A Visit To The Office of Vivian Bucay, MD

BRIEF COMMUNICATION A Visit To The Office of Vivian Bucay, MD D OW S TOUGH , MD Clinical Assistant Professor of Dermatology, University of Arkansas for Medical Sciences, Hot Springs, Arkansas THE ATTENTION to style was evident upon entering the well-lit, brightly colored waiting room. Modern artwork adorned the walls in an elegant, but not overdone fashion. As I walked to the reception area, a Picasso-style logo that characterizes Dr Bucay’s practice immediately caught my eye. I was aware of the anxiety that accompanied my request to intrude upon Dr Bucay’s busy practice and observe her well-recognized expertise with hyaluronic acid fillers. I wanted to glean additional knowledge about its use by observing a true master. I had made this visitation request as a complete stranger; one whose only common bond was the practice of dermatology. ‘‘Welcome. We’ve been expecting you,’’ said the smiling, sharply dressed receptionist. She led me into the modern clinic adorned with light hardwood floors, soothing bright walls and soft blue exam rooms with matching tables. Here I found more artwork, style, and attention to detail. This was a reflection of the clinic’s leader, and the ambiance calmed my initial anxiety over being ‘‘an intruder.’’ No doubt Dr Bucay’s first-time patients apprehensive about cosmetic dermatology would be put at ease by these serene surroundings. Bouncing up the hall with a smile that seemed capable of handling any of life’s problems was Dr Vivian Bucay (boo-ki). She welcomed me with an infectious enthusiasm. ‘‘I’m glad you’re here,’’ she said. ‘‘I hope we will be able to show you some new techniques. We have quite a few cases lined up.’’ Dr Bucay’s background and adventures in life are as interesting as her medical practice. A native of San Antonio, Texas, Dr Bucay is married to cardiologist, Dr Moises Bucay. I had the opportunity to meet their three beautiful children, who like their mother are bilingual. Her devotion to career and community is quite evident. She completed her premedical studies at John Hopkins University and obtained her medical degree from Baylor College of Medicine. Her experience with fillers began during her dermatology training at the University of Miami. After her residency, she practiced for 8 years in Mexico City. It was during this time she honed her experience with hyaluronic acid. Her practice is now located in San Antonio, Texas. Address correspondence and reprint requests to: Dow Stough, MD, 3633 Central Avenue, Suite N, Hot Springs, AR 71913, or e-mail: dowstoughmd@cablelynx.com. Hyaluronic acid fillers are becoming popular worldwide. These are natural hyaluronic acid derivatives that can be stabilized with chemical modifications. Nonanimal stabilized hyaluronic acid (NASHA) is characteristically injected into the dermis and does not disrupt normal tissue function.1 The NASHA gel undergoes gradual isovolumic degradation. The tissue augmentation that is initially achieved can be maintained despite loss of the NASHA polymer. This is due to the fact that as the concentration of the NASHA decreases, the water binding sites increase, resulting in maintenance of the original volume for over 6 months.2,3 These fillers are currently not FDA approved in the United States, but it is anticipated that they receive approval in late 2003 or 2004. There are three forms of NASHA gel based on the gel particle size. All forms are crystal clear biodegradable nonanimal stabilized by hyaluronic acid gels. The largest gel particle is Perlane for injection into the deep dermis. Restylane is composed of an intermediate gel particle size and Restylane Fine Lines is composed of the smallest gel particle size. Each version should be injected at different levels: Perlane into the deep dermis and superficial subcutaneous tissue, Restylane in the middermal plane, and Restylane Fine Lines into the upper dermis. Restylane was launched in 1996 and has proven to be associated with minimal problems. The advantages of this compound include decreased allergic reactions, increased longevity, and advantages in combining therapy with botulinum toxin (Carruthers A, ‘‘New Evidence of Hyaluronic Acid (NASHA) as a Dermal Filler,’’ 11th Congress of the EADV, Prague, Czech Republic, October 2002). The treatment-related adverse events include prolonged swelling, erythema, edema, and small nodules at the injection sites. Hyaluronic acid derivatives are said to confer less risk of an allergic reaction than collagen. Because NASHA is derived from nonanimal sources, transmission of potentially harmful viruses and bacterial agents is greatly reduced. The material is provided in a disposable 1.0-mL syringe with a sterilized 30-gauge needle designed for intradermal injection. In an article by Narins et al.4 it was concluded that NASHA provides a more durable aesthetic improvement than bovine collagen and is well tolerated. When approaching patients, Dr Bucay carefully studies facial characteristics, ascertaining the causes r 2004 by the American Society for Dermatologic Surgery, Inc.  Published by Blackwell Publishing, Inc. ISSN: 1076-0512/04/$15.00/0  Dermatol Surg 2004;30:1038–1040 Dermatol Surg 30:7:July 2004 Figure 1. Dr Vivian Bucay administering Restylane to a patient in her office in San Antonio, Texas. of rhytids, i.e., dynamic versus static, while carefully listening to her patients’ concerns. She never fails to compliment patients on their unique facial features before suggesting areas for improvement. She also strives to keep her patients comfortable, performing nerve blocks when needed and applying soothing, cool ice wands—a mainstay of her practice. After performing intraoral nerve blocks on a patient who was about to undergo lip augmentation, we exited the room to view previous cases on a computer screen. She explained in great detail the rationale for her current technique. ‘‘I really like to cross-hatch with Restylane across the nasolabial groove in more of a perpendicular plane and then layer in a horizontal plane over that. It’s very important to also augment this area,’’ she said as she pointed to the junction of the alar groove and the most superior portion of the nasolabial fold. ‘‘I really prefer to use Perlane in a deeper plane and sometimes I will layer Restylane superficially over the top. I do not find as much of a need for Restylane Fine Lines.’’ The seven exam rooms filled up quickly. I chuckled silently in admiration of the immediate strong rapport Dr Bucay is able to build with her patients. ‘‘Well, this is coming from a woman, and you know how picky we are,’’ she banters with a woman with small, thin lips. The woman also displayed minor dynamic wrinkles over the lower mentum. ‘‘I think we can make a positive change in this area and one in which you would be pleased with.’’ Taking every opportunity to educate, she looks up at me and quickly states, ‘‘Don’t forget a few units of botulinum in the lower mentum to boost the effects of fillers in the lips. Be careful not to place the botulinum too high in this area.’’ She stated as she pointed to the area immediately below the lower lip. The teacher was in her element while carefully explaining her rationale STOUGH: THE OFFICE OF VIVIAN BUCAY 1039 and approach. It is clear that Dr Bucay becomes intrigued by difficult and challenging cases. I realized how inadequate my own fund of knowledge was despite achieving good results on the cases I had attempted. This is an office of a practitioner who loves her work and exudes knowledge and enthusiasm to a degree seldom seen in my visits to other practitioners. As she studies a woman with purse string lips, deep nasolabial folds, deep glabelar creases, and a history of poor results from techniques performed by other physicians, she explains, ‘‘You cannot use botulinum alone here for these deep glabelar creases. You must layer underneath with Perlane, then add Restylane on top and utilize Botulinum injections also to the same area. I found the two work very well together in select cases.’’ Her comments reflect preliminary findings from a study by Carruthers that indicates ‘‘that combination treatment with Restylane and Botox is more effective than either modality individually in correcting glabelar rhytids’’ (Carruthers A, ‘‘New Evidence of Hyaluronic acid (NASHA) as a Dermal Filler,’’ 11th Congress of the EADV, Prague, Czech Republic, October 2002) At the time of my visit to Dr Bucay’s office (August 2003), I had recently attended a meeting where soft tissue filler techniques were presented by some of our experts in the field today. It is clear that techniques vary widely from one practitioner to the next and that the use of NASHA filler substances is evolving and is an area to be explored. As we worked through the day, no two cases seemed alike; patients all varied in their requests and solutions. A pleasant lady appeared upset over her past experience with being injected with a ‘‘Botox-like substance’’ by a physician impostor who quickly left town. Dr Bucay was sympathetic to this patient, who was visiting her clinic for the first time. ‘‘I’m very sorry you had a bad experience, but I think you will enjoy the results from injecting these lines around your eyes,’’ she said pointing to the crows feet area. ‘‘Now, let’s not spend money on this area. Your forehead already looks great,’’ she said to the woman, whose bangs covered her very minor forehead imperfections. A complete stranger had arrived in her office, was placed at ease instantly, gleaned tremendous insights, and learned from a true master. Dr Bucay’s experience in cosmetic dermatology, pharmacology, and use of botulinum and fillers places her firmly among the masters of this field of cosmetic dermatology. There are many things you simply cannot learn from attending a routine medical meeting. The time, effort, and opportunity of visiting another practice will pay tremendous dividends in our own practices and, ultimately, continue to establish the dermatologist’s essential role in the field of cosmetic surgery. 1040 STOUGH: THE OFFICE OF VIVIAN BUCAY References 1. Fitton A. NASHA promising in facial soft-tissue augmentation. Inpharma 2002;1363:11–2. 2. Olenius M. The first clinical study using a new biodegradable implant for the treatment of lips, wrinkles, and folds. Aesthetic Plast Surg 1998;22:97–101. Dermatol Surg 30:7:July 2004 3. Duranti F, Salti G, Bovani B, Calandra M, Rosati ML. Injectable hyaluronic acid gel for soft tissue augmentation: a clinical and histologic study. Dermatol Surg 1998;24:1317–25. 4. Narins R, Brandt F, Leyden J, et al. A randomized, double-blind, multicenter comparison of the efficacy and tolerability of restylane versus zyplast for the correction of nasolabial folds. Dermatol Surg 2003;29:588–95.