The oculoplastic subspecialty offers surgeons the opportunity to expand their practices

With quickly evolving technologies and procedures, cosmetic and reconstructive procedures represent a “new frontier of opportunity” for many physicians.

Editor’s note: This is the second of two articles on the future of the oculoplastic subspecialty. This article focuses on the subspecialty’s unique challenges and opportunities within the mainstream cosmetic and reconstructive surgery marketplace.

Today, Americans do not have to be too wrinkled or too rich to find reason to alter their appearances using cosmetic and reconstructive surgery. The image-conscious of all ages – and genders – quest perfection to “add to,” “subtract from,” “maintain,” or “rejuvenate” that which they received at birth through elective procedures, or what is known in the mainstream cosmetic surgery market as “happy surgery.”

In many ways, “happy surgery” is truly altering the mindsets of the patients electing these procedures and the doctors performing them. For example, one facial plastic surgeon I recently spoke with, who has been in practice for about 20 years and dedicates 90% of his work to elective procedures, said he used to be the social outcast at cocktail parties. “Patients would pretend not to recognize me and I’d have to keep my identity a secret,” he recalled. “Now, with the popularity of cosmetic procedures, patients seek me out at parties and introduce me to their friends. It’s a whole different world.”

With quickly evolving technologies, procedures and growing consumer acceptance, cosmetic and reconstructive procedures represent a “new frontier of opportunity” for many physicians. Additionally, economic considerations may be spearheading the growth of this industry among physicians. For example, in its recent profile of the cosmetic surgery industry, Newsweek attributed increased physician interest expanding into these procedures as being founded on the “frustration with managed care” and “dwindling reimbursements.”

The Newsweek issue also included a breakout of the most common procedures for men and women by age group. Not surprisingly, adults 35 to 50 years of age represented the largest market for “general body” procedures. Most importantly, eyelid procedures were most common for adults 51+. For ophthalmologists, individuals in these brackets generally represent a substantial portion of their patient database. Expansion into cosmetic procedures may be a natural extension among existing patients with whom ophthalmologists have already established strong relationships.

No doubt, ophthalmologists’ migration to perform procedures that are more cosmetic has been a much slower course than in other branches of medicine. Here again, I think public perceptions and physician attitude have played a large part in shaping the evolution of the subspecialty within the “happier” side of cosmetic and reconstructive surgery.

Sources of reimbursement

Today, most ophthalmologists/oculoplastic surgeons perform a majority of non-elective procedures that are covered by Medicare and other third party payors. Many, however, are expanding their cosmetic skills by working in the periorbital area, doing brow lifts and mid-face procedures. Some are going beyond the face and into the greater cosmetic domain. By moving into cosmetic areas, physicians move into situations where patients must pay for services out of their own pockets.

In speaking with George O. Stasior, MD, an ophthalmologist with an oculoplastic specialty who is in practice with his father, Orkan George Stasior, MD, in Albany, N.Y., said that only about 10% of their cases are paid outside of third-party payors. Amarillo, Texas-based ophthalmologist/oculoplastic specialist John Murrell, MD, concurred, “In my town, if insurance doesn’t cover a procedure, patients are usually not interested in having it done.”

Declining reimbursements also have been a major issue with many reimbursable procedures. Just as ophthalmologists who have been performing cataract procedures have seen declining reimbursement over the past 10 years, the same has been true with eyelid surgery. However, eyelid surgery reimbursement started out lower than those of cataract procedures.

For example, if a cataract operation was reimbursed at $2,000 in 1990, a dacryocystorhinostomy (DCR; CPT 68720) was reimbursed at about $1,500. Since then, reimbursement for eyelid procedures has decreased comparably with cataract surgery. For example, in some parts of the country, DCRs are now reimbursed at $663.60. Additionally, ectropion (CPT 67917), entropion (CPT 67924) and ptosis repair (CPT 67904) — three other common eyelid procedures – are reimbursed at $457.71, $449.99 and $500.11 per procedure, respectively. Unlike most cataract procedures, however, these may require additional postoperative care.

Dr. Murrell noted, “In my practice, cataract patients are seen two or three times postop, while eyelid patients are seen four or five times over longer periods of time. That is why in my town, I have concentrated a lot of my efforts on building up my cataract practice and obtaining the best possible results.”

Dr. G. Stasior agreed. “We have found the same thing in Albany. It’s important to keep the ‘eye’ in eye plastic. Many people in your community will know you first as an eye doctor before they realize your extra expertise in eyelids, tear ducts and tumors.” He added that there is much more of a maintenance factor involved with “oculoplastic” patients than with general ophthalmology patients.

In many markets, managed care organizations are demanding that ophthalmologists handle the oculoplastic category of ophthalmology and often try to prohibit physicians from referring non-routine patient cases to subspecialists. For that very reason, general ophthalmologists have to become experts on general eyelid problems and how to correct them.

Dr. O. Stasior noted that he and his son have trained 26 oculoplastic fellows over the years, and that several of them have already implemented training programs where they also are training fellows. Still, he says prospective employers also are asking the younger generation of oculoplastic surgeons, “Do you also do cataracts?” That indicates that many of tomorrow’s surgeons also realize that they cannot survive financially on eye plastic surgery alone — that there is not enough volume and enough adequate reimbursement to do so.

Penetrating the cosmetic market

While many surgical specialties perform cosmetic surgery of the face, oculoplastic surgeons are the most knowledgeable of the anatomical and functional characteristics of the eye. For that reason, they are uniquely qualified to perform procedures of the eyelid and periorbital area, including the brow and the mid-face.

Of the ophthalmologists I spoke with, most were reluctant to move into the commercial aspects of cosmetic surgery. For example, many oculoplastic specialists find it uncomfortable to “negotiate price” with patients seeking elective surgery. Dr. O. Stasior noted that “Patients price-shop for cosmetic surgery. When they come to see us, they may have already seen several cosmetic surgeons. It’s definitely a price thing. Surprisingly, these patients don’t understand the unique skills, knowledge and expertise that an oculoplastic surgeon has over other facial cosmetic surgeons in providing treatment and care.”

The American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) has empowered its individual members to market and promote cosmetic procedures in their communities. Perry F. Garber, MD, the Manhasset, N.Y.-based oculoplastic specialist who also serves as president of ASOPRS, noted that the expense of developing and implementing a large-scale marketing campaign proved cost-prohibitive for the society. “Several years back, ASOPRS attempted to make the general public more aware of its members’ skills and services through the resources of a leading public relations firm. As a small organization, we found it difficult to successfully gain national exposure because of the high costs involved. The society is now developing a first-class informative brochure on cosmetic procedures for our members to distribute to their patients. We also maintain a Web site (www.asoprs.org), where the public can obtain more information about oculoplastic procedures and a list of our membership by geographic location.”

Use of new technologies

In keeping with the name of this column, “Finding Lost Profits in Ophthalmology,” there was discussion several years ago about ophthalmologists getting into CO₂ laser resurfacing. Although laser resurfacing is not a reimbursable procedure, as it is purely cosmetic in nature, I asked physicians whether this procedure was increasing in popularity among oculoplastic surgeons and general ophthalmologists.

Dr. Garber noted that most oculoplastic surgeons have had CO₂ laser training both in cosmetic procedures and as an adjunct to reconstructive surgery. Dr. Murrell noted that to date, he has not been thrilled with the postop results from other surgeons whose patients he has had to manage. “Several weeks to months of seeing patients, whose faces are red and swollen and who have complaints, is not something I want in my practice right now. I believe that laser resurfacing has good long-term results, but I haven’t had the impetus to get into it at this time.”

Said Dr. G. Stasior, “The CO₂ laser is very important in decreasing postoperative edema for patients. In our practice, we use it for blepharoplasties and facial resurfacing. Undoubtedly, it’s very important for the comprehensive ophthalmologists to know how to use CO₂ laser for facial surgery.”

Dr. O. Stasior added, “We’ve been doing full facial surgery for 3 or 4 years and have very happy patients. We also use laser blepharoplasty and resurfacing in conjunction with Botox [botulinum toxin type A, Allergan]. When we inject Botox before doing laser resurfacing, we achieve better results.”

Ophthalmologists also are using the laser for eyelid operations and eyebrow procedures. Using the laser as a cutting tool decreases bleeding, swelling and postoperative discomfort. Patients have less bruising and a faster recovery.

Dr. G. Stasior added, “When laser procedures are functional in nature, they are covered by insurance. For instance, when patients have visual field defects with restriction of their superior and peripheral vision that affects their daily activities, you can get insurance companies to reimburse the use of CO₂ laser for functional blepharoplasty. Of course, cases have to meet certain criteria for pre-approval.”

The Pandora’s Box

Ophthalmologists engaged in CO₂ surgery have become wary of the “Pandora’s Box” attached. On the one hand, by getting into cosmetic laser, they are opening themselves up to a much larger market. On the other hand, they are finding increased competition from facial plastic surgeons, ENT surgeons, general plastic surgeons and dermatologists, who are all fighting for a piece of the same market.

Dr. Murrell said that he thought the laser was an expensive tool to be used solely for incisional surgery. “I would say that if you’re going to make the investment in a CO₂ laser, you must get into resurfacing because that is where it’s uniquely advantageous. Sure, you can use nonsurgical means like chemical peels, but if you want to go surgical, then you have to go with the laser.”

Need for exposure

There is no one in a better position to handle the eyes, the eyelids and the tissue around the eyelids than an ophthalmologist who has intensive training in ophthalmology and additional training in eye plastic and reconstructive surgery. Yet, why aren’t ophthalmologists better known for their skills? The doctors with whom I spoke said that collectively they were striving to educate physicians and the public on the skills and merits of oculoplastic surgery.

Dr. Garber acknowledged a general lack of recognition for members of the subspecialty, stating that ASOPRS encourages its members to develop their practices in their own communities. “Our membership is quite diverse in terms of interests and goals. We also are a relatively small group with limited financial resources, so we must keep our activities modest. We feel that by producing a brochure on cosmetic procedures and maintaining a Web site, we are providing our members with tools that their patients will find helpful and useful.”

“In my town, there doesn’t seem to be same the level of knowledge or respect for the ophthalmic plastic surgeon that I think general cataract surgeons or refractive surgeons are getting,” Dr. Murrell said. Even though many of us were pioneers in establishing our society and education requirements and have high levels of training and care, we have dropped the ball by not letting the public know just how well trained we are and what we can do for them.”

Dr. O. Stasior added, “The public truly isn’t aware of the unique skills we offer. A less qualified physician may snip off loose skin from patients’ eyelids, not knowing that this may trigger extremely bothersome symptoms of dry eyes. Or, patients may not be able to close their eyes at night as a result of surgery, or they may experience a whole series of other problems that require them to see oculoplastic surgeons who also are skilled ophthalmologists.”

The future

General ophthalmologists and more specialized oculoplastic subspecialists are at a unique crossroad. They hold the expertise in eye-related surgery, which may extend into other facial areas, ocular disorders and eye disease, which clearly sets them apart from non-ophthalmic physicians and surgeons. By the very nature of their traditional patient database, they also have their fingers on the “pulse” of the cosmetic eyelid surgery market, patients in the 50+ age group. In my mind, ophthalmic physicians and surgeons have great potential for a strong and successful future.

Without a doubt, marketing is the key to success for every practice in positioning it properly in the community. No matter what an ophthalmology practice specializes in – refractive surgery, cataract surgery, retinal or cosmetic and reconstructive procedures — it needs to develop and use internal and external marketing to reach its publics. Special-interest groups may offer individuals some of the right global messaging and images, but it is truly up to each ophthalmology practice to set its own “mark” with the people it is trying to reach and influence.

In some ways, poor reimbursement for non-elective procedures may drive ophthalmologists to decide between taking a more aggressive approach toward elective cosmetic surgery or remaining in more “classic” ophthalmology. Dr. Murrell added, “Oculoplastic surgeons cannot survive on poor reimbursement. For example, you can do a 3-hour operation where with great finesse you remove a tumor and reconstruct an eyelid and provide 3 months of postop care, and you only get reimbursed $800 to $1,000.”

For now, the future of the subspecialty depends on what ophthalmologists like doing, where their market needs are and what opportunities they can seize. In most parts of the country, ophthalmologists should be able to maintain a more traditional medical and surgical practice and keep their hand in oculoplastics. If physicians decide to place greater focus on eye plastics, they may need to acquire the multiple surgical skills necessary to compete with other subspecialists and specialties, including oral surgery and facial plastics. Moreover, should they choose to migrate to complete plastic surgery, they will need the education and training to do tummy tucks and liposuction. In other words, if oculoplastic surgeons want to survive, they may have to do many different procedures and do them well.

Dr. O. Stasior said, “There isn’t a patient between the ages of 40 and 50 who couldn’t benefit in some way from eyelid plastic surgery. Patients may just want a more youthful appearance, eliminate redundant skin on the upper or lower eyelids, eliminate swollen lower eyelids, raise eyebrows or diminish crow’s feet. Many women at this age have trouble in applying eye makeup and keeping it fresh all day. Certainly ophthalmologists with expertise in oculoplastics can provide patients with the ‘open eye look’ or soften wrinkles that originally Hollywood movie stars, and now an expanding segment of the American public, find highly desirable and satisfying.”

“When patients learn there is a subspecialty that focuses just on the eyelids, they become ecstatic,” Dr. Garber said. “As oculoplastic subspecialists gain exposure in our communities and our procedures and capabilities become more well-known, our future will become brighter.”

This year’s curriculum at the American Academy of Ophthalmology offered general courses for ophthalmologists in facial resurfacing and blepharoplasty using CO₂ lasers. One course included cadavers for endoscopic forehead and brow lifts. Next year, I would not be surprised if we see courses in full facelifts. Bit by bit, this new knowledge will empower both oculoplastic subspecialists and general ophthalmologists to make the right decisions for their future.

For Your Information:

• 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) 365-6430. Dr. Garber did not participate in the preparation of this article.
• John Murrell, MD, is an oculoplastic surgeon in private practice for nearly 30 years. He can be reached at #15 Amarillo Drive, Amarillo, TX 79106; (800) 782-6393; fax: (806) 351-1181. Dr. Murrell did not participate in the preparation of this article.
• 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. Dr. Stasior did not participate in the preparation of this article.
• 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. Dr. Stasior did not participate in the preparation of this article.

Reference:

• Newsweek. September 20, 1999.