Reconstructive Eye, Eyelid
& Facial Plastic Surgery

Ptosis is a condition characterized by a drooping of the eyelid. There are a number of causes of ptosis and with careful evaluation and diagnosis ptosis can often be minimized or eliminated with outpatient surgery to repair the eyelid.

Functional Ptosis or Droopy Eyelid
A common cause of ptosis is the gradual stretching or weakening of the main muscle that lifts the eyelid, the levator muscle. If the eyelid droops enough to block the upper vision it is considered functional ptosis. When it is the actual eyelid that is drooping, whether or not is associated with excess upper eyelid skin, ptosis becomes the diagnosis. Patients with this problem may display strong contraction of their eyebrow muscles in order to lift the eyelid, giving them furrow lines in the forehead. While most patients don’t realize that they are doing this, they may experience significant fatigue over the course of a day. Patients with this condition may appear chronically tired or angry. Not only can this affect a patient’s appearance, but it can also significantly impair the upper and peripheral visual field. The patient may not notice this, as the central vision, which is used for reading or driving, is not affected. When evaluating your ptosis, we might perform special measurements and tests including taking photographs and performing a visual field test. Visual field testing will assess whether the droopy eyelid is impairing the upper or peripheral visual field. For some patients with acquired ptosis it might be possible to provide improvement with prescription eye drops called UPNEEQ® which can be used daily.

For others, an outpatient surgery might be recommended to provide a more permanent correction. If you are a candidate, surgical correction can be done on an outpatient basis.

Congenital Ptosis or Droopy Eyelid
Congenital ptosis is a droopy lid that is present at birth. There are several causes of congenital ptosis and is sometimes can associated with other eye problems including misdirected or misaligned eye muscles. In many instances, the eyelid muscle that elevates the eyelid does not develop well. When significant, the droopy eyelid can block the visual input to the child’s eye and impair the development of that eye and normal vision and often the child may maintain an abnormal head posture in an attempt to see underneath the droopy eyelids. If surgical correction is deemed necessary, your child will have a consultation with our specialist who will then explain the possible approaches to the surgical correction of congenital ptosis, each guided toward severity and cause of the droopy eyelid. The eyelid surgery for correction of congenital ptosis may range from a simple tightening of the upper eyelid muscle if it has adequate function.  If the muscle that normally elevates the eyelid is not adequate then there are several techniques to use the muscles that lift the brow to elevate the eyelid.   Beginning with a thorough evaluation we will guide you through this process so we can be helpful in achieving the best possible results.

We perform eyelid reconstruction most commonly to repair defects and damage to the eyelid that has resulted from trauma or removal of eyelid tumors. More superficial eyelid defects that occur after minor trauma or removal of small growths only require a few sutures and proper wound care to properly heal. With more significant traumatic injuries or removal of larger growths or skin cancers, larger defects may course through the entire lid.  Sometimes these wounds can be sutured together directly, but many others may require more complex reconstructions. In more complex cases, we may need to create “flaps” to transfer closely adjacent tissues or transfer skin “grafts” from other parts of the eyelid, face or body to complete the reconstruction. In instances where the eyelid reconstruction is particularly complex, we may need to perform multiple surgeries in a “staged reconstruction” in order to get the best results.

A skin tag is a small benign lesion which is tag of skin that may have a stalk or peduncle. Skin tags look like a small piece of soft hanging skin. Skin tags can appear on any area of skin on your body but are most often found where skin rubs against skin or clothing. The eyelid and eyelid creases are common sites of skin tags. Skin tags may appear on children but are increasing common as we get older. Most skin tags are an aesthetic concern, do not raise concern and are generally easily removed. We can easily remove skin tags with excellent cosmetic results often using only topical anesthesia. Other lesions that are enlarging or bleed require evaluation to make sure they are not skin cancers.

Growths on or around the eyelids and face are common. The eyelid is an extremely common site of skin cancer accounting for up 10% of the more than 5 million cases diagnosed each year. The vast majority of eyelid and facial lesions are benign and we are able to remove them easily and comfortably right in the office.

Early Eyelid & Facial Skin Cancer Detection & Diagnosis

The approach to early detection, diagnosis and treatment of growths on the eyelids and face is similar to elsewhere on your body. Changes in appearance, size or color are all considered important to bring to our attention. Sometimes a quick and relatively simple in office biopsy procedure may be required to determine whether the lesion is problematic. Should the growth in question be malignant, we may remove it or, depending on the type of malignancy, the breadth and depth, ask that a dermatological oncologist perform a MOHS Micrographic Surgery after which we will perform a reconstructive surgery to create a proper cosmetic and functional result for you. There are several types of malignant growths of the eyelid and face that we want to observe and identify.

Basal Cell Carcinoma
By far, the most common malignant or cancerous growth of the eyelid is known as basal cell carcinoma, a very slow growing malignancy that may be present for several months before it is recognized and fortunately rarely spreads to other parts of the body, but it does require removal and reconstruction. We will perform an evaluation of any abnormal growth of the face and eyelids and will possibly recommend an in office biopsy. Should the biopsy specimen be read by the pathologist as positive for malignancy, further management will be required. This may include a simple office procedure or may require extensive removal and reconstruction in a hospital setting under monitored anesthesia. Once the tumor is removed completely, we will generally keep you under observation yearly over the next several years. It is unlikely that the tumor will recur or cause further problems, but once you have a single basal cell, it is certainly more likely to have others in the coming years. Generally, patients do extremely well and most patients who undergo resection and reconstruction of a basal cell carcinoma can have no residual cosmetic deformity.

Squamous Cell Carcinoma
This too is a relatively slow growing cancer but does have a greater potential to locally invade, as well as metastasize. It can also travel along nerve roots and therefore, can often present with pain. Fortunately, it is much less common than basal cell cancers. It is managed in the same way as a basal cell cancer, although a wide excision may be required. It is also generally dealt with more promptly than a basal cell cancer.

Sebaceous Cell Adenocarcinoma
Sebaceous cell adenocarcinoma is exceedingly rare, but it is most specific to the eyelids. It can clinically mimic several other benign problems of the eye and it is therefore misdiagnosed or diagnosed after delay. It most frequently occurs in patients in their 70’s and 80’s but can occur at any age. It is serious in the sense that it has metastatic potential. Diagnosis is often difficult even when an adequate specimen is obtained and sent for pathologic evaluation.

Melanoma
Like other parts of the body, an abnormal coloration to the skin can represent a melanoma or something along the spectrum of a melanoma. While eyelid and facial melanomas are rare, any pigmented lesion around the eyelid deserves attention. Similar guidelines to pigmented lesions or moles on other parts of the body, certainly apply to the eyelids. Changes in color, size and behavior all warrant evaluation and possible biopsy.

The bony eye socket structure is called the orbit. Any type of blunt force facial trauma can damage the orbital bones and cause an orbital fracture. A fracture is a broken bone in the eye socket involving the rim, the floor or both. These fractures are commonly caused by a blunt object striking the eye socket, such as a rock, baseball, hockey stick, hammer, fist or even as a result of falling off a bicycle or during a car accident. Different types of orbital fractures can occur since the rim of the socket is made of fairly thick bones, while the floor and nasal side of the socket is paper thin in many places: Orbital Rim Fractures, Blowout Fractures or Direct Orbital Floor Fractures.

Treatment of Orbital Fractures

Surgical repair of the facial bones is usually necessary if a blowout fracture traps muscles or soft tissues of the orbit and causes double vision.  If the fracture is large the eye may become sunken.  This sunken appearance can be alleviated by repairing the fracture.  After ensuring that the fracture has not damaged a vital structure, we will replace the orbital contents in their proper position, sometimes using implants, a thin plastic sheet, or a bone graft to connect the broken parts and assist healing.

An orbital tumor refers to any tumor located in the “orbit,” or bony eye socket that contains the eye itself. The bony eye socket is a complicated structure that includes the eye itself along with delicate thin bones, muscles, nerves, blood vessels and connective tissue that support the eye and its function. The eye socket is widest in the front and narrows toward the back, where the optic nerve leaves the socket and connects to the brain. Even a tiny tumor in this small, crowded space can cause significant symptoms, vision loss, eye movement restrictions and functional effects. Larger tumors can cause the eye to bulge forward and cause serious vision problems.

Eye tearing and drainage problems can result from over production of tears, or inability of the normal tears to drain out of the eye through the normal drainage ducts. Any abnormal positioning of the eyelids can also cause tearing, as the normal anatomy is required to direct the tears through the drainage pathway. Nerve damage such as Bell’s palsy is also a possible cause of tearing, as the physiologic tear pump mechanism may be impaired in these situations. Interestingly, people with dry eyes often complain of tearing. This occurs as the backup tear production system of the eye will produce an overabundance of tears in an attempt to protect an eye that seems to be drying out. We have extensive experience in evaluating and treating all forms of tearing, tear and duct structures and drainage problems and as necessary can correct an abnormally positioned eyelid, as well as open blocked tear ducts in both adults and children.

Approximately 70% of thyroid disease sufferers will at some point develop problems related to their eyes. Referred to as Grave’s disease, the eye changes associated with thyroid disease are seen in all types of thyroid disorders. Most commonly, they develop in patients who are or were hyperthyroid (overactive thyroid). Eye problems can occur in patients who have an underactive thyroid or even normal thyroid. Although it is important to control the thyroid hormone levels for medical reasons, the eye disease is not necessarily related to the control of your thyroid levels. Smoking is a significant risk factor for developing thyroid eye disease.  Most people will develop thyroid eye problems within 1 year of their thyroid diagnosis. While most eye problems related to thyroid disease are mild, some can be quite disfiguring and traumatic. There is a great deal that can be done to evaluate and treat patients with thyroid related eye problems.

Double Vision
The immune system’s attack on the eye muscles and their subsequent accumulation of fluid make eye muscle movement problems in thyroid eye disease common. Patients will often complain of double vision and can be noted to have asymmetric or abnormal movement of their eyes. It is important for the patient to understand that this problem requires some stabilization and that correction is possible. Conservative management includes the incorporation of prisms into your eyeglasses. Eye muscle surgery may be performed to realign the eyes as well.

Eye Protrusion or Eye Bulging
The same process that causes abnormalities to the eye muscles and increases the fluid in the eye muscles and orbital fat will cause a forward displacement of the eyeball, simply because of the increased volume in the bony eye socket. As the eye protrudes forward, it can cause several problems. Cosmetic deformity along with the upper eyelid retraction can give the characteristic thyroid stare. Excessive protrusion may make eyelid closure difficult and therefore, eyeball and corneal protection may be compromised. Correction of the upper eyelid retraction and removal of prolapsing orbital fat pockets of the eyelids may help to camouflage the abnormal appearance. When severe, orbital decompression can be utilized to expand the volume of the eye socket and allow the eyeball to achieve a more normal position. We will discuss these considerations with you.

Vision Loss
The most dreaded complication associated with thyroid eye disease is vision loss. This is related to the increase in volume in the eye socket. The eye socket can be thought of as a “cone” where the apex has all of the eye muscles and nerve fibers crowded in a very tight space. Any increase in volume of the eye muscles and orbital fat can compress the optic nerve in this small space. This may not be noticed at first by the patient, but may be uncovered by color vision testing and formal peripheral visual field testing. It can also be evidenced by abnormal response to pupil examination. When severe, it can even be noticed by the patient as a loss of central vision. This serious problem is often referred to as compressive optic neuropathy. Compressive optic neuropathy is usually treated immediately with oral steroids and planning is made for orbital decompression surgery. Occasionally, radiation treatments can aid in treating this problem. Although this is an uncommon problem, it is imperative that all patients with thyroid eye disease be evaluated on an ongoing basis.

Cosmetic Considerations
People with thyroid eye disease often have a characteristic stare related to eyelid retraction and the protrusion of the eye that occurs. Additionally, they may show significant orbital fat prolapse and fluid accumulation, which can account for significant bags around the eyelids. Every patient should understand that while thyroid eye disease can be very frustrating, it can also be treated. With patience and perseverance, together we can accomplish a lot to improve your comfort and appearance.

Teprotumumab (Tepezza) is a new biologic compound that inhibits insulin like growth factor 1 that is an important molecule that is involved in instigating thyroid eye disease.  This is a medication that is given intravenously over a course of 8 weeks.  This medication was FDA approved in early 2020 and has shown promise as a medical treatment to reverse some of the inflammatory findings of thyroid eye disease.

Smoking and Thyroid Eye Disease
While we do not have all the answers to the thyroid eye disease puzzle, we do have good evidence that patients with thyroid eye disease will exacerbate their problems if they smoke. Furthermore, patients who stop smoking, often benefit with an improvement in their thyroid eye disease. Smoking cessation will also improve the healing process should you require surgery.