A Lid Surgery Primer
Expert advice on the approach to blepharoplasty and ptosis repair.
BY MICHAEL E. MIGLIORI, MD
When patients come in complaining that their lids are “droopy,” it is necessary to establish whether they have a true ptosis or merely pseudoptosis. The hallmark of ptosis, of course, is that the inferior margin of the upper eyelid at rest sits lower than normal, thereby encroaching on or covering the visual axis. True ptosis can occur from dehiscence or detachment of the levator aponeurosis, paralysis of the levator muscle, levator muscle dystrophy (myotonic dystrophy oculopharyngeal dystrophy), sympathetic paresis of Muellers muscle (Horner's syndrome), or mechanically secondary to the presence of a mass in the upper lid or superior orbit.
In this article, I will offer the perspective of an oculoplastics subspecialist about the clinical evaluation process and options for surgical repair.
Normally, the upper lid margin rests 4-5 mm above the mid-pupil. A ptotic lid will have an MRD1 of less than that. The MRD1 is a true measurement of the amount of ptosis. It is independent of the amount of redundant skin. When the MRD1 is low enough, the upper lid will cause constriction of the superior and peripheral visual fields.
Pseudoptosis mimics ptosis. In this situation, redundant upper lid skin, with or without prolapsing orbital fat, overhangs the lid margin, a condition called dermatochalasis. Dermatochalasis can be aggravated by brow ptosis. The upper lid skin fold hangs over the lid margin and encroaches on the visual axis, while the lid margin remains at a normal height. The MRD1 may be 4 mm above the corneal light reflex, but the upper lid fold obscures the pupil. In other words, the MRD1 is not a measure of the distance between the corneal light reflex and the upper lid fold; it is a measure of the distance to the upper lid margin. Visual obstruction may still result with a normal MRD1, but the cause here is that the eyelid skin blocks vision, not the eyelid margin.
Pseudoptosis with significant dermatochalasis but no true ptosis.
Repair of a ptotic lid requires advancing or tightening the levator muscle, either directly through a levator procedure, or indirectly through a Fasenella-Servat or conjunctival-Mueller's muscle resection procedure. Treatment of pseudoptosis requires excision of the redundant skin, orbicularis muscle and often prolapsed orbital fat. Removing excess skin and fat without addressing problems with the levator muscle will not raise a ptotic lid. On the other hand, raising a ptotic lid without removing skin can result in an apparent redundancy that was not obvious before the lid was elevated.
Blepharoplasty and ptosis repair can be recommended for cosmetic reasons to improve the appearance of the lids, or for functional reasons to improve vision. The degree of visual obstruction is determined preoperatively with visual field testing. Frequently insurers require a visual field test once with the lids at rest, and repeated with the lids taped up in order to try to demonstrate that raising the lid will result in improvement in the visual field. When ptosis and dermatochalasis exist together, it may be difficult to determine how much of the visual loss is due to the dermatochalasis and how much to the ptosis.
Blepharoplasty
A standard blepharoplasty involves removing redundant skin, orbicularis muscle and possibly prolapsed orbital fat. The excess skin is marked using the pinch test. The lid crease incision is first drawn across the lid. The incision should not extend medial to the upper pomatum, nor laterally beyond the end of the brow. Once the crease incision is demarcated, a smooth forceps is used to pinch the excess skin above this line. The lower blade of the forceps is placed on the lid crease incision line, and the upper blade pinches the redundant tissue.
True ptosis with no significant dermatochalasis.
Concomitant true ptosis and dermatochalasis.
The maximum amount of skin that can safely be re moved is the amount of skin that can be pinched in the forceps without everting the lashes. This is done in three or four spots across the lid, and an arc is drawn from one end of the lid crease incision, through each of the marks, to the other end of the lid crease incision to create a horizontal ellipse. The incisions are made with a #15 scalpel blade along the skin marker lines, and the skin is removed, often with some or all of the underlying orbicularis muscle. If necessary, prolapsed fat may also be removed. The incision is then closed with either interrupted or running sutures of the surgeon's choice.
Ptosis Repair
Ptosis repair can be accomplished either through an anterior or a posterior approach. Surgery to advance or resect the levator aponeurosis is generally performed through a lid crease incision. If an advancement is planned, once the aponeurosis is exposed, the edge is undermined. One to three sutures are passed partial-thickness through the tarsus and then through the aponeurosis to advance it onto the anterior tarsal surface. A single suture is often all that is necessary to elevate the lid, but placing two or three sutures allows for better control of the lid contour.
If a levator resection is chosen as the needed procedure, the levator complex, including the underlying Mueller's muscle and conjunctiva, are divided from the superior tarsal border, and the conjunctiva is dissected from the overlying Mueller's muscle and reattached to the superior tarsal border with a running absorbable suture. The levator aponeurosis is then dissected free, far enough posteriorly to allow for the pre-determined amount of resection. Two or three sutures are then passed partial thickness through the tarsus and then through the levator-Mueller's muscle complex at a distance from the cut edge of the muscle equal to the amount of planned resection.
While both levator advancement and levator resection are performed through a lid crease incision, it is not necessary in all cases to remove excess skin or fat at the same time. A blepharoplasty may be indicated, however, if there is significant redundancy present and the extra skin will overhang the lashes and obstruct vision after the lid is raised, or it can be done to improve the cosmetic result after ptosis repair. Billing issues concerning combined procedures are discussed in the accompanying article below.
Posterior-approach ptosis repair includes either the Fasenella-Servat or conjunctival-Mueller's muscle resection. In both procedures, the upper lid is everted; in the Fasenella procedure, hemostats are applied across the tarsus from either side several millimeters below the superior tarsal order, a suture is run beneath the clamps, and the tissue within the clamps is resected. A conjunctival-Mueller's muscle resection procedure instead resects conjunctiva and Mueller's muscle immediately superior to the tarsus, but does not remove any tarsus.
With both of these posterior approaches, the lid is elevated, but there is no change in the preoperative skin, orbicularis, or prolapsed fat. A standard blepharoplasty through a separate incision using an anterior approach can be performed in conjunction with a Fasenella-Servat or conjunctival-Mueller's muscle resection if there is significant dermatochalasis or fat prolapse.
It is important to recognize preoperatively any ptosis that may be obscured by dermatochalasis. An otherwise perfect blepharoplasty will not relieve visual symptoms if the ptosis is not corrected as well, leaving an unhappy patient with the prospect of having to have additional surgery. OM
| Dr. Migliori is chief of ophthalmology at Rhode Island Hospital and clinical associate professor of ophthalmology at the Warren Alpert Medical School at Brown University in Providence, RI. He can be reached at mmigliori@eyeplasticri.com. |
The Blepharoplasty and Ptosis Surgery Bundles: An Ongoing Saga, By Riva Lee AsbellSurgeons are to be commended whenever improvements in technique enable two or more procedures to be performed in one session. It's more convenient for the patient and improves the efficiency of the practice. Unfortunately, in some instances surgeons are punished rather than rewarded for their ingenuity. Such is the case for oculoplastic surgeons who perform non-cosmetic blepharoplasty and ptosis repair together, stemming from recent changes to reimbursement for combined procedures. The National Correct Coding Initiative (NCCI), a document issued by the Centers for Medicare and Medicaid Services (CMS), correlates CPT codes that cannot be billed together in order to promote correct coding. It is the objective of the NCCI to aid CMS in its goal of decreasing fraud and abuse as well as decreasing the amount of overpayments erroneously being made to providers. The NCCI is issued quarterly. The document essentially lists sets of codes that cannot be used together for various reasons. It is also known as the CCI or “bundling lists.” There are basically two types of codes: (1) Column I-Column II codes and (2) “mutually exclusive” codes. The former contains CPT code pair sets whereas the greater includes the lesser. The latter contains those code pair sets that are felt cannot be reasonably performed at the anatomic site or at the same patient encounter. When code pairs are bundled in the Column I-II category, the code with the greater payment is paid and the second code is not. When code pairs are bundled as mutually exclusive, the CPT code with the lowest RVUs (relative value units) is paid. The code pair set for blepharoplasty (CPT code 15823) and external approach blepharoptosis repair (CPT code 67904) is a mutually exclusive bundle. If you bill them both together you will be paid for the lowest paying code — the ptosis repair. This was not always the case. The original NCCI had the two code sets bundled. At that time, I engaged in presenting information for eliminating the bundles to James Gaither, MD who headed the NCCI at that time. It went through the CMS process and the unbundling became effective. Dr. Gaither always kidded with me that he was one of “the good guys” and I shouldn't forget to credit him. We all were very appreciative of his efforts. However, on April 1, 2009 the same code edit pairs appeared as mutually exclusive edits in the NCCI. Appeals were made by the various societies that represent ophthalmic surgeons and by individuals. The environment at CMS has changed, and the decision remained unchanged. The issue continues to rage and there are serious repercussions from infringement of the rules. Unfortunately, the coding is being taught erroneously in some courses, while at the same time practitioners and billing/coding personnel are trying to be clever to circumvent the bundles. The bundles for CPT codes 15823 (blepharoplasty) and 67904 (external levator resection) should not be broken unless one of the procedures (ie, blepharoplasty repair) is being done on one side and the second procedure (ie, ptosis repair) is being performed on the contralateral side. This would be most unlikely. Typical Fee Schedule ExampleContained in each Medicare contractor physician fee schedule are two sets of codes and their respective payments. One set is used when the service is performed in an office setting; the other set is used when the service is performed in a facility setting. For surgery, the payment for a procedure performed in a facility (operating room of a hospital or ASC) is designated by the “#” sign, whereas the alternate payment listed for the same code designates the payment for that code when it is performed in the office. The higher paying code for the same procedure is the office code, since the physician is thereby reimbursed for the added expense for performing the surgery in the office. The Office of the Inspector General is investigating the billing of procedures with the wrong place of service. Be sure your staff knows the difference. Using the Highmark Medicare in Pennsylvania area 01 fee schedule, here is the current reimbursement for the two sets of codes: Performed in a facility: Performed in the office: The office procedure for each code reimburses higher than the facility code. In a facility, blepharoplasty surgery reimburses higher than ptosis surgery; however, note that within the context of the office setting, ptosis repair reimburses higher than blepharoplasty surgery. How To Bill For Optimal ReimbursementThe recent coding change is an unfortunate setback for oculoplastic reimbursement; nevertheless, one must remain in compliance. When blepharoplasty and ptosis surgery are performed in a facility setting, code for just the blepharoplasty. However, currently, if both procedures are performed together in an office setting, then greater reimbursement will be obtained by coding only the ptosis surgery. Additional tips for proper coding:
Ms. Asbell can be contacted at www.rivaleeasbell.com. |
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