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.