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Skin, muscle and fat: pulling back the layers of oculoplastic surgery

Blepharoplasty,Markup,Close-up,On,The,Face,Before,The,Plastic,Surgery

A sub-speciality that bridges ophthalmic and plastic surgery and interfaces with brain surgeons, oncologists and dermatologists is a unique vocation with a specific skill set, as RHIANNON BOWMAN discovers.

Oculoplastic, lacrimal and orbital surgery is a niche discipline in ophthalmology, recognised relatively recently as a sub-speciality in Australia, with about 60 surgeons specialising in the field.

Although ophthalmologists can perform some oculoplastic procedures, the specific set of skills required in this field often mean that ophthalmologists and plastic surgeons leave certain cases to those with advanced training in ophthalmic plastic surgery.

Surgeons Dr Rodger Davies, Dr Thomas Hardy and Dr Charles Su are among only 12 ophthalmologists who specialise in oculoplastic surgery in Victoria.

All three are members of the Australian and New Zealand Society of Ophthalmic Plastic Surgeons (ANZSOPS), which formed in 1994 to embody and reflect the medical and surgical sub-specialty of ophthalmic plastic surgery, and now has more than 50 members. Hardy is on the executive board and Su is immediate past president.

The trio are also consultants to the Orbital, Plastic and Lacrimal unit at the Royal Victorian Eye and Ear Hospital (RVEEH). They were scheduled to speak about updates in oculoplastic surgery at the Australian Society of Ophthalmologists Expo in Melbourne in June, but the event was postponed due to COVID-19.

They spoke with Insight about how their surgical techniques have remained relatively stable over the past two decades. However, new developments in drugs and biologic agents and alterations to Medicare items are reshaping their niche sub-speciality.

Well-established techniques

Davies graduated from the University of Melbourne, completed his ophthalmic training at RVEEH and a fellowship in oculoplastic and orbital surgery at the Mt Sinai Medical Centre in Cleveland, Ohio (US).

He operates a private clinic in Hawthorn, Victoria and performs day surgery at Epworth, Freemasons, and Manningham Private Hospital.

“In the mid 2000s I was doing about nine cases per day, one or two days a week. Now I do about five cases a day, two days a week. Now I am doing more surgery on each patient on average,” Davies says.

Dr Rodger Davies
Dr Rodger Davies

Oculoplastic surgery was a relatively new specialty when he started in the late 1990s and most procedures have remained unchanged.

However, one procedure that has changed is an endoscopic brow lift, a minimally invasive procedure performed under general anaesthesia, when a patient has droopy brows, impinging on visual fields, then done for visual improvement, or done for cosmetic improvement.

“I make a series of small incisions in the hairline, so you don’t see the scars, peel the lining of the bone up, cut it along the eyebrows, then pull it up,” Davies says.

“The techniques for holding the brows up have changed a bit. When I started 15 years ago, I used screws. Then I used endotines, fitted into holes in the bone, with spikes to secure the periosteum. These dissolve in about one year but are tender lumps during that time. Now I use a glue made from blood products which pterygium surgeons use. This is fibrinogen and factor XII which are mixed together and sticks in three minutes.”

Davies also performs blepharoplasty (blepharo is ancient Greek for eyelid), an operation to remove excess skin and fat from upper or lower eyelids, which is considered ‘cosmetic’ surgery. He also performs surgery to correct ptosis (ancient Greek for droop), when the upper eyelid droops over the eye, impinging on vision, which is considered ‘functional’ surgery.

While some techniques have changed slightly, it does not always equate to faster, painless procedures.

“When performing blepharoplasty on lower eyelids, rather than just cutting bulging fat out, I reposition the fat, to meet the cheek. This reduces the bulge and gives smooth transition in contour to the cheek. It gives a better result but takes longer and is more painful,” he says.

Davies also meticulously explains procedures to his patients – who can be referred from GPs, optometrists, or ophthalmologists – to manage their expectations, gain their consent, and document their discussion.

“On a piece of paper with diagrams of the eyelid, tear duct and orbit, labelled with the patient’s name and date, I go through the medical issues, such as loose skin or fat bulging. I draw to demonstrate the problem and how I repair it, and describe and list day-surgery, post-op care, painkillers, and complications. The patient keeps this after we make a copy. Patients seem to appreciate having it all explained,” Davies says.

“Then it’s up to them to decide.”

Before surgery
Before surgery: bilateral ptosis and lower eyelid dermatochlasis.
After surgery
After surgery: bilateral ptosis repairs and lower blepharoplasties.

Like Davies, Dr Thomas Hardy graduated from the University of Melbourne and trained as an ophthalmologist at RVEEH, before undertaking five years of post-graduate fellowship training in eyelid, orbital and lacrimal surgery in the UK.

“When I was doing my ophthalmology training, I assisted Dr Alan McNab [an ANZSOPS past president] with private surgery, and I enjoyed seeing what he did, and the variety of procedures.”

Hardy says his overseas training made him certain of pursuing this surgically oriented sub-speciality. He is now one of five ophthalmologists – alongside McNab – at Eye Surgery Consultants in East Melbourne and is the oculoplastics consultant for the ophthalmology department at the Royal Children’s Hospital in Melbourne.

He recently performed surgery at the Royal Children’s Hospital on a patient with a very extensive tumour of the skull base invading the eye socket, which he described as a very rare case, whose treatment involved a multidisciplinary team. The patient’s prognosis was yet to be determined at the time of writing.

Hardy enjoys the multidisciplinary nature of oculoplastic surgery.

Dr Thomas Hardy
Dr Thomas Hardy

“There is a lot of crossover with other specialties, including brain surgery, sinus surgery (ear, nose and throat), plastic surgery, and overlap with vascular and interventional radiology,” he explains.

“There is an overlap between the fields of plastic surgery and oculoplastic surgery, with plastic surgeons also performing blepharoplasty, and reconstruction of fractures of the orbit, or eye socket. But there are some areas they won’t delve into, such as watery eyes and tear duct surgery,” he says.

Hardy completed his training in the UK between 2001 and 2005, and says the surgical techniques are generally well-established, and remain predominantly the same today as they did during his training.

“We use various techniques from our toolbox when performing blepharoplasty which involves a combination of removing skin, removing muscle, removing orbital fat, repositioning orbital fat, and reforming skin creases to be more stable and better defined. Some surgeons inject fillers to fill a space, and Botox, which is a chemical neurotoxin, may be used in modifying the periocular region,” Hardy says.

ANZSOPS immediate past president Dr Charles Su is a consultant at the RVEEH and in private consulting rooms in East Melbourne, but he also sees patients at Box Hill Eye Surgeons, and Springvale Eye Clinic.

Having rotated through the oculoplastic unit at RVEEH as part of his ophthalmology training, he found it appealing and subsequently completed fellowships at the Royal Brisbane and Women’s Hospital and the University of Michigan (USA).

“My slightly more favoured area in oculoplastic surgery is the lacrimal system, and DCR surgery,” he says.

Dacryocystorhinostomy (DCR) surgery is a procedure that aims to eliminate fluid and mucus retention within the lacrimal sac, and to increase tear drainage for relief of epiphora (watery eyes).

Dr Charles Su
Dr Charles Su

“As the term implies, DCR is made up of three parts: Dacryo (tear), cysto (sac), and rhinostomy (nose). When a patient’s tear drainage is blocked in the lacrimal system, they have watery eyes, which can be debilitating as it can affect driving, and reading,” Su says.

“Repairing tear drainage is ‘bread and butter’ in our profession, and the technique has not changed in recent years.”

Acquired blocked tear ducts is common in the population aged 60-70+, while inborn blocked tear ducts effect a much smaller proportion of the population (mainly newborns).

“Worldwide, DCR is one of the most performed oculoplastic procedures. External DCR was the most commonly used technique about 20 years ago,” Su says. “Endoscopic DCR – performed inside the nostril – has become more popular in the last five to 10 years, particularly in the US, where 60% of DCR is done endoscopically. Here in Australia, the majority of cases are done using the traditional, external technique. The shift to endoscopic DCR here is slower. Both methods are highly effective and have their place. Endoscopic DCR requires more equipment, which not all hospitals have, for example.”

Recent Medicare changes

In 2018, when he was ANZSOPS president, Su was involved in an administrative review of MBS items for various plastic surgery procedures, including oculoplastic surgery.

“I went through discussions, on behalf of ANZSOPS, to help RANZCO form a position on certain MBS item numbers, including an eyelid skin reduction, known as blepharoplasty, which general ophthalmologists do fairly regularly,” Su says.

(In 1987, before ANZSOPS was formed, RANZCO appointed an oculoplastic committee to provide sub-specialist input).

Medicare announced changes to eyelid surgery (MBS item 45617), effective from the 1st of November 2018.

The change meant that in order for a patient to access a Medicare rebate (MBS item 45617) from their surgeon for blepharoplasty, an optometrist or ophthalmologist must demonstrate that excess eyelid skin is obstructing the patient’s visual field (or satisfy other clinical need criteria as outlined by item 45617). Many in the profession understood that this was to ensure that the procedure was being undertaken for a functional, and not only cosmetic, purpose.

“There was some concern when the item descriptor wording was slightly changed, and some ophthalmologists were unsure if they had to do anything differently,” Su says.

“Essentially almost all ophthalmic surgeons were already making decisions according to these criteria in practice, so the spelling out of the vision effects of skin hooding would have been more relevant to non-ophthalmologists.”

Because of the complexity of oculoplastic, lacrimal and orbital surgery, and the corresponding complexity of MBS item descriptors, Hardy keeps a reference guide within arm’s reach.

“The change to MBS item 45617 a few years ago meant that surgeons had to have documentation from an optometrist or ophthalmologist of visual field interference, or prove there was a clinical need to remove excess eyelid skin as a result of thyroid eye disease, facial palsy, or scarring after trauma, in order to claim the MBS rebate,” Hardy says.

“Before visual fields were introduced as a criteria for eyelid surgery, the criteria was purely if the upper eyelid skin was resting on the lashes,” he says, adding it was a smooth transition to the new criteria.

Hardy says there have also been changes to billing skin lesion treatment and biopsy items under Medicare, but it isn’t clear if these changes include reconstruction and repair of the affected area.

“The main issue which mainly relates to basal cell carcinoma and squamous cell carcinoma, is whether repair is included in the item number, depending on the size of the lesion,” Hardy says.

“A graft or skin flap was a separate item number but now surgeons can’t use a separate Medicare item to repair a defect. The only exclusion is item 31359, for the removal of one-third of the eyelid in the malignant eye.”

Overall, Hardy says, the variety of oculoplastic procedures is not fully reflected in the range of Medicare item numbers, but there is usually a close match.

Biologic agents

Both Hardy and Su are optimistic about developments in drug treatments and biologic agents which are having a positive impact on patients with skin cancer and thyroid eye disease, two patient groups who oculoplastic surgeons regularly operate on.

“A drug called Vismodegib was introduced six or seven years ago to treat patients with advanced basal cell carcinoma, in a primary location, such as the skin around the eye socket,” Hardy says.

Vismodegib is the first systemic treatment for patients with advanced basal cell carcinoma who cannot have surgery or radiation.

“Whereas previously surgeons might otherwise need to remove the eye, patients treated with this drug may now be able to preserve or save the eye,” Hardy continues.

Su says a whole new class of drugs featuring artificially made antibodies are becoming more prominent, and oculoplastic surgeons are seeing the results. These drugs can be administered intravitreally or orally and prescribed by a patient’s oncologist or dermatologist, depending on what medical condition is being treated.

“They have revolutionised cancer treatments – high profile AFL footballer Jarryd Roughead is a case in point – and are often described as wonder drugs but are not as magical as often portrayed. A couple are particularly relevant to oculoplastics and treating orbital disease,” Su says.

Vismodegib, Su says, has proved useful for treating skin cancer around the eye, as Hardy points out, but another new drug to treat thyroid eye disease – a less common condition where the muscles and fatty tissues behind the eye become inflamed, causing the eyes to bulge outwards – is also making its mark.

“Thyroid eye disease sits broadly within auto immune diseases and starts attacking parts of the body – it starts attacking the thyroid, and tissues around the eye in the orbit, or eye socket. It makes the thyroid over-active, it produces more hormone, and ramps up the body’s metabolism,” Su says.

Thyroid disease is managed by an endocrinology specialist, but because the disease can affect eyes, oculoplastic surgeons also become involved.

“Released antibodies attack soft tissue around the eye socket, and they cause tissue to be more thick, rigid, and swollen. A patient has a typical alarmed appearance, and look as if they are staring, as their eyes are bulging because there is more flesh to fit into the eye socket. The eyes are pushed outward, and the patient suffers double-vision,” Su says.

“The oculoplastic surgeon’s role is to relieve the swelling, which can compress the optic nerve and threaten sight, by performing repair surgery on the orbit, or eye socket.”

Su says thyroid eye disease is a debilitating condition with no cure, and strikes young, middle-aged females, and can be cosmetically devastating.

“Up until now, treatment options typically involved multiple invasive surgeries and/or a combination of drugs (steroids) to reduce swelling. But now, biologic agents such as Teprotumumab, combined with surgery, are having life-changing results. Australians are active in clinical research in thyroid eye disease. In fact, Dr JJ Khong, who organised the group speaking at the cancelled ASO Expo event, is one of the leading Australians in this line of research.”

Teprotumumab (brand name Tepezza) received breakthrough therapy designation from the FDA in 2016 and was approved by the FDA in January 2020 for the treatment of thyroid eye disease. It is the first drug ever approved for the treatment of same.

The future of oculoplastics

Looking ahead, Hardy says the profession is in good hands.

“I think there will be refinements over time that result in safer, faster surgery,” he says. “There are a number of up-and-coming oculoplastic surgeons starting and completing their specialty fellowship training programs, and registrars in training that are expressing interests in the field, so I would say the future looks bright for this very surgical subspecialty.”

Su concurs: “Oculoplastic surgery encompasses a rich and diverse range of diseases and treatment modalities, and as such, is a popular subspecialty for new graduates to pursue. As healthcare funding becomes more stretched as time goes on, it is probable that there will be more scrutiny applied to surgical procedures which could potentially be seen as cosmetic. But most oculoplastic procedures are for disease states, in Australia, so at the moment I don’t foresee any significant change in requirements applied to surgeons.”

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