Archive for March, 2010
Oculoplastic surgery is a sub discipline of Facial Plastic and Reconstructive Surgery and is performed by Facial Plastic Surgeons as well as Ophthalmologists who sub specialize in eyelid surgery. There are two components to oculoplastic surgery: cosmetic and reconstructive surgery. Blepharoplasty, ptosis repair, and ectropion repair can be performed for both cosmetic and functional, reconstructive reasons. If they are performed for eye dysfunctions such as obstructed vision, excessive tearing, or eye protection, they are considered reconstructive procedures and if they are performed specifically for aesthetic reasons they are considered cosmetic. Repair of the eyelids from cancer removal or trauma is always considered reconstructive surgery.
Blepharoplasty of the upper eyelid always includes removal of excess skin and muscle and usually removal of excess protruding fat from around the eye. The most optimal incision uses an extended incision compared to a more traditional blepharoplasty incision and is carried over the outer orbital rim to correct excessive lateral hooding because the outer eyelid and brow complex age more rapidly than the central eyelid and brow. When the brow is in low position a brow lift procedure is necessary prior to correction of the eyelid to avoid problems. Lower eyelid blepharoplasty is less straight forward with several techniques employed by many surgeons. The most state of the art technique involves a small imperceptible incision just under the lower eyelash line with conservation of the bulging fat to move it into the tear trough in order to create a smooth, youthful, seamless transition between the lower eyelid and cheek with removal of excess muscle and skin. Removal of lower eyelid fat can create a hollowed effect with an abrupt, unnatural transition between the lower eyelid and cheek.
Ptosis repair involves two primary techniques. The first uses an incision in the upper eyelid to tighten the Levator muscle/tendon complex by removing a portion of the tendon, advancing the tendon and reattaching it closer to the eyelid margin, or plicating the redundant tissue. The second method is performed on the inside to the eyelid and involves removing a portion of Mueller’s muscle elevate the eyelid. Sometimes skin may need to be removed during the ptosis repair depending on the amount the eyelid margin needs to be raised and excess skin that is present. Less frequently, a brow lift may need to be added to the procedure if the brow is in a low position.
Ectropion repair is performed for excessive laxity in the lower eyelid and is performed in two ways: a canthopexy and canthoplasty. A canthopexy is simply repositioning or tightening the eyelid tendon and a canthoplasty involves making a skin incision and removing excess skin and shortening the horizontal distance of the eye. The need for a canthoplasty over a canthopexy is based on the distance the eyelid moves from the eyeball or globe and is commonly performed for excess laxity associated with facial paralysis and age related involutional ectropion otherwise canthopexy procedures are desirable for less severe laxity issues because they don’t shorten the horizontal length of the eye resulting in a more unnatural appearance.
Eyelid reconstruction from Mohs skin cancer surgery or trauma involves evaluating the amount of remaining functional eyelid remaining for full thickness defects. If less than a third of the eyelid is missing then a primary wedge resection repair is indicated because there is enough built in redundancy to the eyelid and relaxation following surgery to achieve an excellent outcome. If there is approximately fifty percent to two thirds of the eyelid missing a tenzel rotation advancement flap is used with a release of the eyelid tendon to gain enough tissue and movement on the remaining eyelid to advance the two edges together and achieve a cosmetically excellent outcome. For near total eyelid defects, pedicled Hughes flaps can be used to replace the entire lower eyelid with transposition flaps to repair subtotal defects of the upper eyelid.
Oculoplastic cosmetic and reconstructive surgery is performed by all Facial Plastic Surgeons as well as Ophthalmologists with specific training. It requires a detailed knowledge of eyelid anatomy and function as well as plastic surgery reconstructive principles to achieve excellent outcomes. Understanding the type of training and knowledge base of your surgeon is critical to avoiding bad outcomes and achieving desirable results.
Post provided by Benjamin C. Stong, MD