Final verdict: Did she have Surgery or Fillers?

This particular patien below came to see me for the bags underneath her lids.  On exam, she has herniated lower lid fat pads which are resulting in her tired apperance. Prior to the advent of eyelid filler treatments, she would traditionally have required blepharoplasty surgery to rejuvenate her lower lids.  But we now know that two things occur with the eyelid aging process:

1) herniation of lower lid fat pockets (bags under lids)

2) and loss of volume below the fat pads resulting in tear trough hollowing (deformity) and in the midface area (which is the area between the eyelid and the nostrils)

In her case, we planned to first address the loss of volume (#2 above) in her tear troughs and midface area using hyaluronic acid fillers (ie Restylane and Juvederm).  This was done in a stepwise fashion such that a further filler augmentation was performed two weeks after her first procedure.  I don't like to place too much product at one setting; I rather reassess after two weeks to make sure the patient tolerates the filler material well.  

 

Pre treatment photos show herniated lower lid fat pads (bags under lids). But she also has hollowing of her lower rim and loss of midface volume, both of which worsen her lower lid appearance. 

Post filler treatment using hyaluronic acid fillers (ie Restylane and Juvederm) shows a dramatic improvement in her lower lid appearance. Although the fat pockets are still present, re-establishing her "normal" lower lid and midface volume allowed for the fat pockets to be less visible.  

Pre treatment side view shows the extent of the tear trough deformity (hollowing) and midface volume loss. 

Post treatment side view shows the improvement. 

So the answer is that this patient ONLY underwent filler injections to her lower orbital rim and midface volume and did NOT have surgery.

Natural appearing lip augmentation

Most of my patients that see me for lip augmentation really just wish for fuller lips that still appear natural.  I avoid the over-filled apperance and respect the natural appearance of a "normal lip" where the upper lip is slightly smaller (up to 33%) than the lower lip.  

I like to use the micro-cannula for my lip augmentation procedures. The patients do not require a dental block; topical anesthesia cream by itself is usually adequate for pain control.  In my experience, the patient's tolerate the procedure so much better than traditional needle injections and have much less incidence of bruising after the procedure.  

Pre injection photos show slightly reduced volume in the upper lip in comparison to the lower lip.

Post injection shows improvement in upper lip volume, a slightly more prominent vermillion border (where the skin meets the lip), and minimal increase in lower lip volume as well in order to preserve the ratio of volume between the upper and lower lip. 

Achieving symmetry in blepharoplasty surgery

Facial asymmetry is seen in almost everyone, especially around the eyelids. For example, one brow may be slightly elevated more than the other side or one eyelid may have more "excess skin" than the other side.  Aging is an evolving process that often accentuates the asymmetries we see in people. I often see people who wish to have upper lid blepharoplasty to remove the excess skin which may be overhanging onto their lashes.The excess skin results in not only a tired appearance, but also can result in difficulty seeing well in their far peripheral vision.  For example, this particular patient below has "excess skin" weighing down on his rigth upper lid resulting in difficulty seeing and lid asymmetry.  The goal was to perform an upper lid blepharoplasty surgery to help achieve better symmetry between the two lids and to allow the patient to see better

See the full gallery on Posterous

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You can see the improvment in symmetry once the right upper lid underwent skin-only blepharoplasty.  

 

 

Using fillers to correct lower lid tear trough hollows or "lower lid bags"

Tear trough deformity is seen in people of all ages.  They can be seen forming in as early as patients in their 20s and upwards. With age, the lower eyelid "trough" or hollow tends to become deeper and people commonly complain of a tired look.  

Patients commonly describe these hollows as "eyelid bags, puffy eyes, and eye bags." Interestingly enough, until recently, surgery used to be the only method for correcting tear trough deformity. As we now understand eyelid anatomy and the aging process better, we realize that the tear trough deformity mainly occurs due to a loss of volume in the midface which results in a hollowed-out appearance of the lower lid.  In order to best treat this volume loss and the tear trough deformity, Dr. Zoumalan uses advanced techniques with or without combination of surgery to rejuvenate this area of the face and to restore a more youthful, natural looking appearance. When performed in the office without surgery, Dr. Zoumalan uses hyaluronic acid filler injections (ie Juvederm and Restylane) to volumize the tear trough and the midface area.  

Picture above. The area of the tear trough deformity is located above the black arrow. It results in a shadow effect which actually worsens the appearance of the hollowing. 

Pre-injection photo above. In order to address this deformity, in office hyaluronic acid fillers were injected using a micro-canula technique.  Note the hollowing (tear trough deformity) with some early los of volume in her midface.   

Photo above: After filler treatment to the eyelid and midface. This photo was taken several weeks after the procedure. The procedure took approximately 45 minutes and was all done in the office using only local anesthesia with no sedation. The patient went home and had little swelling and minimal bruising.    

The tear trough deformity (orbital rim hollowing) has been corrected and midface volume has also been naturally augmented. This particular patient had hyaluronic acid (HA) filler injections consisting of Restylane and Juvederm. Note that this patient did not undergo any sort of eyelid surgery. 

Read our new publication in Plastic and Reconstructive Surgery (PRS) Journal

Little is known about surgical adhesives and their antimicrobial role.  We assembled a team of plastic surgeons and microbiologists to investigate the role of Mastisol and compound tincture of benzoin, both very commonly used adhesives in surgery, in fighting infections. In summary, we show that compound tincture of benzoin and Mastisol manifest antibacterial activity against surgical-site infection-related pathogens, including methicillin-resistant S. aureus. (MRSA). 

Antibacterial Analysis of Surgical Adhesives.

Joseph JM, Voldman A, Zoumalan CI, Lisman RD, Iovine NM.

Plast Reconstr Surg. 2012 Feb;129(2):402e-404e. 

 

 

Case presentation: Ptosis Surgery (Droopy Eyelid Surgery)

This patient was unhappy about her droopy left upper lid. She was a long-time contact lens user, which has been associated with ptosis in younger patients.  She was unhappy about not only her appearance but also was having difficulty seeing well with her peripheral vision.  She underwent ptosis repair to help improve her appearance and also see better.  The surgery takes no more than 20-40 minutes and can be performed using mild intravenous sedation.  There is minimal downtime with this particular type of ptosis surgery as well.  

Figure above shows a ptotic, droopy left upper lid. 

This photo was taken 6 weeks after undergoing posterior-approach ptosis repair surgery. Note the improvement in symmetry and lid height.

Read more about ptosis surgery at Dr. Zoumalan's website:

Ptosis surgery--Dr. Zoumalan

Upper lid blepharoplasty

Upper lid blepharoplasty surgery is a very gratifying surgery for patients.  Dr. Zoumalan is one of a handful of surgeons that exclusively specializes in upper and lower eyelid blepharoplasty surgery. Blepharoplasty is an eyelid surgery which involves the removal of excess skin and fat pockets in the upper and lower eyelids. In the upper eyelids, excess skin can result in a tired appearance to some, while in others, it can actually result in difficulty seeing in the top gaze of your vision (also referred to as limitations in super visual field). 

This particular patient had excess skin blocking her visual fields and resulting in a tired appearance (termed dermatochalasia). She has mild droopy lids (ptosis) as well in addition to a mild left brow ptosis. She underwent bilateral upper lid blepharoplasty, mild ptosis repair, and a left-sided brow lift. 

Preoperative photo of left upper lid dermatochalasia (extra skin), mild lid ptosis, and left brow ptosis. Note the slight asymmetry of the left upper brow resulting in mild asymmetry.

 

Post op photo taken 4 months after surgery showing an improved upper lid and brow contour, appearance, and symmetry.  

Read more about upper lid blepharoplasty surgery on Dr. Zoumalan's website at:

Upper lid blepharoplasty surgery---Dr. Zoumalan

Case presentation: Lower lid ectropion

Lower lid ectropions can result in a droopy lower lid, resulting in an outward positioned eyelid. This not only changes the appearance of the lid but also results in ocular irritation, red eyes, and often tearing.  The eyelids need to be in a normal position to allow for good tear production and drainage and to allow the eyelids to close properly during each blink. When the lids are malpositioned, they can be very irritating to the eye and result in tearing, pain, and even infections. The lower lid positions can change with age, trauma, sun damage, or prior surgery. They can either be turned out (referred to as an ectropion), turned in (referred to as an entropion) or can be retracted or notched.

This patient below had bilateral lower lid ectropions resulting in tearing.

She underwent lower lid ectropion repair and is now doing well and has an improved appearance to her lower lids and also able to blink well with resolution of her tearing symptoms.

New publication about the latest techniques in orbital decompression surgery

My colleagues and I discuss our latest orbital decompression techniques in this recent article that was published in the Operative Techniques in Otolaryngology Head and Neck Surgery Journal. Orbital decompression is type of orbital (eye socket) surgery that restores the normal volume in the eye socket so that the eyeball can rest in a more appropriate position.  One of the most common reasons we perform orbital decompression is in patients who have thyroid-related eye problems.  This article discusses the various ways we go about in performing orbital decompression. 

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.