Dr Michelle Copeland, a New York plastic surgeon, said that she regularly receives such faxes.
"You know it's fake," Copeland said. "It's so inexpensive. I don't know where it's coming from. I would never buy it."
Allergan sells Botox only to licensed health care professionals, according to Fagan. But Advanced Integrated is licensed by the state as a therapeutic massage salon, not a medical clinic, according to state records. The director of the clinic, Thomas Toia, is a chiropractor, not a doctor.
Fagan wrote in an e-mail message that she could not comment on why Allergan shipped any Botox at all to Advanced Integrated, citing the ongoing investigation.
"When any account is established, we require proof of the health care practitioner's license," she added. A voice mail message greeting callers to Toia's line at the clinic said the mailbox was full. The clinic has been closed.
It is next to impossible to contract a case of botulism poisoning from Botox, according to interviews with several plastic surgeons and dermatologists. Dr Alastair Carruthers, a Vancouver dermatological surgeon who has studied botulinum toxin A for three decades, explained that exceedingly small doses of the purified botulinum toxin are injected. The toxin binds to the nerve endings in the injected muscles, blocking the release of the chemical that would otherwise signal the muscle to contract.
"The kinds of doses necessary to produce botulism would be in the range of 100 vials or more," Carruthers said. "And it would have had to have been injected directly into the diaphragm."
Carruthers said that it is unlikely that Allergan produced a faulty batch.
"It sounds like someone was cooking up some Botox in their kitchen or basement and got it wrong," he said.
But how could just anyone get his hands on botulinum toxin A?
"Look outside," he said. "Every shovelful of dirt contains the organism which will produce botulinum toxin." While the bacteria and spores themselves are harmless, the toxin produced when the spores are grown in an anaerobic environment can cause weakness and paralysis and can be fatal.
In the US, an average of about 110 cases of botulism are reported each year, according to statistics from the Centers for Disease Control. Of these, approximately 25 percent are food-borne, 72 percent are infant botulism, and the rest are wound botulism, frequently associated with intravenous drug use.
While Allergan stock took a dip last week, by week's end it had rebounded. "This has not created a panic," said Dr Steven Teitelbaum, a Los Angeles plastic surgeon. "Reasonable people know that hundreds of thousands, if not millions, of people have received Botox treatments," he said, and no one has ever contracted botulism before.
He suggested that patients use common sense. "First, be sure your doctor is a doctor," he said. "Second, be sure they have actually been trained in what they are doing. Third, Google them, and if the second item on the first page of a Google of their name is a link to a story saying that they were arraigned for running a pill mill, then consider finding another doctor."
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