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Aging Eyelids

Eyelid surgery (blepharoplasty, canthoplasty, ptosis repair, fat grafting, fat repositioning...) has evolved. The main focus was to remove excess skin and bags and get rid of wrinkles and the main enemy was gravity. Thus, cutting out eyelid skin and fat and lifting tissue as in traditional blepharoplasty was the solution. Often times this kind of blepharoplasty surgery makes patients look not natural and gaunt.

In the last decade or so we have learned that one of the main reasons we look aged and tired is loss of volume from our faces. This causes skin and muscle to fall and collapse. It is the same thing that happens to grapes as they turn into raisins. With this in mind, when approaching eyelid surgery like blepharoplasty, canthoplasty and ptosis repair, we have concentrated very hard on techniques which replace volume in the face whether they be gel fillers (Restylane, Perlane, Juvederm), or our own fat (fat grafting and fat repositioning).

This has revolutionized how we approach cosmetic blepharoplasty surgery. We no longer emphasize subtractive blepharoplasty surgery (where all we do is remove tissue); but rather focus on replacing what is lost.

This concept of volume loss with age is most apparent around the eyes. The upper and lower lids are supported by muscle, fat and bone. With age the fat shrinks, the muscle weakens and bone is resorbed (lost like bone loss in the body with osteoporosis). With this tissue loss the lids lose support and sag. This leads to bags, dark circles, puffiness, hollows, and wrinkles. The sun damage to the skin accentuates the appearance by causing the skin to lose collagen and elastin (the stretchy material in the skin that allows it to snap back into place like a rubber band).

We now believe that replacing this lost volume during cosmetic blepharoplasty is the most important feature of restoring youth. Rather than tissue reduction during surgery, we emphasize tissue addition (fat grafting, fat repositioning, and the use of fillers like Restylane, Juvederm and Perlane).

Upper blepharoplasty

The goal of upper cosmetic eyelid surgery, is to lift the upper eyelid so that your eyes appear more vibrant and youthful. In more severe cases, upper blepharoplasty is needed to improve vision when the eyelid begins to droop so much that it is obstructing your field of view

 

Blepharoplasty, also referred to as cosmetic eyelift surgery, is on of the most common cosmetic procedure. Surgery can be performed with minimal sedation or local injections of anesthesia. While blepharoplasty is a relatively straightforward procedure, it is still a delicate surgery, which requires a specialist to attain the desired results.

 

Although blepharoplasty is a commonly performed procedure by many surgeons and is widely considered a simple excision of skin and fat from the upper and/or lower lids by most cosmetic surgeons, nothing can be further from the truth. Blepharoplasty surgery requires a unique understanding of eyelid architecture. Over excision of skin, muscle or fat can be devastating.

 

Our goal is to preserve (reposition) fat, form a natural lid fold (crease), elevate a weakened eyelid muscle (ptosis repair), tighten the outer corner of the eyelids (canthoplasty), and have an overall understanding of what beautiful eye looks like. We take a very customized approach to blepharoplasty, creating a surgical plan for each patient that is unique to the needs of their aging eyelids. No two sets of eyes are the same. 

Lower Blepharoplasty

January 01, 2020

Aged eyelids are a consequence of the following factors:

• Loss of tone
• Loss of elasticity & collagen
• Loss of support (underlying bone support)
• Loss of facial fat

These factors can result in droopy or puffy looking eyelids, as well as under eye hollows or heavy bags. Depending on which factors of aging are affecting the appearance of your eyelids, we will determine which treatments will best help you achieve your goals. We may choose to incorporate both an upper and lower blepharoplasty, or he may determine that you need just one of the two procedures. 

The goal of lower blepharoplasty, or eye bag surgery, is to reduce the prominence of eyelid bags, while simultaneously filling depressions around the eyes (ie. dark circles). These depressions are generally referred to as “periorbital or eyelid hollows.” Rather than removing precious eyelid fat, we try to instead transpose the excess fat to the hollows to reduce elevations (fat prominence) and fill the depressions (eyelid hollows). This technique smoothes the contour irregularities and re-creates the natural contours of youth.

Periorbital Rejuvenation

Rejuvenation around the eyes involves treating upper and lower eyelids, crow's feet, the brow and its shape, as well as the immediate forehead und upper midface. 

Treatments may include fillers and botulinum toxin. Mesotherapy may boost tired looking lower eyelids and may help with dark circles under the eyes. 

Sometimes skin resurfacing helps even out the wrinkles (see chemical peels and laser resurfacing). Energy-based radiofrequency treaments also help in that regard. 

 

Surgery is the last resort or are indicated in patients who want a definite result.  

Eyelid Malpositioning, Ectropion and Entropion Repair

Ectropion is an eyelid defect in which the eyelid margin (where the lashes are) turns out – either on the upper or lower eyelid. This leads to a variety of symptoms including ocular (eyeball) irritation, a red eye, pain, infections and tearing. It can be present at birth or acquired after trauma, cancers, other growths, inflammation, or can occur with age (most common). Surgical correction is usually straightforward and quick. In rare instances surgery can be more involved.

 

As opposed to ectropion, in entropion the eyelid margin turns in. This causes the eyelashes to rub on the eye itself, leading to similar symptoms as ectropion (red eye, pain, infections and tearing). In this case however, symptoms are typically more severe and disabling. The causes of entropion are similar to those of ectropion, and surgical correction is also usually minimally invasive. Incisions for Ectropion and Entropion repairs typically follow the eyelid margin (the eyelashes) and are not normally visible to the naked eye after the patient has undergone the complete course of healing/recovery.

Canthal procedures have a common goal of supporting or tightening the lower lid at the canthus (outer corner of the eyes). These procedures include both a canthoplasty and canthopexy. Patients who are experiencing drooping, sagging or bagginess of the lower eyelids may be candidates for a canthoplasty. These problems may appear for a variety of reasons, including unsatisfactory result from previous surgery, age, hormonal conditions, hereditary factors, trauma, or paralysis.

A canthoplasty is a procedure in which the lateral canthus (area where upper and lower lids meet laterally) or temporal lower lid is incised, plus/minus shortened, and secured to the lateral orbital rim. Conversely, a canthopexy is a procedure in which the lower eyelid is suspended to the lateral orbital rim (bone of lateral orbit) with a plication suture without modification of the lateral canthus or terminal tarsus. Essentially, a canthoplasty is a more powerful, yet complex and involved procedure than canthopexy. 

Canthal suspension procedures may be performed in conjunction with a primary blepharoplasty or as a revision procedure to correct lower lid complications from a prior surgery.

Upper Eyelid Ptosis

Ptosis is a condition in which the upper eyelid is droopy. This should not be confused with extra skin, fat or muscle to the eyelid, which are typically addressed with blepharoplasty surgery.

In Ptosis, the upper eyelid margin covers the iris partially when the eye is open. This may lead to visual obstruction. The corrective surgery can be more complicated than the more common blepharoplasty procedure and should therefore only be performed by an oculoplastic surgeon who underwent extensive training in this procedure and performs it more often than a general plastic surgeon.

​Ptosis can be caused by congenital or acquired defects in the muscle (or its tendon), which lifts the eyelid. It is also associated with growths, which weigh the eyelid down, or neurological disease. The most common reason ptosis occurs is simply weakening of the muscle (or its tendon), which occurs with age.

 

Correction is usually a minor surgical procedure, involving tightening of the muscle that lifts the eyelid. This can be performed through the eyelid skin or from the inside of the eyelid. The surgical approach taken depends on specific findings and testing performed during the preoperative evaluation. Incisions for Ptosis repair are typically on the inside of the eyelid and are not visible, once stitches are removed and the full course of healing has taken place. 

Tear and Drainage

Watering eyes are a common problem, particularly in older people. A blocked tear duct is the most common cause, but there are a number of other causes. You may not need treatment if symptoms are mild. An operation can usually cure a blocked tear duct. Other treatments depend on the cause.

 

Watering eyes (tears rolling on to your cheeks) can occur at any age, but are most common in young babies and in people over the age of 60. It can occur in one or both eyes.

 

Just above, and to the outer side, of each eye is a small gland called the lacrimal gland. This constantly makes a small amount of tears. When you blink, the eyelid spreads the tears over the front of the eye to keep it moist. The tears then drain down small channels (canaliculi) on the inner side of the eye into a tear sac. From here they flow down a channel called the tear duct (also called the nasolacrimal duct) into the nose.

What are the possible causes of watering eyes?
-Emotion can make you cry. Anything that irritates the eye can cause you to make a lot of tears. The watering is a protective reflex to help clear irritants away from the eye.

-Chemical irritants such as onions, fumes
-Infection of the front of the eye (infective conjunctivitis).
-Allergy causing inflammation of the front of the eye (allergic conjunctivitis).
-A small injury or scratch to the front of the eye, or a piece of dirt or grit which gets stuck in the eye.
-Eyelashes that grow inwards can irritate the front of the eye. This is called an entropion (see Entropion)
-Thyroid eye disease is an uncommon cause.

-Faulty drainage of tears
-Tears may become blocked at any point in the drainage channels:The most common cause of watering eye in adults is a blockage in the tear duct just below the tear sac. This is thought to be due to a gradual narrowing of the upper end of the tear duct, perhaps caused by persistent mild inflammation. If you have a blocked tear duct, not only will you have watering eyes, but the stagnant tears within the tear sac may become infected. If the tear sac gets infected you will also have a sticky discharge on the eye. You may also develop a painful swelling on the side of the nose next to the eye.
-Sometimes the tear duct is not blocked fully, but is too narrow to drain all the tears.
-Less commonly, there may be a blockage within the canaliculi, or the entrance to the small channels (canaliculi) in the inner corner of the eye may be blocked. This may be due to inflammation or scarring.
-Rarely, a polyp in the nose may block the tears from coming out of the tear duct.

-Some babies are born with a tear duct which has not fully opened. This is common and usually clears within a few weeks without any treatment as the tear duct opens fully. 
-Ectropion. This occurs where the lower eyelid turns outward away from the eye. The ectropion may cause tears to roll off the bottom of the eyelid rather than drain down the canaliculi to the tear sac. See the separate leaflet called Ectropion.

Do I need any tests?
Sometimes the cause is easily identified – for example, infections, ectropion, entropion, and conjunctivitis. If there is no obvious cause revealed by a simple examination, further tests may be advised (clinical exams, radiographs...).

What is the treatment for watering eyes?
Treating eye irritation
-Eyelashes irritating the front of the eye (entropion) can be removed.
-Conjunctivitis can usually be treated with drops.
-Pieces of grit, etc, can be removed.

-Treating tear drainage problems
-Ectropion can usually be treated with a minor operation to the lower eyelid.
-Babies with watery eyes usually grow out of it with no treatment.
-Blockage of the channels in adults:You may not need treatment if the watering is mild or does not bother you much.
-A blocked tear duct can be treated with an operation. The usual operation is called dacrocystorhinostomy (DCR). In this operation a new passage is made between your tear sac and your nose and this bypasses any blockage below your tear sac and allows tears to drain normally again.
DCR surgery is worthwhile if the watering is bad enough to interfere with your activities of daily living. It is also recommended if you have had an infection in your tear sac as a result of the blocked tear duct. The surgery may prevent repeated attacks of a red, painful swelling at the corner of your eye.
There are two ways of doing this surgery, either externally – through your skin or endoscopically – from within your nostril. Your doctor will be able to give you more information regarding this.
A narrowed small channel (canaliculus) which is not fully blocked may be widened by pushing in a probe. However, if it is completely blocked, an operation is an option to drain the tears into the nose.

Tear duct surgery, or dacryocystorhinostomy (DCR), is a surgical procedure performed by ophthalmolgists to unblock or drain obstructed or infected tear ducts or other portions of the tear (lacrimal) system. A blockage of the tear system can result in excessive tearing, lack of tears, or infection within the drainage system. Tear duct surgery is more commnly seen in pediatric ophthalmology.

 

How Tear Ducts Become Blocked

Tears are necessary for keeping the eyes healthy and moist. They are produced from a gland under the upper eyelid called the lacrimal gland and drain into tiny holes (lacrimal puncta) in the inner corner where the upper and lower eyelids meet.

As we blink, tears are pumped into the nose through the tear duct (nasolacrimal duct) and are reabsorbed into the body. The nasolacrimal duct can become obstructed preventing normal tear drainage and increasing the risk of eye inflammation and infection.

 

Common Causes of Tear Duct Blockage

Tear ducts can become obstructed without presenting an obvious reason. The blockage can be partial or total, and can occur anywhere within the tear drainage system.

Common causes include:

-Aging: Over time, the puncta (openings to the tear ducts) can narrow and cause blockage
-Infection: Can cause inflammation and blockage
-Previous surgery or injury: Scarring or bone damage can obstruct tear flow
-Eyelid weakness
-Loose skin cells or dirt particles: Can become lodged in the tear ducts
-Medicated eye drops: Prolonged use of some medicines can result in blockage
-Tumor
-Cancer treatment: Tear ducts can be affected by radiation or chemotherapy treatments

 

Symptoms of Nasolacrimal Duct Obstruction (Blocked Tear Duct)

Patients may be unaware of symptoms at the onset of nasolacrimal duct obstruction. They may notice that their eyes are watering, but not realize that the overproduction of tears is actually a blocked tear duct. While a blockage may resolve on its own, it can also result in ongoing infections within the lacrimal sac (which collects the tears), eye inflammation, and mucous build-up.

 

Diagnosing Nasolacrimal Duct Obstruction (Blocked Tear Duct)

Diagnosing a blocked tear duct will involve discovering where the blockage is located within the lacrimal system. If a blocked tear duct is suspected, your doctor will conduct a tear drainage test to measure if your tears are draining properly. One drop of a harmless dye is placed on the eye’s surface and observed. The amount of the dye that drains off the eye will determine if the duct is blocked.

Other tests that may be used to diagnose a blocked tear duct include:

Probing and irrigation: A thin tube (probe) is placed into the lacrimal system to determine if the duct is open. A saline solution is then flushed through the nasolacrimal duct to test if tear drainage is normal.
Imaging tests: X-ray, CT scan, or MRI may be used to track a special dye placed in the tear drainage system and locate any blockage.

 

Treatment for Nasolacrimal Duct Obstruction (Blocked Tear Duct)

Treating an obstruction in the tear drainage system often requires tear duct surgery, a surgical procedure, to unblock the nasolacrimal duct. This tear drainage surgery is called a dacryocystorhinostomy (DCR). If the tear duct is partially blocked, your doctor may try to open the duct by flushing water through it. If this is unsuccessful or if the duct is completely blocked, tear drainage surgery is typically the most effective treatment.

 

Types of tear duct surgery include:

External DCR: A small incision is made on the top side of the nose near the bridge. The doctor removes a tiny piece of bone to allow drainage between the lacrimal sac and the nose. In some cases, a temporary tube is inserted into the opening to prevent scarring and to keep the duct open. The opening is closed with sutures and the tube is removed about 8 weeks later.
Endoscopic or endonasal DCR: Tear drainage surgery performed through the nose utilizing an endoscope, a small tube with a tiny camera and light attached. The endoscopic procedure is performed similarly to external DCR without the skin incision.
Dacryocystorhinostomy is typically performed as an outpatient procedure under general anesthesia.

Eyelid Reconstruction

The face is frequently affected by skin cancer and the area around the eyes and cheek is the most commonly involved region.

Basal cell carcinoma accounts for more than 90% of skin cancers involving the eyelids. Squamous cell carcinoma is the next most common skin cancer in this area. There are less aggressive and more aggressive and invasive variants of both of these cancers. Fortunately, for most of these epithelial skin cancers, early and meticulous excision is successful in eradicating the disease. Basal cell carcinomas do not metastasize (spread) to remote areas of the body. Squamous cell carcinoma may spread along nerves and to regional lymph nodes. Malignant melanoma and sebaceous cell carcinoma occur infrequently in the eyelid but have the potential to metastasize.

Skin cancer removal can be performed at the time of reconstruction and the tumor margins examined (“frozen sections”) to ensure complete removal. Alternatively, microscopic-assisted resection may be performed by a dermatologic surgeon (“Mohs’ surgery”). This technique offers the potential advantages of less tissue removal and slightly greater confidence of complete cancer resection. Recurrent disease can occur with any type of resection, so patients should have periodic examinations following their surgery.

 

The complexity of reconstruction will, of course, depend on the size and location of the defect. The main goal of repair is to restore adequate eyelid, brow, or facial function. Every attempt is also made to maximize the resulting cosmetic performance. Occasionally, secondary surgical procedures are necessary to modify excessive scarring or to improve the position of the eyelid.

Eyelid reconstruction may be undertaken in a variety of situations. Defects in the eyelid may arise form a variety of situations, but most commonly after trauma or tumor excision.

Simple superficial defects in the eyelid may occur after minor trauma or removal of small growths. Many of these require nothing more than local wound care and will heal on their own in a week to 10 days. Some simple superficial defects may require a few sutures with the same local wound care.

In some instances, such as after traumatic injuries or removal of larger growths or skin cancers, larger defects may extend through the entire lid. Many of these can be sutured together directly, but many others may require more complex reconstructions. In many of these more complex cases, the surgeon will need to use transfer of adjacent tissues (what we call ”flaps”), or transfer of skin from other parts of the eyelid face or body (what we call “skin grafts”) to complete the reconstruction. Some of these more complex reconstructions may require more than one operation to complete (what we call “staged reconstruction”).

If you have had one skin cancer, there is an approximate 30% chance that you will develop another. Exposure to harmful irradiation from the sun is the major risk factor for skin cancer development. Sporadic, intense sun exposure can be more harmful than consistent, intermediate exposures. Even on cloudy days, the harmful effects of the sun should not be underestimated. The sun’s rays are most dangerous between the hours of 10 a.m. and 3 p.m. It is almost never too late in life to start avoiding solar damage.

Facial Paralysis

The Facial Nerve is responsible for facial and eyelid muscle contraction and movement. If this nerve is injured or dysfunctional, then a facial droop and incomplete eyelid closure may result. This condition is called “Facial Nerve Palsy”. If the cause is not known then it is called a “Bell’s Palsy”. Bells’s palsy frequently improves over several months, but other causes (trauma, skin cancer resection, forehead surgery) of facial nerve palsy may be permanent.

Poor eyelid closure may lead to eye exposure. If your eyelids do not blink appropriately, then tears are not spread adequately across the eye resulting in pain, blurred vision, and even vision loss.

 

Patients with a seventh nerve palsy need to lubricate their eyes with frequent (as much as every hour) daytime use of non-preserved artificial tears and lubricating eye ointments before sleeping. The ointment will result in blurred vision in the morning, so it should be washed out of the eye in the morning with an eye wash. If artificial tears do not provide adequate lubrication, then lubricating eye ointment should be applied during the day in addition to night time use.

 

Other methods of eye lubrication and protection include bedside humidifier use, avoidance of ceiling fans and areas of direct ventilation, wrap-around spectacles (commercially availabe), and occlusive eye dressings at night. Opsite® dressing can be purchased at many pharmacies. This clear plastic dressing with a sticky edge can be placed over the eye area after placing lubricating eye ointment in the eye. A moisture chamber may also be achieved by putting Vaseline around the eye and using clear plastic wrap (Saran or cling Wrap) over the eye. 

SURGICAL TREATMENTS of Poor Eyelid Closure
Tear Duct Occlusion
Tear duct occlusion may help limit tear drainage and permit one’s tears and artificial tears to remain on the eye surface for greater periods of time. This can be accomplished with either temporary/dissolvable or longer lasting punctal plugs. Punctal plugs are available in a variety of types and sizes and can be placed during an office visit.

Upper Eyelid Weight Implantation
In order to improve upper eyelid closure, a platinum weight may be placed in the upper eyelid. The weight is secured inside the upper eyelid under the eyelid skin and orbicularis muscle. The weight helps the eyelid come down when the patient attempts to close the eye. The weight does not usually limit eyelid opening as this is controlled by a different nerve (the third (3rd) nerve), and the upper eyelid levator muscle’s strength far exceeds the weight placed in the eyelid. Newer, thinner weights are now available which provide improved cosmesis and fewer complications.

Lower Eyelid Tightening/Elevation
Poor lower eyelid tone due to 7th nerve palsy can also contribute to eye exposure, tearing, and pain. Tightening of the lower eyelid through a small incision in the outside corner of the eye may improve tear drainage and eyelid closure resulting in improved vision and comfort.

Eyelid Reconstruction
A variety of surgical techniques may be considered to potentially improve eyelid closure. Scar release may be necessary, either of the skin or within the eyelid. This may require recession of the eyelid retractors in either the upper or lower eyelid in addition to lysis (release) of the internal fibrosis. If the absence of eyelid skin is the cause of eyelid retraction or ectropion, then augmentation of the eyelid with skin grafting or local skin flaps may be indicated.

Partial Closure of the Eyelids (Tarsorraphy)
Partial or complete closure of the eyelids may be necessary to protect the eye from dryness, infection, and severe vision loss. There are several different short-term and long-term surgical techniques to achieve partial or complete eyelid closure. The technique selected is often based on the patient’s medical condition, corneal sensation, and degree of eyelid dysfunction.

Eyelid Trauma

Eyelid lacerations may occur following blunt or penetrating injuries. When lacerations do not involve the eyelid margin, suture repair of the skin and occasionally the underlying orbicularis muscle may be all that is indicated. When the eyelid margin is involved then meticulous realignment of the marginal structures is necessary.

Trauma to the medial (inside corner) or lateral (outside corner) eyelid may occur if signficant horizontal traction (ex/ dog bites) occurred during the injury. Canthal repair requires specialized reconstructive techniques. Medical canthal injuries frequently are associated with canalicular (tear duct) lacerations. Canalicular repair with lacrimal stent placement may be indicated to minimize the risk of canalicular scarring and tearing following injuries to the medial aspect of the upper or lower eyelid(s).

 

Lacerations of the eyebrow, cheek, lip, and other areas of the face may also require repair following trauma.

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