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Cosmetic procedures tend to go hand-in-hand with other specialties, such as dermatology and plastic surgery

On top, patient presents pre-injection. On bottom, patient after one session of dermal fillers for the lower eyelids
Source: Wendy W. Lee, M.D.

On top, the patient presents pre-laser treatment. On bottom, the patient after one session of laser treatment (in this case, Fraxel (Solta Medical, Hayward, Calif.)) for the treatment of moderately damaged skin
Source: Wendy W. Lee, M.D.

From facial resurfacing to a glaucoma medication now being marketed as a method to grow eyelashes, to treatments for strabismus now being used as wrinkle removers, to blepharoplasty in combination with mid-face peels, cosmetic ophthalmic procedures can provide financial opportunities to practices without them. It’s just a matter of how much time and effort you want to invest, experts say.
“In general, cosmetic surgery is a whole different entity. Many wouldn’t even think of it as ‘healthcare’,” said Wendy W. Lee, M.D., assistant professor of clinical ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami.
“There are many cosmetic procedures that fit nicely into an ophthalmology and oculoplastic practice,” said Jacqueline R. Carrasco, M.D., clinical assistant professor of ophthalmology, Thomas Jefferson University, Philadelphia, and member, Oculoplastic and Orbital Surgery Service, Wills Eye Institute, Philadelphia. In her practice (consisting of four oculoplastics surgeons), services offered include chemical peels of the eyelids/face, radiofrequency tightening, radiofrequency wrinkle smoothing, and non-ablative laser resurfacing, she said.
“All these procedures have eyelid/peri-orbital indications and often require scleral shells for eye protection, which patients may feel more comfortable with in the hands of an ophthalmologist,” Dr. Carrasco said.
There are unique differences between functional ophthalmic surgery and cosmetic, said Jeffrey Nerad, M.D., professor of oculoplastic surgery at the University of Cincinnati, Cincinnati, and author of Technique in Oculoplastic Surgery: A Personal Tutorial.
“With the cuts in reimbursement, we’re faced with doing more volume and trying to maintain the same level of service,” he said. “As the volume goes up, the amount of time you can devote to delivering your quality level of service goes down. It’s the opposite with cosmetic procedures. Because it’s such a competitive marketplace, two key factors influence it: everyone who is sitting in your waiting room wants the surgery, making the delivery of service your priority.”
For instance, he noted a typical ophthalmic practice may be able to schedule as many as 10 patients an hour. “That’s completely unrealistic for a cosmetic practice,” he said, and added he built a new space adjacent to the “functional” office specifically for cosmetic patients.
“It’s a little more luxurious. You have to focus on service with the cosmetic side of things,” he said. He also hired aestheticians and offers a full line of select skin products. “Oculoplastic surgeons have a big advantage over general practitioners in that we already have a steady stream of people coming in who need functional work and who might, therefore, also be interested in cosmetic work.”
Cosmetic ophthalmology “is not something you can jump into,” said Richard Lisman, M.D., clinical professor, New York University (NYU) School of Medicine, New York, and chief of ophthalmic plastic surgery, Institute of Reconstructive Plastic Surgery, NYU Medical Center, New York. Beyond the basics of blepharoplasty, some states allow physicians to dispense drugs like Latisse (bimatoprost, Allergan, Irvine, Calif.) for eyelash growth but other states do not; every state allows any physician to administer Botox (onabotulinumtoxinA, Allergan), and those interested in the subspecialty need to know the individual state regulations, Dr. Lisman said.
Without a doubt, “building a cosmetic practice is a tricky thing,” said Timothy J. McCulley, M.D., associate professor of clinical ophthalmology and director of ophthalmic plastic and reconstructive surgery, University of California, San Francisco. “There’s no surefire way to do it. If you’re just offering Botox Cosmetic, you’re not going to have a very robust practice. And it’s very hard to dabble in cosmetics. You’re either going to offer comprehensive procedures and product lines, or likely not do very well.”

Succeeding as an add-on

It might be premature to say Latisse has done just as much for cosmetic ophthalmology as Botox and fillers, but “it has generated an enthusiasm in a patient base that may not be aesthetically inclined,” Dr. Lisman said. “In New York, patients know we’re not getting reimbursed for it but it does help to add excitement.”
Medical cosmetic advances are “by far the most popular and work nicely into an ophthalmology practice due to their concentration in the peri-ocular area. As ophthalmologists, we are well aware of the lash growth the glaucoma drug Lumigan [bimatoprost ophthalmic solution, Allergan] produces [and is now marketed as Latisse for cosmetic purposes] and are well suited to discuss the benefits and risks of such medication,” Dr. Carrasco said. “Why not discuss with your patients the cosmetic benefits and pitfalls of Latisse, and dispense this medication through your office? Other specialties widely market this medication within their practice, and it can be used as an introduction into other cosmetic services for your practice.”
In Miami, Dr. Lee treats a large number of Asian women who “love Latisse. It really works for them, and as ophthalmologists, we can de-mystify the aura around it,” she said. Still, in her area Botox Cosmetic remains the most common procedure, followed by fillers, hyaluronic acids, lasers/light therapies/skin tightening, and then finally resurfacing.
Dr. Nerad’s practice is relatively new (he relocated to Cincinnati about a year ago), but upper blepharoplasty is the most common procedure performed. “If someone comes in for a cataract consultation, you might be able to integrate cosmetic procedures; it just depends on what kinds of services you want to offer,” Dr. Nerad said. “Cosmetic oculoplastics can be a value-add to your functional stream of patients.”
Ophthalmic practices might also offer skin care products (including Latisse and Botox, as well as fillers). In some states, nurses cannot inject Botox, only physicians can, so ophthalmologists should evaluate the time they’re willing to dedicate to cosmetic offerings, as well as the outlay in medicine costs, he cautioned.
“When it comes to things like eyelid surgery, the ophthalmologist should be a better surgeon than the dermatologist or the plastic surgeon because we’ve been trained in soft tissue surgery better,” he said.
Oculoplastic surgeons in particular are “specially trained to advise patients on the benefits of both medical and surgical cosmetic procedures for around the eye. Ophthalmologists should be aware of all the cosmetic advances that involve the peri-orbital area, since patients will often seek your advice regarding your opinion about safety and effectiveness,” Dr. Carrasco said.

Boutique experience?

While some may argue cosmetic procedures should remain a boutique offering, others believe it can easily be integrated into a general practice and, more importantly, should be.
“Ophthalmologists are well aware of the use of Botox for medical indications around the eye for strabismus, facial spasms, and blepharospasm. Why not bridge this knowledge into the cosmetic indications and offer Cosmetic Botox for Glabella furrows, crow’s feet, or eyebrow repositioning? Most of the complications of Botox injections in the peri-orbital area including ptosis and diplopia are usually managed by ophthalmologists anyway,” Dr. Carrasco said.
Latisse is a “good example” of a product that can easily be incorporated into general practice, Dr. Lee said. “We’re equipped with slit lamps to see if there are any problems. Laser skin resurfacing, however, is more of a boutique offering. Likewise, Botox and Dysport (abobotulinumtoxinA, Medicis, Scottsdale, Ariz.) may be more easily incorporated into a general practice than dermal fillers.”
Practices with the most robust cosmetic offerings “are not the ophthalmic practices in Northern California,” Dr. McCulley said. “It’s the plastic surgeons and the dermatologists who advertise the most profusely.”
In his area of the county, most oculoplastic surgeons spend about 20-30% of their time on cosmetic procedures, and because general ophthalmologists are not trained, “the number and breadth of their offerings even more limited,” he said. Practices that do not offer “just about everything from brow and mid-face to facial resurfacing or aren’t collaborating with someone who does, it’s hard to keep patients.”
Ophthalmologists should also reiterate that products like Botox and Latisse were first introduced in ophthalmology, Dr. Lee said, who added that for aesthetic physicians Latisse is not “a big revenue maker.”
“If you’re passionate about adding a cosmetic portion to your business, you absolutely can add revenue to the practice. But you need to feel there’s a need for the niche,” Dr. Lee said.
Dr. Nerad agreed, saying “there are a lot of opportunities to integrate cosmetic procedures if someone has both the medical expertise and the interest and can make it work from a business point of view.” He also suggested physicians give any new cosmetic practice up to 2 years before deeming it a success.
“There are only two places that successfully increase your patient base—your own internal marketing and word of mouth to bring in new patients,” Dr. Nerad said. Excluding Botox and fillers, blepharoplasty will likely remain the leading cosmetic (and functional in some cases) procedure.
“Botox and fillers are minimally invasive, so people who otherwise would not have cosmetic surgery can ‘test the waters’ with relatively inexpensive treatment,” he said. “They changed the market and made it much more socially acceptable to have a cosmetic procedure.”
Adding cosmetic procedures “is doable to augment a practice’s offerings,” Dr. Lisman said. “If you’re a generalist and maintaining a busy practice, there are a number of cosmetic procedures you can offer relatively quickly and easily, including cosmetic contact lenses.”
In the New York area, it’s likely a surgeon will have “a lot of patients whose expectations cannot be met,” Dr. Lisman said. “In an aesthetic practice, if you don’t have a turn-down rate of about 25-35%—not just surgical but cosmetic included as well—you’re probably not going to be able to maintain a good reputation because you’ve ended up promising something you cannot deliver.”
Dr. Lisman predicts the overall subspecialty will increase in the near future, as “the natural ebb and flow of managed care and the diminution of reimbursement has driven this type of specialty that forces physicians to learn additional skills.”
Dr. Nerad agreed, and said ophthalmologists may be better able to identify people who are not good candidates for cosmetic surgery.
“Patients with ocular surface issues, abnormal eyelid physiology, and periorbital anatomy issues will require much more time to manage,” he said. “If you look at it from a risk-benefit perspective, if a patient’s told they will die without the surgery, there’s not a lot of discussion. If the benefit (i.e., living) is not that high (i.e., fewer wrinkles), they will tolerate much less risk.”
As surgeons implanting premium lenses discovered, most people opting for cosmetic oculoplastic surgery are relatively picky, Dr. Nerad said, “and while they’re likely to be good patients, they’ll be considerably more discerning about the work than if it’s being done for functional purposes only.”

Incorporating cosmetics

Patient satisfaction rates with fillers is “quite high,” and is not quite the stretch to add into a typical ophthalmology practice as might initially seem, Dr. Carrasco said.
“As ophthalmologists we are keenly aware of the benefit of ‘filling’ the anterior chamber with hyaluronic acid formulations. Why not use hyaluronic acid fillers to fill deflated areas of the face? Starting with nasolabial folds is the ‘safest’ area for patient satisfaction and ease of injection. The peri-orbital area along the inferior orbital rim is a more technically difficult area to treat and should be reserved for when you gain more experience with injectables.”
Products such as Vitrase (hyaluronidase injection, Ista Pharmaceuticals, Irvine, Calif.) can dissolve injected fillers if there are problems post-injection, she added.
“Botox, Latisse, and fillers can be added easily [with a relatively small capital investment] to a practice on a small scale to try and then increased as patient volume and interest increases,” she said. “Other non-invasive procedures that require larger capital expenses such as radiofrequency machines and lasers should not be added unless there is a marketing plan to augment the cosmetic side of your practice due to the volume of patients needed to treat to allay the cost of investment. That is, there is smaller return on investment with smaller, more medical based procedures, but also less risk to try. In many metropolitan areas, there may be more volume of cosmetic patients, but there is plenty of competition from our dermatology and plastic surgery colleagues as well.”
Dr. Nerad also suggested considering a full range of skincare products, from sunscreen to moisturizers, and remind current patients of the necessity as a way to introduce cosmetics to a practice.
Aesthetics is a growing subspecialty, Dr. Lee said. “There aren’t many of us who focus solely on that in this country. Even though we’re not inside the eye, we’re all over the face in terms of what and where we treat,” she said. “The specialty as a whole is transitioning away from oculoplastic surgery to oculofacial plastic surgery. The subspecialty’s strength will continue to be our core focus on the eye.”

Note: Some of the procedures described in this article are off-label in the United States.

Editor’s note: The physicians interviewed do not have financial interests in the products or services mentioned outside of offering and performing them. Dr. Lee is on the Allergan (Irvine, Calif.) speakers’ bureau.