The pandemic provided the ultimate opportunity for companies and individuals to prove just how resilient, nimble, and creative they could be in a sink-or-swim situation. Clothing brands immediately produced masks in their best-selling dress prints; New York bars started selling $1 slices of bread, to get around Gov. Cuomo’s food-purchase mandate; and one enterprising Illinois family decided to launch a DIY neurotoxin injection service—presumably, to cash in on the fact that we were all stuck at home, obsessing over our faces on Zoom.
The company, which gives consumers with zero medical training the tools to self-inject neurotoxin, is called Mirror Care (somewhere, a Black Mirror writer is kicking themself for not coming up with this episode). The medical and legal experts we spoke with describe it as dangerous, crazy, obscene, shady as hell, completely unethical, and downright mind-bending, but Mirror Care’s president and cofounder, Stanley Kovak, doesn’t see it that way.
“There has been backlash from the medical community, but we believe those concerns center around patient welfare, and we have the same concerns,” says Kovak. “There’s no question that this is innovative, but that doesn’t mean it’s unethical or dangerous.” Let’s dive in.
How Mirror Care works
Who are Mirror Care’s affiliated physicians?
Interested consumers start by setting up a telehealth consultation with a Mirror Care affiliated physician. According to Kovak, these providers are MDs and DOs, but he has refused to disclose any other details regarding their exact areas of medical training or credentialing. Instead, Kovak explains that Mirror Care’s physician qualifications are based on the providers’ “years of experience injecting neurotoxin” and are vetted by the company’s insurance provider and approved by Mirror Care’s chief medical officer and cofounder, his father, Dr. Stanley Kovak. In short, there’s no easy way of knowing what type of doctor will be overseeing your “care”—it could be a dentist or an OB/GYN. Dr. Kovak himself is solely board-certified as an ER doctor, according to Mirror Care and his eponymous cosmetics practice. However, we were not able to substantiate this certification via any third-party source.
It is also unknown how many physicians are currently affiliated with Mirror Care—and Kovak has declined to provide the figure. The service, however, is currently available only to consumers in Illinois, where Dr. Kovak practices. The company claims that the affiliated physicians need to be licensed in the state where their patients are located and confirmed that Dr. Kovak is one of the providers guiding the self-administered neurotoxin injections.
How do consumers use Mirror Care?
Prior to the initial consultation, the patient is required to watch a series of training videos and complete quizzes that cover topics such as the process of injecting, areas that can be treated, and proper injection techniques—steps that Kovak cites as some of the company’s safety precautions. Mirror Care would not provide us with examples of these videos and quizzes, citing proprietary content.
During the consultation, the physician determines if the patient is a good candidate for neurotoxin injections and, if so, how many units will be needed. It is then the physician’s responsibility to procure and prefill syringes with the neurotoxin of their choice, which they ship 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 engaging in the practice of medicine and that only the physicians are determining the proper treatment for the patients.
Is using Mirror Care safe?
Mirror Care’s self-touted safety measures, however, offered no peace of mind to the board-certified dermatologists and plastic surgeons we spoke with, all of whom pointed out dangerous problems and risks at every step in the process, starting 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 kept at very cold temperatures in order to maintain their efficacy. While Mirror Care claims to play no role in the distribution of the neurotoxin, the company says it provides its physicians with shipping technology that keeps the injectable cold during the overnight shipping. But, as Dr. Mariwalla points out, that doesn’t mean the package won’t end up sitting on someone’s doorstep, in the hot sun, for hours on end.
Product authenticity and safety of the prefilled syringes are other potential risks. “How do you know that the neurotoxin was properly mixed and the syringe sterilely filled and recapped? You have no idea who handled the product, nor can you authenticate what it is or the fact that it wasn’t tampered with,” warns Dr. Mariwalla. Mirror Care customers have no way of confirming what type of neurotoxin they’re receiving. Allergan, Galderma, and Merz, the manufacturers of Botox, Dysport, and Xeomin, respectively, told us they had no knowledge of Mirror Care’s practices and weren’t prepared to comment at the time of publication.
As for self-injecting neurotoxins, Kovak likens the experience to that of other at-home injectable drugs, such as insulin. Yet dermatologists point out that there’s no other injectable where exact placement of the injection matters quite so much as it does with neurotoxin. “Neurotoxin injections need to be precisely delivered, both to the correct area and at the correct skin level, for a good outcome,” explains Dr. Joshua Zeichner, a New York City board-certified dermatologist. “Injecting the wrong location or at the wrong depth will lead to suboptimal results. In some cases, even a millimeter of discrepancy in the location of injection can be the difference between a poor and a perfect outcome.”
A poor outcome might mean not only cosmetic issues but also major 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 that happens, you’re stuck with the result for months, since there’s no way to reverse the effects of neurotoxin, he adds.
Long-term damage is also possible. Imprecise injections can puncture an artery and cause extensive, even life-threatening bleeding as well as possible infection; difficulty speaking, swallowing, or breathing; and vision problems. There have even been some catastrophic events, including death, reported for those treated with botulinum toxin manufactured by unregulated sources, says New York City board-certified dermatologist Dr. Dendy Engleman.
Expert injectors make neurotoxin injections look quick and easy because they’ve received years of training, points out Dr. Mariwalla. It’s a level of skill that the average person simply cannot achieve via a few videos and a telehealth appointment. Factors such as camera positioning and angles can also alter what the patient is seeing, compared to the physician, and affect injection placement.
Is Mirror Care legal?
“From a legal standpoint, based on what I’ve seen on the website, Mirror Care’s business seems questionable and suspect,” says attorney Alex Thiersch, founder and CEO of the American Med Spa Association. “The procurement [of neurotoxin] veers into a gray area, but it’s difficult to point to exactly what law [the business is] breaking,” he says, adding that nothing like this has ever been done before. “However, even if the company is somehow getting around the pharma regulations associated with the distribution of the neurotoxin, in my view, it’s likely not going to get around the basic standard-of-care, supervision, and delegation issues.”
In Illinois, physicians are generally able to delegate medical treatments to both licensed and unlicensed people, 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 generally an RN, APRN, or PA, but in this circumstance, the patient is, presumably, consenting to treat themselves. That means the doctor has to deem that the patient is qualified to do so as well as handle any resulting complications. “Although we haven’t seen how the medical board would react to this particular situation, it’s highly unlikely that the board, or any competent physician consulted with, would find that a quick tutorial of injecting neurotoxin is anywhere close to the necessary training to do the procedure safely,” says Thiersch. “Most experts agree that a weekend course is not nearly enough training, so doing one brief tutorial over video cannot possibly be enough to safely administer a neuromodulator.”
As far as the supervision part goes, typically, supervision for neuromodulators requires that a medical professional be on-site, to handle complications. “Under normal circumstances, if a physician allowed an unlicensed individual with minimal training to perform a treatment off-site, without any medical professional on-site, the medical board would not, in my view, consider it proper supervision,” says Thiersch.
According to the dermatologists, Mirror Care’s business model also poses a number of ethical considerations. “As the physician involved, you can’t guarantee that the person receiving the neurotoxin is the person who is going to be receiving the injections,” warns Dr. Mariwalla. “What’s to stop a teenager from getting ahold of their mother’s syringes—or the patient from getting the package, blowing off the telehealth appointment, and then injecting themselves and/or others as they want?”
Kovak says penalties—such as patients being banned from the platform or being fined financially—are invoked in order to further maintain safety, but Dr. Mariwalla says that these won’t deter people who want to do with the neurotoxin as they please.
According to Kovak, Mirror Care’s existing users are extremely happy, though he has refused to disclose how many there are. He cites features such as convenience, not having to leave home, and accessibility as pros 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 parts of the country. In other words: Why do 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 red flag when it comes to who’s collecting the revenue. He cites Illinois law, which allows only doctors to practice medicine and ensures that the flow of money goes through the physician and includes anti-kickback regulations. You have to wonder who is getting paid for what, between the providers and Mirror Care, he says.
Bottom line
At the end of the day, the legality of what Mirror Care is doing is suspect at best, says Thiersch. “I have no doubt that the medical board in the state of Illinois—and any other states where this company tries to operate—will look at this and immediately open an investigation. If I were a provider and this company reached out to me, I’d run for the hills. The public needs to know that this is not okay.”
“The first oath we take in medicine is ‘Do no harm,’ says Dr. Engelman. “This seems completely contradictory to everything we are taught and hold dear, a breach of ethics that presents huge risk for harm to be caused.”
To put it mildly, this isn’t just a case of buyer beware. It’s a case of: Don’t even think about it.
