not reassure the board-certified dermatologists and plastic surgeons we spoke to, all of whom identified risky problems and hazards at every stage of the process, beginning with the distribution of the neurotoxin.
Dr. Kavita Mariwalla, a board-certified dermatologist in West Islip, New York, explains that neurotoxins such as Botox and Dysport need to be maintained at very low temperatures to preserve their effectiveness. While Mirror Care claims no role in the distribution of the neurotoxin, the company states it provides its physicians with shipping technology that keeps the injectable cool during overnight shipping. But, as Dr. Mariwalla points out, this does not ensure the package won’t end up on someone’s doorstep, exposed to the hot sun for hours.
Product authenticity and the safety of the prefilled syringes are additional potential risks. “How do you know that the neurotoxin was properly mixed and the syringe was filled and capped under sterile conditions? You have no clue who handled the product, nor can you verify what it is or whether it was tampered with,” warns Dr. Mariwalla. Mirror Care customers have no means of confirming the type of neurotoxin they’re receiving. Allergan, Galderma, and Merz, the manufacturers of Botox, Dysport, and Xeomin respectively, informed us they had no knowledge of Mirror Care’s practices and were not prepared to comment at the time of publication.
Regarding self-injecting neurotoxins, Kovak compares the experience to that of other at-home injectable drugs, such as insulin. Nevertheless, dermatologists note that there’s no other injectable where the precise location of the injection is as crucial as it is with neurotoxin. “Neurotoxin injections need to be precisely delivered, both to the correct area and at the correct skin depth, for a favorable outcome,” explains Dr. Joshua Zeichner, a New York City board-certified dermatologist. “Injecting in the wrong place or at the wrong depth will result in suboptimal results. In some cases, even a millimeter of difference in the injection location can be the distinction between a poor and a perfect outcome.”
A poor outcome could not only involve cosmetic issues but also significant problems, including bleeding, ptosis (the technical term for a droopy eyelid), and temporary paralysis, says Dr. Samuel Lin, a board-certified plastic surgeon in Boston. Once this occurs, you’re stuck with the consequence for months, as there’s no way to reverse the effects of neurotoxin, he adds.
Long-term harm is also possible. Inaccurate injections can puncture an artery and cause extensive, even life-threatening bleeding as well as potential infection; difficulties in speaking, swallowing, or breathing; and vision problems. There have even been some catastrophic incidents, including deaths, reported for those treated with botulinum toxin produced by unregulated sources, says New York City board-certified dermatologist Dr. Dendy Engleman.
Expert injectors make neurotoxin injections appear rapid and effortless because they’ve undergone years of training, points out Dr. Mariwalla. It’s a skill level that the average person simply cannot attain through a few videos and a telehealth appointment. Factors such as camera positioning and angles can also modify what the patient sees compared to the physician and affect injection placement.
Is Mirror Care Legal?
“From a legal perspective, based on what I’ve observed on the website, Mirror Care’s business appears questionable and suspect,” says attorney Alex Thiersch, founder and CEO of the American Med Spa Association. “The procurement [of neurotoxin] enters a gray area, but it’s challenging to pinpoint exactly which law [the business is] violating,” he states, adding that nothing similar has ever been done before. “However, even if the company is somehow circumventing the pharma regulations related to the distribution of the neurotoxin, in my opinion, it’s likely not to overcome the basic standards of care, supervision, and delegation issues.”
In Illinois, physicians are generally capable of delegating medical treatments to both licensed and unlicensed individuals, provided that the person they delegate the treatment to is trained, qualified, and properly supervised, and informed consent is obtained, explains Theirsch. In the case of neuromodulators, this is typically an RN, APRN, or PA, but in this situation, the patient is, presumably, consenting to treat themselves. This means the doctor must deem that the patient is competent to do so and handle any resulting complications. “Although we haven’t witnessed how the medical board would respond to this specific circumstance, it’s highly unlikely that the board, or any competent physician consulted, would find that a brief tutorial on injecting neurotoxin is anywhere near the necessary training to perform the procedure safely,” says Thiersch. “Most experts concur that a weekend course is far from sufficient training, so undertaking one brief tutorial via video cannot possibly be adequate to safely administer a neuromodulator.”
As for the supervision aspect, typically, supervision for neuromodulators requires a medical professional to be on-site to handle complications. “Under normal conditions, if a physician permitted an unlicensed individual with minimal training to perform a treatment off-site, without any medical professional present, the medical board would not, in my view, consider it proper supervision,” says Thiersch.
According to the dermatologists, Mirror Care’s business model also presents several ethical considerations. “As the involved physician, you can’t guarantee that the person receiving the neurotoxin is the one who will be administering the injections,” warns Dr. Mariwalla. “What prevents a teenager from obtaining their mother’s syringes – or the patient from receiving the package, skipping the telehealth appointment, and then injecting themselves and/or others as they desire?”
Kovak claims that penalties – such as patients being banned from the platform or being fined financially – are imposed to further ensure safety, but Dr. Mariwalla asserts that these will not deter people who wish to handle the neurotoxin as they please.
According to Kovak, Mirror Care’s existing users are extremely satisfied, although he has refused to disclose the number. He cites features such as convenience, not having to leave home, and accessibility as advantages for consumers.
Mirror Care charges $19 per unit, a flat rate that includes the cost of the neurotoxin itself, as well as shipping, the initial consultation, and the virtual injection session. The doctors were quick to note that this is in line with the cost of having neurotoxin injections administered by a trained professional in many regions of the country. In other words: Why undertake it yourself and risk potentially permanent injury, for the same price it costs to have a professional do it? Thiersch says this pricing structure raises a legal concern when it comes to who is collecting the revenue. He cites Illinois law, which permits only doctors to practice medicine and ensures that the money flow goes through the physician and includes anti-kickback regulations. One has to wonder who is being paid for what, between the providers and Mirror Care, he says.
Conclusion
Ultimately, the legality of Mirror Care’s actions is highly dubious at best, says Thiersch. “I have no doubt that the medical board in the state of Illinois – and any other states where this company attempts to operate – will examine this and promptly initiate an investigation. If I were a provider and this company reached out to me, I would flee. The public needs to be aware that this is unacceptable.”
“The first oath we take in medicine is ‘Do no harm,’ says Dr. Engelman. “This seems completely contrary to everything we are taught and hold dear, a breach of ethics that poses a significant risk of causing harm.”
To put it mildly, this is not just a matter of buyer beware. It’s a case of: Don’t even consider it.
