title: The Role of Surgeon Technique in Current Practice Patterns for Combined Ptosis and Dermatochalasis.
abstract: OBJECTIVE
  The goal of this study is to identify and describe the role of surgical incision preference, insurance reimbursement, and geographical location on the current ptosis repair practice patterns of American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) members.
  
  
  METHODS
  A 9-question survey was designed with surveymonkey.com and a participation link was emailed to all active ASOPRS members' email addresses in February 2015. After a reminder email, the survey was closed and the results were analyzed. There are 3 major questions the survey data is to be used answer: 1) Surgical approach preference: The first question established preferred surgical technique (internal vs. external approach) for ptosis repair. This result was/is used to stratify the remaining responses into 2 groups. 2) Functional versus cosmetic surgical indication: Three clinical scenarios were presented for a functional versus cosmetic patient for ptosis repair and blepharoplasty. 3) Location: The responses were analyzed based on location to determine any geographic bias for surgical preference. For this analysis, the US was separated into 4 regions (West, Midwest, North, and South), as defined by the United States Census Bureau; all international respondents were grouped together.
  
  
  RESULTS
  Three hundred and ten responses were included and analyzed; 61% preferred the internal surgical approach, there was no statistical significance to geographic location (p = 0.17). Surgeons who prefer the external surgical approach (76.1%) were more likely than internal (62.5%) to include a bundled (nonreimbursed) blepharoplasty at no additional charge in the setting of functional ptosis repair (p = 0.015). Treatment plans differed significantly in both groups between functional and cosmetic patients with visually significant ptosis (Margin Reflex Distance < 1.5) and moderate dermatochalasis; with both the internal and external group electing combined surgery at a higher rate in cosmetic patients (p < 0.01 for functional vs. cosmetic within each group, and internal vs. external repair). There was no statistical difference in the timeframe for adjusting external ptosis for functional or cosmetic patients (p = 0.79). More surgeons use nonabsorbable closure for cosmetic blepharoplasty patients (68.7%) than for functional (54.1%) surgery patients (p < 0.01).
  
  
  CONCLUSIONS
  Previous studies have documented the immediate effect of Medicare reimbursement changes on the management of concurrent ptosis and dermatochalasis. This study illustrates current practice patterns for ptosis repair and blepharoplasty. The necessity of creating a separate surgical site for surgeons who prefer the internal approach to ptosis surgery to perform a functional blepharoplasty has a significant influence on surgeon's willingness to perform concurrent blepharoplasty as a nonreimbursed bundled procedure.
authors.affiliation: *Ophthalmic Plastic and Cosmetic Surgery Inc., †Department of Ophthalmology and Visual Sciences, Washington University in Saint Louis, ‡Department of Ophthalmology, Saint Louis University, and §Department of Otolaryngology/Head and Neck Surgery, Saint Louis University, Saint Louis, Missouri, U.S.A.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Neimkin
authors.forename: Steven M
authors.initials: SM
authors.lastname: Couch
authors.forename: John B
authors.initials: JB
authors.lastname: Holds
authors.forename: Zachary M
authors.initials: ZM
authors.lastname: Bodnar
authors.forename: Sara N
authors.initials: SN
authors.lastname: Reggie
mesh_terms: D000328:Adult; D019882:Blepharoplasty / Q000379:methods*; D001763:Blepharoptosis / Q000601:surgery*; D005141:Eyelid Diseases / Q000601:surgery; D005260:Female; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D014481:United States