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Less invasive oculoplastics technologies replacing some periorbital surgical procedures
Nonsurgical and less invasive oculoplastics procedures impose less damage on tissues and allow future maintenance, a surgeon says.
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| Robert A. Goldberg |
Some invasive oculoplastic surgical techniques are being replaced by less invasive procedures that provide equivalent or better results, according to Robert A. Goldberg, MD.
Dr. Goldberg said a substantial range of functional and cosmetic problems can now be treated with nonsurgical or minimally invasive procedures. Often, the same cosmetic effect can be achieved with less invasive procedures as with a traditional procedure, he said.
Injectable dermal fillers, such as Restylane (hyaluronic acid gel, Medicis) and barbed sutures are two recent examples of technologies that can replace more invasive procedures, he said.
“There are fewer and fewer situations for which there are not less invasive options, and that’s where I see the field evolving. But there are still some indications for bigger surgeries, particularly on the functional side,” Dr. Goldberg said. “If patients have fractures, tumors or severe anatomic distortions, those types of things will typically respond better to more traditional or invasive surgeries.”
Periorbital rejuvenation
In the last 5 years there have been advancements in nonsurgical technology that offer alternatives to surgeries, Dr. Goldberg said. Noninvasive techniques for aesthetic rejuvenation of the periorbital area are one example, he said.
“Some of [our approaches] in the past included fat or plastic implants. I still use them occasionally, particularly for patients who cannot tolerate the idea of coming back in, but that requires a fairly big incision with a flap and foreign material,” he said. “A lot of those issues can now be treated with better nonsurgical or noninvasive options, and the patients really like that.”
In the past, volume was added to the periorbital area with autologous fat tissue. Lifting procedures, such as midface lifts, were also used to lift volume from one area to another, Dr. Goldberg said.
“That is the top procedure that I think can be done as well, or arguably better, with a nonsurgical technique,” he said.
Dr. Goldberg said Restylane, which has been available on the market for about 2 years, produces better results than the surgical procedures he has used to rejuvenate the eyelid area.
Restylane is made from a natural sugar that the body metabolizes, Dr. Goldberg said.
“I see the goal as having something that goes away. It is part of what makes the synthetic injectable fillers such as Restylane in my opinion so valuable,” he said. “Part of the safety comes from the fact that it’s going to go away.”
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Images: Goldberg RA |
Lifting techniques
Thread or cable lifting techniques are less invasive techniques for facelifts that have recently become popular, Dr. Goldberg said.
He and colleagues at University of California, Los Angeles, began using these techniques about 5 years ago.
“Nowadays there is a lot of popularity with barbed threads,” he said. “They lift tissues but allow it to be accomplished without any substantial open flap. It essentially lifts flaps from the inside without cutting.”
But Dr. Goldberg said he is not convinced that barbed threads are the best technology.
“There might be something to the technology of the barbed threads, but in my opinion the important concept is the idea of the noninvasive lift,” he said. “I think the technology for exactly what type of material will work the best has not been solved.”
Hidden incisions
Another group of less invasive procedures are operations done through small hidden incisions, Dr. Goldberg said.
“For example, we may use conjunctival approaches as opposed to skin approaches, or use an endoscope to allow a much smaller skin incision,” he said.
For lacrimal surgery, Dr. Goldberg now only uses an endoscopic endonasal approach so there are no visible external incisions.
“I am finding the success rate is higher, and that is true for a number of these less invasive techniques. People first thought success rates would be inherently lower, but we’re not necessarily finding that,” he said.
Minimizing tissue damage
These and other less invasive approaches are based on the philosophy that minimizing normal tissue damage should be a priority, Dr. Goldberg said.
“The main differentiation is the decreased invasiveness so there is less damage to normal tissue,” he said. “Most of the risks in surgery have to do with damage to normal tissue, or what I call collateral damage. The less normal tissue you damage, the less collateral damage you create, and the less risk there is in the surgery.”
“Patients have a very high acceptance for less invasive surgeries,” he said. “There is lower risk and quicker return to activities.”
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Changing faces, changing procedures
Some surgeons may believe that longer-lasting effects are a benefit of invasive surgery. But Dr. Goldberg said that faces change as patients age, and changes that do not last as long may be preferred.
“The perception, and probably a certain amount of reality, is that the noninvasive techniques may not last as long,” Dr. Goldberg said. “But if that’s true, it’s not necessarily negative because the face changes over time anyway. Patients are generally quite receptive to the idea of less invasive procedures that can be maintained over time.”
Minimally invasive techniques lend themselves better to maintenance because normal tissues have not been damaged, he said.
“Typically, the maintenance procedures work well and are easily added,” he said. “I find most patients subscribe to that philosophy and like the idea of coming in from time to time for some maintenance as the face changes or even as styles change or needs change.”
Resisting new techniques
Some surgeons may view the shorter-lasting procedures as a threat, Dr. Goldberg said.
“I think there is a lot of resistance. I think surgeons are inherently threatened by these ideas because, at one level, it makes their skills less marketable,” he said. “For example, if there is a surgeon who only does big open face lifts, and I show results better than open surgeries with injections and minimal incisions, I think it could be threatening on that level.”
Many surgeons also believe that the effect of a procedure should last a long time, Dr. Goldberg said.
“Some of the bigger or open-flap surgeries probably do last longer than the noninvasive techniques, so I think surgeons often have difficulty with this philosophy – doing something that doesn’t last as long – but I see that as a potential advantage, not a disadvantage.”
“When you look at the studies, I’m not convinced that some of these surgeries last as long as we really think,” he said.
In a study recently submitted for publication, Dr. Goldberg and colleagues found that noninvasive eyelid injections of Restylane predictably last 9 months to 1 year.
“I am often getting better results with this than I ever got with any kind of surgery. And I actually prefer materials that go away over time,” Dr. Goldberg said. “Materials that last much more than a year wouldn’t be as appealing to me because I would lose the ability to adjust things as the face changes, and I would lose the ability to build a relationship with the patient over repeat visits.”
For Your Information:
- Robert A. Goldberg, MD, can be reached at 100 Stein Plaza, Los Angeles, CA 90095-7006; 310-206-8250; fax: 310-825-9263; e-mail: goldberg@jsei.ucla.edu. Dr. Goldberg has no direct financial interest in the products mentioned in this article. He is a paid consultant for Medicis.
- Medicis, maker of Restylane, can be reached at 8125 North Hayden Road, Scottsdale, AZ 85258-2463; 602-808-8800; fax: 602-808-0822.
- Daniele Cruz is an OSN Staff Writer who covers all aspects of ophthalmology.