In recent years, little fundamental progress has been made with blepharoplasty. Instead, most professional interest has been directed at the non-surgical or minimally-invasive category of procedures. Heavily promoted during the economic downturn of the past decade as an alternative to more costly "real surgery," this group of mostly dermatologic quick-fixes turned out to be quite lucrative for a wide swath of both specialist and non-specialist practitioners, some of whom have now begun to openly question the cost/benefit ratios of many such treatments.
Throughout this period of developmental stagnation, the most intriguing surgical improvements have involved tissue-sparing procedures, operations aimed at repairing an underlying cause of a negative or aging change rather than simply cutting out its visible effect. Most other "advances" have consisted mostly of minor incremental tweaks to "legacy" operations, not always for the better.
Having performed tens of thousands of eyelid operations over the last thirty-five years, this much has become clear: Blepharoplasty is a procedure in need of some original forward thinking.
In times past, progress in eyelid surgery was spearheaded by a collegial and collaborative mix of surgeons from different specialties, including plastic surgery, dermatology, ophthalmology, and ear-nose-throat. Things have changed. Today, their organizations seem to be more at odds with one another, intent on protecting turf and defending the status quo, neither of which promotes discovery.
Don't worry. What's coming will be altogether different and monumental. Not only will the main innovators not be the physicians, but they may not even originate from the United States, where change in certain fields can too easily be stymied (as discussed below).
So what could this possibly be? Take a cue from a legendary neurosurgeon from Johns Hopkins and Harvard who was far ahead of his time:
"I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least of the work."
-- Harvey Cushing, M.D. (1869-1939)
Performing delicate surgery around the eyes with fingers, scissors, and sutures feels stuck in the past. It's conceptually ancient, mechanically low tech, and operationally imprecise and too destructive. In an era of increasingly sophisticated and intelligent technology, there's no reason this needs to continue.
The future of blepharoplasty and related plastic surgery around the eyes is robotic -- computerized, automated, accurate, but, most of all, smart. "Robot-assisted" to begin with, later "physician-assisted" to a degree, ultimately autonomous.
Still in their infancy, today's so called "robots" used in other surgical specialties are closer to video games than intelligent machines (video), essentially remote-controlled "dumb terminals." Designed to help human surgeons operate endoscopically with more precision and less tissue damage, these awkward room-filling engineering marvels basically provide another way of performing the same classic operations designed many decades ago.
Unlike R2D2 and C3P, present surgical "robots" are based on a "master-slave" model that depends on the surgeon for all decisions and directions. In most studies comparing the results of conventional versus robotic-assisted surgery, final outcomes have been comparable and not always good. After all, the "robot-slave" can only accomplish what its "surgeon-master" orders it to do. Despite what you may imagine when you hear the term "medical robots," computer intelligence and smart automation have very little to do with them. Operating times are longer, costs are higher (hospitals often charge up to twice as much), and documented results are no better than older methods.
While none of these machines are now capable of approaching blepharoplasty, the da Vinci Surgical System (Intuitive Surgical, Inc.) has been employed in Russia as an aid during limited parts of the dissection of the forehead flap during otherwise very standard endoscopic brow elevation, primarily out of curiosity and to test feasibility of current models for future use. Results were comparable to those in conventional operations without da Vinci participation.
Not surprisingly, initial enthusiasm for such technology has waned, with some hospital administrators now claiming that the most significant value of these aggressively marketed multi-million dollar gadgets is as a public relations gimmick to project an image of "cutting-edge" and "state-of-the-art."
Well, that's not what we're talking about.
The real surgical robots of the near future will be very different in appearance and performance. Armed with a comprehensive and ever-updating built-in database of knowledge and options and an impressive array of advanced sensors and novel treatment modalities, today's master-slave relationship will flip-flop or completely go away. Not only will tomorrow's smart robots improve upon human surgeons but likely replace them and their arsenal of twentieth century operations.
Impossible? While this may prove more difficult for some cosmetic operations than others, blepharoplasty offers an ideal plastic surgery starting point. Though far from a "stock operation," it lends itself well to preoperative and continuous intraoperative algorithmic analysis of anatomic variables and knowledge-based surgical options, including personal preferences and "artistic tastes." It's performed on or just beneath the skin, covers only a small area, and allows for elective planning rather than urgent performance, not unlike today's refractive eye surgery but more involved.
But why trust a machine when human surgeons have already mastered the operation? Because no surgeon is perfect, and more than a few are far from it. And because current blepharoplasty is nowhere near a perfect operation, limited in large part by what hand-held instruments and the fingers of individual surgeons with varying levels of skill laboring away in their isolated operating suites can achieve. The operation is mature and can be tinkered with only so many times, a point it reached some years ago.
Once freed from the restrictions imposed by last century equipment, techniques, and thinking, legacy blepharoplasty 1.0 can be finally laid to rest, replaced by an all-new version reimagined from the ground up.
With "Smart Blepharoplasty (2.0)," nearly everything about the operation will change dramatically, not just the instrumentation but indications, predictability, risks, treatment methods, healing times, degree of aesthetic improvement, the need for highly trained surgeons, costs, and so on. And since networked machines can record, store, analyze, and then quickly adapt based on their own results and the results from all other connected machines, future progress will be evidence-based and immediately available.
How soon this will happen depends on three main factors:
(1) Availability of technology: Much of the advanced technology necessary for smart robotics to take off is already here, just not well-known to the non-engineering public, including doctors. With some of the most creative mega-companies as well as many under-the-radar startups around the world now achieving exponential improvement in healthcare software, scanners, sensors, information technology, artificial intelligence, machine learning, machine vision, mechanical miniaturization, tissue engineering, 3d-bioprinting, and more, expect smart technology to advance quickly. None of this is science fiction. In today's compressed time-frames, 10-15 years to nearly full implementation seems an overly conservative estimate; it could well arrive sooner.
(2) Acceptance by patients: Less opposition will occur in countries like Japan and China where smart robotics and automation already play very visible roles in daily life. Once proven safe and effective as an "assistive" technology on less invasive procedures, the jump to inclusive, if not autonomous, should feel less "magical" and more natural.
(3) Adoption by regulatory agencies and providers: Radical change in any industry predictably meets with firm resistance; in this case, it could pose a formidable limiting factor. Cosmetic surgery, like the rest of medicine in the United States, remains a very "broken market" that does not adhere to even basic economic laws like "supply and demand." Despite potential high efficiency with improved results and less cost, the idea that a machine could replace many or even all of a surgeon's duties might prove too daunting to those on the front line. Don't expect such disruption to be welcomed.
Ultimately, however, resistance to progress will prove futile. With digital technology and autonomous robotics already reconfiguring most other spheres of life and enterprise, the present master-slave interface between human plastic surgeons and these incredibly smart machines is destined to evolve in a game-changing manner.