Oculoplastics is an evolving subspecialty

Cosmetic and facial reconstructive plastic procedures are big business in the United States.

Issue: November 1, 1999

ByHoward Gottlieb, OD

Editor’s note: This is the latest article in our series on the future of ophthalmic subspecialties. This is the first of two articles on the future of the oculoplastic subspecialty. This article addresses the oculoplastic subspecialty’s evolving position within the context of eye care and the larger cosmetic and reconstructive surgery marketplace.

Today, cosmetic and facial reconstructive plastic procedures are big business in the United States. In March, the American Society for Aesthetic Plastic Surgery reported that physicians performed nearly 2.8 million cosmetic surgical and nonsurgical procedures in 1998, up 4% from the previous year. Of these, cosmetic eyelid procedures and facelifts represented two of the “Top 5” procedures (up 15% and 1% from 1997, respectively). What is significant about these statistics is that they don’t include the work performed by ophthalmologists — oculoplastic surgeons and general ophthalmologists — in the United States.

Undoubtedly, the ophthalmologists who do eye plastic surgery are the best kept secret in cosmetic and facial reconstructive surgery. Generally, physicians are board-certified in ophthalmology, with special training in the management of deformities and abnormalities of the eyelids, lacrimal system, the orbit and the adjacent face. Yet, unless a patient has some knowledge of these surgeons’ unique skills, chances are likely that they’ll approach a plastic surgeon, otolaryngologist or dermatologist — perhaps even their family physician — for cosmetic or reconstructive surgery before considering their eye physician.

Ophthalmologists engaged in the subspecialty tend to assume a broad range of roles in supporting a profession with decidedly multiple personalities. First, there are the general ophthalmologists, who keep a hand in plastics to meet their patients’ needs and support managed care requirements. Then, there are the surgeons who focus primarily on non-elective procedures and also are engaged to some degree in cosmetic and reconstructive surgery in facial areas. Then, there is an emerging group of ophthalmologists who have extended their expertise to a broader range of body parts in mainstream cosmetic and plastic markets. These physicians tend to be found mostly in larger and affluent urban centers. Given the breadth of professional directions ophthalmologists might take, one might say that oculoplastics is a profession with multiple personalities.

Who’s doing what?

Today, plastic surgeons, dermatologists, facial plastic surgeons and otolaryngologists perform the majority of documented cosmetic and reconstructive cases. Two of the leading “specialty” associations — the American Academy of Cosmetic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery — boast 1,400 and 2,800 members, respectively. Among them, only a modest number include ophthalmologists (about 5% and 10%, respectively).

Among “mainstream” cosmetic and reconstructive surgeons, board certification isn’t as prevalent as one might think. Only about 1,100 physicians are board-certified by the American Board of Plastic Surgery and 400 by the American Board of Cosmetic Surgeons. When recently contacted, both organizations said they include physicians in plastic surgery, dermatology and otolaryngology among their members. Neither group could confirm whether any ophthalmologists were included in their ranks.

For ophthalmic-based surgeons, the 30-year-old American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) is the primary society that drives advancements within the subspecialty. With about 400 members strong, ASOPRS’s purpose is to “advance education, research, and the quality of clinical practice in the fields of aesthetic, plastic, and reconstructive surgery specializing in the face, orbits, eyelids, and lacrimal system.” From its very inception, the society has required a rigorous process for physicians to gain admission as a fellow. The requirements include certification by the American Board of Ophthalmology, a fellowship (or 5 years of practical experience with teaching and publishing), the successful passing of written and oral examinations, and the completion of an original thesis. No other ophthalmic subspecialty society can make this claim. Still, society members desire board certification, which at present remains a relatively distant goal.

Perry F. Garber, MD, FACS, a Manhasset, N.Y.-based oculoplastic surgeon who serves as the current president of ASOPRS, is optimistic that the American Board of Ophthalmology will grant subspecialty members board certification. “Oculoplastic surgeons are uniquely skilled to operate on the eyelids and periorbital areas. With our training in ophthalmology and ophthalmic plastic surgery, we can provide the critical expertise necessary to operate best around the eye. In over 20 years of practice, I have seen our colleagues in other specialties, such as otolaryngology, maxillo facial surgery, dermatology and plastic surgery, come to recognize our skills and refer patients to us for treatment and to manage complications. Now it is time for the general public to recognize our expertise in the area of aesthetic surgery. In our current medical environment, board certification is a very professional way of conveying this message.”

Common procedures

In my consultation with ophthalmologists throughout the country, geography and demographics play big roles in dictating the “profession personality” that physicians adopt within the subspecialty.

For instance, John Murrell, MD, an oculoplastic surgeon in a group practice (six ophthalmologists) for 12 years, indicated that life in the Sunbelt and the rural suburbs of Amarillo, Texas, have presented a patient base of largely nonelective cases. “In my area, there is a high incidence of basal cell carcinomas. Within the practice, I see a large number of patients for blepharoplasty, acquired and congenital ptosis repair, ectropion repair, tumor removal and reconstructive surgery,” he said.

Back east, in a larger urban market (Albany, N.Y.), George O. Stasior, MD, who has been in practice with his father for over 10 years, concurred that eyelid procedures were the predominant surgical procedures he performed. These also included skin cancers around the eye and orbital tumors. His father, Orkan George Stasior, MD, FACS, one of oculoplastics’ early pioneers and the second president of ASOPRS, noted, “We also do quite a number of full-face resurfacing with the CO2 ultra-pulse laser, repairing fractures associated with trauma, such as cut tear ducts from dog bites and other injuries (lacrimal surgery).”

In my speaking with Dr. Garber, whose practice is based in an affluent (and sophisticated) New York City suburb, indicated that aesthetic and functional blepharoplasty, lacrimal surgery and eyelid reconstruction were the leading procedures he performed.

“It is difficult for oculoplastic surgeons to make an appropriate living managing the most unusual and complicated eyelid and orbital problems in a managed care environment. Hence, we need to get more involved in cosmetic procedures,” he said.

With the continued momentum of managed care, many general ophthalmologists are pressured to render care of all the eye problems, including the eyelid. More general ophthalmologists are performing these procedures and handling the complications from eyelid plastic surgery, tumor removal, entropion repair, blepharoplasty and ptosis surgery. However, there comes a point when they have to refer patients to subspecialists.

Knowing that the “threshold” for patient referral will vary from physician to physician, one would question whether general ophthalmologists are encroaching upon the practice of oculoplastic surgeons. The eye plastic surgeons I asked surprisingly responded in the negative.

“General ophthalmologists have to be very careful not to overstep their bounds, but they also have to know how to handle what I would consider a garden variety of problems. They also need to know when to refer cases to subspecialists,” Dr. George Stasior observed. “It is important that each physician do operations that he feels he can handle comfortably and safely,” Dr. Orkan Stasior added.

Dr. Murrell noted that in his area, he has general ophthalmologists who are primarily interested in cataract and refractive surgery and frankly aren’t interested in doing a lot of plastics. “They would just rather do more cataract and refractive surgery and increase their volume of cases,” he observed. He also thinks most ophthalmologists who need to earn a living have to do more procedures that are cosmetic.

For many ophthalmologists, the decision to refer out a patient comes when highly intricate procedures must be performed or improved upon. For instance, many general ophthalmologists are not comfortable performing lacrimal surgery, especially dacryocystorhinostomy (DCR). Dr. George Stasior added, “Specialty procedures are where oculoplastic surgeons have a niche where no other physicians can be as successful.”

General ophthalmologists also aren’t taking on many of the procedures that eye plastic surgeons have traditionally performed because of economic considerations. This is largely because reimbursements for these procedures have historically tracked lower than other ocular surgeries.

Dr. Murrell noted, “In my area, I’m not seeing any significant shift. The ophthalmologists in my area just don’t want to deal with complicated reconstructive surgical procedures to the eyelid. They don’t want to have an adventure in the OR that’s not controlled. They want to focus on eyeball surgery with no bleeding and relatively easy postop care. With cataract and refractive surgery, they know what to expect postoperatively.”

Dr. Orkan Stasior noted that he sees plastic surgeons, ENT surgeons, dermatologists, oral and maxilla facial surgeons, family physicians and general practitioners working on eyelids. “Work in our specialty is divided among so many more other physicians than say subspecialists in retina might experience. These various physicians may not be doing as good a job in treating oculoplastic conditions as the top quality eye plastic surgeons, but they’re doing it,” he said.

Referral sources

Among the subspecialty’s multiple personalities, oculoplastic physicians obtain referrals from a wide range of sources. Again, geography and demographics seem to play key roles.

“I get most of my referrals from ophthalmologists, but as it became apparent what oculoplastic surgeons can do, otolaryngologists, dermatologists, head and neck specialists, neurosurgeons and plastic surgeons started referring to me,” Dr. Garber said. Twenty years ago, this was not the case.” He indicated that lecturing and conducting grand rounds for the different services were the primary ways he kept his referral sources active.

Dr. George Stasior said, “My Dad and I get about 60% of our referrals from ophthalmologists and optometrists, 30% from primary care physicians, and 10% from other patients and self-referral.” In group practice, Dr. Murrell said that he gets about 50% of his referrals from his partners and 50% from other sources. “My group of physicians has no interest at all in touching an eyelid, let alone operating on one. I get several referrals a day from my partners. Usually they are surgical referrals. I do get quite a few referrals from other ophthalmologists, optometrists and by word of mouth. After you’ve been around awhile, people know that you’re the physician who will do this kind of surgery.”

Dr. Orkan Stasior said, “We also see general ophthalmologists referring patients to us after they have attempted various eyelid operations. When general ophthalmologists refer patients to us for eye plastic surgery, we simply do the procedures and then refer the patient right back to them for cataract surgery, glaucoma surgery, etc. We are very careful to restrict ourselves just to eye plastic surgery on the patients.”

With regard to networking with optometrists to develop patient referrals, physicians’ responses are mixed.

For instance, Dr. George Stasior advocated their involvement. “We make a point of talking at monthly meetings of local optometry chapters in our area and discussing members’ problems,” he said. Dr. Orkan Stasior added that the practice also offers continuing medical education courses to optometrists where the “A to Z of eye plastic surgery” is covered.

On the opposite end of the spectrum, Dr. Murrell noted that in his area, optometrists’ patients don’t generally have eye plastic needs. “I’ve given talks to optometrists and I’ve met privately with them for over a decade. I think optometrists are more in tune to looking at the eyeball. The eyelid doesn’t seem to be their area of interest. I just think they’re better trained and are more interested in optics and the eye itself rather than the eyelid and just aren’t looking for eyelid cases to send our way.”

Change and opportunity

Without a doubt, the oculoplastic subspecialty is in a period of change. Today’s specialists are uniquely positioned to mold their services to the requirements of patients in the communities they serve. If that means maintaining a general ophthalmology practice, a more “traditional” ophthalmic/eyelid surgery practice, or a broader cosmetic/reconstructive surgery practice, then ophthalmologists have the opportunity to thrive. As the cosmetic and reconstructive surgery marketplace evolves, it’s likely that specialists will need to place greater emphasis on a much larger picture.

For Your Information:

Howard Gottlieb, OD, is president and CEO of Eyecare Consultants, Ltd., Woodbridge, Conn. The company provides consulting and networking services to ophthalmologists and optometrists and is headquartered at 270 Amity Road, Ste. 220, Woodbridge, CT 06525. To receive your complimentary copy of "The Ophthalmologist's Self-Assessment Business Guide," contact Valerie Goodkin at (800) 633-6962; fax: (203) 389-4660; e-mail: eyecare-con@aol.com.

Perry F. Garber, MD, FACS, is an oculoplastic surgeon in private practice for nearly 25 years. He can be reached at 1380 Northern Blvd., Manhasset, NY 11030; (516) 627-6630; fax: (516) 365-6630.

John Murrell, MD, is an oculoplastic surgeon in private practice for nearly 12 years. He can be reached at #15 Amarillo Drive, Amarillo, TX 79106; (800) 782-6393; fax: (806) 351-1181.

George O. Stasior, MD, is an oculoplastic surgeon in private practice for nearly 10 years. He can be reached at Stasior & Stasior Eye Care Specialists, Vision and Eyelid Rejuvenation Center, 8 Wade Road, Latham, NY 12110-2608; (518) 220-1400; fax: (518) 220-1404.

Orkan George Stasior, MD, FACS, is an oculoplastic surgeon in private practice for nearly 40 years. He can be reached at Stasior & Stasior Eye Care Specialists, Vision and Eyelid Rejuvenation Center, 8 Wade Road, Latham, NY 12110-2608; (518) 220-1400; fax: (518) 220-1404.