Given that it’s cold and flu season, patients will no doubt be headed in droves to doctors’ offices and pharmacies in search of antibiotics – particularly a powerful one called Zithromax, also sometimes called a Z-Pak.
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These prescriptions are most commonly used for bronchitis, sinus infections, pneumonia and other respiratory infections. It tends to be more popular than other similar drugs because its potency allows it to be taken for a shorter period of time.

However, our Boston personal injury lawyers have learned that the drugs are also now tied to a sudden deadly heart problem. That’s according to a recently-concluded 14-year study conducted by Vanderbilt University researchers in Tennessee.

The risk was reportedly relatively rare, but surprising, and not one that has been advertised by distributors or warned about by doctors or pharmacists.

Researchers looked at outcomes for nearly 550,000 patients who were given Zithromax between 1992 and 2006. Of those who took the five-day treatment, there were approximately 30 heart-related deaths. That was more than double the rate of what patients who had taken other antibiotics – or no antibiotics – had suffered.

So per 1 million Z-Pak patients, researchers estimated about 85 would be at risk for a sudden heart death, compared to 32 among patients who took amoxicillin and 30 among those who took no antibiotics at all. To put it another way, there would be 47 more heart-related deaths among those patients given Z-Paks versus those given amoxicillin.

Researchers said they controlled for heart risks, meaning that those in each category were no more at risk for a heart complication or problem than those in any of the other groups.

Although the risk at first glance may appear to be relatively low, consider that some 40 million people in this country are prescribed the drug annually. That means that on average, we’re talking about 3,400 deaths a year from sudden heart problems caused by this drug. That is a significant number.

Those with existing heart complications undoubtedly should be steered away from the drug, as should those with lower-than-normal levels of magnesium or potassium in their blood.

Doctors worry what the longer-term effects might be of this news, and whether there are other potential risks involving the drug that we don’t yet know about. Z-Paks, which are marketed by Pfizer Inc., have only been around for about 20 years, which means we may yet have a lot to learn. Sales last year alone for the drug topped nearly $465 million.

There has been past research that has shown that Z-Pak’s might benefit people who have severe lung disease, but in light of this new information, it’s not clear whether those individuals should continue to take it.

In response to the study, which was recently published in the New England Journal of Medicine, federal authorities with the U.S. Food and Drug Administration have issued a formal notice to doctors. Additionally, the agency announced that new labels warning of the risk would be added to the prescription bottles, so they could be easily read by patients.
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An unfortunate accident in Dorchester left two children seriously injured. According to the Boston Globe, the man is being charged for driving under the influence.

The at-fault driver reportedly struck the children as they attempted to use the crosswalk at the intersection of Dorchester and Talbot avenues at about 6:00 p.m. Accident reports indicate that the 28-year-old drive appeared to be intoxicated and he failed a number of sobriety tests. He has been charged with negligent operation of a motor vehicle, operating under the influence of drugs and operation after license suspension. The child pedestrians were transported to Boston Medical Center.
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Our Boston personal injury attorneys understand that our child pedestrians are most at risk. Whether drivers are intoxicated or not, many of them overlook children. To make it even worse, these young pedestrians don’t always understand the workings of traffic and unknowingly put themselves at risk. Sit down and talk with the child in your family and make sure they know how to act near vehicular traffic — their safety relies on it.

According to SafeKidsUSA, there were close to 400 children under the age of 14 who were killed each year since 2000 in pedestrian accidents. In 2009, there were about 244 child pedestrian fatalities recorded in the U.S. In addition, there were close to 15,000 child pedestrians injured in these same scenarios. Although this number is on the decline, we’re still losing way too many of our youngsters.

With spring break approaching, our children are going to be spending more time outside and spending more time in dangerous situations. The maturity level of children under the age of 10 makes them less able to correctly gauge road dangers and renders them at greater risk for injury and death.

Talk to your child about always using a crosswalk or a street corner to cross the road. Make sure they know to look in all directions before stepping out. They need to know to never assume that a driver sees them. Always make sure that children make eye contact with drivers before attempting to cross.

When you’re walking with your child, make sure to hold their hand. This goes for sidewalks, when crossing the street and even when walking in parking lots.

You should always beware when sending children to the bus stop. Make sure they know to wait at the bus at least 5 giant steps from the roadway. Make sure they’re in bright clothing so that motorists can see them more easily. If they’ve got to walk along a road that has no available sidewalks, make sure that they know to walk facing oncoming traffic as far from cars as possible. You also want to teach them that this is no time for horseplay. Always stay aware of your surroundings.
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If there’s a young child in your household — Listen up! Officials with the Consumer Product Safety Commission (CPSC) recently released new standards to help to keep children safe in play yards.

Play yards are those framed enclosures that have a solid floor and fabric or mesh for side panels. They can be folded for storage or for travel. They can also be dangerous for your child.
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Last month, CPSC officials announced new standards as a part of the Danny Keysar Child Product Safety Notification Act. It’s also called “Danny’s Law” and it was named after a young child who was killed back in 1998 in Chicago while he was napping. He was napping in one of these play yards when it collapsed and he was suffocated. The Act is working to make sure that this doesn’t happen to another family.

Our Boston child injury lawyers understand that these devices are designed to offer our children a safe place to play and nap. Unfortunately, many of the designs are faulty and can serve up some serious dangers to children. With the new standards, the design should be safer and should provide parents with more peace of mind.

New Standards for Play Yards from the CPSC:

-Play yards must have safe rails. They can’t have rails that have sharp edges that can cut children.

-They’re required to have stronger brackets. These brackets are to help to prevent any kind of sharp edges or cracks to prevent a collapse.

-The mattresses are to be sturdier. The attachments that keep the mattresses to the floor are also required to be sturdier. This is to help children from getting trapped, suffocated or sustaining other injuries.

There are other things that parents can do to help to ensure their child’s safety while in play yards and in cribs. These safety precautions start with the items you place in with the children. You want to be careful of the pillow and blankets you offer your child. We want them to be comfortable, but we want them to be safe.

Officials with the CPSC estimate that there were about 700 children under 12-months who were killed from 1998 to 2010 because of the pillow and blankets that were in their cribs and sleep environment. The safest way to allow your child in a crib is with no pillows, no heavy quilts, no thick blankets, no pillow-like stuffed toys or other large stuffed toys and no child carrying devices, recliners or sleep positioners.

Be cautious of what you offer your child in their crib or play yard. Sometimes, the soft and comforting items can quickly turn deadly.
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The federal government has issued a permanent injunction against an Ohio drugmaker for numerous violations related to cleanliness, appropriate practices and investigations.lab.jpg

Our Boston personal injury lawyers know that the U.S. Food and Drug Administration has really given Ben Venue Laboratories Inc. more chances than it ever deserved to get its act together. That the FDA has taken such a strong stance in actually shutting down operations speaks volumes not only of the severity of violations here, but also of a repeated and blatant unwillingness or inability to address these problems.

The FDA has a list of minimum requirements that drugmakers have to meet in order for operations to be considered abiding by good manufacturing practices. The end goal is that the companies will ensure both the purity and quality that the company advertises is actually what patients are getting.

These minimum requirements include things like sterile work environments, efforts to minimize contamination and proper training and protocol for staffers. Drugmakers really should be going above and beyond these standards, as they are a minimum.

But Ben Venue, a primary manufacturer of certain cancer drugs, including Doxil, apparently couldn’t even do that, according to the government, and this move was a long time in coming.

Since February 2002, the firm has had no fewer than 40 recalls of its products and drugs. Ten of those have occurred just in the last handful of years, and France and Germany have actually forbidden Ben Venue’s drugs to be sold. About a quarter of those recalls were prompted by reports of serious negative health effects and the risk of death.

Back in 2010, the FDA conducted an inspection of the company and found that a leaking roof caused metal contamination in two different medications. That inspection also reportedly found mold in areas where the drugs were made, equipment that was rusted, glass contamination and a huge bucket in the manufacturing area that contained urine. A number of the medications were found to have been contaminated with bacteria.

This was followed by another inspection in the spring of 2011. Following that, FDA inspectors reported some 48 violations that included untimely and insufficient investigations, failure to prevent contamination of products, inadequate quality control and employee practices that were sorely lacking.

Another month-long inspection at the end of 2011 prompted company officials to voluntarily shut down operations, where some 1,300 people were employed. A number of drugs were also recalled, including those used to treat patients with ovarian cancer, AIDS, viral eye infections and those with myelodysplastic syndromes (bone marrow diseases).

But the halting of operations at the lab created a huge problem: exacerbation of the serious shortage of Doxil, which already had a waiting list of cancer patients hoping to gain access to the drug.

So as part of the injunction, FDA is allowing the firm to continue making Doxil and a few other in-demand drugs, but under an extremely intense microscope and only after adopting a number of corrective actions. Before the firm can fully resume operations, it must:

  • Hire an outside expert to regularly inspect the facility and to conduct batch-by-batch quality control tests;
  • Develop and implement a remediation plan;
  • Undergo an in-depth FDA inspection to make sure that operations are in full compliance with the law.

Unless and until these criteria are met, Ben Venue will not be able to resume full operations.

That it took such severe and repeated violations for the firm to be ordered into compliance is beyond disappointing. Those who have been harmed by Ben Venue’s products should contact an attorney to discuss the potential for compensation.
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As news spread of the dangerous GranuFlo and NaturaLyte products being used in kidney dialysis facilities across the country, our Boston dialysis lawyers wanted to know how our local dialysis centers are rated when it comes to things like cleanliness, mortality, hospitalizations and infections. injection.jpg

Turns out, there is a troubling amount of room for improvement.

News organization ProPublica conducted extensive research into the issue of kidney dialysis safety, publishing a series of articles detailing widespread problems among the nation’s dialysis providers. Reporters also created a database of facilities nationwide, posting periodic updates with the latest inspection reports on each facility, which is searchable by city or zip code.

Here are the basics:

Every year, taxpayers shell out approximately $20 billion to help pay for patients who are on dialysis. That’s about $80,000 a year per patient, mostly through Medicaid. That is more than any other developed country in the world. And yet, the U.S. has one of the highest mortality rates for those in dialysis care.

It’s true that some 400,000 people a year depend on this treatment to keep them alive, as many patients are gravely ill to start. But it’s precisely this latter fact that causes people not to bat an eye when it’s revealed that someone receiving the treatment has died. It’s sometimes chalked up to the pre-existing condition.

But all too often, that’s not the case, and had the treatments been administered appropriately and according to the minimum standards of care, these deaths would have been prevented.

Among some of the common findings by ProPublica’s year-long research, facilities were notoriously lacking in cleanliness. In some cases, there were instances of pests running rampant and blood splattered on walls, floors and seats.

Many of these facilities may be “overseen” by a doctor, but they are run either by nurses or even LPNs or aides, some without any extensive medical training. As a result, needles are routinely improperly injected. When this happens or when the needle comes out during the procedure, the patient is at risk of severe illness and death.

Several facilities have been cited in recent years when patients were exposed to a host of dangerous infections while receiving treatment there. Among those infections: HIV, tuberculosis, staph and hepatitis. One center out of New York was closed when cross contamination resulted in three patients being infected with hepatitis C within just six months. Considering these individuals are already coping with a weak immune system, this kind of thing is truly unacceptable.

But perhaps more disturbing is the fact that so many of these facilities with ongoing problems remain open. One of those, located in Tennessee, had been cited on numerous occasions for things like: inadequate care, dangerous conditions, improper dispensing of certain medications, subpar clinical results and higher-than-expected mortality rates. But it stayed open. Just nine days after an inspection noting those problems, a 66-year-old who came in for treatment was mistakenly given a dose of medication meant to dissolve clots. He died several hours after leaving the center – of a massive brain hemorrhage.

It should not have happened, though the government oversight agency defended its lack of action against the facility by saying that it’s not in the business of shutting these firms down.

In Boston, there are 10 major dialysis centers noted in the ProPublica database. A number of those appear to meet state standards. However, a few have mortality rates that are more than twice as high as both the state and national averages (47 percent compared to 22 and 20 percent, respectively).

Hospitalization rates were an average of 15 percent higher than the national rate, and there were a number of major deficiencies, which are those characterized by widespread or serious problems with care. One facility was noted to have 33 standard deficiencies and four major deficiencies.

Individuals who have suffered from negligent dialysis center care – or those who have watched helplessly as a loved one endured it – should contact our Boston personal injury lawyers today.
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Everyone who has ever known a doctor or who has watched doctor shows on television knows about the medical residency process. The medical residency process is essentially an apprenticeship (and a test of endurance) wherein a medical school student or med school graduate observes and provides care under proper supervision. The purpose is to learn medical techniques and get real-world hands-on practice treating patients. Residents typically work very long hours, often for minimal pay, and may be on call with few vacations or days off for lengthy periods of time.

While long nights and days may seem a rite of passage for new doctors, on February 22, however, the Wall Street Journal addressed the potential dangers created by a system where those providing care are continuously overtired. Our Boston injury attorneys believe that the points made in the Journal are extremely important ones that should give any patient cause to be concerned.

Medical Residents May be Dangerously Fatigued
According to the Wall Street Journal, there was no limit on the number of hours that a medical resident could work prior to 2003. This meant that residents could work multiple 36-hour shifts in could end up getting little or no sleep for days.

To try to address this problem, the Accreditation Council for Graduate Medical Education established a new rule in 2003. The Accreditation Council is the Council that approves and accredits training programs in U.S. hospitals so hospitals must comply in order to remain eligible to train resident physicians. The Accreditation Council’s new rule limited residents to working only 80 hours per week. In 2011, the Accreditation Council then went even further and banned first year residents from working 24-hour overnight shifts.

Some, however, suggest that hours could be cut even further. In Europe, for example, residents are limited to working only 48 hours per week. One argument in favor of imposing a tougher limit more closely resembling the European standard is that cognitive performance is reduced because of fatigue. A person who gets insufficient sleep, in other words, can be just as impaired and have functioning just as interrupted as a drunk driver and probably shouldn’t be making life and death decisions.

Counter-arguments also exist, of course, and were published in the Wall Street Journal as well. The author of the article, for instance, indicates that the cost of further restricting residents hours could be crippling for cash-strapped hospitals. Further, the author suggests that this extra cost might not be worth it since there is no evidence that limits on residents hours actually help people to stay safe. In fact, shorter shifts means more frequent hand-offs of patients from on doctor to another, which creates a continuity problem that can be dangerous.

How to Keep Patients Safe
The top priority in every situation should be keeping patients safe. Unfortunately, it is unclear whether it is best to restrict residents from working too long, thus avoiding the risks of fatigue but increasing the risk of information being lost as a patient transitions from one care giver to another.

It does, however, seem clear that there is some need to limit the amount of hours that a resident works. Whether the limit should stay at 80 or be reduced to a lower number is an area of controversy, but almost all agree that there does need to be some guidelines to prevent residents from providing medical help when they are too overtired to be safe and effective.
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On February 2, 2013, the New York Times published an article indicating that drugmakers were not placing as much emphasis on television advertising as in the past. Our Boston injury attorneys were glad to hear this news, as television ads can encourage patients to push doctors for unnecessary and untested pills that may later turn out to be dangerous. 1115701_black_and_white_crime_2.jpg

When a drug is advertised on television, its side effects and serious potential risks are often glossed over or downplayed, although they must be mentioned. Drugs may also be heavily advertised that later turn out to be seriously dangerous to patients. Drug advertising is risky because it encourages those watching the ads to jump into taking a medication without a full understanding. As such, any cuts in advertising on TV could help to keep people safer.

Drug Ads Declining
The New York Times provides some specifics on the decline in the popularity of drug ads on television. According to the Times:

  • Spending on advertising name-brand prescriptions on TV has dropped more than 20 percent over the past five-year period. This is a marked contrast in a market that was a fast-growing venue just a few short years ago.
  • Drug companies spent an estimated $3.1 billion advertising their products in 2007 according to Nielsen. However, spending fell considerably in 2010 and 2011 in sharp contrast to the advertising push that began when the FDA lifted its regulations in 1997 to allow drug makers to advertise directly to consumers.

The Times also provides some specific potential reasons why drug makers may be slowing down on the advertising. The reasons include:

  • Controversy over the ads.
  • Complaints from health insurers about the fact that customers were driven to request expensive new drugs.
  • Complaints from doctors who also complain that patients pressure them into prescribing new and potentially unnecessary drugs that are heavily advertised.
  • The risk that dangerous drugs can more quickly become widespread due to heavy ad campaigns, even if the products are new and untested.

In 2004, the last point was illustrated clearly when Vioxx had to be withdrawn from the market. Vioxx had been very heavily advertised before studies revealed an increase risk of strokes and heart attacks for those on the popular medication. Merck had to pull the drug from the market, but the damage was done and many people were hurt solely because they requested a drug that had been so widely advertised on TV.

Why Drug Ads Are Dangerous
Drug ads are very risky because they are most likely to be for new and potentially untested drugs. The longer a drug is on the market, the more problems come to light and the more confident patients can be that the side effects are well-known (but the less interest in ads there will be, especially if a generic version is available and the drug is no longer a big money-maker).

When a brand new drug is released and suddenly everyone is taking it or asking for it because it is so heavily advertised, then it may start to replace older and safer products. A larger group of people may take the new – and dangerous- drug before any side effects become known and more people could be hurt if it later turns out that the drug was harmful.
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GranuFlo and NaturaLyte were two products made by a drug manufacturer called Fresenius Medical Care. The products were used in dialysis centers operated by Fresenius as well as at other centers throughout the United States.

Unfortunately, the Fresenius dialysis solutions turned out to be very dangerous products that significantly increased the possibility that a dialysis patient would suffer from cardiac arrest. Our Boston injury attorneys believe that Fresenius was responsible for the deaths that occurred due to its defective and dangerous products and we believe that the company will be held liable in the numerous lawsuits that have already been filed. 778761_heart.jpg

Lawsuits Filed Against Fresenius
Fresenius products were used by thousands of dialysis patients throughout the United States, all of whom were put at risk. The problem arose because doctors were not warned that GranuFlo contains a substance that converts into bicarbonates when it is in the body. The solution, therefore, was not mixed correctly by physicians to account for the extra bicarbonates. Too many bicarbonates can result in cardiac problems developing, including catastrophic heart injuries and even cardiovascular death.

As a result of the improper use of the dangerous GranuFlo and NaturaLyte products, many patients did suffer heart attacks or experience strokes. Because these adverse medical events can be traced directly back to the bad dialysis solutions, Fresenius should be responsible for compensating victims who suffered.

Lawsuits have already been filed across at least eight different states in order to hold Fresenius accountable for what the company did. The lawsuits were filed in states including Ohio, Texas, Florida and California and all allege dosing errors that resulted from the negligence of Fresenius Medical Center.

The patients who suffered the deaths due to Fresenius who have already filed suit range in their ages from 23 to age 89. All have something in common though: they suffered as a result of the use of Fresenius’ products and some even died from cardiac arrests or strokes.

These initial lawsuits may be only the tip of the iceberg, as many others who suffered from complications due to GranuFlo and NaturaLyte will likely also take legal action or have already begun the process of doing so. When a product is used as widely as GranuFlo and NaturaLyte, it doesn’t just injure a few people but instead injures thousands throughout the country.

All of these plaintiffs normally join together in class actions and/or in multi-district litigations in order to hold the manufacturer of the defective medical product accountable. In fact, on December 12 we discussed a motion that had been filed to establish a multi-district litigation.

Holding Fresenius Accountable
When there are multiple different lawsuits against a single manufacturer based on a single product defect, then the first lawsuit to go to trial is normally very important. This case will be the first to test in court in whether it can be proved that Fresenius is accountable to its patients for injuries. If the trial ends in favor of the plaintiff and a large verdict is awarded, then Fresenius may be much more eager to settle the case quickly and for a fair amount of money for all plaintiffs.

While this can be a desirable outcome for those who have been injured by Fresenius, you should not wait to see how the lawsuits unfold before you take action if you have been hurt. You have only a limited amount of time to file your claim within the statute of limitations and you want to be sure you have a chance to stand up for yourself and to fight to obtain compensation for your own injury or for the loss of a loved one due to the dangerous Fresenius products.
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Transvaginal mesh is a type of surgical mesh product that became a popular choice for treating stress urinary incontinence (SUI) and pelvic organ prolapse (POP). Both SUI and POP are conditions that are caused by muscle weakening and doctors traditionally had to perform surgery to strengthen the muscles. Transvaginal mesh presented an easier alternative by permitting doctors to use the surgical mesh to fashion a sling to hold the pelvic organs in place where they belonged.

Unfortunately, Transvaginal mesh turned out to be far from the easy solution that was promised to patients. The mesh began to cause very serious complications including significant pain for women as well as infections and recurrent POP. Often, revision surgeries were required and the entire process of treating the complications became a painful and expensive one. 1385735_sterilisation.jpg

In light of the many problems, thousands of transvaginal mesh lawsuits were filed, including around 1,800 claims against Ethicon, a manufacturer of Transvaginal mesh and a subsidiary of Johnson & Johnson. The first of these cases went to trial in February and our Boston transvaginal mesh lawyers have been closely monitoring the case as the outcome can affect transvaginal mesh compensation for all injured plaintiffs.

Accusations of Intentional Complications

On February 16, the Herald Online reported an update in the transvaginal mesh case. According to the Herald Online, the attorneys for the plaintiff in the case against Ethicon showed emails and video tapes revealing that Ethicon had ignored reports of complications caused by Transvaginal mesh.

According to the evidence presented, at least one doctor expressed grave concerns about whether the transvaginal mesh products were safe. Ethicon executives, however, apparently ignored these concerns because they were so eager to get their product onto the market and start selling it.

In one of the emails that an Ethicon executive wrote, the doctor expressing concerns was told that his opinion was respected and that Ethicon would be following up. Of course, Ethicon never did follow up and the product was released on the market in order to compete with AMS mesh, a product that was being offered by a competitor.

The Responsibility to the Consumer
The information on the video and in the emails about Ethicon ignoring possible problems with their product is strong information that shows the company should be held responsible for the damages that their product caused.

All manufacturers of products are expected to release only reasonably safe items to the public. In fact, a tough standard called strict liability is used to impose responsibility on manufacturers whenever their products cause harm when used as they should be, regardless of whether a manufacturer was negligent or intentionally did anything wrong.

In this case, Ethicon did more than just fail to identify a potential problem. The evidence indicates that the company had at least one warning that their product caused complications and that they ignored that warning. This is egregious behavior and the company should be responsible for all of the harm they caused to thousands of women.
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Our Boston medical malpractice attorneys are seeing a shift in the kinds of clients who seek legal help for mistakes caused by their cosmetic surgery/procedure providers. syringesandvial.jpg

It’s in line with the trend recently reported by the American Society of Plastic Surgeons. Last year – for the first time in half a dozen years – the number of breast and buttocks augmentations are actually down, while facial surgeries, injections and laser procedures are on the upswing.

Primarily, this is being attributed to the fact that cosmetic surgery patients are skewing older these days. A big part of this is the aging of the baby boom generation. People in their 50s and 60s are less likely to be interested in breast augmentations and more likely to be concerned with smoothing their facial wrinkles and fine lines.

There is, of course, nothing wrong with this, and it’s a major confidence booster to many who undergo these procedures successfully. What’s troubling to us is that these “less invasive” procedures – namely injections and laser treatments – are being colored by providers as somehow being without significant risk. This is not true, and that kind of message is dangerous on two fronts. First of all, patients should be informed of all potential risks anytime they submit to a procedure, whether it’s elective or not. Secondly, regardless of whether a doctor has adequately informed you of the risks, you have a right to expect that he or she has the education, skills and appropriate tools to conduct the procedure without harm.

Too frequently, that’s not what we’re seeing.

Breast augmentations, which remain the most popular cosmetic surgery with about 285,000 women undergoing it last year, has actually dipped by about 7 percent. Buttocks augmentations, dropped by about 35 percent in the last year.

But overall cosmetic procedures saw a 5 percent rise, with about 14.5 million people seeking out either surgery or injections or laser treatments last year.

The latter of these are increasingly the norm, as a growing number of baby boomers are seeking out these kinds of services.

Of course, we all know surgery has its risks – infections, hematoma, numbness, anesthesia complications, even death (though thankfully, that last one is fairly rare). One of the best ways to reduce that risk is to choose a surgeon who is board certified by the American Board of Plastic Surgery.

With facial surgery in particular, there have been problems with things like:

  • Visible scars;
  • Facial paralysis or palsy;
  • Speech problems;
  • Breathing problems;
  • Damage to muscles;
  • Eye drainage problems;
  • Infections.

But there are problems with those injection and laser treatments too.

Sometimes referred to as “skin resurfacing,” laser treatments have been known to result in blistering that can cause permanent scarring. They have additionally been associated with infections and even permanent skin discolorations.

Botox injections, meanwhile, have been known to result in paralysis in some cases. There is also the possibility of an allergic reaction or botulinum poisoning. Either of these can result in severe complications, from respiratory and breathing trouble to paralysis.
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