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Dermatochalasis

Blepharoplasty

Ectropion 

Entropion

Ptosis

Dacryocystorhinostomy, probe and intubation, dacryoplasty

Reconstruction after Moh's surgery

Blind and/or painful eye

Oculofacial Center

Dermatochalasis

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The eyelids undergo changes over time that can result in stretching and excess of the skin, wrinkles, fat bulging, and muscle weakness. If severe, the skin can hang over the upper eyelid and obstruct one’s peripheral field of vision, in addition to adding significant mechanical weight making opening the eyes difficult. Other symptomatic difficulty may include drooping of the upper eyelid lashes into one’s field of vision, and soreness around the skin folds of the upper eyelid due to mechanical chaffing.

Blepharoplasty

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This is a surgery aimed at correcting excess skin, fat, and overall aging changes.

  • A skin incision is usually made with one’s own natural lid crease. If the crease is too high or low, or if a patient desires a certain height to the lid crease, a new crease can be made at the desired or ideal location.

  • Skin is removed, leaving behind a safe amount so the eyelids can close naturally.

  • Areas of puffiness may be related to fat protruding forward from aging around the eyelid and may be removed at the same time.

  • The skin incision can be closed with absorbable or non-absorbable sutures. The cosmetic outcome has been shown to be the same 3 months after surgery. If a laser is used to make the skin incision, non-absorbable sutures should be used and are usually removed 5-7 days after surgery.

  • The incision line may be red for 2-4 weeks, and typically fades to a faint fine line over time.

  • After excess skin is removed from the upper lid, patient’s may notice less need to elevate the brows to open the eyes which make the brows appear to have descended.

  • Excess lateral hooding, or skin falling over the sides of the eyes, is strongly related to brow ptosis (aging changes to the brows causing them to fall), and may sometimes require direction correction the the eyebrows. If not overly severe, extending the blepharoplasty to take skin in this area can be helpful without any brow surgery. 

Ectropion

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The lower eyelids can undergo changes over time that result in a loss of normal apposition, contour, and function. When extreme, the lower eyelid will appear as if it is turned outward, with the moist, pink surface behind the eyelid becoming visible.  Aging, scaring, tissue laxity, and other mechanical forces can contribute to its onset. Symptoms may include eye irritation, dryness, redness, tearing, discharge, crusting, blurry vision, and infection. Over time, permanent damage may occur to the eye, such as scarring and vision loss.

Ectropion repair

The goal of surgery is aimed at restoring the normal position and tightness of the eyelid.

  • A small incision is usually placed in the corner of the outer aspect of the eyelids. The redundant lower eyelid is trimmed to achieve appropriate tightness, then sutured just inside the bone of the lateral eye socket with suture(s). The skin is closed with absorbable sutures as well. If an upper eyelid blepharoplasty is also performed, and the lower eyelid is not too loose, your surgeon may be able to correct the lower eyelid without making an additional incision.

  • Slight overcorrection (over-elevation) of the corner of the eyelid is performed as the natural healing process and gravity will cause the corner of the eyelid to fall slightly.

  • The sutures used to reattach the lower eyelid to the bone can rarely cause an inflammatory reaction, resulting in a small bump about 2-3 weeks after surgery. This almost always will go away with warm compresses and time.

  • The incision line may be red for 2-4 weeks, and typically fades to a faint fine line over time.

  • Some patients may require concurrent elevation of the lower eyelid closure muscles and/or the midface to help elevate the eyelid, although this is not needed for most individuals. Severe cases of ectropion, whereby the skin is pulling the eyelid down, may require a skin graft taken from the eyelids or around the ears, in addition to having the eyelids sewn shut for 1 week. 

Entropion

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The lower eyelids can undergo changes over time that result in a loss of normal apposition, contour, and function.  In some instances the lower eyelid and eyelashes will turn inward causing significant irritation.  Aging, scaring, tissue laxity, and other mechanical forces can contribute to its onset. Symptoms may include eye irritation, dryness, redness, tearing, discharge, crusting, blurry vision, and infection. Over time, permanent damage may occur to the eye, such as scarring and vision loss.

Entropion repair

The goal of surgery is aimed at restoring the normal position and/or tightness of the eyelid.

  • A small incision is usually placed in the corner of the outer aspect of the eyelids. Then from behind the eyelids, the muscle that helps pull the normal eyelid into position, the capsulopalpebral fascia, is identified and reattached the eyelid. There is usually overactivity of the eye closure muscles contributing to entropion, and so these are also gently reduced from the behind the eyelid as well. The redundant lower eyelid is then trimmed to achieve appropriate tightness, and sutured just inside the bone of the lateral eye socket with suture(s). The skin is closed with absorbable sutures as well.

  • Sometimes this surgery is performed with an incision in front of the eyelid, just below the eyelashes, in cases where there is excess skin or a slightly more powerful correction is required. 

  • Gentle overcorrection (over-rotation) of the eyelid may be seen seen immediately postoperatively and is normal. 

  • The sutures used to reattach the lower eyelid to the bone can rarely cause an inflammatory reaction, resulting in a small bump about 2-3 weeks after surgery. This almost always will go away with warm compresses and time.

  • The incision line may be red for 2-4 weeks, and typically fades to a faint fine line over time.

Ptosis

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The upper eyelid is raised by 2 muscles that contribute to the vertical opening of the eye, the levator palpebrae superioris and muller’s muscles. Decreased function of these muscles due to aging changes, intrinsic weakness, nerve paralysis, or other mechanical factors can lead to the appearance of droopy or sleepy eyes. This should not be confused with other factors that can lead to the appearance of a droopy eye, like excess skin hanging over the eyelid. Symptoms related to ptosis may include a reduction in peripheral and central vision, compensatory head position changes, excess forehead and eyebrow use, and even permanent visual loss if occurring at birth.

Ptosis surgery: Conjunctivomullerectomy or levator resection

The goal of surgery is aimed at tightening the eyelid muscles or tendons to restore or improve eyelid elevation. This can be done in one of two ways, depending on the response to clinical testing performed in the office.

Conjunctivomullerectomy:

  • This is a surgery to correct drooping of the upper lid when it responds to phenylephrine eye drop testing performed in the office. Based on the response to the drop, a predetermined amount of tissue is removed to tighten the muscle that elevates the upper eyelid.

  • The upper eyelid is everted, then the planned amount of tissue to be removed marked and clamped. Absorbable sutures are run under the clamp, with the suture ends externalized on the skin, and then redundant tissue within the tissue is cut and removed.

  • Results can sometimes be seen as early as 1 week after surgery, but typically takes 1-3 months to become apparent and unchanging.

Levator resection:

  • A skin incision is usually made with one’s own natural lid crease. If the crease is too high or low, or if a patient desires a certain height to the lid crease, a new crease can be made at the desired or ideal location.

  • The tendon or the muscle controlling the movement of the upper lid is then identified and attached to the lower part of the eyelid.

  • The patient will then be asked to the open the eyes naturally, and look up and down. These maneuvers are used to assess the contour and height of the eyelid. Some overcorrection of the eyelid height is to be expected as the eyelid has a tendency to decrease in height with healing.

  • Additional sutures may be placed to achieve an optimal height and eyelid contour.

  • The skin incision can be closed with absorbable or non-absorbable sutures. The cosmetic outcome has been shown to be the same 3 months after surgery. If a laser is used to make the skin incision, non-absorbable sutures should be used and are usually removed 5-7 days after surgery.

  • The incision line may be red for 2-4 weeks, and typically fades to a faint fine line over time.

  • Because the muscle/tendon is shortened, the eyelid may no longer close fully in some. Also, because the eye is opened more, there is more exposure of the ocular surface potentially increasing dryness of the eye. Although most patients tolerate this fine, artificial tears, gels, or ointments may be required afterwards for an indefinite period of time.

  • Results can sometimes be seen as early as 1 week after surgery, but typically takes 1-3 months to become apparent and unchanging.

Dacryocystorhinostomy, probe and intubation, dacryoplasty

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The eyes must be constantly bathed in tears to lubricate the ocular surface and allow normal vision. These tears are normally drained by the lacrimal system, which starts at the inner corner of the upper and lower eyelids. A punctum, or small orifice, is present in most individuals on the upper and lower eyelids, and acts as a sink to pull tears from the eye. These tears then move within the eyelid into the lacrimal sac, found adjacent to the inner aspect of the eye socket. From here, tears are pumped into the nose through the nasolacrimal duct, which is a soft tissue lined bony opening.

Disturbances to any part of the lacrimal system can result in excess tearing, much in the same way one might find in a slow or obstructed kitchen sink. This can result in blurry vision, discharge, infection, pain, and skin irritation.

The most common site of obstruction is the nasolacrimal duct, which, over time, becomes narrow in some individuals leading to decreased outflow. In children, the nasolacrimal duct can be congenitally narrow but often opens on its own during the first year of life. Other causes of nasolacrimal duct narrowing can be due to chronic allergy, medicated eye drop use, and chemotherapy just to name a few. When the nasolacrimal duct is completely obstructed, it can lead to a severe infection called acute dacryocystitis in some individuals, as the stagnant tear fluid unable to exit from the lacrimal sac becomes infected by bacteria.

We will assess your lacrimal system with in the office with tear outflow testing and possibly intranasal exam using an endoscope if indicated. Furthermore, other factors that often contribute to tearing, including eyelid malposition and overproduction of tears, will be thoroughly examined as well. 

Mild to moderate blockage of the nasolacrimal duct can be improved with probing and silicone intubation, along with balloon dilation if indicated, to widen the existing duct.

Lacrimal probing and silicone intubation, with/without balloon dilation:

  • For milder cases of blockage of the tear drainage system, widening of the existing passageways can be of use. There are 4 orifices in the corners of the upper and lower eyelids that help drain tears from the eyes so that they go into the nose. These orifices are dilated temporarily and then a metal probe is passed into the system. This probe first goes through the eyelid portion of the tearing system, then through the bony portion, then to the nose.

  • Decreased drainage of tears due to greater narrowing of the bony portion of the tear drainage system can additionally be improved by dilating the area with a balloon catheter if indicated.

  • A silicone tube is passed through both puncta, or orifices that the tears enter along the inside corner of the upper and lower eyelid. This tube passes through the existing tear drainage pathway into the nose and tied. The tube is typically removed 3 months after surgery in the office, and is placed to prevent the widened tear system from narrowing. This tube is not usually visible to most people, and is well tolerated. The tube can sometimes prolapse from rubbing of the eyelids and irritate the surface of the eye, especially if it crosses into the colored by of the eye, or iris, when one is looking straight ahead (it is normal for the tube to be close to the iris when one looks inward). If this occurs the tube can usually be repositioned in the office through the nose, although if the tube is significantly prolapsed, sometimes early removal may be required. Rarely individuals can have allergies to the silicone tubing characterized by significant itching, swelling, and redness, in which case the tube would have to be removed earlier than normal.

  • The main complications after surgery are bleeding, and the tube prolapse described above. Mild trickle of blood in the nose is common and can be decreased with intermittent icing and compression of the nose. Any blood should be spit out as it can irritate the stomach. This may last 1-2 days.

  • No nose blowing is allowed for 1 week after surgery. It is ok to sniff in. If one must sneeze and it cannot be stopped, just sneeze. It is worse holding the sneeze then just letting it go. Any picking of the nose should be avoided as one could theoretically accidentally grab the tube in the nose.

Moderate to severe blockage of the nasolacrimal duct can be improved with dacryocystorhinostomy, which bypasses the malfunctioning nasolacrimal duct and involves creating a new pathway for the tears into the nose. The preferred approach is endoscopically through the nose, which avoids the need for skin incisions, and has been shown to have equal efficacy as the traditional external approach. Typically those who elect to undergo an external dacryocystorhinostomy typically are patients who are unfortunately not healthy enough to have general anesthesia.

Sometimes we may refer you to an ear, nose, and throat (ENT or Otolaryngologist or Rhinologist) specialist for combined surgery if you have a severely deviated septum blocking the area we perform the dacryocystorhiniostomy and/or if concurrent sinus surgery may be helpful. It has been shown that combining these measures, when needed, often leads to much better outcomes for your tearing surgery. 

Dacryocystorhinostomy:

  • A new pathway for tears will be created, bypassing the narrowed or completely blocked tear duct. A roughly 15x15mm area of bone is removed around the lacrimal sac, which collects tears from the eyes. The lacrimal sac is opened and trimmed, with the borders flush with the bony opening. This bypasses the tear duct or nasolacrimal duct that arises below the lacrimal sac.

  • A silicone tube is passed through both puncta, or orifices that the tears enter along the inside corner of the upper and lower eyelid. This tube passes through the new pathway into the nose and tied. The tube is typically removed 1.5-3 months after surgery in the office, and is placed to prevent the newly created pathway from scarring closed. This tube is not usually visible to most people, and is well tolerated. The tube can sometimes prolapse from rubbing of the eyelids and irritate the surface of the eye, especially if it crosses into the colored by of the eye, or iris, when one is looking straight ahead (it is normal for the tube to be close to the iris when one looks inward). If this occurs the tube can usually be repositioned in the office through the nose, although if the tube is significantly prolapsed, sometimes early removal may be required. Rarely individuals can have allergies to the silicone tubing characterized by significant itching, swelling, and redness, in which case the tube would have to be removed earlier than normal.

  • If performed externally, a 1cm sized incision will be placed near the inside corner/nose of the eye. If endoscopic, no incisions will be placed. The outcome for both methods is the same.

  • The main complications after surgery are bleeding, and the tube prolapse described above. Mild trickle of blood in the nose is common and can be decreased with intermittent icing and compression of the nose. Any blood should be spit out as it can irritate the stomach. This may last 1-2 days.

  • No nose blowing is allowed for 1 week after surgery. It is ok to sniff in. If one must sneeze and it cannot be stopped, just sneeze. It is worse holding the sneeze then just letting it go. Any picking of the nose should be avoided as one could theoretically accidentally grab the tube in the nose.

Eyelid and periocular lesions and reconstruction after Moh’s surgery

There area various benign and malignant lesions that can develop around the eye and face. These most commonly result from long term sun exposure, but can also arise independent of any particular exacerbating factor. Most lesions can be biopsied or removed in the office under local anesthesia. When cancerous, further surgery may be needed with the help of a dermatologist who performs Moh’s surgery or with the removal of any lesion or residual lesion with wide margins of normal tissue.

Moh’s surgery and reconstruction after Moh’s surgery

  • When a suspicious lesion is biopsied, a small portion is typically taken unless the lesion is amenable to removal in total without distortion of the surrounding tissue. The reason why the entire lesion is not always removed is to preserve as much normal tissue as possible in case the lesion is malignant. These lesions often extend far beyond what can be seen visibly, and require significantly wider excisions with increased tissue loss and possible morbidity if an attempt is to remove them in total. If ultimately benign, any residual lesion can be further removed safely without unnecessarily wide excision and reconstruction. 

  • Moh’s surgery is a tissue removal technique most often used for malignant tumors.  You may see a dermatologist specializing in Moh’s surgery who can remove any additional malignant tumor in the affected tissue, confirming it immediately by examination under a microscope, like a pathologist. The tissue removal continues until there is no further observed tumor. This allows the highest rate of tumor clearance while limiting the amount of tissue needed to be removed, permitting a better aesthetic and sometimes easier method of reconstruction.

  • Moh’s surgery is usually performed the morning of the anticipated date of reconstruction so that repair can be done the same afternoon, but it  can also be safely done 1-2 days after  in most cases.  

  • The type of reconstruction performed varies widely depending on the affected location and the degree of tissue loss. Therefore it is often impossible to know how involved the reconstructive effort may be until after Moh’s surgery is performed and the area seen by the surgeon. In general, small defects can be closed with manipulation of mainly the tissues around the area. Larger defects, usually greater than the size of at least the size of a half dollar, may require significantly more work such as with the use of skin grafts or  recruiting skin from the cheek, lower face, forehead, and/or even from the neck.  

Blind and/or painful eye

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When the eye is poorly functional and causes significant discomfort, one’s quality of life can be severely diminished. If there is no way to improve vision or alleviate eye pain, often times the best treatment is removing all or part of the eye. The procedure relieves discomfort, and can sometimes look at least as good or better than traumatized or diseased eyes that have undergone degenerative changes.

Enucleation/Evisceration:

  • Enucleation involves removal of the eye as a whole, while evisceration preserves the sclera or the white part of the eye, with removal of all contents in the eye. Both methods are equally effective and give approximately the same amount of cosmesis and eye movement with a prosthetic eye after surgery. The choice of of which procedure may be best depends on several factors which your physician will discuss with you.

  • The eye or eye contents are removed and a porous polyethylene or silicone sphere is placed in the eye socket. The tissues of the eye are closed on top of the implanted sphere, and a temporary conformer (large contact lens) is placed to prevent contracture of the eye socket. The eyelids will be sutured closed, and a patch is placed on the eye.

  • The patch can be removed as early as 5 days after surgery, but I typically recommend patients just leave it on until follow up with me about a week after surgery.

  • Ointment is started only after the patch is removed.

  • If the conformer falls out, please clean it with soap and water only, then placed back in the eye. The conformer is somewhat shaped like a football. The longer part should go into the eye horizontally. It is easiest to put the conformer in first by pulling the upper lid up, then tucking the conformer under the upper eyelid. Next, while still holding the conformer, pull the lower eyelid down and allow it to fall on top of the conformer. Trying to place the conformer in the eye socket without pulling the eyelids is very difficult.

  • This conformer must stay in for at least 2 months, after which a permanent ocular prosthesis can be made with the help of an ocularist. After this prosthesis is made, one should make a follow up visit to assess the fit and check the healing response to surgery.