RECONSTRUCTIVE / REPARATIVE PROCEDURES
Reconstruction of the Eyelids, Eye Sockets, Tear Drains, and Surrounding Facial Regions
Dr. Walrath performs a full range of functional surgical and nonsurgical procedures of the eyelids, forehead, and midface, to help patients to see better, to improve their ocular health, and to help relieve discomfort. In addition to surgical disease, Dr. Walrath manages chronic diseases of the eyelids, tear drains, and eye sockets as well.
RECONSTRUCTIVE / REPARATIVE PROCEDURES
Dr. Walrath performs the following upper eyelid surgeries for patients who have discomfort, difficulty seeing, or compromise to the surface of their eyes:
- Ptosis repair: fixing the droop of the eyelid
- Blepharoplasty: removing the excess skin of the eyelid that interferes with vision. A typical postoperative course can be viewed here.
Entropion repair: fixing the inturned upper eyelid to prevent further damage to the cornea
- Retraction repair: lowering the upper eyelid, often retracted due to sequelae of thyroid eye disease or prior surgery,and improving appearance and ocular health
- Lid weight implantation: placing gold weights or other materials in the upper eyelid to assist with eyelid closure in patients with paralysis of the facial muscles, often due to Bell’s palsy.
Ptosis of the eyelid refers to a loss of function of the main lefting muscle / tendon of the eyelid, and is different from simply having excess skin hanging over the eyelid.
Ptosis is usually due to one of two processes: the tendon that connects the muscle to the substance of the eyelid becomes thinned, weakened, or detached; or the muscle that lifts the eyelid degenerates or is otherwise abnormally replaced with fat or fibrosis.
Surgery is generally divided into three groups:
- External incision eyelid surgery (levator advancement, levator resection)
- Internal incision eyelid surgery (conjunctivomullerectomy)
- Eyelid and forehead surgery, for severe cases (frontalis suspension)
This external surgery involves making an eyelid incision for the length of the eyelid (when both lids are involved, so that excess skin will also be removed), then locating the levator muscle and tightening it up, then re-securing it to the substance of the eyelid. The success rate (in terms of acceptable lid height and shape) in cases where both eyes are done at the same time is usually reported to be about 90%. A review of Dr. Walrath’s surgical series from 2015 (approximately 200 levator surgeries) found a reoperation rate of 4%.
This patient (postoperative) underwent external eyelid surgery to correct drooping that was present on both sides — you can see her preop photo in the photo gallery. Swelling and bruising are usually minimal after ptosis surgery.
Post: Bilateral upper lid lift, bilateral lower lid blepharoplasty
You can see what a reasonable expectation would be for the degree of swelling and bruising one week after surgery here and here.
Internal eyelid surgery involves numbing up the inner aspect of the eyelid as well, then flipping the eyelid and removing a measured amount of the inner eyelid muscle. The surgery is rapid and has a high success rate, with no external incision required. The success rate is similar to the external surgery.
When the eyelid muscle has very poor function, eyelid surgery itself will not be able to fix the problem. In these cases, the solution is to help the patient use their forehead to improve the eyelid lift. These patients often use their foreheads quite a bit anyways, so this is a natural solution for them. This technique is required most often in those who have had droopy eyelids for their whole lives and occasionally in those who have degenerative muscle or neuromuscular conditions.
This child (postoperative) recently had the right eyelid lifted with by frontalis suspension. The small forehead incisions are 1 week old, but these usually heal without a visible scar. Preoperative photos of a similar patient can be viewed in the photo gallery.
Not infrequently, eyebrow descent interferes with vision. In those instances, Dr. Walrath can perform direct brow elevation to assist in improvement of appearance and visual function. This procedure involves making an incision immediately above the eyebrow, and is the most powerful method for lifting a heavy drooping brow. Typically this is only recommended in men or in patients with heavy wrinkles that can conceal an incision line.
Dr. Walrath performs reconstructive surgery of the eyelids after:
Prior complications from cosmetic surgery. Usually, the problem area involves the lower eyelids. Over-resection of skin or aggressive laser treatments or chemical peeling of the skin can shorten the lower eyelid — this can be a real problem when the eyelids no longer close. Over-resection of upper eyelid skin during blepharoplasty can also have the same effect. (Here is a strategy for reducing your risk of these types of complications when choosing your surgeon.) In no uncertain terms, patients lose vision from cosmetic surgery when it is not done properly.
Trauma. Most traumas fall into two categories: eye socket fractures, and eyelid lacerations / avulsions. Half of the “simple” eye socket fractures that I see require observation only; the other half require surgery when the fracture is simply so large that the eye may sink back into the socket over time, or if there is double vision from the fracture. Eyelid trauma involves the tear drain system more often than not, and this needs to repaired along with the eyelid itself.
Resection of skin cancers of the eyelids. If you would like to learn more about different types of skin cancers that can affect the eyelids, please refer to my recent blog entry on the topic. That entry will also link you to articles in wikipedia on some of the different types of cancers. Needless to say, an important component in the treatment of most of these cases is surgery: removal and reconstruction.
“Ectropion” refers to a folding out of the eyelid. There are several causes, and several solutions. Ectropion can be age-related and require canthoplasty and various modifications to tighten the eyelid. Age-related ectropion of the lower lid takes about 10-15 minutes to fix and can be done asleep or awake.
Ectropion can also be caused by scarring and contraction of the skin of the lower eyelid, which can pull the eyelid away from the eyeball. This type of ectropion often requires skin grafting to repair.
In rare cases, ectropion can compromise the eyeball. In general, for significant cases, it should be repaired.
“Entropion” refers to a folding in of the eyelid. Entropion can be age-related and require canthoplasty and various modifications to tighten the eyelid and turn the lashes back out against the eye. Age-related entropion of the lower lid takes about 10-15 minutes to fix and can be done asleep or awake.
Entropion can also be caused by scarring and contraction of inside of the lower eyelid, which can turn the eyelid inwards and abrade the eyeball. This type of entropion may require advanced techniques to repair.
Entropion should always be repaired, as it is usually chronically painful and can damage the eyeball.
“Retraction” refers to a pulling down of the eyelid. This can happen in patients who have really prominent eyes, or in certain disease states like Graves disease or high myopia. Repair of retraction often requires a lower eyelid implant. One common implant is “off-the-shelf” collagen, for mild cases. In more significant cases, a better choice of implant is a strip of the patient’s own ear cartilage.
Nasolacrimal (tear drain) surgery includes surgery on the the canaliculi (the portions of the tear drain that reside within the eyelids), the lacrimal sac, and the bony nasolacrimal duct (in the nose). Depending on the location and severity of the tear drain blockage, different procedures may be of benefit to you.
Often the patients are fortunate that their tearing is only caused by punctal stenosis! The “puncta” are holes on each of the eyelids that the tears drain down. If they are narrowed, an office procedure at the time of your initial visit may fix the problem. Below is a photo of that procedure — the small triangle of tissue is removed, opening up the tear drain hole on the inside of the eyelid. There is no pain afterwards.
Functional nasolacrimal obstruction
Functional obstruction implies that the tear pump mechanism is faulty, even though the actual drain is partly open. The tear drain pump mechanism relies on the tension of the eyelids and the contraction of the muscles that close the eyelids. It also relies on the normal function of a series of “valves” at the various junction points within the tear drain system. These obstructions are the most difficult to properly diagnose, though once the diagnosis is secure, the treatment follows a prescribed course. The reason for the diagnostic challenge is because:
The eyelids are usually lax to some extent, which may implicate a tear pump mechanism instead of a valvular or nasolacrimal duct problem.
The tear drains are demonstrably open clinically, although there may be some subjective resistance during testing.
Locations of obstructions that can occur in functional nasolacrimal duct obstruction are depicted in red below:
The most useful feature of the clinical examination in these cases is to compare the right and left sides: for example, if both lower eyelids have similar tone and yet only the left side tears, odds are that treating the nasolacrimal system will have a better chance of success than tightening the eyelid. Nevertheless, occasionally multiple procedures will be required to completely treat these problems.The first step in treating these problems is to attempt a ballon dilation of the tear drain in the operating room. It has a 50/50 long term success rate but requires no incision and is well-tolerated. If that fails, the decision must be made as to whether eyelid laxity is playing a part, or if the problem is still within the tear drain. Occasionally, Dr. Walrath requires special testing (dacryoscintigraphy) to be performed at a medical center to help with this decision-making. The general algorithm that I use in the decision making process for fNLDO is below:
Complete acquired nasolacrimal duct obstruction
The definitive blockage of the nasolacrimal duct. It may manifest as constant tearing or recurrent severe lacrimal sac infection. The treatment, dacryocystorhinostomy (DCR), has upwards of a 90% success rate. It is performed under general anesthesia and involves the creation of a new tear drain, by removing bone in the nose. The procedure can be performed internally, or it can be performed externally, with a small skin incision. The external approach generally has a higher success rate. As you can see here, the scar is almost entirely invisible within 3-4 weeks in almost everyone.
The obstruction is usually within the duct, somewhere in the nose, as depicted in red below:
The DCR surgery involves removing some bone from deep inside the nose, creating a new tear drain, and placing a silicone tube in the system to keep it open while it heals. This is depicted below:
Canalicular blockage (blockage within the eyelid portion of the drain)
Canalicular blockage is probably the most difficult type of blockage to treat satisfactorily. If the blockage is near the tear sac, a modified DCR can be attempted. However, usually, a glass tube needs to be inserted in the inside corner of the eyelid, which bypasses the blocked system and conducts tears directly into the nose. This tube stays in for life.
Dr. Walrath has experience injected the tear glands with Botox when “all else fails” and the tear drain abnormality is recalcitrant to surgical correction. Botox has been well-tolerated, with a low incidence of side effects, with the exception of a chance for temporary eyelid droop. However, the botox will only last 3-4 months before it needs to be repeated.
Finally, if you are wondering if you might be suffering from tear sac infection (dacryocystitis) or infection of the eyelid portion of the nasolacrimal system (canaliculitis), below are some pictures of what it might look like:
Dr. Walrath takes care of complicated problems of the eye socket, including:
- Graves eye disease
- Eye socket tumors
- Eye socket trauma
Orbital decompressions can be utilized to help reset eyes that “bulge out” due to eye socket congestion. In some patients with thyroid eye disease, this can significantly decrease the ache that they feel. It involves controlled breakage and removal of some of the bony confines of the eye socket, giving the eye socket tissue more room to expand. Fat removal is part of this procedure as well.
The majority of eye socket tumors are benign and can be monitored. Suspicious tumors are biopsied.
The majority of eye socket trauma is also observed, and not treated with surgery. However, there are certain indications for prompt surgical treatment, and Dr. Walrath can discuss these issues with you in detail.
Dr. Walrath has worked closely with local ocularists, such as Angela Cotton, BCO, to optimize the care for patients who have lost their eye and need to wear a prosthesis. Sockets with false eyes intermittently require surgery for:
- Extrusion of the eye socket implants
- Loosening of the eyelids
- Inability to maintain the false eye, leading to embarassing social situations
- Drooping of the eyelids
- Inturning of the eyelids
- Loss of the “pocket” that helps retain the false eye
A common complex of complaints is a “hollowing” appearance of the upper eyelid, combined with downturned lashes that stick to the prosthesis. I have developed some reliable techniques for helping patients with these problems. I work very closely with local ocularists, often taking cues from them so that together we can achieve the optimal response for our patients with false eyes.
Dr. Walrath also has had much experience in removing diseased eyes, traumatized eyes, and cancerous eyes.
Botox & Fillers
Dr. Walrath has injected Botox regularly in many patients with benign essential blepharospasm, in whom it is usually the best treatment for control of this often debilitating movement disorder. He also injects Botox in patients with uncontrolled tearing who have failed or do not want to try other conventional treatments.
Dr. Walrath has used injectable fillers for patients with false eyes who have difficulty maintaining their false eye or who have developed deep hollowing under the brow. Occasionally fillers can be helpful in patients with eyelid malposition.
Dr. Walrath continues to operate at Children’s Healthcare of Atlanta, Egleston. He has performed countless surgeries for pediatric eyelid abnormalities, as well as benign and malignant eye socket tumors. While at Emory, Dr. Walrath performed the vast majority of pediatric eyelid and eye socket surgeries that were being done at Emory and CHOA Egleston.
He continues to operate in the CHOA system. Many of his patients have congenital drooping lids and tear drain problems, though several cases involve reconstructions after trauma, congenital defects, or bad facial burns. You can locate several pediatric patients before and after eyelid surgery in this gallery.