Oculoplastics
Oculoplastic aces:go-to oculoplastic procedures

How surgeons can shuffle the oculoplastic deck in their favor

Squamous cell cancer: S/P tarsorraphy & lower lid skin graft
Source: William Conrad, M.D.

All too often oculoplastic surgeons are called upon to right clinical abnormalities ranging from simple chalazians to droopy eyelids to orbital fractures and more, according to Robert B. Penne, M.D., director, Oculoplastics & Orbital Surgery Service, Wills Eye Institute, Philadelphia. “The most common procedure that I do in the operating room that requires a surgeon at our facility is ptosis,” Dr. Penne said. “The most common thing that I do all in all in the office is probably excising eye lid lesions, whether they be big or small chalazians.”
Kami K. Parsa, M.D., Beverly Hills, Calif., sees blepharoplasty as one of the quintessential oculoplastic procedures. “I would say probably the most common reason anybody gets referred to an oculoplastic surgeon is for upper and lower eyelid blepharoplasty,” Dr. Parsa said. “If it’s an upper blepharoplasty it could be either for a cosmetic reason or for a functional one.” In functional cases the patient can’t see because their superior visual field is blocked.
“The way that you determine if something is functional is based upon a Medicare criterion, which requires improvement in the superior visual field when you do a ptosis visual field on the patient,” Dr. Parsa said. “Then you need to have a documented photo and a clinical exam.” If these criteria have been met, then some insurance companies will accept the case as a functional rather than a cosmetic one and will pay for the procedure.
Dr. Parsa finds that there are generally three reasons why patients come in seeking brow lifts. “It could be that their brow is too droopy, or it could be because they have extra skin above the eye lid, or it could be that they have droopy eye lids,” Dr. Parsa said. “It could in fact be a combination of all of these three.” In dealing with these patients Dr. Parsa tries to break this down. “When we examine them we say, ‘OK, 30% of this is because of your brow, or no 90% is because you have extra skin above your eyelid, or 5% is because of ptosis,” he said. “Once we examine them and the visual field shows that they see better then part of it at least should be covered by insurance.”

The changing rules

Besides blepharoplasty patients also arrive at his practice for a variety of other reasons as well. “I would say that about one-third of my practice is reconstructive surgery, which involves patients who have had trauma, who have had cancers, or who have had some sort of a pathological problem with the eye sockets or the eyelids,” he said.
The rest of the procedures tend to be more cosmetic and involve everything from optional brow lifts, to upper or lower eyelid surgery as well as cheek lifts or fat injections. “The paradigms have changed in a way that it’s all about minimalism,” Dr. Parsa said. “Most patients don’t want to have a long recovery they, just want to have a quick fix so that they just look rested and the negative stigma of looking operated is gone.”
Dr. Parsa turns away about 30% of patients because they have unrealistic expectations. “We spend about one hour per patient contact time with them, during which we listen to them, see what their expectations are and what they want to achieve,” he said. “Really that has saved a lot of headaches for me in my practice because you get rid of a lot the people who show up with a picture of Angelina Jolie and want to look like her but who don’t have the framework.”
In recent years, oculoplastic paradigm has changed quite a bit in favor of minimalism. “Less is more and you want to make it look natural,” Dr. Parsa said. “The old paradigm was to go out and take out skin and take out a lot of fat so that the patient ended up looking very hollow and kind of wasted—kind of sick looking.”
Unfortunately, even some of the most alluring early Hollywood actresses fell victim to this tact, often coming away looking gaunt rather than glamorous. Now the approach is to personalize the procedure for everyone. “Now we have more than 70 different techniques just for the upper eyelid,” Dr. Parsa said. “I think oculoplastics as a field has really contributed significantly to different ways of really diagnosing the anatomical problems and doing procedures that do not come with the negative stigma of having been operated on.”

Treating the cards dealt

Meanwhile, some of the most frequent clinical complaints that Dr. Penne deals with include ptosis, ectropion, entropion, and DCR (Dacryocystorhinostomy) for tearing. Less commonly he also faces procedures such as orbital reconstruction, removing masses and repairing orbital fractures. More orbital fractures he finds occur during warmer weather. “It seems like fractures are a little more common in the spring and early summer and then less common in the winter, just because people aren’t doing things and are less likely to get sustained fracture,” Dr. Parsa said.
The indications for treating such orbital fractures vary. “It’s either because tissue gets caught in the fracture and the patient has double vision, or it’s because the fracture itself is big enough that the eye will look sunken in because of the increased volume of the orbit,” Dr. Penne said. “With cheekbone or zygomatic fractures people will have trouble chewing or pain when they chew and also the cheek looks deformed or is flat.”Dr. Penne usually collaborates on such cheekbone surgery with ear, nose and throat or oral maximal surgeons.
Over the years he has seen improvement in the technology applied for fractures. “There have been some changes in the implants that you use for fractures and how they’ve integrated plastic with titanium,” he said. “The implants are more moldable and a little easier to use.”
Dr. Penne finds that ptosis surgery has also been made easier thanks to improvements in technology. “We have something called a silicone rod which is stretchy like a rubber band,” he said. “In general people with ptosis don’t have a functional muscle so you have to distend the lid with some material up to the brow and traditionally you would use something non-flexible that pulls the eyelid up but that the patient then has trouble closing.” Modern technology is more akin to putting a rubberband in place. “It pulls it up but yet it allows the eyelid to close,” he said.
Some of the keys to success with occuloplastic surgery revolves around patient selection Dr. Penne finds. “It’s important to make sure that the patient is doing the procedure for the right reason,” he said. Practitioners need to make sure that the procedure truly can alleviate patient symptoms and meshes with their cosmetic expectations.
When it comes time for the surgery itself, Dr. Penne stresses that it’s important to make sure that patients are off any compounds that can contribute to bleeding. “We used to say that that was aspirin, coumadin, and maybe Plaviks,” Dr. Penne said. “But now some of there’s also some of the fish oil and some of the herbal things—there’s a lot of things that can potentially make people bleed a little more.”
Dr. Parsa finds that one of the biggest oculoplastic challenges currently can be scar tissue. “If a patient has had a previous trauma or previous bad surgery and there’s a lot of scar tissue I think that that just makes reconstruction very, very difficult because the tissue is not the way that it should be,” he said. “There are of course a lot of different solutions but none of them are perfect.”

Winning hands

Despite the challenges oculoplastics also offers great rewards. One case of Dr. Penne’s that came to mind involved an 18-year-old girl who had a very large vascular growth behind the orbit. She had had this excised a couple of times when she was younger. “These are things that you can’t help not wanting to operate on because they can be very bloody,” Dr. Penne said. “Then the results if she is bleeding a lot can be almost worse than you thought.”
When the young woman first approached Dr. Penne her eye was about 10 mm proptotic due to the vascular growth. “We were able to excise it,” Dr. Penne said. “It turned out to be more encapsulated than we thought so it really came out very well and she looks fantastic.”
Dr. Parsa meanwhile was most moved by a humanitarian trip that he took to Cambodia where they do not have any oculoplastic surgeons. There he was met by a line of 150 children needing ptosis surgery—without it they could be left functionally blind due to amblyopia. During the ten days spent in the country Dr. Parsa was able to treat just 25 of these young patients. He was, however, able to impart the sling technique to two local ophthalmologists. “It was fun to operate on the 25 kids, but what’s really exciting is that I was able to teach these two doctors how to do this procedure,” he said.
In congenital ptosis cases the levator muscle does not function and the patient cannot open their eye. In its place, oculoplastic surgeons use a sling procedure to instead utilize the eyebrow’s frontalis muscle. “This sling in a way acts by raising the eyelid by utilizing the force of the frontalis muscle,” Dr. Parsa said. “If we use a sling that goes from the eyelid to the eyebrow so that you can raise your brow and you can raise your eyelid and your brain takes over in a sense that you don’t have to think about doing that.” Now the local Cambodian ophthalmologists are handling the ptosis cases. “They can treat it locally and they don’t have to depend upon anybody,” Dr. Parsa said.
Going forward, Dr. Penne thinks that there will be a lot of improvement in forestalling proptosis from thyroid eye disease. “I think that there’s hopefully going to be less need for our services,” he said. “We’re going to find a way to stop the inflammation so that they don’t have the huge deformities that they develop and that they don’t require surgery.” He also foresees changes in tear duct surgery. “We getting better at doing it endoscopically where you don’t make an incision externally but instead you go up through the nose,” Dr. Penne said. “The success rate for that was always much lower, however, now it seems like it is getting closer to the external rate.”Since this procedure is less invasive the patient tends to be less bruised and beat up after surgery.
Overall, Dr. Parsa remains enthusiast about the oculoplastic field. “It’s my passion. I wake up in the morning and I’m excited to go to work,” he said. “At the end of the day it’s about the patient and being able to establish a relationship with that person.”

Editors’ note:Drs. Penne and Parsa have no financial interests related to their comments.

Contact information

Parsa: 310-777-8880, kamiparsa@gmail.com
Penne: 215-928-3250, dpenne1@comcast.net