NOV 2012

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

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18 EW NEWS & OPINION November 2012 Pharmaceutical focus A new wrinkle for general practitioners by Maxine Lipner Senior EyeWorld Contributing Writer Casting a fresh eye on neuromodulators and fillers I n the ophthalmic realm, "Botox" and facial fillers aren't just for the oculoplastics spe- cialists anymore. Neuromodu- lators, which include several agents that are better known to the public by the brand name Botox (onabotulinumtoxinA, Allergan, Irvine, Calif.), and fillers are making their way to offices of many general ophthalmologists, according to Richard B. Simon, M.D., Center for Excellence in Eye Care, Miami. "If you look at the general ophthalmol- ogist, I would say that you probably have a 50/50 chance that he's doing fillers," Dr. Simon said. However, of the two, Dr. Simon believes novice general practitioners are usually more comfortable with neuromodulators. "It's easier to un- derstand," he said. "It's also more risk free from the point of view of the physician." Bulletproof Botox He pointed out that neuromodula- tors, which inhibit muscle move- ment and thereby skin folding, have a built-in failsafe since these subside within a few months. "Whether patients love it or hate it, it's going to wear off," Dr. Simon said. "By the time they get angry enough at you to run to the lawyer, they're back where they started." This can help to ease the mind of a general practi- tioner flirting with the idea of adding a cosmetic arm to his or her practice. Unlike with other surgeries, which can go awry, he sees the neu- romodulators as fairly bulletproof. "You can make patients look worse for that wedding that they have planned in 2 weeks, but you can't make them look bad permanently," Dr. Simon said. Neuromodulators are easier to incorporate in a general practice, agreed Stuart R. Seiff, M.D., emeri- tus professor of ophthalmology, University of California, San Fran- cisco, and in private practice, Pacific Center for Oculofacial and Aesthetic Plastic Surgery, San Francisco. Currently there are four approved botulinum toxin agents available in the U.S. These include Botox, Dysport (abobotulinumtoxinA, Ipsen Biopharm Ltd., Wrexham, Pre-glabellar botulinum toxin (Allergan) and Restylane (Medicis Aesthetics, Scottsdale, Ariz.). "Hyaluronic acid is a material that is normally in our bodies anyway," Dr. Simon said. He pointed out that it is a chemical that cataract surgeons have been using for decades in the form of the viscoelastic Healon (Abbott Medical Optics, AMO, Santa Ana, Calif.). In this case, instead of filling the eye during cataract surgery, it is used to plump out wrinkles. Dr. Simon has used Juvederm and Restylane equally through the years. Recently, he has begun to lean more toward Juvederm. "I like the packag- ing a little better," Dr. Simon said. He also favors the newer Juvederm Ultra XC, which is a little thicker and helps to inflate a furrow. These hyaluronic agents are the Post-glabellar botulinum toxin Dr. Simon agreed that while Filler for brow lift Source (all): Stuart Seiff, M.D. Wales), Xeomin (incobotulinumtox- inA, Merz Pharmaceuticals, Greensboro, N.C.), and Myobloc (rimabotulinumtoxinB, US WorldMeds, Louisville, Ky.). How- ever, Myobloc is not used a lot cosmetically, Dr. Seiff pointed out. The other three are all pretty compa- rable, he added. Where possible, he currently opts for Xeomin, based solely on cost. "Right now Xeomin is giving price breaks—it's about 20% less expensive," he said. "For a cosmetic patient, it makes a differ- ence." However, he recognizes that par- ticularly for someone starting out in this area, product name recognition may play an important role. "I would probably start off with Botox because if you're just getting started with it you don't want to be explain- ing to your patients why you are using something other than what they have heard about," Dr. Seiff said. these neuromodulators vary in how they bind to protein, they're all spinoffs of the same botulinum toxin. Practically speaking he sees these as interchangeable. "You can pick one or the other," he said. "Personally, when I have used Dysport or Botox, I can't tell the difference." He has a tendency to stay with Botox for several reasons. "People know the name Botox the same way they know the name Kleenex," he said. Also, since he was one of the original investigators to use Botox, after 27 years it has become second nature to him. He pointed out that each of these must be mixed up in different concentra- tions. For the Botox mixture, he no longer has to look at the literature. Both practitioners recom- mended starting out by using neuromodulators in the glabellar furrows, more commonly known as the frown lines between the eye- brows. "It is pretty forgiving and you will usually get a good result," Dr. Seiff said. Dr. Simon agreed. "Those almost always look good afterward," he said, adding that this is true even for novices. Filling a need When it comes to the different fillers, Dr. Simon recommended that practitioners just getting their feet wet stick to hyaluronic acid, which includes products such as Juvederm easiest fillers for the aesthetic novice to successfully use, agreed Dr. Seiff. One of the reasons why he is partial to these for beginners in particular is that if the practitioner or the patient doesn't like the results, these can be instantaneously dissolved away with Vitrase (hyaluronidase, ISTA Pharmaceuticals, Irvine, Calif.). Otherwise, fillers must run their course, which may be in the neighborhood of 1 year or more. As a rule, fillers tend to be used for the lower face and neuromodula- tors in the upper, Dr. Seiff said. "We'll use a filler to plump up the lips, to spread out the purser lines around the upper or the lower lip," Dr. Seiff said. "We'll also use it to fill the nasal labial folds." A filler like Sculptra Aesthetic (Sanofi-Aventis, Bridgewater, N.J.) may also be used to revolumize the face, especially in athletic women where there may be some wasting and deflation. "We can fill the tear trough under the lower lid where you get hollowness," he said. "We can shape the mid-face contour with fillers." However, Dr. Seiff recom- mended that those branching out into fillers begin with the lines that travel from the corner of the nose to the corner of the mouth. "The most forgiving thing is going to be filling the nasal labial folds," Dr. Seiff said. Dr. Simon agreed that this is the best area to start with. "The biggest sin might be that you did not put enough in," he said. continued on page 20

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