I am often asked what drew me to the niche field of oculofacial plastic surgery. The truth is, I had never heard of the specialty when I entered medical school, and to date, many of my fellow physicians are unfamiliar with it.
My first exposure to oculofacial plastic surgery was as a third-year medical student at Columbia University. Because the school prided itself on producing so many surgeons, we had the opportunity to rotate through several surgical fields during our clinical rotations, including ophthalmology. The week on ophthalmology was a whirlwind of time spent in classroom didactics, in the office seeing patients, and in the OR observing surgeries. I was amazed at the breadth of surgical procedures I witnessed, including cataract procedures, corneal transplants, vitrectomies, and ptosis repairs. I was also impressed by the wide demographic of patients on whom the surgeons operated, including adults and pediatric patients.
My time in clinical research focused on macular degeneration, so, naturally, when I entered my ophthalmology residency program, I gravitated toward retina as a subspecialization. However, my time spent in oculoplastics during my first year as a resident swayed my views. I gained an appreciation for the number and variety of surgical procedures that oculofacial plastic surgeons performed, the scope of clinical conditions they managed, and the interdisciplinary nature of the subspecialty.
As I progressed through my residency and fellowship, I realized that while larger academic centers consider oculoplastics to be an integral part of their hospital systems, smaller communities were unfamiliar with the types of conditions we treat and what role we play in patient care. Some surgeons whose scope of practice overlaps with ours may consider our field redundant or, worse, a threat, but the reality is that we provide a unique skill set that is invaluable and deserves broader awareness and appreciation.
Here are some things I wish other physicians knew about the field of oculofacial plastic surgery:
Oculoplastic Surgeons Are Specially Trained in Surgical Procedures That Other Disciplines Do Not Routinely Manage
While it is true that other surgeons perform procedures like upper and lower blepharoplasty, our field goes well beyond this subset of procedures. I like to think of oculofacial plastic surgeries in three broad categories: eyelid, orbit, and nasolacrimal.
In the realm of eyelid surgery, aside from upper and lower blepharoplasty, oculofacial plastic surgeons perform eyebrow lifting, eyelid reconstructive procedures post-skin cancers like basal, squamous, sebaceous, and melanoma, entropion procedures, ectropion procedures, laceration repairs, and ptosis repairs. Reconstructive procedures can involve obtaining grafts from donor sites such as other eyelids, the inside of the mouth, or ear cartilage. We also do corrective procedures such as canthopexy, canthal tightening, and retraction repairs with middle lamellar spacers.
Within orbital surgery, oculofacial plastic surgeons perform orbital explorations and biopsies, orbital fracture repairs, and orbital decompressions.
In the realm of nasolacrimal surgery, we can perform nasolacrimal stenting procedures, punctoplasties, dacryocystorhinostomy, conjunctivocystorhinostomy, and congenital nasolacrimal procedures.
Oculoplastic Surgeons Work Extensively With Other Medical Specialties, Including Neurosurgery, Pulmonology, Otolaryngology, Endocrinology, and Oncology
When training or working in an academic center, oculoplastic surgeons must be comfortable working with other disciplines such as ENT, neurosurgery, and pediatrics. For example, orbital abscesses often extend from adjacent sinuses, and with the assistance of ENT, these can be drained concurrently. In some cases, when patients have a deviated septum or enlarged middle meatus, working with ENT on nasolacrimal cases can benefit the patient. Accessing the orbit may require collaboration with neurosurgery, depending on the locations of certain tumors or vascular deformities. In trauma cases, particularly with polyfacial fractures, oculoplastics can work with oral and maxillofacial surgery or facial plastics in repairing the injuries. Collaboration is critical to ensuring that the patient’s entire surgical issue is addressed, thereby ensuring an efficient and comprehensive recovery.
Oculoplastic Surgeons Can Help Diagnose Systemic Diseases
Systemic diseases can often manifest in the eye and eyelid, and orbital and nasolacrimal conditions are no exception to this rule. Inflammatory conditions such as IgG4, sarcoidosis, and lymphoma can present as masses in the eyelid or eye socket. Infectious conditions such as necrotizing fasciitis can present in the eyelids. Individuals with sleep apnea may develop structural changes in the tarsal plate of their eyelids, a condition known as floppy eyelid syndrome, necessitating a consultation with a pulmonologist if they do not already have established care. Elevated cholesterol levels can lead to deposits in the periocular skin known as xanthelasmas. Thyroid dysregulation can often present initially as red eyes, bulging eyes, or eyelid malposition. Sebaceous cell tumors of the eyelid can be linked to gastrointestinal tumors. Finally, certain oncologic diseases, such as breast cancer and lung cancer, can often present initially as masses in the orbit. As an example, I recently saw a patient who had been noticing hollowing of one of the upper eyelids. On examination, the patient had notable enophthalmos. or a sinking in of the eye, so rather than a volume insufficiency, the cosmetic issue was related to a process affecting the eye socket. I ordered an imaging study, which revealed that the patient had silent sinus syndrome, requiring coordination with an otolaryngologist to rehabilitate the facial skeletal changes in addition to the orbital changes.
Oculoplastic Surgeons Undergo Post-Residency Fellowship Training
In highly specialized fields such as ophthalmology, it can be hard to imagine that there can be further subspecialization. However, a fellowship in ophthalmic facial plastic and reconstructive surgery is merely one of many choices for post-residency training as an ophthalmologist. There are traditional and nontraditional paths to obtaining fellowship training in oculoplastics, but the most widely recognized path is through an accredited fellowship with the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS).
These fellowships are structured as apprenticeships and are scarce, ranging from 20 to 24 single-spot positions across the country in a given year. As a result, some fellowships are only available in certain application years. These fellowship programs are two years long and include training in pediatric oculoplastic surgery, aesthetics, reconstructive, and functional procedures. The settings can vary from private practice to academic centers, but the number of surgical procedures is logged, and a thesis is required after the fellowship to be inducted into ASOPRS.
Oculoplastic Surgeons Practice in Many Different Settings, Including Academia, Group Private Practice, and Solo Private Practice
Oculoplastic surgery allows the opportunity to select from a plethora of practice settings, depending on one’s inclinations. Academic centers often provide the most challenging and diverse exposure to conditions and surgical cases and allow for interdisciplinary involvement. As is the case for many other fields, oculoplastic surgeons are increasingly joining larger groups, including private equity-acquired practices. However, as a group, they also include a great many entrepreneurial individuals who establish solo practices. Given the generally lower overhead costs compared to some other fields within ophthalmology, they can easily find their niche in the private practice community.
For someone who was ambivalent about a career in clinical medicine, I'm deeply fulfilled working as an oculoplastic surgeon. It provides an outlet for my creativity in the form of varied surgical and medical conditions, and the elective nature of the procedures allows for the pursuit of my interests outside of medicine. Although the training path is competitive and challenging, I am grateful to work in a field where I can operate regularly and stay connected to my colleagues.
What are some little-known things you wish other physicians knew about your specialty? Share in the comments!
Dr. Mahsa Sohrab is an oculoplastic surgeon located in Greenwich, CT. When she is not busy managing her own practice, she enjoys writing, sewing, reading, and globetrotting with her husband and daughter. Follow her on Instagram @drmahsasohrab. Dr. Sohrab is a 2024–2025 Doximity Op-Med Fellow.
Illustration by Jennifer Bogartz
