With proper training, cosmetic oculoplastics provide added revenue, creative outlet

With the eye being the centerpiece of the face, ophthalmologists are in prime position to embrace cosmetic oculoplastics. Whether it is reshaping the periocular region with an injectable dermal filler or botulinum toxin, or performing a blepharoplasty, ocular specialists can master both the technique and creative aspects of aesthetics.

Good experience and background are paramount to performing aesthetic surgery, OSN Oculoplastic and Reconstructive Surgery Section Editor Mark R. Levine, MD, FACS, said.

“Unfortunately, the general ophthalmologist who completes a residency training program at most institutions is not provided enough experience in aesthetic or functional surgery to develop a proficiency in these areas,” Levine said. “For the most part, the general ophthalmologist lacks across-the-board comprehensive training in the principles of surgical technique.”

Getting started

Proper training is provided by enrolling in cadaver dissection courses offered by the American Academy of Ophthalmology and by observing oculoplastic 
surgeons perform cases.

“Most oculoplastic surgeons are willing to have general ophthalmologists watch,” Levine, an emeritus professor of ophthalmology at Case Western Reserve University School of Medicine in Cleveland and a staff physician at Cleveland Clinic Foundation, said. “You spend perhaps 2 or 3 days with them. Then you pick a very easy case, such as a patient around 80 years old with extra skin hanging onto his lashes that is affecting peripheral vision. The outcome is not as critical as if the patient is 45 years old.”

Treating the area around the eye, for example, injecting toxin around the eye or brow, is the ideal starting point for someone who has been trained in ophthalmology and wants to build a cosmetic practice, Joely Kaufman, MD, FAAD, said.

“Patients truly trust their ophthalmologists with this area. Then gradually you can expand to include other areas, such as areas around the mouth or the nasolabial folds and the forehead,” she said.

Kaufman, a cosmetic dermatologist in private practice in Coral Gables, Fla., and an assistant professor of dermatology at the University of Miami Miller School of Medicine, said, “The whole brow changes the eye, and we all know that the eye is the focus of the face, so an ophthalmologist is in a perfect position to treat this area.”

For injectable toxins, Kaufman recommended that for those just starting out to have their patients return to the office 10 to 14 days after the injection, when the toxin has taken full effect.

“This will give you a good idea of the clinical results and how you can modify your injections,” she said. “To see the results is very important when you are starting out. Unlike when injecting filler, you don’t see the results of toxin right away.”

Kaufman also said it is important to maintain excellent charted records documenting points of injection.

“Everyone’s face is different, so you want to remember what you did when someone returns and says, ‘I love the way you did my Botox.’ You need to have your diagram specific for each area — how many units you used and where you injected. You want to be able to repeat treatment,” she said.

Physician satisfaction

Steve G. Yoelin, MD, a general ophthalmologist in private practice in Newport Beach, Calif., who mostly performs cosmetic procedures, enjoys the freedom associated with a fee-for-service environment. Patient satisfaction, too, is a motivator, as is the creative aspect of offering cosmetic procedures.

“Medical care can sometimes be algorithmic in nature,” Yoelin said. “Aesthetic medicine poses the questions, ‘What is beauty?’ ‘What facial features make people look more youthful?’ ‘Which ones make people look more rested?’ Our injectables toolkit for rejuvenating these features keeps expanding.”

Yoelin, who has performed cosmetic procedures since 2001, said he believes that toxins are a key component of injectable aesthetics.

“There are now lower face treatments, including vertical lip line effacement and platysmal band reduction, that bolster our existing armamentarium to treat the upper-third of the face,” he said. “We now better understand how the muscles of the entire face interact, which leads to a more comprehensive and effective approach.”

Injectable toxins

The U.S. Food and Drug Administration has approved three injectable botulinum toxin type A products: Botox Cosmetic (Allergan), Dysport (Medicis) and Xeomin (Merz).

“All three of these injectables work via the same mechanism of action by inhibiting the release of acetylcholine at the nerve terminal, thus weakening the muscles and thereby decreasing wrinkles,” Wendy W. Lee, MD, an associate professor of ophthalmology at Bascom Palmer Eye Institute who specializes in oculofacial plastic and reconstructive surgery, said.

Botox Cosmetic is the most widely used of the three products in the United States. Its use for cosmetics became popularized in the 1990s, although FDA approval for cosmetic indications was not granted until 2002, Lee said. In contrast, Dysport has been more widely used overseas and was approved by the FDA in 2009. Xeomin is the newest player, receiving FDA approval in 2011.

All three botulinum toxins have the same FDA-approved cosmetic indications for glabellar lines.

“All other cosmetic applications are off label,” Lee said.

Lee does not have a product preference and uses all three injectables in her practice. She bases her particular selection in large part on patient feedback regarding past treatments and patient requests.

“However, if someone has a severe cow milk allergy, then I avoid Dysport because it is made with lactose,” Lee said.

Lee has seen a quick onset of action with Xeomin, within 24 hours in some patients, and so she may consider Xeomin for a patient who has a special event the next day. In contrast, Botox Cosmetic and Dysport in general take slightly longer to yield results: 1 to 2 days for Dysport and 2 to 3 days for Botox Cosmetic, with maximum effect achieved in 7 to 14 days.

The effect of Botox Cosmetic and Dysport has been approved to last up to 4 months, while Xeomin is approved to last up to 3 months.

Dermal fillers

There are more than a dozen different types of dermal fillers, according to Gene R. Howard, MD, MPH, a clinical professor of ophthalmology at the Medical University of South Carolina in Charleston and an oculoplastic surgeon in private practice at Carolina Eyecare Physicians in Charleston, ranging from collagen fillers to hyaluronic acid (HA) fillers.

“Normally, the patients I treat with Juvéderm (Allergan) do not like their nasolabial folds — the folds between the cheek and upper lip — and marionette lines,” Howard said. “As we age, we sort of become more saggy and deflated; particularly women in the perimenopausal and postmenopausal period lose a bit of their fatty tissue in the subdermal tissue, so their skin does not seem as thick. It becomes slightly thinner.”

A surgical facelift is undesirable for many of these patients because of the expensive and lengthy downtime.

“A dermal filler can essentially rejuvenate the face a little bit and plump it up slightly, so the patient does not look as sunken in the areas that the patient perceives,” Howard said. “This may be under the eyes or on the lips; particularly the upper lip starts to thin, to the point where it almost disappears.”

Howard said that historically a lot of the dermal fillers were collagen.

“It works very well, but the downside is that it was made primarily from bovine collagen. As a result, patients needed to be allergy tested and there was some risk of allergies,” he said.

Collagen-based fillers have been surpassed by HA-based fillers that stem from the HA fillers used chiefly in cataract surgery.

“Juvéderm generally comes preloaded in a syringe in a finite amount and looks like a clear jelly,” Howard said. After the clinician is properly trained, it is straightforward to inject, he said. Besides treating around the mouth, Howard also injects to a degree under the eyelids. Most patients require one treatment session, with effects lasting 6 to 9 months, and up to as long as 1 year. Juvéderm is approved by the FDA for correction of moderate to severe facial wrinkles and folds.

Belotero Balance (Merz), an HA filler approved in 2011, can be injected more superficially under the skin, to fill areas where the wrinkles are under very thin skin, Howard said.

“One of the challenges of some of the other HA fillers is that if you inject them too close to the skin surface, they can cause a bluish discoloration of the gel (Tyndall effect),” he said.

Restylane (Medicis) was the first HA filler approved by the FDA. It is indicated for moderate to severe facial wrinkles and folds, including nasolabial folds.

Yoelin extensively uses HA-based fillers because they can be administered nearly anywhere on the face and are reversible with hyaluronidase.

As with real estate, in which “location, location, location” is the mantra, for aesthetic medicine, it is “train, train, train,” Yoelin said. “Like cataract surgery, you need to practice if you are going to become very good at it.”

Compared with other specialties, such as dermatology and plastic surgery, ophthalmology patients tend to be older and less aesthetically oriented.

“In general, the mean age of my injectables patient base is probably about 50 years old,” Yoelin said. “As ophthalmologists, we are extremely attentive and detailed. My personal focus on these characteristics has improved my technique and my ability to evaluate patients’ faces.”

Storage, shelf life

The three injectable toxins vary slightly in the way they are made, according to Lee. Unit size and storage requirements before reconstitution with saline also differ.

“Units are not interchangeable,” she said. Dysport comes in a 300-unit vial, whereas Botox Cosmetic and Xeomin are available in both 50- and 100-unit vials. “Most aesthetic injectors will reconstitute these three products very similarly,” Lee said.

Xeomin can be stored at room temperature for up to 2 years before reconstitution, whereas Botox Cosmetic and Dysport are kept cold before reconstitution.

“After reconstitution, though, all three products need to be refrigerated — not room temperature and not frozen; otherwise, the neurotoxins will be altered,” Lee said.

Prescribing information for Botox Cosmetic and Xeomin suggest use within 24 hours after reconstitution; for Dysport, 4 hours is suggested. However, several published studies, including one coauthored by Lee, show equal efficacy after 2 weeks or more.

The shelf life for the three products is 2 years.

Lee said that all three injectables can be used within the same treatment session.

“I sometimes use two, but very rarely three,” she said. Her most common combination is Dysport in the forehead and Botox Cosmetic or Xeomin elsewhere on the face.

Complications, consent

Injection pain is minimal for all three products, according to Lee, who uses insulin syringes with a small 31-gauge needle. Furthermore, some clinicians believe that diluting the toxin injection with preserved saline may be associated with less pain compared with non-preserved saline.

“Most of us use preserved saline anyway, although the FDA indication is to use non-preserved saline,” Lee said.

Potential clinical complications are also uncommon.

“Botulinum toxins in general are very well-tolerated,” Lee said. “There is very rare complication of allergic reaction to either the toxin or any of the products that are included with the toxin.”

Other clinical complications are blepharoptosis, which occurs in less than 2% of the population and whereby the toxin seeps into the levator muscle; brow ptosis; and ectropion. An even rarer complication is extraocular muscle imbalance.

To decrease the likelihood of ptosis, Lee recommended ensuring the patient is in the upright position for the injection, using the nondominant thumb to protect the orbital rim, and then massaging the toxin in the glabellar area after injecting. Using concentrated doses in small amounts and staying 1 cm above the orbital rim are two other tips.

“If you are unfortunate enough to encounter ptosis, you can use a glaucoma drop such as apraclonidine to stimulate Müller’s muscle for a temporary lift,” Lee said.

“It is important to read the literature and see what complications are being reported,” Kaufman said, noting that she added blindness to her consent form last year. “Injecting a filler into a vessel can cause multiple complications, including skin necrosis or blindness. Understanding the anatomy is essential.”

A literature review of blindness as a direct consequence of cosmetic injection of the face appeared in Plastic and Reconstructive Surgery in 2012. The paper cited 29 articles that described blindness in 32 patients, 15 of whom became blind after injections of adipose tissue and 17 after injections of various materials, including corticosteroids, paraffin, silicone oil, bovine collagen, polymethylmethacrylate, HA and calcium hydroxyapatite.

For both toxins and fillers, Kaufman feels most clinicians rely on the standardized consent forms provided by the manufacturers or from their medical societies, which should then be modified for each individual office. For fillers, the list of complications can be gleaned from the package insert. Kaufman also said filler should not be injected unless the clinician understands how to recognize and treat the possible complications.

Pearls

Kaufman is using a new dermal filler technique around the eye. She injects filler under the brow via a cannula, which elevates the brow and opens up the eye.

“This makes patients look well-rested,” she said. “And by using a cannula as opposed to a needle, there is relatively no bruising. No one wants to have a black eye.”

Howard believes that the needle vs. cannula debate for injectables is most relevant for treatment under the eyelid skin. Especially for a tear trough deformity, which is filled in the area under the eyelid where there are a number of large veins, Howard would choose a cannula as a better option.

To optimize the results of dermal fillers, Howard advocates addressing the symmetry of the face.

“I don’t try to fill one side completely at first,” he said. “I’ll fill a little bit on one side and then fill a little on the other side. It is sort of a stair-step filling technique. You need to go back and forth.”

Howard also encourages patients to watch the injections being administered in real time by holding a large mirror, so that the patient can participate in determining the correct amount of fill.

“One of the big fears and anxieties of patients is that they do not want to look like a duck. They don’t want to be overfilled,” he said. “They are afraid of disfigurement.”

With the aging population, the demand for both functional and cosmetic eyelid surgery is “increasing exponentially,” according to Howard, particularly among patients who have visually significant dermatochalasis.

“Blepharoplasty can be performed for functional reasons, but there are clear distinctions about who is cosmetic and who is functional. Contrary to what has been reported in the media, Medicare is not picking up a big tab for cosmetic surgery. By and large, cosmetic patients end up paying for cosmetic surgery,” Howard said.

Profitability

An ophthalmologist can indeed offer cosmetic oculoplastic procedures “that are absolutely lucrative,” according to Levine.

“But you have to differentiate between aesthetic surgery and functional surgery. Aesthetic surgery is purely cosmetic. It enhances one’s appearance and does not really interfere with vision. Aesthetic surgery is also outside the domain of submitting to insurance companies because insurance companies do not cover aesthetic or cosmetic surgery,” he said.

Levine reiterated that cosmetic surgery is all self-pay, based on what the provider feels is the value of his service.

“For example, in general, a four-lid (upper and lower) blepharoplasty can cost the patient between $4,000 and $7,000, for 90 minutes to 2 hours of work,” he said. “You bill what you want to bill. And if the patient is willing to pay it, it’s a match.”

On the other hand, another clinician with a good reputation may charge $2,000 less for the same procedures. “Make sure you are competitively priced with your local competition,” Levine said.

Levine said there is a “blurred area” between aesthetic and functional oculoplastic surgery in 25% to 30% of cases.

“In those cases, you need to submit to the insurance company for pre-approval,” he said. “This requires sending pictures to show that the condition is interfering with the patient’s vision, as well as a visual field showing that it is interfering with peripheral vision.”

For the marketing of cosmetic procedures, Levine has updated his website, which now includes preop and postop pictures and lets the potential patient know why he is uniquely qualified to perform a particular procedure, as opposed to a plastic surgeon or a facial plastic surgeon.

“The distinct advantage that an ophthalmologist has is that the eyelids are obviously related to the eyeball and, hence, lids that may be malpositioned, droopy or retracted can result in exposure of the eye or the lids’ inability to close the eye,” Levine said. “The general ophthalmologist is trained to appreciate and treat these conditions, whereas the plastic surgeon is not. We are ophthalmologists first. For us, it’s about maintaining good vision and protecting the eye.” – by Bob Kronemyer