As our Inside Cosmetic Surgery series continues, we learn about the integration of ophthalmology with facial plastic surgery. Very few areas on our body are more sensitive than they eyes. We speak with Ophthalmologist and facial cosmetic surgeon Dr. Briggs Cook, of Charlotte, NC, on this delicate balance. He also tells you why seeking an ophthalmologist for your eyelid surgery may be better than seeing a general practitioner.

Listen to the engaging interview or read through the transcript below!

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Sharon Odom (SO): Hi everybody, this is Sharon Odom from CosmeticSurgeryToday.com and welcome to the call. Our special guest today is Dr. Briggs Cook, an eye and facial plastic surgeon who practices near Charlotte, North Carolina. Hi Dr. Cook, how are you?

Dr. Briggs Cook (DBC): I’m fine. How are you?

SO: I’m great. Well, thank you for joining us today to discuss the integration of ophthalmology with facial plastic surgery, and when you first suggested that, I thought to myself, “How in the world do you combine all those two?” So maybe you can explain to us what is ophthalmic plastic surgery?

DBC: Ophthalmic plastic surgery usually goes by different names. A lot of people would refer to it as either ophthalmic eye and facial plastic surgery or eye and facial plastic surgery. And typically what that combines or the origin of it is either facial plastic surgery combined with eyelid or eye plastic surgery, or eye plastic surgery extending down into the neck region or facial plastic surgery. There are different ways to get into this field, and one of the ways is through ophthalmology, and my training is technically through ophthalmology, or study of the eye.

But one of the sub-specialties within ophthalmology is eye plastic surgery. An eye and facial plastic surgery involves any of the structures around the eyelids or on the surface of the eyes or behind the eyes and facial plastic surgery obviously involves any facial reconstructive or cosmetic procedures on the face or around the eyelids itself.

SO: Okay.

DBC: So I guess to answer your question, ophthalmic plastic surgery or eye and facial plastic surgery encompasses anything around the eyes, eyelids, structures around the eyes, behind the eyes or anywhere else on the face.

SO: Now, is there such a thing as ophthalmic cosmetic surgery, or is that the same thing? I mean, a lot of people don’t know the difference between cosmetic surgery and plastic surgery. So could you sort of talk about that a little bit?

DBC: Sure. I guess I would consider eye and facial plastic surgery to be either cosmetic or what we call reconstructive or functional, and what that means is eye and facial plastic or cosmetic surgery is usually not covered by insurance, and we can cover that in a little bit, but that is what a person might come in and say, “I have a little bit of tissue on the upper lids or fatty tissue underneath the eyes, or I’m looking to do something like a face lifting procedure or injection of filler or Botox or something like that.” That would be considered cosmetic.

But functional or reconstructive procedures might be any kind of skin cancer, repair around the eyelids or on the face, after trauma which I do a lot of, either car accidents or anything that might cut the eyelids or any structures of the face or anything behind the eyes like tumors. So it sorts of encompasses anything all the way from cosmetics, which we can consider self-paid, to functional reconstructive, which is covered by insurance.

SO: Okay, all right. Now, how did you get into this specialty?

DBC: I can honestly tell and a lot of people ask me, a lot of my patients ask me how I got into this procedure. I was very fortunate enough to train at the Mayo Clinic with a physician who was chairman of the department at that time, and his specialty was eye and facial plastic surgery, and he sort of gotten me involved and interested in the specialty. His special love was anatomy of the face and eyelids, and that’s what he taught me. It was to love the anatomy, and eye and facial plastic surgery is all about anatomy.

One particular story I like to tell patients, for example, when a patient might come in with a droopy upper eyelid, a lid that might cover the pupil, is that it seems easy enough to lift the eyelid on the eye surface, but there are actually eleven layers between the front of the eyelid and the back side of the eyelids. If you are not aware of any one of those layers that’s violated or severed, then you are in trouble. So you need to know the layers, you need to know the anatomy, and once you know that it actually becomes a very fun and easier procedure.

SO: Okay, so that’s where the ophthalmology training comes in.

DBC: That is correct.

SO: Okay, so you are an ophthalmologist first?

DBC: I was, and once I finished my ophthalmology training, I did a sub-specialty fellowship in eye and facial plastic surgery as well as cosmetic surgery of the face, and that was at the University of Wisconsin-Madison, so that was a two-year fellowship in addition to the ophthalmology. So I don’t do cataract surgery. I don’t do LASIK. I don’t do any of those kinds of procedures. I just concentrate 100% on facial plastic and eye plastic surgery.

SO: Okay, so that means you can’t do anything for my keratoconus then, right?

DBC: Well, I could help you out with contacts, but I couldn’t do any of the surgery, but my partner would.

SO: All right, so when should someone consult an ophthalmic plastic surgeon?

DBC: That’s a good question, and I guess the way to answer that is with an example. A lot of times people will come in and say, “My friend has her eyelids done by a plastic surgeon, and why should I have you do my eyelid surgery, removal of excess skin or droopy eyelids, or repair around the eyelids, or on the face? Why should you do it instead of my friend’s plastic surgeon?” And there are a couple of ways to answer the question.

General plastic surgeons or people who went to a plastic surgery fellowship and decided to specialize in the face are trained basically to treat any kind of plastic surgery problems, and they do a very good job with that, but they can treat anything from ulcers on legs to tummy tucks to breast augmentations, breast reconstruction, breast reduction, anything like that, whereas I specialize in one particular area.

I’m very calm and used to working around the eyelids and it doesn’t faze me to be very close to the eye, because a lot of times when we are doing eyelid surgery or working on the lower eyelids, we are within several millimeters with the eyeball itself and that’s not very comfortable for general plastic surgeons or anybody who is not used to doing it.

So it’s a comfort level working around the eyeball. I think it’s one of the main reasons that people would seek out and choose an ophthalmic plastic surgeon.

SO: That brings up a very good point because I’ve been to lots of cosmetic surgery websites and I routinely see a doctor offer everything from eyelid surgery to tummy tucks to everything, so should patients be concerned if they are getting an eyelid surgery from, not general practitioner, but a general cosmetic surgeon?

DBC: I think patients now are doing their homework a lot more and the way I best describe with the patient is that I know a lot about a little, and they tend to know a little about a lot, and so we focus and specialize on one particular area and we do the best jobs that we can and do a very good job on that one particular area.

So I think the amount of knowledge I have is about that one particular area is a lot compared to they have a lot of knowledge about a lot of areas. So I would have trouble keeping it all straight in my mind if I did tummy tucks and breast augmentations and face lifts and whatnot.

SO: You are right. I mean, I’ve spoken to several doctors and they seem to specialize in a particular area. I’m noticing that more and more. That people are specializing in one particular area. So what type of procedures fall under the description? Like what type of procedures would people come to you and talk to you about?

DBC: Okay. A lot of times, what it tends to be is either upper eyelid or lower eyelid surgery in terms of excess skin or drooping of the upper lids, excess fatty tissue or excess skin in the lower lids, skin cancer repair around the eyelids, around the face. Face lifting procedures, I do quite a lot of those. I do a lot of orbital surgery, which is the removal of tumors from behind the eye or trauma around the eye or trauma to the eye.

For example, if you had an auto accident, and this falls under the [reconstructive procedures], if you had an auto accident, then you ruptured your eye or things like that, I take a lot of trauma calls in one of the local hospitals to do that. Anywhere from there to Botox around the eyelids to help relieve crow’s feet lines or frown lines or forehead lines, to injections of fillers to help relieve the folds around the nose or around the mouth to pop up the lips. So anything from the reconstructive to the cosmetic realm I do.

SO: So you do the filler, the injectables as well?

DBC: Correct.

SO: Okay. Is anesthesia required for any of these procedures?

DBC: For the lesser involved procedures such as Botox or filler injections, I might use a little bit of local anesthesia like a little bit of Novocaine underneath the skin to numb the area for filler injection. Botox never requires an injection of local anesthetic.

For anesthesia for eyelid surgery or facial surgery, including face lifting procedures, we typically use what we call Twilight anesthesia, which is an intramuscular, not an IV injection, of the same medication you would get for colonoscopy, Versed and Demerol, and what that does is it just acts as a general Twilight anesthesia. The patient is not asleep with a breathing tube or an IV. We can talk to them and they are very aware during the procedure and aware of the end of the procedure, but they don’t need to be asleep with the breathing tube.

SO: Okay, so they don’t feel any pain. They are just sort of very relaxed.

DBC: That’s correct, and after we give them the Twilight anesthesia, I give them a little bit of local anesthesia underneath the skin to numb that up, but they are not feeling that at that point, they are just very relaxed.

SO: Okay. Now, are the results permanent with all of your procedures?

DBC: Results typically last anywhere from probably 10 to 15 years. That’s about the lifetime of any plastic surgical procedure, any kind of face lift or eyelid procedure, anything like breast augmentation or breast reconstruction, so I think most surgeons would say 10 to 15 years would be the life for it.

What’s going to happen over time with any kind of eyelid procedure or face lifting procedure is your body will continue to age at the rate that it was aging previously. It’s like putting you back on the conveyor belt. If I lifted your eyelids up and put you back on the conveyor belt 10 to 15 years, your skin is still going to age and so that’s where we also offer the rest of skin care regimen and things like that to help preserve the results or make them last as long as possible.

SO: Right. Which one is the most likely to be covered by insurance?

DBC: Okay. That’s a good question. Eyelid lifting procedures, for the upper lid procedures, we usually investigate through the insurance company to see if that would be a covered procedure. With lower eyelid procedures, if the lower eyelid turns out or it pulled down, sometimes that can be covered by insurance. Of course, any kind of skin cancer repair is covered. Face lifting procedures are typically not.

If it’s an eyelid procedure and we think it might be covered by the insurance companies, we used photographs as well as what’s called the visual fields to look at the restrictions of what people can see above their eyes, above their eyelids and then at that, by taping up their eyelids like it would be after surgery and usually people can see more light, and that’s one of the indicators that insurance companies have used as a preauthorization requirement.

SO: Right. So do you try to see if it can be covered by insurance? I mean, do you help people try to justify the procedure?

DBC: We do, and we take care of all that for folks. I guess as an example, if somebody came in and they had a lot of excess skin in their upper lids and typically the skin might need to rest on the upper lid lashes for it to be covered, what we will do is we will talk to them. I will take some photographs and do a visual field, and I’ll send a nice letter off to the insurance company and get it preauthorized for them. So we will just check out all their insurance benefits and make sure it’s preauthorized and covered, and we will contact them to set up a surgery time.

SO: Now, is it possible sometimes to combine a plastic and a cosmetic procedure?

DBC: Absolutely. Yesterday in the office we actually did two in the afternoon where we did an upper eyelid surgery on two separate patients as well as lower eyelid surgery. The upper eyelid surgery or an upper eyelid lift with removal of skin, both of those was covered by the insurance companies. The lower eyelid procedure, which was removal of fatty tissue and excess skin were not covered by the insurance company, so the patient paid out of pocket for those procedures.

SO: But the insurance company paid for the anesthesia, oh no, not anesthesia, but the rest of it, right?

DBC: Correct. They paid for the upper eyelid procedures.

SO: So any other good patient stories you would like to share, I mean, some examples of some of these surgeries that you’ve done?

DBC: I guess, there is one example, and you just sort of mentioned a good example of combining procedures. The first patient that I did yesterday in the office was what we call quick lift or mini face lifting procedure. This sort of combines a lot of the things that you asked about. The patients are originally complaining of excess tissue on the face and down in the neck, a fatty tissue underneath the chin, which some people consider a water on the neck or excess skin and also complained of excess skin in the upper eyelids, lower eyelid fatty tissue, lower eyelid excess skin.

Also complained of the folds next to the nose and lines in between the brows. So when we originally talked about doing surgery, we said what we would do is do a face lifting procedure in the office with some liposuction of the neck. The fatty tissue that we retrieved from the liposuction of the neck I would put in the folds next to the nose to help soften the folds like a filler, but it’s their own fatty tissue. It’s theirs. I might as well use it. Once I removed it, to put it back in, and combine that with an upper eyelid lift and lower eyelid lift and removal of fatty tissue, as well as Botox between the brows.

So the patient paid out of pocket for everything except the upper eyelid lift, which was covered by insurance, and a procedure like that probably took about three hours in the office. We saw them back at one day, today, and the nice part about these procedures now that we can do a lot of these face lifting procedures and upper eyelid lift outside of the hospital setting without general anesthesia is that that patient had extremely little bruising and swelling today, even one day after surgery from the face lift, upper lid lift, lower lid lift, liposuction of the neck and jowls, and it was wonderful.

That’s one of the things we like about these procedures now is they have a much quicker recovery instead of three, four, five or six weeks of recovery. We talk now in terms of seven to ten days of recovery.

SO: So how much time do they have to miss from work?

DBC: We typically tell them if they have a procedure towards the end of a week, for example, on a Tuesday or Wednesday, maybe to take the next week off. It depends on how the patient is, but typically about seven to ten days.

SO: Right. That sounds great. That sounded like a pretty big makeover you did on that person.

DBC: I would say yeah, that was pretty much everything cosmetic and a little bit of a functional procedure that you can do. We pretty much did on him.

SO: So you do actual face lift, or face lifting procedures you call them?

DBC: I do, and what you would consider a routing face lift, those are what we do quite a bit of in the office, and we do them in the office, we don’t need to go to the surgery center in the hospital to do that.

SO: Excellent. So what can you do for the chicken neck?

DBC: That would be the same kind of procedure with what we call quick lift. What that involves is again Twilight anesthesia, but injection of Novocaine underneath the skin, and the incision for that typically would be in front of the ear just slightly and hide it behind that lobe part called the tragus in front of the ear.

Let’s go behind the ear and the ear crease and along the hair line and lift up the deep tissue underneath the skin, remove all the excess skin, and what that’s going to do is it’s going to pull the sides underneath the chin and hiding up all that what you considered chicken neck, remove the excess skin and bring the edges back together. And once it heals, my job is to hide all the incisions like the scar pretty much invisible, and that’s what happens.

SO: Excellent. Was there anything else you would like to say about ophthalmic plastic surgery? I must admit I had never heard of it before, and is there anything else you would like to tell us about it?

DBC: I can’t think of anything else right now. I think you did a good job of covering it, and I think one of the biggest things with patient education in terms of we are specialists just like a specialist you might go to for tubes to put in your ear. You would go to a specialist for that, and for the eyelids if anybody was considering eyelid surgery and facial plastic surgery.

I think the patient should ask the question, what do you specialize in? Do you these procedures even down the face because that gives a good indication that you are trying to branch out and do a lot of different things, but you are concentrating on doing pretty much one thing.

SO: Well, this has been very informative. Thank you very much, Dr. Briggs Cook. Would you like to tell people how they can learn more about your practice or give them your website perhaps?

DBC: Sure, absolutely. We have two different offices. We have a main office in Charlotte and a satellite office in Huntersville, North Carolina. Our primary office number 704-237-1160 and our website is www.skincenternc.com.

SO: Well, thank you very much Dr. Cook. It’s been a pleasure, and perhaps we will have you back to talk more about this very fascinating subject. Thank you.

DBC: Fantastic. I appreciate it.