Ophthalmic Plastic and Reconstructive Surgery

Ophthalmic plastic and reconstructive surgery, also called Oculoplastic Surgery, includes a broad range of services both for medical conditions and aesthetic improvements. Surgery of the eyelids and eyebrows can improve vision in many patients, and improve aesthetic appearance. In addition, Oculoplastics includes medical and surgical treatment of problems involving the tear drain system, and tumors and trauma of the eyelids, face, and orbit. In addition, there are a number of eyelid and orbit conditions which may arise secondary to thyroid disease. Our Oculoplastics specialist, Dr. Kavanagh, has extensive training in the medical and surgical treatment of these conditions. She is board certified in Ophthalmology and fellowship trained by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

As we age, the skin around our eyes begins to sag leading to a tired appearance. Changes include drooping of the excess skin, bulging of the fat pockets, and atrophy of the tissues around the eyes. Similarly, the eyebrows may also droop as well (see Eyebrow Lift). These changes aesthetically alter the way we look by giving us a sad, tired, and aged appearance. If the changes are severe, they can also affect one’s vision by either blocking one’s peripheral vision or by causing difficulty wearing glasses (sagging lower eyelids). Surgery to correct the sagging and fullness of upper and lower eyelids is called Blepharoplasty.

Blepharoplasty is performed as an outpatient. The procedures is done using a local anesthetic. The eyelids are tightened, excess skin is removed, and if present, excess fat may also be removed or redistributed. Typically, bruising and swelling is experienced for the first one to three weeks, although the healing time varies for each person.

The position of one’s eyelids is important for vision and for aesthetic considerations. Sometimes, however, sagging of our eyebrows and forehead from the aging process contributes significantly to eyelid droop (the brow tissues droop into the eyelids.) Patients with significant eyebrow drooping can experience loss of vision and headaches or strain from having to raise their eyebrows using the muscles of their forehead to get the best vision possible. Surgical repositioning of the eyebrows is called Brow Lift.

Brow lifting procedures can improve vision, decrease strain, and improved aesthetic appearance. There are two distinct types of brow lifts. The first, called a Direct Brow Lift, removes the heaviness and excess tissues thereby leading to a tightening through an incision directly above the eyebrow hairs. This can be very effective in treatment of eyebrow droop. The second procedure, called an Endoscopic Brow Lift, uses hidden incisions behind the hair line to raise the forehead and eyebrows. Since the incisions are above the hairline in this procedure, an additional benefit is a lifting of the entire forehead thereby leading to a dramatic reduction in forehead wrinkles. Both types of procedures are performed as outpatient surgeries using local anesthesia. As with eyelid surgery above, the healing time varies from one person to the next, but typically, one can expect one to three weeks of swelling and bruising.

As we age, wrinkles and creases form on our forehead, and around our eyes and mouth. Many years of smiling, frowning, and squinting contribute to this process and the appearance of these unwanted lines. They include glabellar folds, ‘Crow’s feet lines’, forehead lines, and ‘lipstick lines’. Botox™ treatment for wrinkles has become the most common cosmetic procedure performed in the U.S. Treatment with Botox is effective at reducing these unwanted and unsightly lines, as well as preventing new ones from forming. Dr. Kavanagh is a co-author on a textbook chapter on the cosmetic use of Botox™ in Ophthalmology and Oculoplastics which teaches other physicians how to use this treatment.

Drooping or sagging of one’s eyelids and/or eyebrows, if severe, can dramatically impair one’s vision by blocking out part of one’s field of vision. Often times this process has developed slowly over time such that one may not even notice this to be the case, even though up to one half of one’s vision may be missing. This loss of peripheral vision can greatly affect one’s ability to perform daily activities, such as driving. An eyelid lift (blepharoplasty) can restore one’s vision if the problem is due to eyelid drooping. Sometimes, drooping of the eyebrows can be the primary problem thereby affecting the position of one’s eyelids. In these cases, raising the eyebrows with surgery can significantly improve vision. Often times these two conditions co-exist, thereby requiring a combination of the two procedures (performed at the same surgery) for maximum improvement. In any of these scenarios, the eyelid lift and/or eyebrow lift is considered a procedure for medical indications and is therefore covered by insurance companies and medicare. In order to establish whether this could be the case, a visual field test is performed in the office. See ‘Eyelid Lift’ and ‘Eyebrow Lift’ in the Cosmetic section for further details.

Eyelids can droop from age related skin and fat changes. However, sometimes the problem lies in weakening of the muscles which raise and lower the eyelids. Most often this is also due to aging, although in some cases, people may be born with this condition or it can develop from injury or neurologic conditions. Drooping eyelids due to weakened lifting muscle is called ‘Ptosis’. When your eyelids droop into your vision due to weakened eyelid muscles, many things may ensue. Patients may notice eye fatigue, loss of vision, and sometimes headaches (due to straining of one’s forehead muscles to raise the eyelids to see better).

Surgery to tighten the eyelid lifting muscle is done as an outpatient using a local anesthetic. The results from this procedure can be very dramatic as patients often notice a significant improvement in their symptoms and their vision.

The position of your eyelids is very important for the overall health of your eye. Ectropion is medical condition in which the lower eyelid turns outward which can cause the surface of the eye to be too exposed. This leads to irritation, redness, crusting, and discharge. This is also a common cause of watery eyes or excessive tearing. Ectropion is most often caused by age related changes, but injury, skin cancers, scars, paralysis, and birth defects can also lead to this condition. Entropion is a condition in which the lower eyelid turns inward. This also affects the health of the eye as the eyelashes can touch and rub against the surface of the eye itself. Common symptoms of entropion include redness, irritation, crusting, discharge, and a foreign body sensation.

Both ectropion and entropion can cause scarring of the eye and are a risk factor for eye infections. Severe cases can cause loss of vision. Both of these conditions are treated by a tightening procedure to reposition the lower eyelid and restore its natural relationship with the eye. An Oculoplastics specialist is best suited for this type of surgery due to his/her specialized training in both plastic reconstructive surgery and ophthalmology.

There are numerous types of lesions which can be found around the eyes on the forehead, eyebrows, eyelids, or midface. A majority of these lesions are benign (not harmful) but they can grow to become unsightly or even impair vision depending on their location. In addition, skin cancers (harmful due to risk of spread) can affect these same areas and commonly affects patients in different ethnic groups, especially those with significant sun exposure. When skin cancers affect the eyelids, they may cause loss of eyelashes, ulceration, bleeding, or change in the natural architecture of the eyelids. Dr. Kavanagh can evaluate lesions around the eyes and recommend whether the lesion could be followed with close watch or whether a biopsy and/or removal of the lesion would be best. In severe cases, this may require reconstruction of the eyelid. The eyelids are a unique place in the body to reconstruct due to their intricate structure, function, and relationship to the overall health of the eye.

Injury to the eyelids often requires repair and reconstruction performed by a physician trained in Ophthalmic plastic surgery due to the intricate structure of the eyelids as well as their importance functionally for the health of the eye. If left untreated or inadequately repaired, eyelid injuries can lead to scarring, poor function or drooping of the eyelids, poor position of the eyelashes, and irritation of the eye itself. Furthermore, injuries occasionally also affect the tear drain system due to its relationship with the eyelid. Reconstruction of the eyelid by a specialist trained in these areas offers the best chance of minimizing these adverse effects of the injury.

Watery eyes or excessive tearing is a common problem for which patients present to their ophthalmologist. This can be a very troublesome and inconvenient problem. There are a number of causes of excess tears which are very different in their nature and thus the treatment.

Ocular Surface Disease

For example, numerous conditions related to the health of the surface of the eye such as infection, inflammation, dryness, excess exposure, and scarring can lead to watery eyes.

Another common problem is that the aging process leads to an increase in the laxity of the eyelids. This eyelid laxity can lead to welling up of tears due to inefficient flow of the tears into the tear drain system. Eyelid laxity is treated similar to Ectropion (see above) with a procedure used to tighten the eyelids. Commonly along with the eyelid laxity, the opening to the tear drain system (called the punctum) is sometimes poorly positioned relative to the area of pooled tears. This is called Punctal ectropion and this condition is surgically treated in conjunction with an eyelid tightening surgery.

Another common cause of excessive tearing is blockage of the lacirmal (tear drain) system. In children, this is typically congenital and often resolves with conservative management comprised of massage and medical treatment alone. Occasionally further surgical intervention may be required. In adults, the blockage can be due to a number of causes including inflammation, infection, tumors, or injury. Furthermore, the blockage can occur at a number of different points along the tear drain system. If the blockage is located towards the end of the tear drain (the nasolacrimal duct), a surgery called a Dacryocystorhinostomy (‘DCR’) may be recommended. In this surgery, the point of blockage is bypassed by creation of a new channel for tears to flow from the tear drain into the nose. A small silicone stent is placed in the tear drain system which is later removed.

Thyroid eye disease is a common problem in patients who have an underlying thyroid condition, both hypothyroidism as well as hyperthyroidism. The eye part of the condition is an autoimmune process where the body sees areas around your eyes as being ‘foreign’ and therefore attacks the tissues. More specifically, the muscles and soft tissues around the eyes becomes inflamed and infiltrated. This has many affects on the eyes an eyelids including problems with eye movements, double vision, exposure problems, dryness, a bulging appearance of the eyes (called Exophthalmos), improper position of the eyelids (called Eyelid Retraction), and in some cases, compression of the optic nerve leading to vision loss. Given all of these difficulties, thyroid disease is a chronic disease process which requires regular care and attention. These patients are best taken care of by a combination of physicians including a primary care provider, an endocrinologist, an ophthalmologist, and an oculoplastics specialist. Patients with thyroid eye disease often benefit from surgery to reposition their eye muscles and/or eyelids. In severe cases where their eyesight is at risk, a combination of steroid treatments, radiation, and surgery called orbital decompression may be necessary to preserve vision. Orbital decompression creates more space in the orbit and helps to place the eye back into its natural position which can significantly improve the appearance, can improve the health of the eye if exposure related problems are present, and can preserve vision. This type of surgery typically requires overnight stay in the hospital.

Tumors can occur around or behind the eye in the orbit. The orbit is a small space with crucial elements for vision and eye function, including the optic nerve and eye muscles. Tumors can be longstanding and benign or they can present with rapid growth with the potential for malignant spread. Furthermore, tumors of the orbit may originate in this location, or they can result from spread of cancer from other parts of the body. Orbital tumors typically present as a patient or their family may notice asymmetry in their appearance with one eye seeming to bulge forward which is called proptosis. Sometimes orbital tumors can lead to double vision, pain, or in severe cases, loss of vision due to compression of the optic nerve. Some orbital tumors can be followed over time for any changes, but some tumors may need to be biopsied and removed with surgery. Depending on the tumor type, co-management with an oncologist is sometimes recommended. If surgery is recommended, due to the orbit’s proximity to the sinuses and the brain, occasionally a patient with an orbital tumor will need to also be evaluated and treated by an ENT specialist or a neurosurgeon, and a team approach may be most appropriate for removal of the tumor.

Injury to the orbit can occur in the setting of blunt injury, sports injuries, or motor vehicle accidents. Orbital fractures present a unique challenge due to their proximity to the eye. An Oculoplastics specialist is best suited for evaluation of such injuries. Approximately half of orbital fractures may not require surgical repair. However, in some cases, repair of the fractures is indicated to restore the natural positioning, function, movement of the eye. Similar to orbital tumors, due to the orbit’s proximity to other structures including the sinuses, midface region, the mandible, and the brain, other surgeons (such as an ENT specialist, a neurosurgeon, an oral maxillofacial plastic surgeon, or a general plastics surgeon) may be involved and a team approach to repair may be recommended.

Our primary goal as Ophthalmologists is to preserve and restore our patients’ vision. However, in occasional cases, this may not be possible. Furthermore, removal of the eye is sometimes warranted in cases of severe injury, disease, trauma, or infection. To have an eye removed is a significant event which requires a knowledgeable and supportive team. Fortunately, due to modern day advances, prosthetic eyes look very realistic and are easy to use. Many patients who have undergone this type of procedure are pleasantly surprised at how difficult it may be to tell that they are wearing a prosthesis once the proper healing has occurred. Because of the unique nature of this condition, a patient who has had an eye removed requires routine care involving an Oculoplastics specialist to follow for any problems that can develop such as poor fit of the prosthesis, problems with the implant, infection, and drooping of the eyelids.

A number of conditions which can be present at birth involve the eyelids, the lacrimal system, and/or the orbit. Examples of this include congenital tumors, ptosis, nasolacrimal duct obstruction, eyelid and orbital malformations, microphthalmos, anophthalmos, and craniofacial anomalies. Some of these conditions are treatable with surgery and can improve a patient’s activities of daily living, aesthetic appearance, or quality of life. Several of these conditions may be part of underlying syndromes involving multiple organ systems. In these cases, a team approach with other specialists may be recommended.