Aesthetics in Ophthalmology

Marguerite McDonald, MD, invites Emily MacQuaid, MD; Wendy Lee, MD; and Laura Periman, MD, to share their expertise on aesthetics treatments such as oculoplastic surgery, filler injections, skin care, and intense pulsed light therapy. Learn more about patient referrals and how ophthalmologists can incorporate aesthetics procedures into their practices.

MARGUERITE: Welcome. I’m your host, Marguerite McDonald of the Ophthalmic Consultants of Long Island, in Lynbrook, New York and this is Informed Consent: Getting to Yes—the podcast where we focus on the fair and balanced phraseology leading eye care professionals use to get their patients to say yes to the type of treatment or IOL they recommend.

For today’s edition about Aesthetic treatments, I spoke to three highly qualified specialists to talk about oculoplastics, Botox and filler injections, dermatology, and even IPL—Intense Pulsed Light.

So, let’s meet my esteemed guests. Dr. Emily MacQuaid is Director of the MacQuaid Eye Institute in Baltimore, Maryland.

EMILY: Hi. Thank you for having me.

MARGUERITE: My pleasure. Next is Dr. Wendy Lee, Associate Professor in Oculoplastic Surgery and Dermatology at the Bascom Palmer Institute of Miami. Welcome, Wendy.

WENDY: Thank you.

MARGUERITE: And last but not least, I spoke to Dr. Laura Periman, an internationally renowned dry eye specialist at the Redmond Eye Clinic in Redmond, Washington. Laura is an expert in IPL.

LAURA: Thank you so much. It's delightful to be here as your guest.

MARGUERITE: Let’s begin today with a question I asked Wendy that applies to ophthalmologists like myself.

In my case, I'm at a big practice with two great oculoplastic surgeons. I'm trying to refer to them and I'm trying to think of the best way to broach the subject without offending them. Let's first take my situation. Do you have any tips for how I could refer a patient to someone like you?

EMILY: The first thing is I think it's a lot of cataract patients where they'll get to me after cataract surgery and they'll actually say that “the cataract surgeon caused my bags.” Where, in fact, they can just see better, or they see their crow's feet now. One way you can even approach this is to say, "I want to point out you have a little excess skin. You had this prior to your cataract surgery. If you want this addressed after your cataract surgery, I would suggest you see Dr. so and so."

In plastics, we always point out any discrepancies prior so we don't get blamed.I think with cataract or refractive surgeons you have to do the same because I do see it quite frequently where the cataract surgeon gets blamed for the crow's feet that have been there for years.

MARGUERITE: That is a great tip and I have had patients come back and be upset with me for something that was there for the last 30 years.

EMILY: The first thing you have to do is give them a mirror and say, "What bothers you?" You have to ease into it. If you notice they have a double chin and Kybella would work wonderfully for them, but they're not ready to go that leap, you just address what they're concerned about.

WENDY: If you, yourself, are going to incorporate aesthetics in your practice, then I think it's important to work with a mirror and to work with an aesthetic questionnaire. Because if you have your patient fill out a questionnaire that includes these aesthetic questions while they're waiting for you in the waiting room, number one, it gives them something to do.

Then you review it quickly before you go in and you say, "Oh, I see that you listed you're bothered by these lesions," or "You're bothered by these wrinkles between your brow," so it's much easier and you'll include everything from forehead down including the neck and out. It's really easy with a patient questionnaire to broach those subjects.

MARGUERITE: This reminds me of a friend who was in her late 50s when she went to a plastic surgeon. On the way she said, "You know, I need almost everything done but I love my chin, but I need everything else done." When she went to the surgeon, he said, "If you let me do only one thing, let me fix your chin."

WENDY: Oh, my gosh, that's hilarious.

MARGUERITE: So I guess-

WENDY: Did she let him?

MARGUERITE: She laughed, she let him, and she looks a whole lot better.

LAURA: I propose these treatments centered on addressing their dry eye disease. I say to them, "By the way, there's a significant mechanical component to this that can be corrected with fillers." So I'm not saying, "You look old. You look tired." I'm saying, "This is part of the problem that you came to me for. Here's what I'm seeing. There is something we can offer you."

Maybe open-ended questions too, it’s like the patient is happy with their excellent cataract surgery, their premium IOL, not wearing glasses anymore and they'll notice the lines and the bags, maybe an open-ended question, "I'm so glad you're pleased with your results. Is there anything else you'd like to bring to our attention that concerns you?" Oftentimes, that opens the door for them to bring it up, and if it's their idea that definitely helps in getting to yes, if it comes from the patient. Sometimes it's just about planting a seed, delicately, gently.

WENDY: I feel like being organized is really important with my patients. My organized fashion for aesthetics is after we go through what the patient needs, I like to present it from least invasive, to more invasive. If they need topicals, which everyone needs topicals, so we talk about skin care, really briefly, very basic skin care. Then I go into injectables including botulinum toxin and dermal fillers. Then I go into devices if they need, or candidates for devices, such as lasers and light therapy, and then we'll go into surgery.

I organize my discussion that way and it can go very quickly. Most of it is done in the evaluation portion after we have had a chance to talk about what bothers them and what they currently use and what they have or haven't tried.

MARGUERITE: How often do you get somebody who has either unrealistic expectations about how much younger or better they can look, or an unrealistic timeline, like my daughter's getting married in three days and what can you do to make me look younger. Does that happen to you?

WENDY: Every single day, 100%. I think you bring up a really, really important point, Marguerite, that the most important aspect of dealing with the cosmetic patient is setting realistic expectations and weeding out those with unrealistic expectations. If I know that I can't provide them with what they're expecting, and I can't coach them into that realism, then it's a no for me.

MARGUERITE: When you run through your logical sequence from least to most invasive, do you finish with, "But for you, I think it should be lasers," or, "For you I think ..."

WENDY: Yeah. What I do is we'll have the discussion and then when I determine what is right for that patient, I may not even discuss surgery. If they're not a candidate, there's no use in me discussing surgery, or if they're not a candidate for laser, they have a really dark skin type, then I'd leave that out.

After the evaluation and when I'm going into the discussion of what's best for that patient, I'm going to tailor the discussion and only talk about what they're candidates for. If they're candidates for all four, then I'll go in that order. Everyone is a candidate for topicals so I'll talk about that first, most are candidates for injectables, as well, plus-minus devices and surgery.

MARGUERITE: Pretend I'm Mrs. Smith, Emily, and tell me how do you quickly review Botox, filler pros and cons and get me to say yes?

EMILY: As far as Mrs. Smith, if she came in, I would say, "Botox and filler would help." Then, I prefer to use a filler that's dissolvable, especially in someone who's there the first time. A lot of patients like that it's reversible. That if I get this done and I don't like it, it can be reversed. I think that's a big selling point for patients and it's also an easy selling point to say, "If I don't like this I can just dissolve the filler and it's gone in two weeks." That is how you typically can get patients to make a quicker decision.

MARGUERITE: How often does that happen? I would not imagine very often.

EMILY: I probably only used dissolve filler once in one of my own patients in 11 years, but I do see a lot of outside patients who want their filler dissolved, just from malplacement.

MARGUERITE: Do you find recently divorced people who are putting too much emphasis on changing their appearance? Is there a group or a type that you say, "Watch out," when they walk in?

EMILY: Well, unreasonable expectations, where they haven't had anything done, they're in their 70s and they think they're going to walk out and look like Heidi Klum. Those patients, or, as I always say, "If I can make my husband look like George Clooney I would." But I can't. There's only so much I can do and you have to relay that to the patient. If you do see them, I do have some patients I'll turn away and say, "I don't think I can meet your expectations." Or, if you think you can meet their expectations and they can be reasonable, I think the important thing is document, document, document.

Then, what you also ... take tons of photos. All preoperative photos are taken and stored that way if a patient has an issue we can show them their pre-op photo, their post-op photo, whether it's surgery or for filler. We take it, actually, from multiple different angles. The best way to protect yourself is with photos.

MARGUERITE: Do you take them under standard lighting or magnification? Do you have a photo area or do you just use your iPhone right in the exam lane?

EMILY: I have two different ways to take photos. I do have an area that's just plain lighting with a professional camera in it. I also utilize the EMR system Modernizing Medicine. I do have the iPad-based technology. I like that because it does upload right into the chart. If I have a feeling the patient might want multiple photos or might be difficult, I'll actually take multiple photos with different cameras. I'll take it not only with the iPad that uploads into the EMR system, I'll also take it with the professional camera and upload it myself.

MARGUERITE: I asked this next question of Dr. Lee.

MARGUERITE: If I were sitting in front of you and asking about Botox and filler, I've never had it before, and I want to look younger, there's no deadline coming up, I just want to roll a few years off my face, what is the fastest, easiest way to talk about Botox and filler to cover a quick informed consent?

WENDY: Okay, well, first of all botulinum toxins and dermal fillers are very, very safe and have been widely used for many, many years. So we know the safety profile and we know its efficacy. It's very, very effective in decreasing wrinkles on a face.

Dermal fillers can be used best in combination with the botulinum toxins because they do different things. We relax the muscles that cause wrinkles with the botulinum toxins, and then we use the dermal fillers to fill in volume deficits. They work beautifully together. I think it's important to explain to patients how they're not the same thing and they work very differently, but work beautifully together.

MARGUERITE: Do you tell them to expect much downtime?

WENDY: Minimal downtime with botulinum toxin; that's the easiest thing. You come in, you don't even need to numb. You don't see results right away. You have to let your patients know that it'll start taking effect in two to three days with maximum effect in one to two weeks. Whereas dermal filler, you want to come in likely, some people put topical numbing cream on for 15, 20 minutes, some people don't at all. Ice helps, as well. If you can inject that, you see the results immediately with the dermal filler.

As far as downtime with dermal filler, you may have some bruising unless the provider uses cannulas, then there's less likelihood of having bruising. But I usually warn my patients just in case they're on a blood thinner, if that needle hits a vessel, they may have some bruising, they can cover it up with makeup, I usually give them a good recommendation. I know some of my aesthetic colleagues who actually give each patient a little container of Kat Von D, which is this really good concealer that covers up tattoos and bruises.

Light therapy, there's no downtime but if you get all the way into the ablative devices, then you're looking at about a week of downtime. Then surgery, of course, even longer; one week of major downtime, at least a couple weeks of swelling.

MARGUERITE: This next question went to Dr. McQuaid.

MARGUERITE: Which would you rather have? Somebody who's 48, 50, and starts coming for little things, if you will, Botox, filler every two or three years. Is that person, probably, more likely to avoid the big facelift than the 70-year-old who shows up for the first time and says, "My husband died two years ago and I want to re-enter the dating world. Fix me."

EMILY: Right. Well, the 70-year-old whose husband just recently died is probably one of the more dangerous patients because they'll have unrealistic expectations. The person that starts out in their 40s getting a little filler or Botox has more reasonable expectations. They typically just want one tiny line filled, whereas a 70-year-old sometimes might believe that one syringe and filler can fill all of the lines on the face. Which just isn't feasible.

MARGUERITE: Before we wrap up with advice on how ophthalmologists can get into aesthetics, I asked Dr. Periman about IPL.

MARGUERITE: In your dry eye center of excellence, I know that you use IPL a great deal. Tell us a little about IPL and then what kind of patient you would propose it for.

LAURA: Well, thank you for that question, I do offer IPL frequently. I find that patients are thrilled at the option and readily accept it.

MARGUERITE: And it is performed on the lower lid after, of course, protecting the eyes. How long is the treatment in your hands?

LAURA: I spend a little more time on the treatment than some people do. I will do a full rosacea treatment followed by a refined lower energy treatment, called the twilight settings. I find that combination gives me fantastic results in a very short period of time. When you look at the techniques in the various papers that have been published recently, there's a lot of variability in the actual techniques that are used, and yet, the results appear to be very good across the different papers with the different techniques that they're using. So I think there's a lot of fudge factor there and a lot of room for experimentation and trial and error.

MARGUERITE: How do you explain to the patients and to non-user doctors the mechanism of action?

LAURA: Well, here's where stuff gets really interesting. We know that there's plenty peer- reviewed literature to support this that there is a photocoagulation effect where you use the light energy to close off the abnormal telangiectatic vessels. So, when you're aware of ocular rosacea and facial rosacea, and you start paying closer attention to the presence of those telangiectasias, that's a target for your IPL machine and that becomes a potential candidate. So, there is photocoagulation of the vessels. There is photosanitization effect. We know that it photo ablates Demodex and bacterias—you get control of the Demodex burden and in addition the bacterial burden that goes along with Demodex at advanced stages of MGD. Additionally, there is a photo-rejuvenative effect, on a cell to turn the cellular machinery to a younger version of itself. It literally simulates the cytochrome-c within the mitochondria to give it the cell more energy and how to behave energetically younger, which is pretty cool.

I'll touch on those ideas in general terms when I'm counseling my patients, but then at the very end I'll say, "And there's another part of IPL that you will appreciate, and that is improvement in your skin color, extra tone, and appearance of fine lines." It's pretty funny, because at that point the patient stops thinking and says, "Sign me up." I'm interested in getting your eye disease under control, but that's the part the patient likes. It's funny.

MARGUERITE: Laura, our listeners really want to hear exactly what you say to patients. Let's pretend I'm Mrs Smith, and you think I need IPL. How would you propose it?

LAURA: So Mrs. Smith, after a thorough evaluation, I believe that a significant percent of your problem is due to meibomian gland dysfunction. There are different problems involved in meibomian gland dysfunction, including these red vessels that you see on your photograph, this abnormal expressability of the gland. There's thickening of the eyelid. There's bacteria and Demodex evidence on you. We can address those issues with a broad spectrum efficient approach, using IPL therapy. It's typically a ... Plan on four treatments. Sometimes you can get away with three, but plan on four treatments, roughly one month apart. You will notice an improvement in your skin color, texture, tone, and the appearance of fine lines at the end of your treatment, which is a nice little benefit. I am interested in offering you this technology as a rapid way to approach those specific aspects of meibomian gland dysfunction. Then we'll maintain it with a simple program of omegas, an immunomodulator, and then if you still are in need of further procedures, we can offer you Lipiflow, but I find that doing this first to control those abnormal vessels and the Demodex burden, and the swelling and edema, and following it with Lipiflow is the best approach to your problem.

When you're talking about, specifically the rosacea settings and the aesthetic settings, there's going to be a little or very brief millisecond snap, hot rubber band snap sensation. But it's short-lived. I tend to start off with the rosacea settings, do a full face treatment. That's a little more intense, so that by the time I get to the treatment around the eyes, it's much lower energy and patients tolerate it beautifully.

MARGUERITE: Laura, do you do all the treatments yourself, or do you have a tech do them?

LAURA: I do them myself. It really only takes probably five minutes, by the time the patient's prepped. That time with the patient, they really appreciate it. It's a chance to chat with them, to be with them, be invested and involved in their care, and they really feel cared for. Everybody walks out with a big smile on their face.

MARGUERITE: That was great, Laura.Let’s close with some thoughts on whether ophthalmologists should get into aesthetics.

WENDY: I think that ophthalmologists of all sorts are great candidates to bring aesthetics into their practice and we're seeing it more and more. I'm speaking at more and more general ophthalmology conferences, more and more anterior segment conferences, and I think that it's a great crowd.

EMILY: The most important thing is training. There are many reported cases of blindness or tissue necrosis with fillers. If the appropriate training is performed, there's no reason why they can't do them.

MARGUERITE: Appropriate training might be a two or three week course, or even a mini fellowship for a month?

EMILY: I would say more like a mini fellowship. They have to be reasonable on what they think they can do. Otherwise, you'd end up in a compromising situation, especially if you cause tissue necrosis. You don't have the proper credentials behind you and you just performed that procedure.

WENDY: There are different ways to get live injection exposure. Number one, you could watch me and other faculty do live injections, but if you really want to get your own hands-on experience, then once you develop your aesthetic practice, you set up an account with one or all of the three big aesthetic companies and then they'll bring in a trainer to help show you one-on-one, hands on. You bring your own patients, you'll inject two to three patients of your own, and then the faculty is right there to guide you through it. I think that's a great resource, as well.

MARGUERITE: With that great advice, I’d like to thank my guests, Dr. Wendy Lee...

WENDY: Thank you, Marguerite, pleasure being here.

MARGUERITE: Dr. Laura Periman...

LAURA: Thank you so much for the opportunity.

MARGUERITE: and Dr. Emily MacQuaid.

EMILY: Thank you.

MARGUERITE: And also thanks to our listeners. I hope you found it useful and will join us for the next edition of Informed Consent: Getting to Yes.