John Martin’s father loved being a general ophthalmologist. So when he earned his medical degree, Dr. Martin figured he would follow in his father’s footsteps. That is, until he started performing blepharoplasties. Twenty years and a fellowship in plastic surgery later, Dr. Martin, in Coral Gables, Fla. has a practice dedicated exclusively to facial plastic surgery, 95% of which is cosmetic.

“I started just with eyelids and now I do facelifts and neck lifts,” Dr. Martin says. “I take fat out of other areas of peoples’ bodies and put it into their face as a type of filler to replace lost volume as they get older. I do Botox injections and I have a whole variety of lasers to tighten skin, remove scars, and the newest one is for getting rid of unwanted body fat.”

There are approximately 500 fellowship-trained, ocular facial surgeons (the subspecialty’s new name) in the United States. And like Dr. Martin, most practice no ophthalmology, according to Robert Goldberg, MD, president of the American Society of Ophthalmic Plastic and Reconstructive Surgery.

“My preference is that they don’t,” says Dr. Goldberg, chief of ophthalmic and orbital surgery at UCLA. But, he adds, there are thousands of general ophthalmologists who do both. The society’s fellowship program, he says, is robust, and will soon have 60 fellowship slots nationwide. There are several fellowships — plastic surgery, head and neck surgery, and dermatology — that can lead to a career in facial plastic surgery. But Dr. Goldberg is understandably partial to ophthalmologists and an ocular plastics fellowship. Ophthalmologists, he says, are already familiar with using small instruments and have “stunning training for detailed work.”

“When you think about surgery on the face the most important working part is the eye,” he says. “That is why so many patients come to ophthalmic plastic surgeons for cosmetic surgery around the eye.”

As to why these patients can find these services, the answer is simple. Declining reimbursements, increased competition and a health-care system in flux have ophthalmologists in search of new revenue streams — and afloat are cosmetic procedures and aesthetic treatments on the more lucrative waterways.

It makes good business sense. Baby boomers with disposal income are willing to pay cash for cosmetic surgery and other aesthetic treatments to help fend off aging, or at least its appearance.

“People are living longer, working longer, staying in the job force longer and want to maximize their cosmetic opportunity to feel as healthy and rejuvenated as possible,” says Steven M. Silverstein, MD, president of Silverstein Eye Center in Kansas City, MO.

CONSIDER THIS

Before you plunge into cosmetic facial surgery and its aesthetic sidekick, you should consider costs and competition. Depending on the technology, an intense pulse light laser can run $50,000 and a Fractionated Co2 laser $75,000. Even with a five-year lease agreement, that’s still many treatments to make before you’re in the black.

Some ophthalmologists new to the cosmetic market are taking a different, less expensive approach, doing Botox injections and selling nutraceuticals like Omega 3 fatty acids and cosmetic creams.

“It’s not in any way unlike doctors selling glasses with all types of frames, from inexpensive to designer, as a convenience to the patient and an alternative source of revenue,” says Dr. Silverstein, whose offerings include Botox (Allergan), Latisse (Allergan) and blepharoplasties. He began offering cash products some 20 years ago.

As for the competition, it is coming from, as Dr. Goldberg would not prefer, other general ophthalmologists and plastic surgeons, along with specialists like Dr. Martin.

Anne Rowland, MD, knows about that. Even with an ocular facial plastics fellowship on her CV, she says the hardest part of building the aesthetics side of her practice has been cracking the cash-only cosmetic side of the profession. Of those interviewed, Dr. Rowland and Dr. Silverstein still practice traditional ophthalmology.

“The cosmetic side has been harder to advertise just because of the competition,” says Dr. Rowland, part of the Eye Specialty Group in Memphis, TN. “I’m the only ocular plastic surgeon here but general plastic surgeons and general ophthalmologists are doing a lot of the other cosmetic things.”

All this said, starting an ocular plastics practice can be less expensive than opening a general ophthalmology practice because ocular surgeons can “start out with very little equipment doing surgeries and injections,” according to Dr. Goldberg. The biggest first-year expense will be for marketing and rent — say about $5,000 a month.

YOU’LL NEED A NEW STYLE

Word-of-mouth is the best way to find patients. But first you have to have patients to spread the word. That means creating a website and advertising — online, in the local newspaper — and visiting general ophthalmologists and colleagues in other medical specialties.

Moreover, when patients do come to your office it has to meet their expectations.

“It won’t work if you don’t have a good office,” Dr. Goldberg says. “The whole office has to be appropriately upscale and concierge-like so that patients with disposable income will want to have their surgery there.”

START SMALL, STAY FOCUSED

A new ocular facial practice can work effectively with just three employees, or, if you’re Raminder Saluja, MD, just one. After finishing a dermatological cosmetic surgery fellowship in 2007, Dr. Saluja left a group practice to start her own. “I was scrubbing my own toilets and answering my own phones in the beginning,” says the founder of Saluja Cosmetic and Laser Center in Charlotte, N.C.

Dr. Saluja started with one leased laser. Today she has 14 different lasers and primarily focuses on cosmetic facial surgery. When asked by colleagues, she always advises they build one laser at a time.

“You just kind of hear what your patients are asking for and what would kind of distinguish you in the market you’re in,” she says. “You always chew off one bite at a time and get that laser successful before you add something additional.”

Lasers are an important tool for ocular facial plastic surgeons. With laser and scalpel Dr. Martin not only accomplishes an eyelid procedure, but also improves the patient’s skin texture. After beginning with blepharoplasties, he moved on to face- and neck lifts.

“Once you become involved in the laser world, you sort of know this laser may work well in tightening in a certain group of people but other new technologies may work well for other people,” he says.

But be leery of what you buy. While it’s important for a young practice to offer in-vogue laser treatments, salespeople tend to exaggerate how much or how often you will use their product. Just because you have it doesn’t mean patients will come, at least not right away.

Unless you’re a specialist with a solid track record and reputation, says Dr. Martin, tapping into the laser and cosmetic surgery market will take time and require patience to build a steady stream of patients.

THE AESTHETIC SIDE OF COSMETICS

A practice doesn’t have to dive off the high board to enter ophthalmology’s cosmetic revenue stream. It can wade in via the slowly sloping banks of aesthetics. Aesthetics covers a wide range of injectables like Botox and other fillers. Both are inexpensive to do and have a relatively shallow learning curve. Injectables are “very popular and a core part of our specialty training,” Dr. Goldberg says. “It’s a driver of patients because people are seeking those kinds of services.”

As for nutraceuticals, like Omega 3 fatty acids, and rejuvenating skin and facial products, these are available only in ophthalmic offices. Dr. Silverstein’s office also carries moisturizers and offers aminocaproic acid treatments and chemical peels. Latisse, which started life as a glaucoma treatment, is a popular aesthetic for its secondary effect of increasing eyelash thickness and growth.

At Saluja Cosmetic, a staff aesthetician performs facials, dermabrasion, chemical peels and some laser treatments like hair removal and Pelleve (Cynosure) radio frequency treatment.

“It’s nice to have that as part of your practice because sometimes patients just want a peel,” she says. And if the aesthetician notices someone has rosacea she can refer the patient for a laser treatment. “That’s another referral for you.”

From Dr. Silverstein’s perspective, having aesthetic services and products available for patients requires little capital investment and is a win-win. Patients benefit because it is convenient and offered by someone they trust. The practice benefits because patients like it. And that is simply smart business.

“I think doctors have to become better business people,” he says. “And part of being a good business person is to find legitimate avenues and sources of revenue streams that complement the core and foundation of what we do.” OM