March 01, 2003
7 min read

Spain’s demand for cosmetic surgery increases

Spain’s improving economy brings increasing consumer demand for elective procedures. Can the country’s small number of oculoplastic surgeons keep up?

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BARCELONA — Patients here at the university hospital of ophthalmic microsurgery are queuing up for cosmetic surgery — after nearly a 3-year wait.

“There is a tremendous amount of reconstructive and cosmetic surgery that needs to be done in Spain,” said Dr. Ramón Medel, one of only two oculoplastic specialists here at the Institut de Microcirurgia Ocular (IMO). “We have an enormous waiting list for orbital disease and other functional maladies.”

While oculoplastic surgeons in Spain tend to needed ocular reconstructive and therapeutic surgeries, the demand for elective cosmetic procedures is also increasing.

Drs. Lucia Fernández-Vega and Javier Fernández-Vega Sanz performing surgery at Instituto Oftalmológico Fernandez Vega in Oviedo.

“More patients are seeking cosmetic surgery,” said Dr. Shoib Myint, a visiting associate professor of oculoplastic and reconstructive surgery at the Instituto Oftalmológico Fernandez Vega in Oviedo, Spain. “As a result, techniques here are advancing and becoming refined with the increase in popularity.” Dr. Myint and his partner, Dr. Frank Nesi, both visit Spain to perform surgery at the institute twice a year.

Cosmetic procedures are becoming so popular here, in fact, Spain is now eighth in the world in volume of overall plastic surgery procedures, according to data from the International Society for Aesthetic Plastic Surgery. An ISAPS survey found that Spanish member respondents carried out more than 20,000 aesthetic procedures in 2001, up 3% from 2000, bringing in nearly 900 million euros from patients last year.

Near the top of the list of requested aesthetic procedures in this country of 41 million people is blepharoplasty. According to the ISAPS, eye lifts, tucks and tweaks are currently the third most desired cosmetic procedures in Spain, after liposuction and breast augmentation.

“The demand has risen significantly in the past 5 years,” said Dr. Javier Fernández-Vega Sanz, grandson of Spain’s ophthalmic pioneer Aldolfo Fernández-Vega, MD, and a member of Spain’s family of ophthalmic physicians who run the Instituto Oftalmológico Fernandez Vega.

According to Dr. Fernández-Vega Sanz, the regeneration of Spain’s economy has led to a frenzy of facial fine-tuning, with surgeons scrambling to keep up.

Economic growth spurs interest

Since Spain joined the European Union in 1986, the country’s economic climate has markedly improved. Shortly after joining the EU, Spain undertook a program of privatization that reduced the size and influence of the government and helped aid economic recovery.

According to the Wall Street Journal’s 2003 Index of Economic Freedom, this trend continued through the 1990s under the direction of Prime Minister Jose Maria Aznar. Spain’s banking, energy and communications sectors were liberalized as a decline in public spending was instituted. The gross domestic product increased by 2.4% in 2001, the first time in 5 years it has been under 3%.

Unemployment in Spain also decreased, from 22.9% in 1995 to 12.7% in 2001. With the growing economy, consumer confidence has grown, and the rise in elective procedures may be a result of this.

“Just since I began practicing, in 1997, I have seen the volume of oculoplastic surgeries increase by 200%,” Dr. Medel said. “The increase has been quick and dramatic.”

“People have more money to spend on this sort of thing, now that the economic state has improved,” Dr. Fernández-Vega Sanz added. Under Spain’s national health care system, all elective surgeries are paid for out of pocket.

However, while the country is catching up to the United States and Brazil (the countries that currently lead the world in plastic surgery volume, according to the ISAPS) in its demand for cosmetic surgery, the supply side is struggling to keep up. With few ophthalmologists specializing in oculoplastics, the task is difficult.

Subspecialty training

Oculoplastic and reconstructive surgery is a fairly new subspecialty in Spain. In fact, it is a fairly new subspecialty throughout the world.

“Surgery of the orbital region was developed as a subspecialty of ophthalmology in the mid-20th century by Scottish physician John Mustarde,” Dr. Medel said. “Dr. Mustarde studied ways of treating eyelids, orbital and lacrimal problems.”

Dr. Frank Nesi performing surgery as Drs. Shiob Myint (left) and Maria Castroviejo (right) observe.

It was not until the 1960s that oculoplastics emerged as a formal subspecialty of ophthalmology. Since then, the anatomy of the orbit and eyelids has become better defined, allowing ophthalmologists to take a deeper interest in surgery in these areas.

Both Drs. Medel and Fernández-Vega Sanz trained in oculoplastics outside Spain. There was no formal fellowship program in Spain at the time of their training. The lack of a fellowship program has caused the number of oculoplasic surgeons here to remain low, they said. In fact, Dr. Medel said he is one of only four surgeons in Spain who are specifically oculoplastic surgeons.

Of the 3,000 members of the Spanish Society of Ophthalmology, Dr. Medel said, only 40 to 50 surgeons perform oculoplastic procedures.

“This is an increase from years ago, when many ophthalmologists didn’t want to do eyelid surgery. They sent their patients to specific surgeons or plastic surgeons who could carry out the job,” Dr. Medel said.

Now, with increased demand for plastic surgery of the eyes, eyebrows and midface, more surgeons want to perform the surgery than ever before, he said.

To meet the demand for training, Dr. Medel’s hospital at IMO has started a fellowship program for ophthalmology residents who want to subspecialize in oculoplastic and reconstructive surgery. The program is held in conjunction with the department of ophthalmology of the University of California–Los Angeles. One fellow is taken on per year.

“Ours is the only program of its kind that I am aware of in Spain,” Dr. Medel said.

Blepharoplasty popular

While Spain struggles with its limited manpower for oculoplastic procedures, the surgeons who are trained in the area are increasing their levels of expertise.

“Plastic surgeons in Spain are performing many different oculoplastic techniques,” Dr. Myint said. He said popular aesthetic procedures for the eyes include endoscopic forehead-lifts, endoscopic eyebrow lifts, cosmetic and functional blepharoplasty, Botox injections and CO2 laser skin resurfacing.

“Blepharoplasty continues to be one of the most desired procedures,” Dr. Fernández-Vega Sanz said.

Therapeutically, blepharoplasty is a procedure that addresses muscle spasms, uncontrollable blinking or blepharospasm. With the availability of Botox (botulinum toxin type A, Allergan), physicians can address some of these problems medically instead of surgically. Botox injections can paralyze the affected muscles to stop the spasm. When Botox therapy becomes inadequate to treat blepharospasm, blepharoplasty is indicated.

While Botox has been used therapeutically for conditions such as hemifacial spasm, strabismus and cervical dystonia, it is not yet approved in Spain for cosmetic applications.

“The majority of our blepharoplasties are cosmetic, and we are training our fellows with the latest techniques we have to offer,” Dr. Medel said. “For these procedures, we take out small wrinkles by removing excess skin, muscle and fat.”

Both argon and CO2 lasers are employed in blepharoplasty, Dr. Medel said. The argon laser can cut and coagulate, and the CO2 helps resurface the skin and allow a new epidermis to grow in its place. In Dr. Medel’s clinic, he uses both a CO2 laser and an argon laser.

“The CO2 laser creates a heating of the skin, which is very good to stimulate collagen, which we like,” Dr. Medel said.

Dr. Fernández-Vega Sans agreed. “The CO2 laser is a nice complement to blepharoplasty because it smoothes out wrinkles in middle-aged patients,” he said.

According to Dr. Medel, “bloodless” surgery with the CO2 laser reduces surgical and recovery time. CO2 laser procedures can be performed in the office or in a hospital outpatient setting.

New techniques

Another procedure that Dr. Medel teaches his fellows to perform is partial rhytidectomy in the midface region, also called a midface lift. The partial rhytidectomy can be used for therapeutic or cosmetic indications.

“We are doing a lot of midface lifts,” Dr. Medel said. “It is popular for wrinkles and saggy cheeks, but it is also effective for facial palsy or disorders of the midface.”

The procedure can be done transconjunctivally, raising the cheek structures without making any incisions in the skin. Consequently, surgery and rehabilitation time is reduced, Dr. Medel said.

“To raise the cheek, we work through the conjunctiva and underneath the cheek to raise the structures,” he explained.

This technique can be applied to patients who want tighter cheeks and higher-appearing cheekbones.

Additionally, reconstructive surgery can be performed if transcutaneous blepharoplasty has left scarring, he said.

“For this indication, we use a skin graft. It’s a nice procedure and it brings excellent results,” Dr. Medel said.

Dr. Medel said he is also using a new technique for ptosis repair.

“We are trying to improve ptosis in patients with functional ptosis by using a frontalis sling,” Dr. Medel said. Surgeons repair ptosis in this procedure by supporting the upper eyelid with a sling of thin fibrous tissue. The tissue is usually transplanted from the thigh.

“We like using this technique because it can be done quickly and leaves the patient with less inflammation during recovery,” Dr. Medel added.

Blepharoplasty boom may lead to malpractice, surgeons say

As the volume of cosmetic surgery increases in Spain, so may the risk of malpractice litigation.

“Malpractice lawsuits are becoming a big problem,” Dr. Javier Fernández-Vega Sanz told Ocular Surgery News. “Every day, patients and lawyers are becoming more capable of bringing cases against the medical profession.”

As more and more patients seek elective surgery, there is potential for the rate of surgical complications to increase, spurring a rise in malpractice lawsuits.

Dr. Ramón Medel agreed.

“Malpractice is something that we should all be aware of and careful of the ramifications,” he said. “While I have not encountered this problem in my hospital, I feel that once the rate of surgeries increase, malpractice issues can become a problem.”

According to Dr. Medel, refractive centers performing LASIK procedures were hit hard with litigation as a result of the refractive surgery boom in Europe in the late 1990s. There is potential for oculoplastics to expereince the same phenomenon.

According to Dr. Fernández-Vega Sanz, when insurance companies are forced to pay large sums in malpractice lawsuits, physicians and patients will suffer.

“Insurance companies increase their rates and make us have to raise ours,” Dr. Fernández-Vega Sanz said. “Sadly, it is then that we look like the enemy to our patient.”

For Your Information:
  • Ramón Medel, MD, can be reached at the Instituto De Microcirurgia, Munner 10, Barcelona, 08022 Spain; + (34) 93-253-1500; e-mail:,
  • Shoib Myint, DO, FAACS, can be reached at Consultants in Ophthalmic and Facial Plastic Surgery 29201 Telegraph Rd., Suite 305, Southfield, MI 48034 USA; +(1) 248-257-5100; e-mail:
  • Javier Fernández-Vega Sanz, MD, can be reached at the Instituto Oftalmológico Fernandez Vega, Centro Quirungico, Avda. Dres. Fernandez Vega, 33012 Oviedo, Asturias, Spain; +(34) 985-24-5533; fax: +(34) 985-23 3288; e-mail: