The Botox craze: Are injections appropriate for every practice?

More surgeons trying to expand patient bases by offering Botox injections. This is the final installment of a three-part series.

With the popularity of Botox injections steadily increasing, a growing number of surgeons worldwide are incorporating the drug into their practices.

More than a decade after the Food and Drug Administration approved botulinum toxin for ocular spastic disorders, physicians have found that Botox (botulinum toxin type A, Allergan) and its more recently approved sister product, Botox Cosmetic, can be used to treat a host of cosmetic and functional indications.

A note on nomenclature

Allergan has two product formulations of botulinum toxin. Botox (botulinum toxin type A, Allergan) is indicated for the treatment of cervical dystonia in adults and for the treatment of strabismus and blepharospasm. Botox Cosmetic (botulinum type A, Allergan) is indicated for temporary improvement in the appearance of glabellar lines in adults 65 years of age and younger. Some surgeons use one or the other of these preparations “off label” for other indications.

Patients, meanwhile, have been lured by the promise of a minimally invasive procedure that offers often dramatic results. When used for cosmetic purposes, for instance, Botox Cosmetic can improve deep furrows by about 80% and superficial lines by nearly 100%, according to Mark R. Levine, MD, an oculoplastic surgeon in Cleveland and the Oculoplastic and Reconstructive Surgery section editor for Ocular Surgery News.

In the face of the financial enticements of Botox cosmetic treatments, ophthalmologists must consider whether their practices are prepared to offer these types of procedures — and they also must be realistic about whether they can attract enough patients to make it profitable, experts say.

Steven Fagien, MD, who codirects the Plastic Surgery Education Initiative, supported by Allergan, said that Botox may not be appropriate for every general ophthalmology practice. Surgeons must be willing to invest considerable time in acquiring the necessary knowledge fund, he said.

“I think that there may be some unforeseen risks, if you look at it simply from an economic standpoint. Just like everything else in surgery, you shouldn’t be doing it unless you’ve seen it, understand it and start slowly,” said Dr. Fagien, of Boca Raton, Fla. “If the physician is not willing to take the time to understand exactly what they’re doing and where they’re going with Botox, then they may have a tough road. And the tough road is going to be unhappy patients.

“The complications, fortunately, are temporary and mostly aesthetic and are usually due to an incomplete understanding of the drug and its properties, facial anatomy and patients’ expectations. These events should not be related to the Botox itself and are due to what is situated proximal to the syringe,” he said.

Cost-benefit analysis

Botox itself is expensive. Inadequate storage may deactivate or change the effect of the drug, and even when properly stored, the vials must be used within a few hours of when they are opened. Therefore, surgeons must generate enough patient volume to make the procedure cost-effective, according to Allen M. Putterman, MD, SC.

“Hopefully, with time, the cost of the drug, which is still pretty high, will come down,” he said. “If that’s the case, I think, like anything else, more [patients] will be doing this.”

The cost of a vial of Botox Cosmetic varies from region to region, but it is generally in the range of $400, according to surgeons interviewed. Dr. Levine noted that patients might require anywhere from a quarter to full bottle.

“You have to commit yourself to bringing it out to the patients all the time” with advertising, brochures in examination and waiting rooms, and by having informed technicians to answer questions, Dr. Levine said. “For the general ophthalmologist, it’s going to be a hard sell to your patients.”

He emphasized that the demand for Botox Cosmetic treatments is dependent on the economy and, to some extent, varies from city to city. “Cleveland is pretty conservative,” he said. He added that in a tighter economy, residents are not spending disposable income on elective surgery.

Economy-driven

In general, however, most surgeons interviewed said they have found that recent economic hard times have not hurt – and may have even helped – the demand for Botox Cosmetic in their practices.

“Even in the face of economic downturn over the past couple of years, cosmetic surgical services as well as Botox injections in my practice have actually grown,” said William J. Lipham, MD, FACS, of Bloomington, Minn. “I think this is happening because people want to do something to make themselves feel better.”

He noted that the typical Botox Cosmetic patient is between the ages of 35 and 50, and that this segment of the population is more likely to have disposable income to spend on the procedure. He added that these patients typically receive injections for 4 or 5 years before undergoing more invasive procedures such as laser skin resurfacing, chemical peels and dermal filler agents.

“In the past, some patients had even requested Botox to delay surgical intervention until the economy improved,” said Dr. Fagien. He noted an increase in interest and patients presenting for this treatment when the national economy dipped.

“When the economy is not doing well, to the opposite of what some might expect, people look for minimally invasive procedures,” he said. “They may be considering surgery, but financially they’re not ready to take that leap yet.”

Billing

Despite the growing demand for Botox Cosmetic injections, cost is still the biggest barrier to patients, according to Dr. Lipham. The cost of the procedure might cause some patients to wait longer than the suggested 3 or 4 months before returning for another set of injections, he noted.

“If you have a loss of a cosmetic patient, it’s because they [ask themselves whether] the results justify the expense over a long period of time,” he said.

Surgeons are currently billing for the procedure in one of two ways, Dr. Lipham explained. Most surgeons will bill patients based on the amount of Botox injected, but some charge patients based on the area of the face treated, he said.

Marketing

Physicians who offer Botox Cosmetic are using a number of tactics to attract new patients.

Dr. Lipham noted that the patient demographic is coincident with the patient base for refractive surgery, and ophthalmologists in a group practice might attempt to coordinate with refractive surgeons to internally market the cosmetic treatments.

Dr. Fagien also acknowledged the importance of internal marketing. But he added this caveat for general ophthalmologists: Surgeons must understand how cosmetic patients’ expectations and mentalities differ from functional patients.

Compared to functional patients, aesthetic patients are typically younger and “more demanding,” he said. “There’s much more hand-holding. There needs to be a greater appreciation of what the needs and desires are of the aesthetic patient,” he said.

‘Botox parties’

Oculoplastic surgeons, meanwhile, are using Botox Cosmetic to promote other procedures they offer and vice versa, according to Dr. Levine, who noted that there are “two camps” on how to market Botox.

Pain prevention

Most patients understand that beauty is pain, but according to one surgeon, discomfort from botulinum toxin injections will play a role in whether some patients elect to undergo the procedure. “These do hurt,” said Allen M. Putterman, MD, SC. “I think doctors who try to minimize the discomfort will probably be a little bit ahead of the game.” Dr. Putterman offered physicians these suggestions for reducing discomfort at the injection site. Before injecting botulinum, Dr. Putterman said he instructs patients to apply ice compresses to the site for 15 to 20 seconds. He often has patients hold the compresses on one side of the face while he is injecting the other. Dr. Putterman said he also has patients apply Betacaine (lidocaine 5% topical gel, Canderm Pharma) to the skin 30 minutes before the procedure. “I think the combination of the Betacaine plus the ice compresses works better than using one or the other alone,” he said. He also advised surgeons to administer the injections slowly, since quick injections generally induce more discomfort. According to Steven Fagien, MD, “Now that we have received the green light to use bacteriostatic saline (instead of traditionally used preservative-free saline), in my practice the discomfort is minimal and the injections are highly tolerated even without the use of any topical application prior to treatment.”

While some surgeons commit resources to advertising the botulinum injection itself, others may use Botox to entice their patients to try more complex procedures, from blepharoplasty to face lifts.

“Botox parties” – where guests are served wine and hors d’oeuvres and receive injections for a nominal fee – may not even prove profitable to the practices that host them, according to Dr. Levine (who said he places himself in the former camp). Instead, physicians hope to create a rapport with potential patients, he said.

While such parties have created a stir in the lay press, the American Society of Plastic Surgeons warned patients in a statement that such events might compromise their ability to make informed decisions. The statement specifically referred to the settings of the events (often private homes, banquet halls and hotel suites) and the influence of alcohol as possible concerns.

Public perceptions

Publicity – both good and bad, spread through the Internet and the mass media – has affected Botox’s popularity in the United States and Europe. Similar to the scrutiny that has followed LASIK, the accessibility of Botox, the potential for misuse and a few high-profile stories about complications have increased public wariness.

“Only a minor percentage of patients request it for cosmetic reasons, even if their number is slowly increasing,” Carlo de Conciliis, MD, wrote in an e-mail from Milan, Italy. “The cosmetic patients, in my experience, fear a little the word ‘toxin’ and ask about the long-term complications.”

He noted that, in Italy, Botox is still the domain of dermatologists and plastic surgeons.

In the United Kingdom, Botox and its clinically similar European competitor, Dysport (botulinum toxin type B, Beaufour Ipsen Group), have witnessed a “steady rise in interest,” according to Manchester oculoplastic surgeon Brian Leatherbarrow, FRCS, FRCOphth.

“There are more and more patients seeking this treatment in the United Kingdom, and I think what mainly influences the decision about cosmetic treatments is publicity,” he said. “Just as it’s grown in the States, it’s growing very rapidly here.”

Dr. Fagien stressed that surgeons can acquire many of the skills to meet patients’ expectations of “aesthetic, effective and predictable” results, as long as they receive the appropriate training and gain adequate experience. “I think the sentiment ought to be optimistic. However, the novice injector should proceed with intelligence and caution and will build on experience by an initial conservative approach,” he said.

For Your Information:

• Carlo de Conciliis, MD, can be reached at Quattroelle Eye Center Via Cusani 5, Milan 20121 Italy; 39-02-877571; fax: 39-02-700420375; e-mail: eyeplast@tiscalinet.it. Dr. de Conciliis has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Steven Fagien, MD, can be reached at 660 Glades Road, Suite 210, Boca Raton, FL 33431; 561-393-9898; fax: 561-347-0772. Dr. Fagien has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Brian Leatherbarrow, FRCS, FRCOphth, can be reached at Bupa Hospital, Russell Road, Whalley Range, M168AJ Manchester, United Kingdom; 44-161-232-2435; fax: 44-161-232-2255; e-mail: bollin@mighty-micro.co.uk. Dr. Leatherbarrow has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Mark R. Levine, MD, can be reached at 1611 S. Green Road, Suite 306A, S. Euclid, OH 44121; 216-291-9823; fax: 216-291-0550; e-mail: m.levine@eye-lids.com. Dr. Levine has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• William J. Lipham, MD, FACS, can be reached at Minnesota Eye Consultants, 9117 S. Lyndale Ave., Bloomington, MN 55420; 612-813-3600; fax: 612-920-0441; e-mail: wjlipham@mneye.com. Dr. Lipham has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Allen M. Putterman, MD, SC, can be reached at 111 N. Wabash, Suite 1722, Chicago, IL 60602; 312-372-2256; fax: 312-372-1762; puttermanmd@hotmail.com. Dr. Putterman has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

• Allergan, maker of Botox and Botox Cosmetic, can be reached at 2525 Dupont Drive, Irvine, CA 92612; 800-433-8871; fax: 714-246-5913; Web site: www.allergan.com.
• The American Society of Plastic Surgeons can be reached at 444 E. Algonquin Road, Arlington Heights, IL 60005; 847-228-9900; Web site: www.plasticsurgery.org.
• The Beaufour Ipsen Group, manufacturer of Dysport, can ve reached at 33-14-4 304 -215; fax: 33-14-4304-204; Web site: www.ipsen.com.

References:

• Fagien S. Botulinum Toxin Type A for Facial Aesthetic Enhancement: Role in Facial Shaping. Plast Reconstr Surg. 2003;112 (Suppl.):6S.
• Fagien S. Botox for the Treatment of Dynamic and Hyperkinetic Facial Lines and Furrows: Adjunctive Use in Facial Aesthetic Surgery. Plast Reconstr Surg. 1999;103:701.