Answer: Most advances are in cosmetics, says Steve Anderson, M.D., an oculoplastic surgeon at Park Ridge Hospital in Chattanooga, Tenn. The newest oculoplastic surgeries in the past three years include laser skin resurfacing, endoscopic brow lift and transconjunctival blepharoplasty.

Dr. Anderson also singles out three recent advances for reducing wrinkles:

• Botulinum toxin. Injections of this substance relax the tissue to flatten out wrinkles. It's also used for blepharospasm.

• Microdermabrasion. This is like a mini-sandblasting, Dr. Anderson says. The instrument blasts aluminum oxide crystals that remove the outer layers of skin.

• Cool Touch laser. This procedure first numbs the skin cold with a cryogen spray, followed immediately by an erbium:YAG laser pulse to treat the collagen underneath. The bad news is that it takes 4-6 months to see results. The good news is that it doesn't leave the skin with the alarming red effect of laser skin resurfacing.

Question: What is the O.D.'s role in comanaging patients who've had oculoplastic procedures?

Answer: Get involved, first of all. "Most O.D.s—and most M.D.s too—look only at the eye," Dr. Anderson says. "They forget about the tissue around it."

When O.D.s do notice a problem—a cosmetic one in particular—they're not comfortable talking about it, says Christopher J. Quinn, O.D., of Omni Eye Services in Iselin, N.J. A functional oculoplastic procedure, like that for an ectropion, is an easy, straightforward referral, he says. But O.D.s get tongue-tied about cosmetic procedures.

Dr. Quinn explains that you have three reasons to bring up the subject of cosmetic surgery:

• Many patients appreciate at least hearing about the option.
• You stand to lose the patient to someone who does offer these services.
• You should control the referral process to make sure the patient sees a surgeon who specializes in oculoplastics, not just any plastic surgeon.

How do you broach the subject appropriately? Dr. Quinn suggests a few ice-breakers just to see if the patient is interested in talking further.

For cosmetic blepharoplasty: "Have you ever considered removing some of the excessive skin around your eyelids?"
For cosmetic ptosis: "Are you ever bothered that your eyelid on that side is somewhat droopy?"

For skin resurfacing: Tug a little bit laterally on the skin. Say, "Have you ever considered a procedure to smooth the surface a little here?"

Some patients will say, "bah!" But others will say, "Yeah, that's been bothering me."

Postoperatively, Dr. Anderson sees the patient at one week, then refers to the O.D. for the one-month visit. The surgeon takes care of most complications by that time. But three things you should still look for in monitoring the healing process are infection, overly aggressive healing (i.e. excessive scarring), and excessive pigment formation, Dr. Quinn says.

Those occurrences are rare, though. For functional procedures, such as tear duct surgery, check for functional improvement. For cosmetic procedures, the number-one post-op factor is patient satisfaction.