Oculoplastics and Cosmetic Surgery

Blepharoplasty

As we age, the delicate skin around the eyes can appear puffy or saggy. Eyelid skin stretches, muscles weaken, and the normal deposits of protective fat around the eye bulge. The surgical procedure to remove excess eyelid tissues (skin, muscle, or fat) is called blepharoplasty.

Blepharoplasty can be performed on the upper eyelid, lower eyelid, or both. The surgery is performed for either cosmetic or functional reasons. Sometimes excess upper eyelid tissue obstructs the upper visual field or can weigh down the eyelid and produce tired-feeling eyes. Most often, people choose blepharoplasty to improve their appearance by making the area around their eyes firmer. When blepharoplasty is performed to improve vision, rather than for cosmetic reasons only, it may be covered by insurance.

Blepharoplasty for the lower lid removes the large bags under the eyes. It is unusual for third party payers to cover lower lid blepharoplasty.

The surgery is usually performed on an outpatient basis and can take one to three hours. Upper lid incisions are made in the natural crease of the lid, and lower lid incisions are made just below the lash line. A procedure for lower lid blepharoplasty, called transconjunctival blepharoplasty, removes excess fat through an incision inside the lower lid. Incisions are closed with fine sutures.

Swelling, bruising and blurry vision are common after blepharoplasty. Stitches are removed three to five days after surgery, except in the case of transconjunctival blepharoplasty where the self-dissolving sutures require no removal.

Possible complications associated with blepharoplasty include bleeding and swelling, delayed healing, infection, drooping of upper or lower eyelid, asymmetry, double vision, and dry eye. It is important to note that the puffiness of the fat pockets may not return, but normal wrinkling and aging of the eye area will continue.

Botox Injections

Botox is the trade name for botulinum toxin. In its pure form, botulinum toxin is a type of food poisoning that causes muscle weakness. It acts as a nerve impulse blocker, preventing muscles from contracting. In an extremely dilute form, botulinum toxin has many medical applications.

Botulinum toxin can be injected directly into muscles of the face or eye when facial muscles are overactive. Botox causes the overactive muscles to relax. It usually takes a few days for the therapeutic effect to be noticeable. The injections may need to be repeated every 4 to 6 months.

Botulinum toxin is used in ocular conditions such as blepharospasm, an excessive contraction of the eyelid muscles that forces the eyelids closed, and hemifacial spasm, an excessive contraction of the facial muscles on just one side of the face. For certain types of double vision, botulinum toxin can be injected directly into the eye muscle opposite the paralyzed eye muscle. Some wrinkles also become less prominent if injected with botulinum.

Side effects of the injection are temporary. They can include a droopy upper eyelid, double vision, and inability to close the eyelids.

Browlift (or Forehead Lift)

Sun, wind, and gravity affect the skin and muscles of the face over time. One of the most noticeable aspects of aging is a progressive drooping of the eyebrows. This can cause wrinkling of the forehead from raising one's eyebrows, as well as vertical wrinkles or furrows between the eyebrows. Sometimes the eyebrows or excess eyelid tissue can obstruct vision.

A browlift or forehead lift elevates the brow and smooths forehead skin, and can remove vertical lines between the eyebrows. Incisions are made in inconspicuous places, either behind the hairline, in one of the forehead wrinkles, or immediately above the eyebrows. If an endoscope (a small tube with a fiberoptic light) is used, the incisions can be very small. After the muscles are tightened and excess skin is removed, the incision is closed with sutures. The operation is usually an outpatient procedure that can take several hours.

Swelling and bruising, common after a browlift or forehead lift, begins to subside in seven to 14 days. Numbness and itching are common during the healing process. Sutures are removed within seven to ten days after surgery. Incisions in the hairline may damage hair follicles and result in some hair loss.

Chemical Peel

A chemical peel or facial peel is a nonsurgical technique used to smooth some of the fine facial wrinkles associated with aging. Areas of sun-damaged skin and certain skin discolorations also respond to the procedure.

An acid solution is applied to the face, causing the top layer of skin to peel, revealing new, fresh layers of skin. Chemical peels affect superficial, medium, or deep layers of skin depending on the strength of the acid, the duration of contact, and skin type. Deeper peels increase the risk of scarring.

Creams are often prescribed to prepare the skin several weeks before the procedure. The acid can produce a burning and tightening sensation, but most people do not require anesthesia.

With superficial peels, skin will appear pink or red following the procedure. Mild facial swelling may develop, especially around the eyes and on the chin. Some areas of skin may become crusty or scaly.

Medium depth peels cause more intense swelling. The skin is initially white, becoming increasingly red for the first 24 to 48 hours. The skin then peels as if severely sunburned. Peeling lasts from four to eight days. Skin may appear pink for several weeks.

While bandages are not necessary, a thin layer of prescribed ointment keeps the skin clean and moist after a chemical peel. Patients who are taking Accutane can have problems with scarring following peels.

Ectropion

Ectropion is an outward turning of the lower eyelid, most commonly caused by aging, although eyelid burns or skin disease may also be responsible.

Normally, the eyelids help lubricate and cleanse the eye during blinking. An eyelid that is drooping and has lost contact with the eye can cause dry eyes, excessive tearing, redness and sensitivity to light and wind.

Surgery can be performed to tighten the eyelid and return it to its normal position. The eyelid can then protect and lubricate the eye properly, so that irritation and other symptoms subside.

Eyelid surgery to repair ectropion is usually performed as an outpatient procedure using local anesthesia. After surgery, an eye patch is usually worn and antibiotic ointment is prescribed.

Entropion

Entropion is an inward turning of the eyelid and lashes toward the eye, usually caused by relaxation of the eye muscles and tissue due to aging.

Entropion usually affects the lower lid. The skin and eyelashes rub against the eye and cause discomfort and tearing. The irritated eye can produce mucous, and become red and sensitive to light and wind. If entropion is not treated, rubbing of the skin and eyelashes can cause infection or scarring of the eye, which can cause vision loss.

Surgery can be performed to tighten the eyelid and return it to its normal position. The eyelid then protects the eye properly, and irritation and other symptoms subside.

Eyelid surgery to repair entropion is usually performed as an outpatient procedure using local anesthesia. After surgery, an eye patch is usually worn and antibiotic ointment is prescribed.

Eyelid Surgery

Eyelid surgery is a common method of treatment for entropion (inward turning of the eyelid), ectropion (outward turning of the eyelid), ptosis (drooping of the eyelid), and some eyelid tumors.

Eyelid surgery is usually an outpatient procedure with local anesthesia. Risks of surgery are rare, but include asymmetry of the eyelids. Differences in healing between the eyes may cause some unevenness after surgery.

After eyelid surgery, a black eye is common but goes away quickly. It may be difficult to close your eyelids completely, making the eyes feel dry. This irritation generally disappears as the surgery heals. Serious complications are rare but include vision loss, scarring, and infection. To most people, the improvement in vision, comfort and appearance after eyelid surgery is very gratifying.

Eyelid Tumors

A tumor is an abnormal growth of any tissue or structure and can be either benign or malignant. A tumor can affect any part of the eye, such as the eye socket, eyeball, eye muscles, optic nerve, fat and tissues. Sometimes tumors grow into the eye area, or tumors from other parts of the body travel to the eye. Most tumors of the eye are benign.

Basal cell carcinomas are the most frequent type of malignant tumor to affect the eyelid (85-95% of all malignant eyelid tumors). The most frequent location is the inner portion of the lower eyelid, particularly in elderly fair-skinned people. Prolonged exposure to sunlight seems to be a risk factor for developing this form of tumor.

There are many different types of basal cell carcinomas but the nodular variety is one of the most common. It appears as a raised, firm, pearly nodule with tiny dilated blood vessels. If the nodule is in the eyelash area, some lashes may be missing. The nodule may have some superficial ulceration and crusting and look like a chalazion or stye. While these tumors are malignant, they rarely spread elsewhere in the body. For most of these tumors, surgery is the most effective treatment. In severe cases when the tumor has been neglected for a long time, it can spread into the eyesocket, which may ultimately require removal of the eye and adjacent tissue.

Squamous cell carcinoma is the next most frequent malignant eyelid tumor (occurring in approximately 5% of malignant eyelid tumors.) As with basal cell carcinoma, the most common location is the lower eyelid, particularly in elderly, fair-skinned people. This tumor also appears as a raised nodule that can lead to loss of eyelashes in the involved area. When detected and treated early, the outcome for this type of tumor is excellent. However, if the tumor is neglected, it can spread to the lymph nodes in the neck. Surgery is the most effective treatment.

Sebaceous cell carcinoma originates in glands of the eyelid in elderly individuals. It is relatively rare but still accounts for 1 to 5% of malignant eyelid tumors. These are highly malignant tumors that may recur, invade the eyesocket, or spread to lymph nodes. The tumor may look like a chalazion or stye, making it difficult to diagnose. Surgery is usually necessary for this type of tumor.

Malignant melanoma makes up almost 1% of all malignant eyelid tumors but accounts for many of the deaths from malignant eyelid tumors. As with any other type of malignant melanoma, these tumors on the eyelid can arise from a pre-existing nevus or mole, or may arise with no other pre-existing cause. Again, these tumors tend to occur in sun exposed areas of elderly fair-skinned people. Any pigmented area should be examined, especially if it is growing or changing color. Surgical removal is usually the recommended treatment.

Lacrimal Drainage Dacryocystorhinostomy (DCR)

Keeping the eyes moist and healthy requires tears. Tears are produced in the lacrimal glands, some of which are located under the upper eyelid. Tears drain from the eye into the nose through the nasolacrimal duct, or tear duct. A blockage of this drainage duct can cause wet eyes or excessive tearing. A blocked tear duct can also cause mucus buildup in the eye or ongoing infections in the lacrimal sac where tears collect. Infections are noticeable as a swelling of the inner corner of the lower eyelid.

Nasolacrimal duct obstructions can happen with no obvious cause. Sometimes previous sinus or nose surgery, or facial trauma with broken facial bones, can obstruct the tear duct.

Lacrimal drainage surgery is called dacryocystorhinostomy (DCR) and can be performed in different ways. One type of operation is an external DCR where an incision is made on the side of the nose, where eyeglasses might rest. A small amount of bone is removed to permit a new connection between the lacrimal sac and the inside of the nose. Small plastic tubes are sometimes inserted at the time of surgery to help keep the newly created opening from scarring shut during the healing process. The tubing is removed a few months after surgery.

Another type of operation uses a special instrument called an endoscope. The endoscope is a small tube with a fiberoptic light that facilitates the creation of a new opening into the nose. Various types of laser have also been used to perform the DCR operation.

In extreme cases where the tear duct cannot be reopened or repaired, an artificial tear duct can be implanted. The artificial tear duct is called a Jones tube and is implanted behind the inner corner of the eyelid to drain tears into the nose.

Laser Skin Resurfacing

Laser skin resurfacing is a relatively new laser procedure to improve the appearance of the skin. The laser burns the superficial layers of the skin to treat wrinkles, scarring, or facial pigment abnormalities. When the skin heals, the new skin layers are tighter and the wrinkles are less apparent.

The laser can be used to treat the entire face, or can be limited to the fine wrinkles around the eyes and mouth. Aging, cigarette smoking and a lifetime of sun exposure are some of the factors associated with wrinkles.Laser skin resurfacing is not a substitute for a face lift procedure, which tightens and repositions loose skin on the face and neck, but can be combined with it to diminish some of the fine wrinkles. Younger patients who are not yet candidates for a face lift may be candidates for the laser procedure.

Laser resurfacing can be done as an outpatient procedure using local anesthesia. If the entire face is treated or if this procedure is combined with other cosmetic procedures, intravenous sedation or a general anesthetic may be used. The procedure can last from a few minutes to two hours depending on the treatment area.

After surgery, the treated skin must heal much like any wound that removes skin. There is significant swelling of the treated skin, especially around the eyes and lips. If treatment included upper eyelids, the eyes may be swollen shut. New skin layers take five to ten days to grow, depending on the depth of treatment with the laser.

Laser skin resurfacing has advantages over traditional resurfacing methods such as chemical peels and dermabrasion. Healing is generally quicker and there is less postoperative discomfort after a laser treatment. While there is similar redness and swelling after surgery, there is less chance of scarring or skin pigment changes.

A consultation with your physician is necessary to determine if you are a candidate for laser skin resurfacing in combination with other types of cosmetic surgery or as an alternative to other procedures. It is important to tell your physician if you have had previous cold sore infections, are using the drug Accutane, or have any other conditions that might interfere with normal healing.

Ptosis

Ptosis is drooping of the upper eyelid. The lid may droop only slightly or it may cover the pupil entirely. In some cases ptosis can restrict and even block normal vision.

Congenital ptosis, or ptosis that is present at birth, requires treatment for normal visual development. Uncorrected congenital ptosis can cause amblyopia, or lazy eye. If left untreated, amblyopia can lead to permanently poor vision.

Except in mild cases, the treatment for childhood ptosis is usually surgery to tighten the levator muscle that lifts the eyelid. In severe ptosis, when the levator muscle is extremely weak, the lid can be attached or suspended from under the eyebrow so the forehead muscles do the lifting. Children with ptosis, whether they have had surgery or not, should be examined annually by an ophthalmologist for amblyopia, refractive disorders, and associated conditions.

Ptosis in adults is commonly caused by separation of the levator muscle from the eyelid as a result of aging, cataract or other eye surgery, an injury, or an eye tumor. Adult ptosis may also occur as a complication of other diseases involving the levator muscle or its nerve supply, such as diabetes.

If treatment is necessary, it is usually surgical. Sometimes a small tuck in the levator muscle and eyelid can raise the lid sufficiently. More severe ptosis requires reattachment and strengthening of the levator muscle.

The risks of ptosis surgery include infection, bleeding, and reduced vision, but these complications occur very infrequently. Although improvement of the lid height is usually achieved, the eyelids may not appear perfectly symmetrical. In rare cases, full eyelid movement does not return.