JUN 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

Issue link: https://digital.eyeworld.org/i/137624

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August 2012 just looking to appeal to your own in-house population with a little bit of advertising." The patients will likely respond well to the idea, said Jacqueline R. Carrasco, MD, assistant professor of ophthalmology, Thomas Jefferson University, Philadelphia, and member, oculoplastic and orbital surgery service, Wills Eye Institute, Philadelphia. "Especially around the eye, patients are very comfortable with their ophthalmologist knowing the benefits and risks of using botulinum toxin," Dr. Carrasco said. Dr. Grant said the fact is that many ophthalmologists are already well versed in using neurotoxins, making them a natural place to start. "Ophthalmologists have [a lot of] experience with neurotoxins, having used them in blepharospasms for decades," he said. Dr. Carrasco agreed. "Certainly if you're using botulinum toxins for facial spasms it's an easy thing to tack on," she said. Aesthetic botulinum beginners Botox is not the only botulinum toxin available. Many savvy practitioners are also using Dysport (abobotulinumtoxinA, Ipsen Biopharm, Wrexham, Wales) and Xeomin (incobotulinumtoxinA, Merz Pharmaceuticals, Greensboro, N.C.). For those starting out, however, Dr. Carrasco's advice is to stick with just one. "They all cost about the same, so there's not a huge price difference, but it is quite expensive to carry all three types of products," she said. While Botox has the most name brand recognition, she said that Xeomin may be an easy addition since it can be stored unopened at room temperature. Dr. Bunin favors using either Botox or Dysport. "I've been using Botox on patients since I did research as a resident, so I have a lot of experience with it," she said. "But I now use Dysport a lot—it tends to have a quicker onset and it tends to last a little bit longer, so I find it preferable in certain areas (like the forehead). But it does have a larger diffusion area, so be careful around the upper eyelid to avoid ptosis." She recommended that novices stick with treating the upper half of the face with these since the lower half takes a lot of finesse. Dr. Bunin advised those new to using botu- linum toxin not to be afraid to treat patients in stages. "Start with the glabellar area and reassess the forehead furrows a few weeks later— often the forehead lines are compensatory and will lessen after the glabellars are treated. One rule— if in doubt undercorrect and bring the patient back," she said. For novices, Dr. Carrasco views using botulinum toxin in the glabellar region as a win/win situation. "It is low risk and high yield for patients to do their '11' lines," she said. "Also, the lateral canthus area (the crow's feet) tends to have good benefits as well." However, she added, with the crow's feet you have to be careful not to go too low in the lower lids as this can cause an eyelid ectropion. Finessing fillers A good complement to the botulinum toxins is the hyaluronic acid fillers, Dr. Grant said, since these are probably the easiest to learn how to use. These, he pointed out, have very little in the way of downsides. "They do wear off on their own," he said. "Their longevity is anywhere from six to 12 months depending on where they're injected and at what viscosity the product is used." While neurotoxins tend to be used in the upper face, fillers generally are used in the mid and lower face to add volume, Dr. Grant explained. "For fillers, the easiest area to learn how to treat would be the nasal labial folds," he said. The next level of competence would be the marionette lines around the mouth, as well as lip augmentation. "The trickiest things, which I would leave for last, would be the tear troughs," Dr. Grant said. "The skin is thin and you don't need a lot of material to make a big difference." He tends to use a lot of Juvederm (Allergan) in the lower face for areas such as the nasal labial folds. For the tear troughs he likes Restylane (Valeant Pharmaceuticals, Madison, N.J.), which he terms relatively hydrophobic. "It has a tendency not to run and diffuse so it stays where you put it," Dr. Grant said. "Juvederm Ultra Plus is thicker but has a tendency to diffuse a little bit so when you're trying to blend it into a larger area it works better." Dr. Carrasco likewise stressed that the hyaluronic acid fillers are the best to start with since these have an instant "eraser" in the form of an injection of hyaluronidase, with either Vitrase (Bausch + Lomb, Rochester, N.Y.) or Hylenex (Halozyme Therapeutics, San Diego). She finds that Juvederm and Perlane (Valeant Pharmaceuticals), a thicker hyaluronic acid that is placed a little more deeply, tend to work well in the nasal labial folds and marionette lines. Radiesse (Merz Pharmaceuticals) is another filler that is effective, but Dr. Carrasco suggests working up to this. "That may last a little longer, like one-and-a-half years, but it's not easily erased," she said. Practitioners can learn to use these by taking courses. In addition, many companies will have nurse injectors come to show practitioners the ropes. "We have a nurse injector come and then we offer it to the ladies in our office—usually we have volunteers easily," Dr. Carrasco said. EW NEWS & OPINION 15 Dr. Bunin suggested starting out by working with one company for both botulinum toxins and fillers. This can result in better pricing for product, and the company will help with marketing materials and training. Overall, Dr. Bunin urges other ophthalmologists to consider this avenue. "I think on the whole we are better trained [for this] than our general medicine colleagues," she said. "We are well trained and well suited to a lot of these and well positioned to add these to our practice." EW Editors' note: The physicians have no financial interests related to this article. Contacts information Bunin: 610-435-5333, lbuninmd@yahoo.com Carrasco: 610-649-1970, eyeplastics.carrasco@comcast.net Grant: 410-955-1112, mgrant@jhmi.edu

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