Oculoplastic surgery is performed to either correct a functional or a cosmetic eye problem.
The FDA initially approved Botox in 1989 for the treatment of a variety of ocular conditions such as blepharospasm (an excessive contraction of the eyelid muscles that forces the eyelids closed), hemi facial spasm (an excessive contraction of the facial muscles on jut one side of the face) and strabismus. Both physicians and patients began to notice that the injections had the beneficial side effect of decreasing the dynamic wrinkles on the side of the face that was treated. When doctors began injecting the normal side to "balance" the effect of treatment, physicians and patients realized that Botox could be successfully used to treat unwanted dynamic wrinkle lines in healthy patients. After several years, the FDA has finally approved the medication for cosmetic use.
Botulinum Toxin Type A is produced from bacteria called Clostridium Botulinum. This is the bacterium we know as a type of food poisoning caused by improperly processed canned food. For therapeutic use, the toxin is rigorously purified and enormously diluted. The typical cosmetic injections contain 20-30 units. Botulinum toxin works by interfering with a neurotransmitter called acetycholine, which transmits nerve impulses to the muscles. When the medication is delivered to the desired muscle, muscle contraction is diminished thus decreasing the appearance of wrinkle lines. The amount and location is tailored by the physician to each individual to obtain the desired effect.
There are several types of facial wrinkling: gravitational redundancy, intrinsic aging with loss of elasticity, sleep creases, and dynamic facial lines. The dynamic lines induced by muscle contraction are the type of wrinkles that respond remarkably well to treatment with Botulinum toxin. It is theorized that the repeated creasing of the skin over time induces changes in the dermal structure resulting in eventual formation of crease lines at rest as well as deepening of the crease when the muscle is contracted. Therefore, BOTOX will help treat and prevent the type of dynamic facial wrinkles that are caused by muscle contraction. BOTOX works best for the frown lines between the eyebrows, horizontal bands of wrinkles across the forehead and crow’s feet located near the corner of the eye.
The alternatives to BOTOX injections have included surgical excision, laser skin resurfacing, or augmentation with fat, or collagen. While these methods are helpful in reducing fine lines and creases, they do not address the cause of the fold, which is hyperactivity of the underlying muscle. In some cases, these surgical procedures can be used in conjunction with BOTOX to enhance the cosmetic outcome.
The patient is first evaluated with a thorough review of their medical history, medications, and prior plastic surgery. A detailed discussion of the patient’s facial lines and their desired outcome is reviewed. A series of small injections are carefully placed in the specific areas of the face to achieve the desired effect. Most patients report little discomfort during the procedure. Clinical expression of the effects typically takes 24 to 48 hours, and maximal effect is not seen for about a week. The effects are temporary and resolve between 2 and 11 months after the injection. After the injections are completed, the patient is asked to come back to the office at 2 weeks to evaluate the effect of the toxin. If lines are still bothersome to the patient, additional toxin may be injected at this time. When the muscles are adequately weakened and a pleasing facial skin contour has been achieved, the patient is instructed to come back when the facial lies again become prominent. In general this is about 4 to 6 months. In some patients, who have been treated a number of times, the BOTOX effect seems to last for longer and longer periods, perhaps related to behavior modification.
Pre-injection counseling should cover the potential side effects of the BOTOX injections as well as highlight the beneficial aspects of treatment. Most side effects that have been reported have been in patients receiving the treatment for therapeutic reasons such as double vision, blepharospasm and facial tics. The most common side effects from BOTOX given for cosmetic reasons include local bruising or discomfort and decreased sweating in the areas of injection. Less common and temporary side effects include droopy eyelid or lip, double vision, inability to close the eyelids, and dry eye. The injection site and amount is determined by the doctor to help minimize these side effects. Also, the patient is told not to lie down, lean over, or rub the injection site for at least 6 hours after treatment to help decrease the chance for the injection site to spread to other facial muscles.
If local adjacent muscle weakness does occur such as lid droop, it will disappear with time. Some patients ask if the muscle is permanently damaged from BOTOX injections. Muscle biopsies have not shown any evidence of permanent damage or degeneration. Other patients may ask if they will develop resistance to the medication. It has been reported that those patients receiving very high doses (>300 units, such as for tortcollis) may develop antibody to the toxin. These antibodies block the effect of the toxin, making the patient resistant to further therapy.
Overall, Botulinum toxin injections for dynamic facial lines have been found to be extremely safe and useful alone or in combination with other modalities. Patient satisfaction with the injections is very high.
Ectropion is an outward turning of the lower eyelid (photo "A"), 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 in our surgery center. After surgery, an antibiotic ointment is given for two days followed by warm compresses for two days. Common side effects from surgery include local swelling, bruising, and tenderness. It usually takes about 2-4 weeks for the eye swelling, bruising and symmetry to return to normal. Complications are rare but include asymmetry of the eyelids, scarring and infection. To most people, the improvement in vision, comfort and appearance after eyelid surgery is very gratifying.
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 (photo "B"). 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 can then protect the eye properly, and irritation and other symptoms subside.
Eyelid surgery to repair entropion is usually performed as an outpatient procedure in our surgery center using local anesthesia. Side effects from surgery include local tenderness, bruising and swelling. It usually takes about 2-4 weeks for all swelling and bruising to resolve. After surgery, an antibiotic ointment is given and the patient is told to place cold packs on the eye for two days following by warm compresses for two days. Serious complications are rare but include vision loss, scarring, infection and asymmetry of the eyelids. To most patients, the improvement in vision, comfort and appearance after eyelid surgery is very gratifying.
As we age, the delicate skin around the eyes can appear puffy or saggy (photo "C"). Eyelid skin stretches, muscles weaken, and the normal deposits of protective fat around the eye bulge forward. 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. 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 enhancement, it may be covered by insurance. Blepharoplasty for the lower lid removes the large bags under the eyes. It is unusual for insurance to cover lower lid blepharoplasty.
Blepharoplasty is performed on an outpatient basis and can take one to three hours. The patient is instructed to discontinue all aspirin and nonsteroidals for up to 1 week prior to surgery. 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 the 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. After surgery, an antibiotic ointment is given to apply to the stitches and the patient is instructed to apply ice to the eyelids at least 10-15 minutes out of every hour for the first two days and then apply warm compresses four times a day for two days. The patient is instructed to sleep with the head elevated and to decrease physical exertion for the first week following blepharoplasty.
Possible complications associated with blepharoplasty include bleeding and swelling, delayed healing, infection, drooping of upper or lower eyelid, and dry eye. Serious complications are rare but include vision loss, scarring, double vision and asymmetry. It is important to note that the puffiness and fat pockets will not return, but normal wrinkling and aging of the eye area will continue.
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 (photo "C").
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. Sometimes a second operation is necessary. In rare cases, full eyelid movement does not return. To most people, the improvement in vision, comfort and appearance after eyelid surgery is very gratifying.
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 carcinoma 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 eye socket, 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 eye socket, 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.
Trichiasis occurs when eyelashes grow inward toward the eye or when the lid is rotated and the lashes rub against the eye. Most of the time this constant rubbing will cause the cornea to become scratched or irritated and the lashes will need to be removed. Conventional treatment involved plucking the lashes away. This procedure is repeated in a couple of months when the eyelashes grow back. Another procedure that is used is cryotherapy, which can cause scarring of the lid margin and discomfort after the procedure. This method is painful and may cause permanent scarring of the lid margin. Maryland Regional Maryland Eye Associates has a new method to treat trichiasis with the Ellman surgitron. This is a new treatment that involves a thin wire that is inserted in the tiny hair shaft and radio waves are used to destroy the hair root. Radio waves are effective for cutting and to stop bleeding with minimal damage to adjacent lid tissue. In this way, the surgeon can remove the lashes without damage to adjacent lid tissue. The procedure is performed in the examination room. Local anesthesia is used to eliminate pain. The misdirected eyelashes are isolated and the thin wire is inserted into the hair shaft. The lash is then removed easily with forceps with no resistance. In most cases, the procedure does not need to be repeated.