Starting or expanding into an aesthetics practice is an investment that can be rewarding on many levels, but having your staff prepared for the most common aesthetic scenarios is priceless. When we first started offering aesthetics, I found that many of my staff weren’t sure how to work up patients and would end up just putting them in a room with a progress note and alert me that “we have a Botox.”

I know from experience that shifting gears from ophthalmic to aesthetic can be a confusing and possibly frustrating curveball to throw to even an experienced ophthalmic tech. Here’s how we have learned to tackle everything from Botox to blepharoplasty in our office.

First learn the basics

Our technicians are first trained on ophthalmic chair skills and demonstrate mastery before moving into aesthetics work up. All patients, aesthetic and otherwise, undergo a basic exam that includes elements such as chief complaint, visual acuity, intraocular pressure and a review of systems, allergies and medications. These patients are in an ophthalmology office, so there’s no reason not to document the basics. Plus, medicines and disease history can influence aesthetic decision making.

In addition, all aesthetics patients get photographs for their charts and a photographic release consent form. After all procedures, staff are available for any clean up required, to review post procedure instructions, to escort patients to the checkout, and to ensure they receive any skincare recommendations. They also discuss financial options — financing options like CareCredit can be used for those with financial concerns, and, depending on the company, FSA/HSA funds can sometimes be used.

Next, master individual procedures

Lid surgeries

These are our bread and butter, with about half functional and the other half cosmetic. We do upper and lower blepharoplasty, ptosis surgery and lateral tarsal strips in office.

If patients go through insurance, staff obtain prior authorization prior to scheduling. Staff pull instruments and supplies the day before the procedure to keep our day running smoothly as well.

Staff obtain photos and consents, assist me in measuring and/or marking patients prior to prepping, draping and reclining patients. Patients typically receive oral sedation in addition to local. Once prepped, we turn on the patient’s favorite relaxing music and the staff assist me during the procedure as needed. After the procedure, they lend a hand with clean up, bandaging the patient, reviewing post op instructions with the patient and their driver, and finally, help patients into their vehicles after sedation.

Injectables

Botox is a loss leader, but it often leads to use of other injectables in the future like filler and Kybella for facial sculpting. To prep these patients, my staff have them sign consents for the procedure they came in for. But, if the patient isn’t sure what they want that day and want to discuss their options with me, they obtain consent for other injectables as well. I’ve found this to be a huge timesaver instead of having conversation with the patients, then going back to pick up other informed consents.

Staff take the pre-op photos, document the areas of concern and any budget the patients might have in mind, prep the area with iodine (as long as they are not allergic), and apply topical numbing according to patient preference.

Radiofrequency microneedling or CO2 resurfacing

Both procedures tighten, firm, and brighten the skin, but each has important differences. Radiofrequency (RF) microneedling is definitely more comfortable, but results are more temporary. CO2 resurfacing results last longer, but the procedure requires topical numbing.

To start, consents and pre-op photos are taken. Pre-procedure numbing is optional for RF microneedling and standard for CO2 resurfacing (I’ve found the optimal time to numb is 20-40 minutes). For my deeper resurfacing patients, we administer oral sedation with Vicodin, Valium, Phenergan (topical anesthetic can be used as well) after signing sedation consents and confirming that they have a responsible driver.

Weight loss

We’ve dabbled in RF weight loss and skin tightening but never got the “wow” factor we were looking for in weight loss until now.

With the nationwide shortage, we have been able to produce compounded versions of semaglutide and tirzepatide (Ozempic, Novo Nordisk; Mounjaro, Lilly, respectively) for appropriate candidates. Our pharmacy is 503A (regulated by the FDA —we source from the same FDA-approved manufacturing facility that supplies the branded products, and we test each batch according to USP guidelines. We are licensed in 49 states and currently awaiting CA licensure.)

Prior to our in-person or telehealth visits, we have patients complete informed consents, detailed weight loss questionnaires, and the regular clinic health histories and demographics forms. During my consultations I rule out pertinent negatives such as history of gallbladder disease, pancreatitis, thyroid nodules or cancer, family history of thyroid nodules or cancer, MEN2, liver or kidney disease and pregnancy. Because these medications have been proven to be directly anti-inflammatory and useful in auto-immune disease, we are currently investigating potential improvement in patients experiencing dry eye with and without autoimmune disease.

My staff then communicate with the patients, which includes getting mailing addresses, taking payment, ordering medication from the pharmacy, and setting the next telehealth appointment, while I order lab work and communicate with primary care providers or specialists.

I check in with my patients every 3 weeks to evaluate response and side effects and to make plans for the next month’s dosage.

Hair and eyebrow transplants

Since we added the SmartGraft follicular unit extraction (or FUE) hair restoration system to our practice, we have learned how to best prepare for hair/eyebrow consultations and procedures. I created a comprehensive “before the consult” hair questionnaire to understand medical, behavioral, and hormonal aspects of hair loss. My staff take nine standard photos of a patient’s head prior to hair or brow transplant consult or direct the telehealth patient on how to do the same.

Staff are responsible for having all instruments and supplies prepped for the procedure along with the informed consent and pre-op paperwork for me to discuss with the patient. We have trained some of the staff to assist with the procedure as needed, and they provide support when reviewing the post-operative instructions with patients and their caregivers, and preparing patient take-home supplies: a few chux, Neosporin, Medrol dose pack, oral antibiotic, and some 4x4s for home use.

Conclusion

Aesthetics can seem like a completely different world from a standard general ophthalmology practice, but the same care and attention to detail can help both doctors and technicians be successful in both worlds. Having standardized forms and procedures can help staff successfully prepare these patients for consultations or procedures and make integrating aesthetics into your practice as smooth as a Botoxed forehead. OP

Dr. Toyos is partner and research director of Toyos Clinic in Nashville, Tenn. Email her at Mtoyos@toyosclinic.com. Disclosures: Dr. Toyos reports financial relationships with Bausch + Lomb, Biohaven, Glaukos, Kala Pharmaceuticals, Lumenis, Novartis, Oyster Point, Sun Pharmaceuticals and Zeiss.