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Surgical trends, residency training key topics in oculoplastic surgery
In this report from the OSN Section Editor Summit, Mark R. Levine, MD, FACS discusses recent news in oculoplastic and reconstructive surgery.
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In oculoplastic surgery right now we are focused on facial rejuvenation.
Botox (botulinum toxin A, Allergan) has been a revolutionary product for the field of oculoplastic surgery. There is no question that the number of procedures in the subspecialty of oculoplastics has grown because of the increase of the use of Botox. It gives an unbelievable, reproducible result.
Botox is also reasonably priced. I was fortunate enough to be on the early study of botulinum toxin for essential blepharospasm and hemifacial spasm, when the bottles were $25 each.
In addition to Botox we now also have Restylane (hyaluronic acid, Medicis) for augmentation procedures.
Surgical trends
| Mark R. Levine |
One of the controversial issues in oculoplastics today is large incision surgery vs. small incision surgery. For example, in brow-enhancing surgery, we used to perform a large coronal incision, bring the brows up and tack it down. Then the trend went to midface forehead surgery. Midface forehead surgery worked well, but it can leave some significant scarring unless the forehead has a lot of furrows.
So then we went to endoscopic surgery, which is a good procedure, but it is technique-driven, time-consuming and tricky to perform. You can injure the facial nerve, and you can raise the brows up too high so the patient always looks like he or she is surprised.
Most recently, we have been hearing news about Endotine implants (Coapt Systems), which are bioabsorbable implants. Through a blepharoplasty incision, you dissect up under the frontal bone and insert these bioabsorbable implants. There are little tines that stick out and keep the brow up.
This is minimally invasive surgery, but how well it works compared to the more significantly invasive surgery is not yet known. From what I see in some of the product literature, the brows are only minimally elevated. A good blepharoplasty and a little internal brow fixation into the periosteum would probably work just as well.
Another thing we are hearing a lot about is the thread facelift with polypropylene barbs, which grab the cheek and the jowls and bring everything up. These barbs actually grab the tissue. It might be problematic when you are counting on sutures to support your midface. We will want to see longer-term results with this technique.
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Residency training
We have talked at these meetings in past years about the oculoplastics training programs in this country. I think that a lot of the residency programs in the United States do not provide a good, well-rounded experience in oculoplastics, which is really too bad. The residents’ surgical skills in oculoplastics are not good. So when the residents go out into practice, they are not prepared to increase their surgical armamentarium.
I think it is important that residents understand that oculoplastics is an area of ophthalmology that can be rewarding and remunerative to them.
Truthfully, the simple, straightforward blepharoplasty in the aging patient, as well as involution ptosis, entropion and ectropion, is really easy to do. These pay as well as, if not better than, cataract surgery and can be done in the office setting.
My practice is in a building that has an ASC, and I have my own operating room, so all my cosmetic blepharoplasties are done in a basic setting. I do not have to worry about infections because I use betadine prep. I have a certified registered nurse anesthesiologist come in, and it goes well. So there is a minimal expense with a great profit margin.
For more information:
- Mark R. Levine, MD, FACS, is a clinical professor of ophthalmology, 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.