Oculoplasty, Aesthetics And Oncology
Ophthalmic plastic surgery or ‘Oculoplasty’ is the branch of ophthalmology that deals not only with the diseases of the eye, but also important structures around the eyes like eyelids, eyebrows, orbit and the tear system which are vital to the normal appearance and function of our eyes. Common conditions needing ophthalmic plastic surgery:
Cosmetic Blepharoplasty (eyelid surgery) is the removal of excessive, sagging or wrinkled skin, as well as fat and sometimes muscle from the upper and/or lower eyelids. This treats eyelid “hooding” and under-eye “bags” which can cause a tired or aged appearance. Functional blepharoplasty is also performed when excess eyelid skin interferes with vision. The result is a more youthful, rested appearance of the eyes, softening of wrinkle lines, and widening of visual fields for partially blocked vision.
Eyelid Surgery is usually performed in patients aged 40 and above, although it can be done as early as the 20s or 30s for inherited traits.
Upper eyelid Blepharoplasty removes excess eyelid skin and fat through an incision hidden within the crease of the eyelid. The lower eyelid fat is removed through an incision inside the eyelid (trans-conjunctival) so that there are no visible scars. If there is a minimal to moderate amount of excess lower lid skin, the wrinkled skin can usually be treated with a chemical peel or laser resurfacing. Large amounts of extra lower eyelid skin may require an incision just below the eyelashes to remove the skin for effective treatment.
Eyelid Surgery is performed on an outpatient basis under local anesthesia and takes about 45 minutes for the upper or lower eyelids, or an hour and a half for both together. Discomfort is minimal. Stitches are removed in 5-7 days. Most patients are back to light work within a week.
Notes:Excess eyelid skin may be a sign of drooping eyebrows, in which case a Endoscopic browlift or Forehead lift is the preferred treatment. In addition, many patients with concerns of lower eyelid bags actually have a sunken appearance and would benefit from fat transfer to fill in the lower eyelid area, rather than fat removal.
- Endoscopic Brow Lift or Forehead Lift
Due to constant action of the muscles that pull the brow down (with every blink and squeeze), the eyebrow droops with age, thereby lengthening the forehead. The Brow Lift or Forehead Lift re-fixates the eyebrows to a higher position, and smoothes the forehead. The result is a more youthful and rested appearance to the forehead andupper eyelids and a softening of lines in the forehead and between the eyes.
A Forehead Lift can be performed as early as the 30s, or even beyond the 70s.
The Brow Lift can be approached through several different incisions depending on the individual’s anatomy, hairline, and preferences. By far the most common approach is the Endocsopic surgery using a tiny camera through very small incisions in the scalp. Other possible incisions are just above the eyebrows, within a horizontal forehead crease, or along the hairline. During endoscopic browlift procedure, the muscles that cause frowning are carefully weakened during surgery to create a pleasant, relaxed appearance. This creates the same effect as Botox injections but unlike Botox, which is temporary, the effects of surgically weakening the muscles are permanent.
Brow Lift Surgery is performed on an outpatient basis with local anesthesia and oral or IV sedation, and takes about an hour. Discomfort is minimal to moderate. Stitches or skin clips are removed in 7 to 10 days. Most patients return to work in one to two weeks.
- Enucleation and Evisceration
Enucleation and evisceration are procedures used to remove a diseased eye. During an evisceration the contents of the eye and the cornea are removed, but the sclera, or outer covering of the eye, remains. During an enucleation the entire eyeball is removed.
Reasons for removal of an eye
In some cases, blind eyes can become painful because of increased pressure or inflammation. Pain can sometimes be controlled with eye drops. You may also elect to have the eye removed. In most cases removal of the eye leads to dramatic pain relief.
A blind eye may become shrunken or have an unsightly appearance. A scleral shell resembles a large contact lens and is made of hard acrylic painted to resemble an eye. A scleral shell is worn in front of your natural eye.
A medical practitioner who specializes in making “artificial” or prosthetic eyes.In many cases, the natural blind eye is too sensitive to tolerate a scleral shell, and you may elect to have the unsightly eye removed. After surgery, you can be fit with an artificial eye, improving your appearance.
Occasionally an eye can become so severely infected that there is no hope of recovery. The eye is then removed in order to prevent the spread of the infection to the tissue around the eye and to the rest of the body. In most cases of infection, an evisceration is performed. An evisceration removes the internal contents of the eye and leaves the sclera to prevent spread of the infection to the tissues around the eye. If the sclera, the outer covering of the eye, is also infected then an enucleation, with complete removal of the eye, is necessary.
Some eyes with a cancerous growth are removed to prevent spread of the cancer. In these cases, an enucleation with complete removal of the eyeball is necessary.
Sometimes the eye gets so badly injured that no functional vision is possible. Even repairing it will not givde any benfit rather can be a cuase of sympathetic ophthalmia. In these cases as well evisceration + implant followed by prosthesis gives a good cosmetic rehabilitation to the patient.
At the time of enucleation or evisceration an implant is placed within the orbit or within the remaining scleral shell to replace the missing socket volume and to allow the remaining ocular muscles to function. The implant is buried in the socket tissue. When the socket has healed it will appear like a pink pocket behind the eyelids. The buried implant will move in the pocket with movement of the other eye.
Type of Implant
After deciding on the procedure to remove the eye, you and your surgeon should discuss the type of orbital implant that will be placed into the socket during surgery.
In general, there are two types of implants in common use. One type of implant is a solid ball, sometimes called a Jardon. In many people a solid implant is the best choice. A solid implant produces an acceptable socket appearance and has a very low rate of complications. However, with time, this implant may slip in the orbit causing a sunken appearance to the socket. The second type of implant is an “integrated” implant made of porous material. The tissue from your orbit will grow into small the small holes, in effect making the implant part of your body. This ingrowth of tissue prevents slippage within the socket. But integrated implants have their own set of complications and hence becoming less popular.
In many cases you will admitted to the hospital overnight after the procedure for pain control. Usually the acute pain resolves after a day or two. However, many people describe a dull headache after surgery, which lasts about two weeks. After surgery the operated eye will be patched for 1-2 days. While the patch is in place, no special care of the socket is needed except to keep the bandage dry. After removing the patch you will be instructed to place an antibiotic ointment into the socket. Please do not clean or rub the inside of the socket. For two weeks after surgery please do not expose the socket to dirt, go swimming, or lift objects over twenty pounds. At the time of surgery the surgeon places a conformer in the socket. This will remain in place until you are fit for your artificial eye by an ocularist. You should wait at least four weeks after an evisceration and four to six weeks after an enucleation before the ocularist fits an artificial eye. If an artificial eye is not fit within a few months of the procedure the socket may shrink, and it may become difficult to wear an appropriate artificial eye.
Custom made prosthesis
After your socket has healed, you may obtain an artificial eye, called a prosthesis. A prosthesis is a hard acrylic shell which is held in position by the eyelids. A prosthesis is made by an ocularist. The ocularist takes a mold of you socket, from which the custom prosthesis is made. It typically takes at least two visits to make a prosthesis
Secondary Surgery in People Wearing Artificial Eyes
In some cases, people wearing an artificial eye will require additional surgery. After wearing a prosthesis for a number of years, the soft tissue of the eyelids and sockets can change.
Lower lid looseness and Socket Shrinkage
After supporting the ocular prosthesis for a number of years, the lower lid may loosen. This results in exposure of the prosthesis below the iris. This is often associated with shrinkage of the lower socket or “pocket”. This may result in the artificial eye falling out. The lower lid is tightened with an incision at the outside corner of the eyelids. A shrunken pocket can be expanded with a graft from the inside of the lower lip or with donated material.
Upper lid Drooping and Sinking
After surgery most patients have a somewhat sunken appearance of the upper lid. You may require a larger orbital implant or a fat graft can be taken from your hip and placed into the upper lid to fill out the eyelid.Also, the upper lid can droop, called ptosis. Modifying the ocular prosthesis can raise the eyelid. If modifying the implant is not effective, the muscle which raises the eyelid can be tightened.
Orbital Implant Exposure
The tissue in the socket can break down, causing exposure of the orbital implant. In patients with an older style implant, covered with metallic mesh, the implant itself must be removed and replaced. If an “integrated” implant becomes exposed, the implant can usually be left in the socket. During surgical repair, the exposed area is smoothed and covered with a graft.