Ophthalmic Plastic and Reconstructive Surgery

What is Ophthalmic Plastic and Reconstructive Surgery?

Physicians with combined training in ophthalmic plastic surgery and ophthalmology have unique abilities to perform a host of delicate procedures around the eyes while taking advantage of opportunities to cosmetically enhance a patient's appearance. This skill set complements the expertise of every ophthalmic sub-specialist and makes an important contribution to the services of practitioners in other medical disciplines.

Cosmetic surgery is generally perceived as a "beautification" procedure rather than as the repair of a physical flaw. Most of the work Bascom Palmer's ophthalmic plastic and reconstructive surgeons perform strikes a balance between surgical science and facial appearance. They apply their knowledge of ophthalmology, anatomy and tissue behavior, as well as an awareness of existing limitations, with the wisdom to know what to do and why.

Some of the more common problems treated surgically include droopy brows, droopy lids, redundant upper and lower eyelid skins, furrows on the forehead and around the eyes, and congenital disfigurements.

As members of Jackson Memorial Hospital's Ryder Trauma Center, much of the team's practice involves eyelid repair and tissue replacement in cases related to facial burns, domestic violence, auto accidents, gunshot wounds, lacerations, and bite wounds.

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What are the different types of aesthetic and ophthalmic plastic surgeries?

Bascom Palmer's ophthalmic plastic and reconstructive surgeons repair many problems that interfere with the normal function of the eyes. These surgeries are referred to as "functional," because they are necessary to restore the normal protective function of the eyelids and restore a full field of vision. However, some patients elect to have similar procedures, known as cosmetic surgeries, performed to enhance appearance and sense of well-being. In most cases, elective cosmetic procedures are performed on an out-patient basis. Click here for greater details, including information on surgical and non-surgical cosmetic enhancements.

Ptosis pronounced "tosis") is the medical term for drooping of the upper eyelid, a condition that may affect one or both upper eyelids. When the level of the upper lid margin falls, it can interfere with the upper field of vision. Symptoms include a decreased ability to keep the eyes open, eyestrain, and eyebrow fatigue from the increased effort needed to raise the eyelids.

The out-patient surgery for ptosis is performed under local anesthesia, so there is no need for an overnight stay. Sutures remain in the eyelids approximately one week, and recovery time is about two weeks.

Upper and lower eyelid blepharoplasty, ectropion, and entropion repairs are other out-patient surgeries with similar recovery times.

Upper eyelid blepharoplasty (eye lift) reduces excess skin and fat in the upper eyelids. This overlapping skin often interferes with normal vision and has to be corrected to regain a functional visual field. During the out-patient procedure, the physician marks the incision sites (one incision on each eyelid), following the contour of the eyelid crease. Excess skin and fat is then removed, and the incision is closed with fine sutures. Typically, the incision is barely visible and fades over time. The physician often recommends blepharoplasty if a significant improvement in the visual field can be achieved.

Lower eyelid blepharoplasty reduces excess fat and skin in the lower eyelids. The surgeon makes incisions (either inside or outside the lower lid) and excess fat is removed. Incisions made inside the eyelid are not visible; incisions outside the eye are barely visible and generally fade.

Ectropion is the sagging and turning outward of the lower eyelid margin and lashes. An uncomfortable foreign body sensation results and can lead to tearing and eye irritation. Most cases of ectropion are due to age-related relaxation of the eyelid tissues.

Entropion is a condition where the eyelid margin turns inward. It often results from muscle spasm in the lid or from trauma-related scarring. The lower lashes rub against the eye, causing irritation, scratchiness, tearing, and redness. Typically, surgery is recommended to correct the problem.

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What about Botox treatments?

Botox treatments are non-surgical procedures used to reduce or soften the deep lines around the eyes or forehead. The procedure is performed easily and safely with a few injections of very low doses of Botox that relax the muscles that cause the deep lines to form. Botox, a purified, diluted form of botulinum toxin type A, is a protein produced by the Clostridium botulinum bacterium.

How does Botox work?

Normally, the brain sends electrochemical messages to the body's muscles to make them move. These messages are transmitted from a nerve to the muscle by a substance called acetylcholine. Botox works by blocking acetylcholine to the facial muscles responsible for the development of dynamic lines. Following a Botox injection, the muscles gradually become relaxed allowing the overlying skin to appear smooth and unwrinkled.

Why should I go to an ophthalmologist for Botox treatments?

No one knows eyelid and eye anatomy better than an ophthalmologist. Ophthalmologists have a unique understanding of the eyelids, brows and orbit, which most other physicians using Botox do not have. Knowledge of the orbital muscles is key to good results when using Botox around the eyes.

Ophthalmologists and ocuplastic subspecialists have been using Botox for blepharospasm (involuntary spasms of the eyelids), strabismus (crossed eyes), and hemi-facial spasm since 1989. Following treatments, ophthalmologists noted that forehead and eyebrow lines were lessening in appearance in those patients receiving Botox. This led to further research, which confirmed the effectiveness and safety of the Botox vaccine for use in improving wrinkles due to overactive muscles of the face. In Spring 2002, the Food and Drug Administration approved the use of Botox "to temporarily improve the appearance of moderate to severe frown lines between the eyebrows."

What can I expect during a Botox treatment?

Your ophthalmologist will determine exactly where to administer the tiny injections in order to achieve the best results. No sedation or anesthesia is required, and there is no special recovery period necessary. The entire procedure takes approximately ten minutes. Discomfort is minimal and brief, mild bruising may occur at injection sites, but they may be easily covered with makeup. The result of the injection usually becomes apparent within 2 to 4 days. The effect of a Botox injection generally lasts four to six months.

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What ophthalmic diseases and disorders involve plastic and reconstructive surgery?

Graves' Ophthalmopathy is a thyroid-related disorder that causes inflammation of the eye muscles, which enlarge within the eye socket. As a result, the eyes bulge and/or stare; the eyelids retract and often cannot close; and the eye's surface dries and becomes uncomfortable. The swollen muscles can exert pressure on the optic nerve and threaten vision loss, the most serious consequence of Graves' disease.

Graves' disease demands a multispecialty approach, often involving strabismus, oculoplastic and reconstruction expertise, as well as the skills of a neuro-ophthalmologist, a radiation expert, and an endocrinologist.

When other medical therapies fail to reduce muscle swelling, special procedures can:

• relieve pressure on the optic nerve by removing the part of the bony wall and floor of the eye's socket, creating additional space for swollen muscles
  
• reconstruct the eyelids to protect the cornea and cosmetically improve the patient's appearance. This involves dropping the upper eyelids and raising the lower eyelids (by adding tissue taken from the roof of the mouth --- a hard palate graft), and placing them at a cosmetically appropriate level.

Bascom Palmer physicians also help preserve vision by assisting neuro-ophthalmologists diagnose and treat patients who are losing vision in both eyes due to increased intracranial pressure. In such cases, they perform an optic nerve sheath "fenestration," creating a "window" in the lining of the nerve, which releases built-up pressure.

Plastic and reconstructive surgery offers other important therapies for specialists treating patients with complicated glaucoma. Filtering surgery, for example, reduces pressure within the eye, but usually creates a "bleb" (blister) on the eye's surface. If this bleb is exposed, the eye is at risk of serious infection. If the bleb is large, it can affect the eyelid's function. In either case, surgical adjustment of the eyelid allows it to function well and protects the bleb --- without affecting the pressure control benefit of filtering surgery itself.

In cases of end-stage glaucoma, or old trauma, there can be complete loss of sight and excessive pain. To relieve the pain, oculoplastic surgeons often remove the eye (enucleation) and place an orbital implant. Approximately five weeks later, a custom-made ocular prosthesis is made by an ocularist. This artificial eye will restore a more normal appearance and relieve discomfort.

Some patients requiring ophthalmic plastic and reconstructive surgery have problems related to the lacrimal drainage system and the outflow of tears - problems which may be secondary to congenital anomalies, infections, tumors, long-term glaucoma therapy, nose injuries, sinus problems, and natural aging. Yet others have orbital (eye socket) problems caused by sinus infections or tumors extending into the orbit, Graves' disease, and fractures due to accidents or physical violence.

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Who are the Ophthalmic Plastic and Reconstructive Surgeons at Bascom Palmer Eye Institute?

Thomas Johnson, M.D.
Wendy W. Lee, M.D., M.S.
David Tse, M.D.

Other Resources

American Academy of Ophthalmology
American Society of Ophthalmic Plastic and Reconstructive Surgery
Eye Cancer Network
Eye Resources on the Internet
National Eye Institute

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