Rare injury but lucky patient: Man's eye saved after impalement

Although rare, these are cases that involve many doctors of various fields to help in the care of the patient that suffer severe orbital injury: from neurosurgeons, maxillofacial surgeons, otolaryngologists, plastic surgeons to oculoplastic surgeons.   I saw similar cases, although not inolving shears, during my residency and fellowship training.  I had the opportunity to work at two very busy county hospitals: Santa Clara Valley Hospital during my training at Stanford University and at Bellevue County Hospital during my fellowship training at NYU.  We had cases of gun shots, pencils, forks, and even knives piercing the orbit and luckily leaving the eyeball free from injury.  However, there were also those cases where the eye was severely injured and had to be removed and replaced with an orbital implant and a prosthetic.  Read this CNN article below for more about this latest case from Arizona.

Man's eye saved after impalement

Revisional eyelid surgery: A case of upper lid ptosis and lower lid retraction

A common reason patients see me is for abnormal eyelid positions. The term revisional eyelid surgery refers to the correction of the eyelid position (either upper or lower lid) after having undergone prior eyelid surgery. A few of the more common reasons for eyelid malpositions are from prior blepharoplasty or eyelid reconstruction from trauma or removal of an eyelid skin cancer.

The eyelid is a series of aesthetic units that all together makes it an extremely challenging area to operate on. It is difficult to tell which patient is at risk for having an eyelid malposition prior to any surgery but in many cases, we as surgeons do our best in preventing such circumstances.

My goal in revisional eyelid surgery is to customize the management to each patient. Conservative therapy can often help in some symptoms, but ultimately, most patients will end up requiring some form of revisional eyelid surgery. There are various components to performing revisional eyelid surgery and it depends on each patient's clinical findings.

 I recently saw a patient that had undergone prior upper and lower blepharoplasty in the past (see below photograph). He complained of a droopy appearance to his upper lids (termed ptosis) and irritation in both eyes due to the retraction in his lower lids. Retraction of the lower lids is a result of a downward displacement of the lower lids either from prior surgery (cosmetic or trauma), thyroid related problem, or just as a result of aging changes. The retraction can be a direct result of the laxity (or looseness) of the lower lids, or secondary to the scarring changes that may occur after surgery, or a combination of both factors.   He also had ptosis in his upper lids which may have worsened with time. He wished to have his eyelids appear more natural appearing, see better, and improve his irritation.

Preoperative Diagnosis: Bilateral upper lid ptosis and lower lid retraction

The goal of my surgery was to help him see better by lifting his eyelids and also to correct the laxity and retraction he had in his lower lids. The retraction in his lower lids prevents him from closing his eyes at well so he has problems with excessive exposure to the eyes. This results in his irritation and redness to the eyes. As a result, he underwent bilateral upper lid ptosis surgery with no additional removal of eyelid skin though. He also underwent retraction repair to help lift up his lower lids to a more normal position by a canthoplasty. A canthoplasty is a type of a lower lid resuspension technique.

Postoperative Photograph, four weeks after underging bilateral upper lid ptosis surgery and lower lid retraction repair through a canthoplasty lid resuspension technique.

Surgeon: Christopher Zoumalan, MD. Oculoplastic Surgeon.

Location: Beverly Hills, California

Lip Augmentation using Juvederm

Lip augmentation is commonly performed on patients that wish to have a fuller upper and lower lip. Although various products can be used for lip augmentation,  augmentation can be achieved successfully using hyaluronic acid products such at Restylane or Juvederm. They produce an incredible result that patients are extremely happy with, well tolerated and safe, and reversible. This is one patient that wished for fuller upper and lower lips. She was an excellent candidate for lip augmentation using Juvederm Ultra Plus to the uppper and lower lip.

Pre Procedure photograph showing thin upper lip. Patient was seeking lip augmentation.

She received one syringe treatment of Juvederm Ultra Plus to augment her upper and lower lips to create a better ratio between the two lips. She was very pleased with the results and tolerated the procedure well. Topical numbing cream was applied before the procedure and anesthesia was mixed within the filler product as well for pain control. Depending on the patient tolerance, I may or may not add a dental block as well to better control the discomfort that some may have.

Hughes Flap: Eyelid reconstruction for large skin cancer of the lower eyelid

Oculoplastic surgeons like myself routinely perform the removal of an eyelid skin cancer and then the reconstruction of the eyelid defect. The most common eyelid skin cancer is basal cell carcinoma but other kinds also include squamous cell carcinoma. The first part of the procedure involves removing the skin cancer and the second part involves eyelid reconstruction. There are two options for the removal of the skin cancer: the first is to remove it directly in the operating room and wait for the pathologist to make sure the margins are clear. This can often take a lot of time so I usually work with a Dermatologist who is trained in Mohs surgery.  Fellowship-trainined Mohs surgeons are dermatologists who have received additional training in treating skin cancers. Once the Dermatologist sucessfully removes the eyelid skin cancer, I then see the patient (usually the same day or next day) to reconstruct the eyelid defect.  There are various techniques that can be employed in the repair of an eyelid defect, and it depends on various factors such as the size of the defect and the laxity of the skin.

If it is a small defect, often local tissue can be rearranged or brought together to repair the eyelid.  If it is a large defect like seen in the photo below, up to 80 percent of the lower lid is mssing along with the tear duct system.  In such instances, tissue from the upper lid is often needed to repair the defect through a procedure called a Hughes flap (aka tarsoconjunctival flap) named after one of the pioneers in Oculoplastic Surgery, Dr. Wendell Hughes. Tissue is taken from the upper lid as seen in this following photo and transfered in the lower lid. Unfortunately, the eyelid is sewn shut for at least one month until the flap takes place. A second surgery is then performed to "take down" the flap and allow for the eyelid to be reconstructed to a normal-appearing eyelid.

 

This photo shows a squamous cell carcinoma of the right lower lid that after its complete excision, was left with a defect that spanned the markings drawn on the photo.  The resection also involved her lower lid tear duct system.  This particular patient did very well after the first stage and went home the same day with little discomfort.

 

The patient underwent a a second stage surgery which was performed several weeks later to detach the flap and reconstruct both upper and lower lids to position them as close to their natural, presurgcial position as possible. She is cancer free, can see from that eye now, and has a good position and contour of her lower lid. Note that she has lost her eyelashes in the lower lid which occured once the tumor was removed in the primary excision. 

 

Ptosis surgery (Droopy eyelid surgery)

Ptosis is the medical term for droopy lids, which can occur in one or both lids. Children with ptosis are often born with it, whereas adults usually get ptosis as a result of aging, prior surgery, or even long term contact lens use. There are various different ways to repair a ptotic lid and it depends on the type of ptosis and the surgeon’s preference. I perform various types of ptosis procedures and each one is catered to the patient’s type and severity of ptosis.  The recovery from ptosis surgery is usually quite rapid, and patients find themselves returning back to work within a few days.

This patient below had a mild ptosis of her right upper eyelid. She had a tired appearance and was unable to see well without having to raise her eyelids manually.

Figure1. Preoperative photograph showing a right upper lid ptosis. Note that her right upper eyebrow is also raised in order to compensate and help raise her right droopy lid.

Figure 2. One month after undergoing a ptosis surgery in the right upper lid. Note the improvement in the lid height, eyebrow position, and the symmetry she has in both eyelids.

Face Transplants

Although I am not direclty involved in performing face transplants, I have been following the procedure's progress over the last several years.   Most recently, a group in Brigham and Woman's Hospital in Boston perfromed a full face transplant and the patient is now doing well and making good recovery. 

People that receive face transplants are those that have full facial burns or trauma which have left them severely disfigured.  They have to undergo a battery of medical and psychiatric tests to make sure they will be good candidates. The procedure itself involves a team of plastic surgeons who transplant the nerves, skin, and facial muscles of a donor onto the recipient.  The surgery takes many hours and involves the use of careful microsurgery.

Unfortunately in this particular case, the patient also lost his eyes from his injury which are not able to be transplanted. 

Read more in LA Times.

Beauty and Fashion Exhibit to Open in LA

This should be an interesting exhibit to check out.  It's the first of its kind--demonstrating beauty in all forms from modeling shoots to photos demonstrating lip and botox injections.  All of these subjects are examined in “Beauty Culture,” the first fashion- and beauty-themed exhibition to be held at the Annenberg Space for Photography in Los Angeles, the heartland of Hollywood goddesses and plastic surgery, which opens on May 21 and runs through Nov. 27.

Read more in NY Times.

An interesting surgery I performed today...

I performed an interesting case today on a patient with constant tearing and irritation in her eyes.  On examination, she has has very lax (or loose) lower lids which do not help in her ability to blink well and drain her tears effectively. You can see this by the rounding to her eyelids in the corner of each eye.  In addition she has small, stenotic openings to her tear drainage system.  The tiny openings you see along the eyelid (close to the nose) actually drain the tears from the ocular surface into the nose and mouth. In order to help her, I had to address both of her problems which were causing her to tear constantly. First, I performed a lower lid resuspension technique to allow for tighter and better positioned lower lids in order to help her blink more effectively. This is also called an ectropion repair.  Next, I attempted to dilate her stenotic tear drainage system to allow for better drainage by placing a baloon dilator to dilate the canaliculi.  My team and I recently published the use of this in a prior medical study (see below link).  Silicone tubes were then placed to intubate the tear drainage system and I will remove those in my office in several weeks. Overall, she tolerated everything well and was home the same day. 

 

See link to my prior blog on our study on canalicular stenois.

 

What are effective scar treatments???

This is a great article summarizing the challenges in scar treatment.  I actually find silicone sheets quite effective for some early scars.  In cases of hypertrophic healing (excessive scarring) or abnormally raised edges, carefully thought-out regimen of low dose steroid injections may be beneficial.  Care must be taken not to inject high doses of steroids around thin skin, such as the eyelids, though.  Laser resurfacing can also be helpful in selected cases.   Read more in LA Times!

Is a Well-Rested Doctor a Better Doctor?

Do better hours for medical students and residents result in better patient care? It's difficult to tell since no real well-controlled study has been published.

Work hour limits have improved the lifestyle of junior doctors, but decreasing their fatigue seems to have had little effect on how patients actually do. Read more in NY Times.

Recent publication out regarding the finding of a new but rare type of orbital tumor we discovered.

I was part of a team of New York Oculoplastic Surgeons who identified a rare type of orbital tumor (located next to the eyeball but within the orbit itself) and the clinical findings and treatment were described in this month's Ophthalmic Plastic and Reconstructive Surgery Journal.  "A rare variant of adenoid cystic carcinoma is the dedifferentiated sarcomatoid form, which has previously been reported in the hard and soft palate, maxillary sinus, submandibular glands, and nasal cavity. The authors report the first case of a dedifferentiated sarcomatoid adenoid cystic carcinoma occurring in the lacrimal gland, that of a 52-year-old man. The patient presented with a 4-month history of diplopia, decreased vision, and right upper eyelid swelling. Radiographic imaging showed a soft tissue mass in the extraconal compartment superolateral to the right eye. The patient subsequently underwent surgical debulking. Histologic examination of the tissue revealed classic cribiform adenoid cystic carcinoma and a sarcomatous component consisting of malignant spindle cells and fusiform cells arranged in whorls. Dedifferentiation is a well-established phenomenon in salivary gland tumors that is associated with aggressive behavior and poor prognosis; however, the exact nature of such dedifferentiated neoplasms remains unclear." 

See Abstract Text in Pubmed.gov.

It's not just females who had an increase in plastic surgery last year, but also men.

More and more men are seeing plastic surgeons for either non invasive procedures (such as Botox and subdermal fillers such as juvederm, restylane, fat injections) or surgical procedures such as blepharoplasties (eyelid lifts) and face lifts.   The baby boomers are now at the age of noticing their aging changes and want them addressed, male or female.  Believe it or not, up to 20% of my Facial Aesthetic practice is males in their 30's to 50s that come in for Botox and fillers (juvederm and restylane).  The most common reason I see males is for Botox to their forehead and eyelid crows feet wrinkles.  In general, males end up needing more Botox for a particular area than woman do.  But at the end of the day, the feedback is that the males enjoy looking "less-tired" at work and have less of the "frowning" appearance.  All of these surely equates to better performance at work!

Read more here

Learning to See the Strike Zone With One Eye

A very inspiring story of an college athelete who lost his eye from an injury while playing baseball.  Despite the thought that he would never play baseball again, he is and playing at the level if not better than before his injury. Read more in NY Times.

Orbital fractures are commonly seen in trauma

I am often involved in the repair of orbital fractures, which occur from trauma such as car accidents, falls, and assaults.  The orbit is a series of bones that comprise the wall (or socket) that contains the eyeball and other important contents that allow us to see and move our eye in all directions. Parts of the orbit are more prone for injury (such as the floor, which has a paper thin bone that can often break with force that usually doesn't break other bones in the rest of the body. Such fractures may need to repaired when they result in double vision, difficulty seeing, or deformity of the socket or eye.  The surgery involves exploration of the fracture and reparing it. I use various materials to repair the fracture depending on its size and patient factors. Implant materials range from titanium mesh, Medpor implants, and calvarial bone graft (bone graft taken from the calvarium or skull). 

Figure 1. CT scan showing a large orbit floor fracture

Figure 3.  Intraoperative photo taken showing the repair of the orbital fracture. In this case, the fracture was so large that a titanium mesh with bone graft was used to repair the fracture.

The arrow indicates the mesh being placed into the orbit.

Medical tourism--it's cheap but beware of the risks!

More and more Americans are going to Asia for cosmetic surgery, where surgical procedures such as rhinoplasty or Asian eyelid surgery are the cost of what they are here in the States. There are serious risks to having surgical procedures overseas--it's not so much the risk for the surgery but more so the complications that can occur when the patient returns back home.   Read more in the LA Times.

Selphyl Injections---the modern Vampire Face-Lift???

More and more physicians are offering Selphyl injections in their office to patients as an alternative to other fillers (such as as fat injections, Juvederm, Restylane, and Sculptra). It is a filler that is composed of your own blood cells after it is spun down using a centrifuge and reinjected into the face to help stimulate collagen.  It appears safe but the question is whether it is really effective for long term rejuvenation??? Studies are currently being conducted to evalute its long term effects. Read more in the NY Times.

Difficulty in treating canalicular stenosis---new study we published

We recently reviewed a new technique in addressing canalicular stenosis of the lacrimal system, which can result in tearing of the eyes.  There are various ways of treating such conditions, but we found this study worthy of publication in the Ophthalmic Plastic and Reconstructive Surgery Journal.

 

Tattoos as Permanent Makeup--Read the Fine Print

Although some people have found a benefit from permanent makeup due to hair loss from alopecia or burn injuries, it is important to be aware of the risks that are involved.

This is a great article put out by NY Times.

 

Ethnic issues being raised in Plastic Surgery such as Asian Eyelid Surgery

As the demand for perfection in plastic surgery continues to increase, plastic surgeons develop niche markets that tailor to cultural preferences and specific ideals of beauty. One of most sought-after procedure among Asians is “double-eyelid surgery,” which creates a crease in the eyelid that can make the eye look rounder as seen in the figure in this blog taken from a NY times article. This is one of the may types of eyelid surgery that I perform in my Oculoplastic practice.  It is important for patients that undergo such procedures to make sure their doctor is trained and an expert in that procedure.  Read more in NY Times.

Beauty Enhancement Day at Dr. Zoumalan's Office, Feb 22nd!!

We hope that you are having a wonderful start to the new year.  So...we are having our first event of the year on Tuesday February 22nd and would love to invite you! Here is what we have to offer:

1. Long and dashing eyelashes!!
With the purchase of 1 Latisse Box ($100), you will get a second one free!
 

 

2. The Youth Elixir--Botox and Fillers
With the purchase of one syringe of Juvederm for $550, which is already a $50 savings, you will get 20 units of Botox free!

And if you get a second syringe of Juvederm, you will get an additional 20 units of Botox free! So you can have up to three sites complementary treated after buying 2 syringes of fillers!!! 

 

3. Botox

If you decide not to get Latisse or Fillers, you still get a great discount on Botox at $10/unit. 

 

We are scheduling appointments for this event so please email us at askus@bheyelids.com so we can get you a time that works. If you haven't already, please visit Dr. Zoumalan at his website and sign up to follow up his blog at www.BHeyelids.com.  You will be updated with all his latest practice info!

Facial exercises to reduce wrinkles?

Although certainly ineresting and makes a jab at Botox, it's hard to make such claim without actually running a randomized clinical trial.   See more in the LA Times article.

Breast implants still plagued by safety concerns

The FDA is investigating an increased incidence of a rare type of breast cancer called anaplastic large-cell lymphoma, or ALCL, in women who have had breast implants. Although it is an incredibly low risk, women should be aware of the symptoms of ALCL, which include swelling, pain or lumps around the implants. Further studies will need to be done to evalute the risk factors for ALCL in breast implants. 

Read more in LA Times.

Orbital foreign bodies. Take it or leave it??

One of the surgeries I deal with is removal of foreign bodies within the orbit.  For example, this can happen from BB bullet or a shard of glass being lodged into in the orbit but miraculously sparing the eyeball. In certain cases such foreign bodies need to be removed.  The surgery needs to be carefully planned so as to protect the eye and the surrounding structures (such as the eye muscles, optic nerve, blood vessels, and other nerves).

One patient recently showed up with a BB bullet lodged under her eyeball. See the photos below.  It was causing double vision and swelling around her eye.  She underwent an orbital surgery to carefully remove the BB bullet.

 

CT scans showing the foreign body above the orbital floor and below the eyeball.

 

Intraoperative photo showing the BB bullet being retreived from the orbit after succesfull orbital exploration.

 

A couple of my colleagues and I published a paper on the management of orbital foreign bodies several years ago which shows an interesting working paradigm on their management. Click here to download the manuscript.   Open Reconstructive and Cosmetic Surgery, 2008, 1, 1-3