Surgery of the Eyelids, Lacrimal System and Orbit
Ophthalmic, plastic and reconstructive surgery is a specialized area of ophthalmology which deals with the management of deformities and abnormalities of the eyelids, lacrimal (tear) system, orbit (the bony cavity around the eye) and the adjacent face. An ophthalmic, plastic and reconstructive surgeon is an ophthalmologist (medical doctor and eye surgeon) who has completed additional training in plastic surgery and also provides any care that the patients eyes may need.
The eyelids are extremely complex and delicate structures which are vital to the preservation of sight. The eyelids protect the eye and spread tears across the surface of the eye. The position and contours of the eyelids are an important feature of a normal facial appearance. Abnormalities in the eyelids position, function and appearance can result from a variety of causes, including birth defects, aging, tumors, injury or medical diseases, such as thyroid disorders. Depending on the cause of the eyelid abnormality and the purpose of the surgical repair, eyelid operations may be either reconstructive (functional) or cosmetic (appearance only). Almost all eye surgery is done under local anesthesia as outpatient surgery. As a general rule, insurance companies will cover part of the cost of functional eyelid surgery but not cosmetic surgery.
Baggy eyelids usually develop as a result of hereditary tendencies and aging. Allergies and smoking may accelerate the aging of the eyelids and cause the bags to appear at a relatively young age. Bags under the eyelids are composed of loose skin and muscle, bulging fat and, sometimes, fluid. Blepharoplasty is the operation performed to correct these deformities. The surgery may be either reconstructive or cosmetic, depending on the severity of the problem and upon whether vision is impaired by the eyelid or extra skin drooping in the vision. The surgery is performed by making an incision in the eyelid crease and removing extra skin. Upper eyelid fat pads can be trimmed at the same time through this incision. Lower eyelid blepharoplasty can also be performed by making an incision just below the eye lashes so that it doesnt show. Extra fat and skin is removed. In patients without a great deal of extra skin, the fat pads (bags) can be removed through the inside of the eyelid, i.e., the conjunctiva. This can be combined with removal of the wrinkles using the carbon dioxide laser. The carbon dioxide laser is used as a precise cutting instrument for incision in the upper eyelid blepharoplasty and transconjunctival, lower eyelid intraoperative hemostasis, reducing operating time with less postoperative swelling and ecchymosis (redness). The wrinkles on the lower eyelids and crows feet areas can also be removed using the carbon dioxide laser.
Recent advances in the carbon dioxide laser technology have produced lasers that can precisely remove thin layers of skin with minimal thermal damage to the surrounding tissue. Carbon dioxide laser energy can be administered either as a rapid, short pulse or as a rapidly scanning focus beam. The sharp pulses of intense energy remove the epidermis and dermis while being fast enough to limit heat damage to the underlying skin. This laser and tissue interaction is based on the theory of selective photothermolysis which specifies that thermal tissue damage can be minimized with pulse duration of laser beam that is shorter than the target tissue thermal relaxation time. I.e., the laser works so fast that there is no time for the heat to be transferred to surrounding tissues which can damage them. The carbon dioxide laser has been used to treat numerous disorders including superficial skin cancers, rhytids (wrinkles), acne scars and warts. Current interest centers around skin resurfacing and eyelid rejuvenation. The early results suggest that the laser may be an effective alternative to dermabrasion and to chemical peels. Dermabrasion is associated with blood exposure and its risks. With chemical peels, it can be difficult to judge the depth of the peel and therefore, is riskier. The laser is used to efface various mild to moderate facial rhytids, forehead furrows, peri-orbital creases, peri-oral rhytids and facial rhytids. Reported complications of the carbon dioxide laser include persistent erythema (redness), hyperpigmentation, hypopigmentation, herpes simplex, contact dermatitis, scarring and ectropion (eyelid turning out).
As all facial structures may sag and droop with age, so may the brows. Drooping brows (brow ptosis) may be so severe that they rest on the eyelids and prevent them from opening fully. An eyebrow lift (brow ptosis surgery) is surgery that positions the brow back to a normal location. This is frequently performed in conjunction with a blepharoplasty and may be considered either reconstructive or cosmetic surgery. There are many different ways to elevate the eyebrows.
Direct browplasty remains a popular choice for correction of eyebrow ptosis. This involves directly removing tissue from the forehead area with the inferior portion of the incision being based on the superior row of brow hairs or on a brow furrow to hide the incision. The desired contour of the eyebrow can be directly marked on the forehead and effectively achieved. A significant disadvantage is related primarily to the contour of the reconstructed eyebrow and the noticeable incision scar above the eyebrow. A coronal eyebrow/forehead lift involves placing the incision within the scalp hair and undermining the forehead to raise the eyebrows. This approach elevates the eyebrow to its normal position and simultaneously rejuvenates the forehead and glabellar (region between the eyebrows) region. Endoscopic eyebrow lift techniques involve placing several small incisions through which the forehead, eyebrows and glabellar regions can be elevated. The eyebrow is secured to its new position with screws and staples.
Droopy eyelids (eyelids ptosis) occur when the edge of the upper eyelid, that contains the lashes, falls too low. When the edge of the eyelid falls and covers part of the pupil, it blocks the upper part of the vision. In severe cases, it is necessary to tilt the head back or lift the eyelid with a finger in order to see out from under the drooping eyelid. A droopy eyelid can occur as a congenital defect in which the muscle that lifts the eyelid fails to develop properly. A rigid contact lens wearer can experience eyelid lifting muscle stretching, resulting in ptosis. In most cases, a drooping upper eyelid results from aging of previously normal structures. Typically, the tendon that attaches the lifting muscle of the eyelid stretches and the eyelid falls too low. Since the muscle that lifts the eyelid has normal strength, surgical correction of a drooping upper eyelid which was once normal, involves repair of the stretched tendon. It is not uncommon for one to develop a droopy upper eyelid following cataract surgery. Cataract surgery is apparently the "last straw" that causes a weak tendon to finally stop working.
Drooping eyelids are corrected through a blepharoplasty (eyelid crease) incision. At the same time, the tendon and muscle are strengthened to raise the eyelid, extra skin may be removed to give a better appearance and also to improve function if there is a great deal of extra tissue. The eyes are not patched after surgery.
EYELIDS THAT OPEN TOO WIDELY
Eyelids that open too widely (eyelid retraction) produce a wide stare and may result in drying of the eye. A variety of problems can cause eyelid retraction, but the most common is thyroid eye disease. An eyelid crease incision is made in the upper eyelid just as in eyelid ptosis surgery. However, instead of tightening the eyelid muscle or tendon, these are relaxed to allow the eyelid to return to a normal position. Similarly, for the lower eyelid, the tendon that pulls the eyelid down is stretched and a spacer of tissue is placed in this to raise the eyelid up to give a more normal appearance. By narrowing the distance between the two eyelids, the eye becomes more normal in appearance and also functions better with less of a "dry eye" feeling.
Lagophthalmos is a common problem associated with facial nerve palsy (Bells palsy). This can result in exposure and drying of the cornea secondary to poor eyelid closure. Implantation of a gold weight on the epitarsal surface (underneath the skin) of the upper eyelids is an effective technique to promote eyelid closure. The gold weights are fabricated from pure gold and are available in weights ranging from 0.6 g. to 1.6 g. Associated with Bells palsy also is turning outward of the lower eyelid and this can usually be corrected at the same time. Because the brow is also affected with Bells palsy, sometimes a browplasty is also required.
EYELIDS THAT TURN OUTWARD (ECTROPION)
When the lower eyelid turns outward and no longer touches the eye (ectropion), it cannot properly spread the tear film out. The exposed inner lining of the eyelid becomes dry and inflamed. Tearing often occurs because the tear duct on the lower eyelid towards the nose is turned out and is not up against the eye to effectively drain the tears from the eye. Tearing surgery is usually indicated to restore the eyelid to a normal position. Most often, this involves a small incision of the lateral corner of the eye to tighten the eyelid to put it in a more normal position enabling the tears to drain and prevent exposure to the inner eyelid.
EYELIDS THAT TURN INWARD (ENTROPION)
When the skin of the eyelid and lashes constantly rub on the eye, eye irritation and discomfort usually result. An eye so irritated is at risk for developing severe infection and scarring that may result in permanent visual loss. Surgical correction of an entropion is recommended and is very similar to the ectropion repair (trichiasis is similar to entropion with inturning of the eyelashes, however only a few eyelashes are turned in.) This can be associated with chronic inflammation (blepharitis) of the eyelids or other infections. The eyelashes can be epilated with forceps or the eye follicles can be destroyed with laser or cryotherapy (freezing).
Scars of the eyelid and face can often be made less objectionable through surgery. This involves simply a revision of the scar or more complicated surgery. Scars may affect the eyelashes, which then rub on the eye. Sometimes if there is a shortage of tissue on the inside of the eyelids (conjunctiva), a conjunctival graft or mucous membrane graft from the inside of the cheek may be required to relieve the scarring and put the eyelid in more normal position. Normally, a shortage of skin on the upper or lower eyelid can cause the eyelashes to turn out and the eyelids to not close well, resulting in discomfort and eyelid deformity. These situations may require a skin graft.
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