Oculoplastic surgeons hoping for subspecialty recognition

In this report from the OSN Section Editor Summit, Mark R. Levine, MD, FACS, discusses competition with plastic and facial plastic surgeons.

Issue: July 15, 2004

Mark R. Levine, MD [photo]
Mark R. Levine, MD

Oculoplastic and reconstructive surgery is a subspecialty that involves basic skills. I look at oculoplastic surgery with the Vince Lombardi approach. He said football is all about blocking and tackling. Our equivalent is structure and function. It’s all about structure and function.

We don’t have to use radiofrequency and laser. The surgery is very nice with those devices, but we don’t need it. We can use a simple No. 15 blade, and we have a lot of leeway and creativity.

The market is unlimited for us because everybody is developing dermatochalasis, chalazia and ptosis.

The way things are evolving, oculoplastic surgeons are not competing with the general ophthalmologist or the other ophthalmic subspecialists. We’re competing with facial plastics and plastic surgery.

Subspecialty recognition

We’re working to get subspecialty certification so we can compete with the plastic surgeon and the facial plastic surgeon. There should be an answer any day now. In each state, the Board of Councillors was asked to review and give an opinion on whether or not oculoplastic surgery should get specialty status from the American Board of Ophthalmology.

What would an oculoplastics subspecialty certification mean for ophthalmology?

There are fears on the part of the general ophthalmologist. Are we trying to keep all of them from doing ectropions, entropions and ptosis? No.

Oculoplastic surgeons are attempting to be recognized when it comes to hospital certification. We’re expanding out into other areas because our base of knowledge from the American Society of Oculoplastic and Reconstructive Surgery is so broad. The structure of our society requires a 2-year fellowship, a written test, an oral test and a paper. We go through all the disciplines, including endoscopic forehead lifts.

This structure allows a lot of us to do it. On the other hand, we can’t do it all, and it is in our best interest to teach the comprehensive ophthlamologist to do a lot of the basic procedures and then some, based on surgical abilities.

New products

We have some good new products available to us, and others are on the horizon. I think Botox (botulinum toxin type A, Allergan) has been exceptionally effective for the oculoplastic surgeon. This has not been true for general ophthalmologists because I don’t think they know how to market it. It has to be kept on hand, and it’s not cost-effective for occasional use.

Restylane (hyaluronic acid, Q-Med), a dermal filler, was approved late last year. The good thing about this product is that it is not like Zyderm and Zyplast (bovine collagen, Inamed), with all the potential complications of bovine-derived products. And while Zyderm and Zyplast last only 3 months, Restylane will last from 6 months to one year.

Restylane is bacterially fermented; it is a high-molecular-weight substance. You can place it nicely in folds and creases. Again, for the oculoplastic surgeon, it is going to be helpful. For the comprehensive ophthalmologist, it is not going to be helpful, for the same reasons as Botox.

Comprehensive thoughts

Lindstrom’s view

Richard L. Lindstrom, MD [photo] As we survey the people who attend the courses we run and the Ocular Surgery News meetings, oculoplastics comes in as something in which they are still very interested. We appreciate the effort that Dr. Levine and the other members of this editorial board section make to keep us aware of advances in this field. It is important for this information to reach our readers.

Richard L. Lindstrom, MD
OSN Chief Medical Editor

The comprehensive ophthalmologists need to be more marketable. For 30 years I have been involved with resident teaching, and to a great degree my job as an educator is trying to get comprehensive ophthalmologists to the point where they can do a lot more procedures. I do not want them to be split off and cubbyholed because they can not do certain procedures.

This is difficult to do because often new ophthalmologists lack surgical skills, since they have not gone through the right disciplines to get there. I think it would be helpful if they had taken general surgery, at least 6 months of it, so they are in a position to be able to expand.

So what I would like to do in the Oculoplastic and Reconstructive Surgery Section of Ocular Surgery News is to try to help the mainstream comprehensive ophthalmologist expand his or her skills. Another aim is to help oculoplastic and reconstructive surgeons compete with the plastic surgeons and the facial plastic surgeons.

As section leader, I will review the products that are coming out and suggest articles to get this information to the comprehensive ophthalmologist so that they can make good choices.

For example, we’ve been involved with the Medpor (Porex) and hydroxyapatite, integrated implants to help ocular motility in prosthetic eyes. It intuitively makes a lot of sense, but when you look at the motility compared to a basic spherical implant, studies have shown that it is not much better. A regular spherical methylmethacrylate implant costs $30. The hydroxyapatite Medpor implants are anywhere from $350 to $500.

Summary

In oculoplastics we use the basic building blocks, structure and function, nothing fancy. It is teachable. We can bring the comprehensive ophthalmologist along, if they can understand and are willing to buy in to structure and function and how to use basic surgical technique. Of course, this has to be taught in the residency training program, and programs may need to be restructured to emphasize surgery rather than internal medicine.

Once they are willing to do that, they can build upon that and move on to blepharoplasties, ptosis, Botox and Restylane. If comprehensive ophthalmologists do not do that, they may end up once again segmented off, doing, if you will, comprehensive ophthalmology and referring out everything complicated. That is what I am trying to avoid.

Kenyon on cornea/external disease

The August 1 issue will feature OSN Cornea/External Disease Section Editor Kenneth R. Kenyon, MD.

For Your Information:

Mark R. Levine, MD, FACS, is a clinical professor of ophthalmology in the department of ophthalmology, Case Western Reserve University. He 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: m.levine@eye-lids.com.