Changing the Face of Ophthalmology

Should your practice adopt aesthetic cosmetic procedures?

BY LESLIE GOLDBERG, ASSOCIATE EDITOR

Should an ophthalmologist consider doing an elective procedure that is purely aesthetic in value — a procedure where the results and the level of patient satisfaction cannot easily be quantified? While cosmetic surgery can be a lucrative field and many candidates may already be sitting in your office, you may ask yourself, is this the right direction for me?

The Right Skill Set

"The bottom line is all ophthalmologists perform cosmetic procedures," says Stuart R. Seiff, M.D., an oculoplastic surgeon at Pacific Eye Associates in San Francisco and vice president of the American Society of Ophthalmic Plastic and Reconstructive Surgery. "It's part of your basic training in ophthalmology. As far as I am concerned, the concept of doing cosmetic or aesthetic surgery should not be an addition to your practice. You need to be doing it, because it's what you are trained in."

Dr. Seiff says that part of an ophthalmologist's training is achieving an aesthetic result no matter whether the ophthalmologist is starting with an aesthetic procedure or not. "I do only oculoplastics — 70% is functional and 30% is patient-paid because the insurance company deems it to not be of medical necessity. The definition of aesthetic surgery is surgery that insurance will not pay for.

"All board-certified ophthalmologists are trained in eyelid surgery," says Dr. Seiff. "The real definition of whether or not blepharoplasty is cosmetic or functional is decided by their particular insurance company."

Taking the First Aesthetic Cosmetic Steps

According to the American Society of Plastic Surgeons, nearly 11 million cosmetic plastic surgeries were performed in 2006 in the United States alone.

Mark Brown, M.D., of Vision Partners, Mobile, Ala., an ophthalmic plastic surgeon, has been in practice 10 years. He says aesthetic enhancement has always been a part of oculoplastic surgery but the cosmetic side of his practice has grown over the years due to his increased experience.

"Initially, you may not attract cosmetic patients because you lack the personality and the experience of dealing with cosmetic patients," says Dr. Brown. "Now, about half of the patients I see are new to the practice. They are brought in by advertising specifically designed to target them."

Dr. Brown says female patients come in saying, "friends tell me I look tired." He says that they have heaviness of the upper eyelid, or a functional complaint of their eyes feeling heavy or an inability to put makeup on (Figure). The primary complaint he hears from men is that they are having trouble hunting because of excess upper eyelid skin.

Personal Experiences

Botox (botulinum toxin type A, Allergan) has a long history in ophthalmology and was first used for strabismus and spastic eyelid disorders in the 1980s. "Botox started in strabismus and has limited application there today," says Dr. Seiff. "One of its main uses today is in treating blepharospasm. Ophthalmology is where Botox evolved," explains Dr. Seiff.

Basil Pakeman, M.D., F.R.C.S., is the medical director of Manhattan Surgical Eye Care in New York City. Dr. Pakeman is trained in general and pediatric ophthalmology, but his expertise is in eyelids. "I began using Botox basically for strabismus and blepharospasm, so I had experience with it before it was approved for cosmetic use," says Dr. Pakeman. "I was pushed more in the cosmetic direction because I do a lot of eyelids — a lot of adult eyelids. It was purely incidental — I was just filling patient requests. The cosmetic blephs led to patients wanting fillers and Botox. Then we added chemical peels."

Figure. Before and after photographs of a patient who had a lower blepharoplasty procedure.

Dr. Pakeman explains that incorporating cosmetics really grew out of patient requests. "Once it got going, existing patients would request a procedure and then refer others to the practice," says Dr. Pakeman. "I would say about 35% of my practice is cosmetic-based and 65% routine ophthalmology care. The benefit to the patient is an ophthalmic surgeon looks at function as well as appearance."

"Over the years I have added plastics to my practice, but did not have a lot of experience with it in my residency," says Neal Nirenberg, M.D., F.A.C.S., East Valley Ophthalmology, Mesa, Ariz. "I have been in practice with partners who are very good at plastics. I was a partner with Richard R. Tenzel, M.D., one of the founding fathers of ophthalmic plastic surgery."

Dr. Nirenberg watched Dr. Tenzel perform blepharoplasties, saw him deliver postop care and manage his patients. Also at that time, one of his partners, a pediatric ophthalmologist, was in on the early use of Botox for strabismus. He also has a friend who is a dermatologist and one of the leading users of Botox in the country. Dr. Nirenberg's gained experience from different doctors who excelled at specific procedures. These mentoring experiences, as well as the Academy-sponsored classes he has taken, have formed his cosmetic background.

"The difference between myself and a plastic surgeon is that no one knows eyelid, orbital anatomy and what is better for eye health than an ophthalmologist," says Dr. Nirenberg. "An ophthalmologist is most concerned about your eye. For example, I know how important it is to have good lid closure, especially in patients who have dry eye, which is found mostly in older patients."

Concerns With Plastics

"This whole filler type of practice is concerning to me because of the expectation and unpredictable nature of the drug," says Dr. Brown. "If someone wants a little more skin removed, I can take care of that in the OR. If someone is unhappy with their filler, it may be due to the filler or unmet expectations. Results vary from patient to patient."

Dr. Brown says filler procedures are expensive and take up chair time. "The additional revenue per patient is not worth the risk of an unhappy patient," says Dr. Brown. "Doctors may think that these procedures are a way to work a patient in to surgery, but the risk of having an unhappy patient through no fault of the surgeon is not worth it."

Good Candidates for Cosmetic Surgery

"With cosmetic surgery, patients demand satisfaction and a higher degree of personalized care," says Dr. Pakeman. "A good candidate for cosmetic surgery seeks to improve his or her appearance and has realistic expectations about what the surgery can accomplish." Dr. Pakeman explains that because these patients are paying cash for a service, they have higher expectations and demand a different level of treatment. He says that managing expectations ultimately lies in the hands of the physician.

"You need to find out what bothers the patient in the first place. What options are available to him/her? How much correction is appropriate? What is possible to achieve? Cosmetic surgery involves a patient's psyche. We provide an honest evaluation and turn away poor candidates," says Dr. Pakeman.

"If we've done our job well, patients will have the aesthetic surgery and then refer us to friends and family," says Dr. Brown. He says that this is how many of his patients enter the practice. "My aesthetic patients may not have an eye doctor when they come to me, but after surgery they stay with our group. This generates income for years to come."

Ophthalmologists may be particularly well suited for dealing with aesthetic surgery patients. The refractive surgery patient, familiar to many ophthalmologists, is often equated to the cosmetic plastic surgery patient, says Dr. Seiff. He says the refractive surgery or multifocal IOL patients have different expectation levels and personalities than the standard ophthalmology patient, and this poses little problem for many ophthalmologists.

"However, there are ophthalmologists who want no part of that personality " says Dr. Seiff. "They will not deal with them for refractive surgery and they do not want to deal with this type of patient for eyelid surgery either.

"Generally, speaking, however, ophthalmologists are wonderfully prepared to deal with the aesthetic-minded patient," concludes Dr. Seiff. "We should be advocating that we do more cosmetic procedures." OM