I remember the first time I saw a hyaluronic acid (HA) filler treatment being applied. It was a bit more than 10 years ago, while I was doing my fellowship in Toronto. I recall thinking: “How great is this? Getting your lips plumped with a nonpermanent filler, improving your cheeks, hiding some lines!” As I was being trained as an ophthalmologist at the time, these kinds of procedures were supposedly outside of our area of interest—but they were certainly not outside of mine.
Some years later, while working as an ophthalmic plastic surgeon, I realized that, quite often, my patients asked about nonsurgical options to address their under-eye bags or circles, sunken upper eyelids, or droopy eyebrows—things that they became aware of after refractive or cataract surgery helped them to see themselves better. This was how I decided to start doing periocular treatments; I started with botulinum toxin and HA fillers.
But as I started offering these treatments around the eyes (Figure 1), I realized that it didn’t make sense to treat the highly complicated and delicate periocular area and not the rest of the face. This led to the establishment of our oculofacial rejuvenation unit in an exclusive ophthalmic clinic in Barcelona.
STARTING FROM SCRATCH
When we decided to open the unit, we had to start from scratch. We had to adapt a space that we already had—an examination room—by making key changes to update it from a regular ophthalmology office. We added more light, bought new furniture, added more space, and gave it a more attractive appearance. We opted for a semi-surgery room design that met the sterile requirements of all our treatment units, with conservative decoration and profile.
Once the space was designed, the next step was to increase our knowledge about the extensive numbers of treatments and products available. We chose to start with two main brands of HA fillers and botulinum toxin (Galderma and Merz Aesthetics), always making sure we used the best quality products. Initially, we offered only these two treatments for the entire face, from the forehead to the chin and even the neck.
We also trained our clinical assistants and nurses regarding how to work with this type of patient and these procedures because we quickly learned that aesthetics patients expect a different and more exquisite level of treatment than standard cataract and refractive surgery patients.
As the procedures we offered and the patients we treated increased, we gradually added other therapies to our service. These included other fillers (Figure 2) such as calcium hydroxyapatite (Radiesse, Merz Aesthetics) and poly-L-lactic acid (Sculptra Aesthetic, Galderma), tension threads, collagen induction therapy (Figure 3), peelings, mesotherapy, skin boosters, carboxitherapy, CO2 laser treatments, and high-intensity focused ultrasound (Ultherapy, Merz Aesthetics; Figure 4). These additions allowed us to address all the diverse requests of patients. We always ensured that we had thorough training and documentation of the pros and cons of each new treatment.
Because we had adopted a conservative practice profile, we decided not to openly advertise our new services to the public. This is mainly because our target clients are our existing patients—patients who want natural and subtle changes and who desire absolute discretion. If people see you walking into an ophthalmology clinic, they will hardly assume that you are coming for an aesthetic treatment! Offering this kind of privacy limits how openly we can advertise. Therefore, if a person doesn’t know us or know someone who was treated by us, he or she will probably walk into any of the hundreds of other aesthetics clinics in Barcelona instead of coming to us. But our good and natural results are the key to our success.
I sometimes get the feeling that, eventually, all aesthetically treated patients end up looking almost the same (and, in some cases, even like their own physicians). I don't like that clone-like result. I like uniqueness; I believe in highlighting the strengths of each patient, as we all have certain facial features that are worth emphasizing and others that we want to hide. That is what we offer at our clinic: natural rejuvenation, a fresh look, and a younger version of that individual with just a few retouches.
Word of mouth is our best advertising, and even patients who don’t want anyone to know that they had an aesthetic or rejuvenation procedure end up telling someone. For that reason, today we are well positioned with a fully functioning aesthetics service. We have two exclusive rooms dedicated to nonsurgical rejuvenation, and these work in parallel with the three or four ophthalmic plastic surgery service rooms. We now can offer the best solutions for everything our patients are looking for.
If you are about to embark on a quest like ours, I recommend doing it gradually. As ophthalmologists, we know the anatomy of the periocular area better than anyone else, and that makes us the most suitable specialists to treat the tear trough and under-eye bags—not only surgically but with fillers, too. This is the main differentiator between us and other aesthetics practitioners, and it is something that we need to explain to our patients.
If you feel comfortable treating the areas around the eyes, there is no reason why you shouldn’t feel comfortable treating the rest of the face. I recommend starting with HA fillers until you feel comfortable treating the entire face, then proceed with more complex fillers. Botulinum toxin is the star treatment: Learn how to use it subtlely but effectively, and you will have satisfied patients who will come back to you at least twice a year and who will listen to any suggestion you give to improve their appearance.
The key to success is to communicate with your patients, to explain the options, to go little by little, and to give realistic expectations with natural results.