Ocular aesthetic procedures increasing as technologies improve, baby boomers age

Ophthalmologists are finding more baby boomers in their offices who are looking for more aesthetic surgical procedures, including Botox and dermal fillers. And while oculoloplastic surgeons are similarly expanding their scope of practice beyond the eyes, the distinction between the two specialties has blurred.

Charles B. Slonim, MD, FACS, uses hyaluronic acid to fill facial lines and grooves. Image: Riddick M

“Oculoplastics traditionally referred to the eyelids, orbit and tearing system,” Jay Justin Older, MD, an OSN Oculoplastic and Reconstructive Surgery Board Member, said. “Now, with new technology and advances, some of my colleagues have spread out, and now many of these doctors do the entire face. But the cosmetic part of oculoplastics is primarily blepharoplasties, brow lifts, ptosis and now injectables.”

There are essentially two types of oculoplastic surgery: reconstructive and cosmetic/aesthetic. Reconstructive facial plastic surgeries are typically medically necessary and covered by insurance or Medicare. Aesthetic procedures are not medically necessary and not covered.

The lines blur when the same procedures are used for different purposes. For instance, blepharoplasties are performed for either reconstructive or aesthetic reasons, with the distinction based on visual acuity and other criteria established by Medicare.

The lines in aesthetic surgery have blurred even further regarding who performs ocular or facial procedures. In addition to oculoplastic surgeons, otolaryngologists, dermatologists, oral maxillofacial surgeons, comprehensive plastic surgeons and comprehensive ophthalmologists are trained to perform cosmetic facial procedures. Injectables such as Botox (botulinum toxin type A, Allergan) can be administered by a range of medical professionals, from internists to gynecologists.

The overlap among medical specialties administering the same aesthetic facial procedures, including full face-lifts, had caused friction over scope of practice issues in the past.

However, as the cosmetic field has expanded with new procedures and products, specialists have forged positive working relationships. Many ophthalmologists now work together with comprehensive plastic surgeons, otolaryngologists and dermatologists in treating aesthetic cases. In addition, some specialists regularly attend society meetings in other medical fields.

The popularity of aesthetic procedures has led to increased business in the field. Jeffrey A. Nerad, MD, FACS, an OSN Oculoplastic and Reconstructive Surgery Board Member, said that as expensive and invasive aesthetic surgical procedures have been declining in popularity, more affordable, less invasive procedures have been increasing.

Jeffrey A. Nerad

“There has been a trend over the last 10 years for more and more aesthetics to be done as baby boomers get older,” Dr. Nerad said. “There’s also been a trend toward lesser invasive surgeries. Rather than bigger face-lifts, there are easier, quicker procedures like Botox and fillers.”

He said comprehensive ophthalmologists might not realize the extent to which the subspecialty of oculoplastic and reconstructive surgery has expanded in scope of practice, leading to it being renamed “oculofacial plastic surgery” by some in the field.

“Oculoplastic surgery is a pretty new specialty, some 30 to 40 years old,” he said. “Traditionally it was based on reconstructive surgeries for functional eyelid problems, and that’s continued with an increasing sophistication for restorative or reconstructive surgery. But now there are a number of surgeons in oculoplastic surgery who do all types of oculofacial aesthetic surgeries.”

Training

With no specific board certification for subspecialties within ophthalmology, all ophthalmologists are trained in basic plastic surgery procedures that can be performed for aesthetic reasons, including blepharoplasty, entropion, ectropion and ptosis.

The oculoplastic/reconstructive subspecialty is relatively small. The American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) has some 500 members worldwide. The field remains small partly because of its highly specified nature, according to Mark R. Levine, MD, FACS, OSN Oculoplastic and Reconstructive Surgery Section Editor.

According to Dr. Levine, many residents prefer to stick to learning cataract and refractive surgery and shy away from oculoplastics because of the amount of additional training needed to perform oculoplastic surgery.

“In ophthalmology, residents do the bulk of their surgery in their last year,” Dr. Levine said. “You cannot learn to do a lot of this if you are learning it all in 1 year, so they just tend to stay away from it.”

Experience and skill sets in the field can differ between learning institutions and training programs.

ASOPRS has a 2-year fellowship training program in the United States, based in both private practices and universities, according to Dr. Nerad, who is president-elect of the society.

“There is a curriculum that is prescribed in terms of both functional reconstructive procedures and aesthetic procedures that are a suggested minimum experience,” Dr. Nerad said. “There’s no maximum. We want all of our fellows to be trained to be competent reconstructive and aesthetic surgeons.”

Thomas A. Bersani

Oculoplastic specialist Thomas A. Bersani, MD, has trained ophthalmology residents for more than 20 years. He said some of his former comprehensive ophthalmology residents perform minor plastic surgeries, while others refer cases to oculoplastic surgeons and other specialists. The referrals are made based on each ophthalmologist’s comfort level performing those procedures, he said.

Ophthalmology residents specializing in oculoplastic and reconstructive surgery typically have 1 year of general medicine and surgical training, 3 years of ophthalmology-focused training and 2 years of oculofacial plastic surgery training, Dr. Bersani said. Other specialties, including otolaryngologists and comprehensive plastic surgeons, do not have this intensive training in periocular structure and function, he said.

Both otolaryngologists and comprehensive plastic surgeons have thorough and intensive medical training in facial structures. Although ophthalmologists do not have extensive training in this area they have an excellent grounding in facial function, according to Dr. Bersani. He said ophthalmologists have several advantages over other plastic surgery specialties because of the high degree of precision required in ophthalmology.

“We are a very detailed-oriented specialty. We are used to working in millimeters and microns inside the eye with extremely small tolerances,” he said. “So when we decide to do an eyelid operation or an eyebrow operation or a mid-facial procedure or even a face-lift, I think we have already proven ourselves to be very good at detailed work. The step to something like a full face procedure is pretty easy. It’s just a matter of learning a new anatomy.”

Another advantage for ophthalmologists in performing aesthetic oculofacial surgery is that they have been trained in diagnosing and treating diseases of the eye.

“A number of aesthetic procedures are performed on patients who also may have concomitant eye or orbital disease, such as glaucoma or dry eye or Graves’ disease,” Dr. Bersani said. “We are in a position with our training to evaluate and treat these problems simultaneously, or at least know how to not make them worse.”

Aesthetics in ophthalmology

Charles B. Slonim, MD, FACS, an OSN Oculoplastic and Reconstructive Surgery Board Member, said the nature of non-cosmetic or functional medicine, which necessitates reimbursement from medical insurance companies, has prompted many medical specialties to adopt cosmetic aesthetic procedures. Physicians and other medical professionals often learn how to administer Botox and dermal fillers through company-sponsored training courses, he said.

Some comprehensive ophthalmologists might have to pursue administering more aesthetic procedures to supplement their income if insurance reimbursements fail to meet their rising administration office costs, Dr. Slonim said.

“Just short of the Hippocratic Oath, which says we should do no harm to any patient, the fact is that the practice of medicine is still a business,” Dr. Slonim said. “You still have rent, you have staff, you have salaries, you have equipment costs. You have everything that every other business would have.”

Comprehensive ophthalmologists should be aware, however, of the volume of patients that is needed to meet overhead costs in an aesthetic practice, Dale R. Meyer, MD, FACS, an OSN Oculoplastic and Reconstructive Surgery Board Member, said. Botox costs more than $500 per 100-unit vial, and advertising and marketing are often required to attract a large volume of patients, so the business of cosmetic surgery might not be as lucrative as some would think.

Dale R. Meyer

“There is a certain sort of style or structure to your practice that one has to consider and pursue, if one wants to attract a large volume of cosmetic patients. That does require a certain commitment in terms of some type of marketing plan, as well as a skill set and personal interest in taking care of these type of patients,” Dr. Meyer said.

Current trends

Dr. Slonim said his cosmetic patients are predominately women concerned with maintaining a more active, youthful appearance. Women undergo the majority of aesthetic procedures – 81% of all facial cosmetic surgical procedures and 82% percent of all nonsurgical procedures were performed on women, according to a 2007 survey by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS).

“Women are more likely, from a priority standpoint, to want to look good more than any other priority,” Dr. Slonim said. “That’s their No. 1 priority. Everything else falls into place after that. I’ve not seen a downturn on my Botox business because once they’ve become ‘hooked on’ Botox for their wrinkles, they will not go outside if they have a wrinkle. … For a man, if he ends up with a wrinkle, he’ll call it a ‘line of distinction.’ Women do not tolerate their wrinkles as well.”

Men are increasingly undergoing aesthetic procedures, with a 30% increase in all new procedures, compared with 26% of new procedures in women, the survey found.

The AAFPRS reported that in 2007, the most common facial cosmetic surgical procedures performed were face-lifts, blepharoplasties, lip augmentations, rhinoplasties and ablative skin resurfacings. In 2008, those trends continued, the society noted.

The most common nonsurgical cosmetic facial procedures in 2007 were Botox injections, microdermabrasions, hyaluronic acid dermal filler injections, which include Juvéderm (cross-linked hyaluronic acid, Allergan), Restylane (cross-linked hyaluronic acid, Medicis Aesthetics) and Perlane (cross-linked hyaluronic acid, Medicis Aesthetics), and chemical peels.

Dermal fillers, one of the latest developments in aesthetic surgery, have been popular for facial cosmetic enhancements. The injectable substances fill facial lines, gaps and grooves with different durations of effectiveness.

“It used to be in the past that collagen was used. Now we’re using hyaluronic acid, which is a natural substance that the body produces and biodegrades with natural enzymes that are already present in the body,” Dr. Slonim said.

Botox has historical ties to the field of ophthalmology. Developed by an ophthalmologist, it was devised for the treatment of strabismus and blepharospasm. Dr. Bersani has worked with Botox for more than 20 years, training with a mentor who was among the first to use it on humans in the mid-1980s.

“For ophthalmologists and oculoplastic surgeons, Botox is a very old product that we’ve been using for many, many years,” Dr. Bersani said. “More recently, in the last 10 or 15 years, it has gained popularity for cosmetic surgeries. We have found it very easy to make the transition from functional to cosmetic.”

He has used it to treat hundreds of patients for both blepharospasms and aesthetic reasons. The well-tolerated drug is notable for its efficacy, safety profile and long-lasting influence on the cosmetic industry, he said.

New products, techniques

Other products and techniques continue the trend toward less invasive surgical aesthetic procedures. In December, Allergan received U.S. Food and Drug Administration approval for Latisse (bimatoprost ophthalmic solution 0.03%), a novel treatment for eyelash hypotrichosis. Bimatoprost, used in the treatment of glaucoma, was found to also enhance eyelash appearance, causing the eyelashes to lengthen and change in thickness and color.

Dr. Bersani said he has seen a heightened interest in the product but has not yet prescribed it.

“It sounds like a fairly safe and good product, and there may be certain types of patients who are better candidates for it than others, and this may take time to sort out,” he said.

An innovation in the last 3 decades has been radiosurgery, according to Dr. Older. He both performs and teaches the procedure and said the high frequency radio waves result in less bleeding and bruising after surgery, speeding recovery time, Dr. Older said.

According to Dr. Bersani, the customization of treatment for the individual patient in the field of facial aesthetic surgery has significantly improved in recent years. Standard blepharoplasties are no longer as common as in the past, with physicians tailoring the procedure to the specifics of the patient’s facial structure and the latest advances in technology.

“What we’re realizing is, you have to really individualize, and you have kind of a basic procedure that has many variations,” he said. “You may transfer fat in some cases. You may remove skin or maybe not. You may combine it with a mid-facial lift or not. You may combine an upper lid blepharoplasty with a ptosis repair or not.”

Dr. Nerad said the two words in oculofacial surgery that explain natural aging are “descent” and “deflation.” Patients want to retain a natural and younger look, one that addresses lost facial volume and sagging, he said.

“A bad aesthetic surgery is a surgery that you know that the patient had,” he said.

Future of aesthetic ocular surgery

With the current economic downturn and a decline in cosmetic procedures anecdotally reported in some areas of the United States, the future profitability of the industry remains uncertain.

Sales of Botox for cosmetic uses in treating dynamic wrinkles had been steadily increasing. In 2007, cosmetic sales of Botox grew at a rate of approximately 29% compared with 2006. However, in 2008, sales grew at a rate of only 8% compared with 2007. Allergan is estimating full-year 2009 Botox product net sales of between $1.15 billion and $1.19 billion; in 2007, the company estimated product net sales for 2008 of between $1.37 billion and $1.42 billion.

Some aesthetic practices have had a downturn in business in recent months. Dr. Meyer said he has seen a decline in business in the last 3 months. However, he has experienced drops in business before, followed by a resurgence in cases.

“I think there’s just a general mood that occurs when the economy is down – people’s mood is somewhat depressed, and so they’re just not inclined to go out and pursue these things,” he said.

Dr. Bersani said he has not seen a decline in his practice, but he does not rule out the possibility. He said people will often do all that they can to continue to maintain their appearance, even in times of economic hardship.

He said technology will most likely continue to improve aesthetic procedures and techniques, with an increased number of minimally invasive procedures and reduced recovery periods after surgery. An emphasis on tissue volume could also assist in treating the aging process in the most naturally appearing way.

Physicians should also keep in mind their duty to treat and administer the best and most necessary care to patients, he said.

“I think it’s important that physicians remember that with the privilege of doing this comes a huge responsibility to not abuse our position,” Dr. Bersani said. “Patients put themselves in a very vulnerable position, and we should always keep their best interests in mind. Sure, we make a living at it, but that’s secondary. The most important thing is to not lose sight that we’re really doing it for the patient. That’s nothing new. That’s medicine for the last 5,000 years. But it’s especially true in cosmetic surgery.” – by Erin L. Boyle

Do you think a line should be drawn to determine what aesthetic/cosmetic procedures ophthalmologists perform?

• Thomas A. Bersani, MD, can be reached at Eye Plastic and Reconstructive Surgeons, 1810 Erie Blvd. E., Syracuse, NY 13210; 315-422-3937; fax: 315-422-4432; e-mail: tab@ThomasBersaniMD.com.
• Mark R. Levine, MD, FACS, can be reached at University Suburban Health Center, 1611 South Green Road, Suite 306A, South Euclid, OH 44121; 216-291-9770; fax: 216-291-0550; e-mail: mlevine@isgwebnet.com.
• Dale R. Meyer, MD, FACS, can be reached at Ophthalmic Plastic Surgery, Lions Eye Institute, Albany Medical College, 1220 New Scotland Road, Suite 302, Albany (Slingerlands), NY 12159; 518-533-6540; fax: 518-533-6542; e-mail: meyerd@mail.amc.edu. Dr. Meyer has no financial interest in any of the products or companies mentioned.
• Jeffrey A. Nerad, MD, FACS, can be reached at University of Iowa Hospitals & Clinics, Eye Department, 200 Hawkins Drive, Iowa City, IA 52242-1009; 319-356-2590; fax: 319-356-0363; e-mail: jeffrey-nerad@uiowa.edu.
• Jay Justin Older, MD, can be reached at Older and Slonim Eyelid Institute, 4444 E. Fletcher Ave., Suite D, Tampa, FL 33613; 813-971-3846; fax: 813-977-2611; e-mail: jolder1@tampabay.rr.com.Dr. Older receives honoraia from Ellman International, maker of a radiosurgery instrument, when he gives some lectures discussing radiosurgery for oculoplastics.
• Charles B. Slonim, MD, FACS, can be reached at Older and Slonim Eyelid Institute, 4444 E. Fletcher Ave., Suite D, Tampa, FL 33613; 813-971-3846; fax: 813-977-2611; e-mail: slonim@eyelids.net.