YOUR JOURNEY TO RADIANT EYES BEGINS HERE

The BOTOX^® Craze
Commonly Asked Questions

INTRODUCTION

Despite recent marketing hype, BOTOX^® (Botulinum Toxin A) is neither new, nor a cure all. BOTOX^® was developed more than 20 years ago by an eye doctor to treat crossed eyes and muscle spasms around the eye. Although in my practice I have used BOTOX^® since 1985 for eyelid spasms (Blepharospasm, Hemifacial spasm), wrinkles and frown lines, many physicians have just recently “discovered” it’s many benefits. The list of conditions it has been found to benefit seems to be growing almost on a monthly basis.

BOTOX^® has become one of the most popular methods for treating frown lines and laugh lines in the eyebrow, forehead and eyelid area. The quick, painless treatment has no down time for healing, and produces marked improvement in wrinkles caused by dynamic contraction of facial muscles.

Exactly What is BOTOX^®?

BOTOX^® is the trade name for a neuro-toxin produced by a bacteria known as Clostridium. This bacteria is found worldwide in earth and water. Under certain low oxygen conditions, it activates and produces a protein called “botulinum toxin”. Such is the case when vegetable or meat products are contaminated by the bacteria and stored in an airtight container. If this contaminated food is ingested along with enough botulinum toxin, paralysis of various muscles throughout the body develops. This type of food poisoning is referred to as “botulism”. A purified version of the toxin in minute quantities (up to 500 times less than what would be needed to cause systemic symptoms) can weaken muscles when injected selectively into certain parts of the face.

How Does It Work?

When used in very small doses, BOTOX^® works by paralyzing the muscles that create frown lines, crow’s feet, and horizontal forehead wrinkles. BOTOX^® protein acts by preventing the release of a neurotransmitter (acetylcholine) at the nerve-muscle junction. Without acetylcholine the nerve cannot stimulate muscle contraction, and the overlying skin will therefore not wrinkle or fold. The result: smoothing of the overlying skin that lasts three to six months.

What Are The Side Effects?

It is very important to place the right amount of BOTOX^® in the right place. The side effects of BOTOX^® therapy are mild and self-limited and are more related to technique than toxicity. Occasionally a person may have some mild bruising or temporary swelling at the injection site. In less than 3% of patients, the upper eyelid may droop slightly, but this resolves as the drug is absorbed over the next few weeks. If a droopy eyelid does occur, an eye drop (Iopidine) is available to raise it. Having injected over 10,000 patients in the last 17 years, I am amazed at the low incidence of side effects with this product.

How Is The Treatment Performed?

BOTOX^® is administered through a small acupuncture-sized needle at those sites requiring wrinkle reduction. The crows feet usually require 3 to 6 injection sites per side while the forehead may require 9-12 injections (depending upon the number of lines) and the wrink les between the eyebrows 6-7 injections. Although discomfort is minimal, topical anesthetic cream can be applied prior to the injection for those patients desiring it.

How Long Does BOTOX^® Last?

Within 3 to 5 days of injection, the BOTOX^® has taken effect to weaken the muscles. The human body slowly breaks down the botulinum protein until it is inactive and normal muscle function returns. Facial lines stay smooth for 3 to 6 months before another round of injections is needed.

Does BOTOX^® Work In Everybody?

Almost everybody. On very rare occasions someone will have little or no response to the treatment. The lack of response is more likely due to in-adequate amounts of BOTOX^® given, or BOTOX^® administered in the wrong place due to lack of experience with the product. As a result the patient is unhappy and thinks the BOTOX^® did not work. It is very important to place the right amount of BOTOX^® in the right place. Following the first injection of BOTOX^® the patient should be seen in follow-up about 2 weeks later to be sure the dose given was the right amount for that particular patient. Some patients do require more than others. The Botox injection (dose and injection sites) should be customized for each patient.

What If I Want To Keep Some Facial Expressions?

Too much BOTOX^® will give the person a mask-like face. It is important to individualize BOTOX^® treatments and find out exactly what each individual would like. This can easily be done. Having some facial expression is important, as it is essential for communication. When properly injected, BOTOX^® will smooth frown lines, crows feet, furrowed brows and lines brought on by years of repetitive facial expressions.

Once I Start, Am I Committed To Using It?

No. You can try it, if you like it, have another when it wears off. If you want to wait for whatever reason, it’s okay to wait. Have another when you are ready.

What Are The Common Facial Areas That Can Be Treated With BOTOX^®?

• Vertical frown lines between the eyebrows
• Horizontal forehead lines
• Crows feet
• Unequal brow height
• Upper lip wrinkling
• Down turning of the mouth
• Bunny lines along the side of the nose
• Horizontal neck lines
• Vertical bands in the neck
• VerticalOther: excess underarm sweating, hand or foot sweating

Does BOTOX^® In One Area Cause Wrinkling In Adjacent Areas?

Generally not. When one area (ex. furrows between the brows) is treated, this area flattens out and becomes wrinkle free. Some patients will notice wrinkles in adjacent areas only because the area treated is so smooth. Thus, the wrinkles in other areas were actually there all along, it’s just that the patient is noticing them. Very occasionally, when a patient is trying to recreate a certain facial expression in an area with BOTOX^® on board, the adjacent areas may seem to fold more, in an attempt to make the lost expression. This situation could potentially cause more noticeable wrinkling in adjacent areas. This can easily be treated by slightly broadening the area of BOTOX^® injection so these adjacent muscles are also included in the BOTOX^® treatment as well.

What About BOTOX^® Parties?

BOTOX^® parties are frowned upon by most physicians.

BOTOX^® treatment should be customized to each patient’s desire and pattern of facial expression. The areas of injection should be discussed in a professional manner in an office setting with no outside influences acting. This is difficult to do in a social gathering where friends may be pressuring one another. Alcohol and BOTOX^® do not mix. Alcohol is a vasodilator. Injecting BOTOX^® into a patient with alcohol on board is potentially dangerous. With dilated vessels in the area of injection there is a greater risk for systemic absorption as well as an injection directly into the dilated vessels. Obtaining informed consent when the patient has alcohol on board invalidates the consent.

BOTOX^® is a powerful drug that should be administered with care and with the appropriate Doctor-patient relationship respected. A party atmosphere with socialization of the Doctor and patient violates the ethical responsibility of the physician.

Figure 1

Pre Botox injection – lots of vertical frown lines.

Figure 2

1 week post Botox injection – in the relaxed position → there are no vertical frown lines.

Figure 3

1 week post Botox injection – Patient is trying to frown but cannot. There are no vertical lines.

If you have any questions regarding the topics of this newsletter, or requests for future topics of InSight, please contact Dr. David R. Jordan office by telephone at (613) 563-3800.

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Cosmetic Eyelid Surgery

Commonly Asked Questions

INTRODUCTION

Your eyes are generally the first thing people notice about your face and are an important aspect of facial attractiveness. People with heavy or droopy eyelids are often perceived as being older than their age, tired, and of lower IQ than people with normal appearing eyelids.

The upper and/or lower eyelids become “droopy” or “baggy” over time as the eyelid skin stretches, muscles weaken and fat pockets bulge to become more prominent. This process most commonly occurs because of the aging process but also may be a hereditary condition that runs in ones family. Your eyebrows may also sag or droop as part of the same process.

As the excess skin and/or fat accumulates, the overall attractiveness of one’s eyes decrease leading to a tired and older appearance. When severe, these conditions may lead to an impaired field of vision (baggy upper eyelids) or difficulty wearing glasses (baggy lower lids).

When Should You Consider Cosmetic Eyelid Surgery?

Cosmetic eyelid surgery is a personal decision. Whenever you feel the excess lid skin and fat bags are affecting your facial attractiveness and the way you feel about yourself, it’s time to think about cosmetic eyelid surgery. Most people don’t start thinking about it until their forties, or fifties but it can be considered earlier or later depending upon the individual. From an anatomical standpoint as long as there is enough excess skin and fat to remove, make a visible difference, and, allow the eyelids to open and close properly, cosmetic eyelid surgery can be performed. The best time to do it is when the patient is motivated to have it done. It is an individual choice and each individual needs to make his/her own mind up with no outside pressure to do so.

What Are The Possibilities?

Upper Eyelids – in a surgical procedure known as blepharoplasty, incisions are made in the natural fold of the eyelids to remove excess skin, muscle or fat. Those incisions are then closed with very fine sutures so that, after healing, the surgical sites become virtually unnoticeable. This procedure relieves eyelid heaviness and unnecessary folds, leaving a smooth platform for makeup and a more youthful, energetic appearance.

Lower Lids – Blepharoplasty is also used to correct bulges or puffiness associated with the lower eyelids. Here, the incisions are made directly below the eyelashes to remove excess skin. If only fat and no skin needs to be removed, the incisions can be made behind the lower eyelids in a procedure known as transconjunctival blepharoplasty.

When Should The Brows Be Considered?

Male brows generally lay along the orbital rim or slightly lower while female brows generally are above the orbital rim or parallel to it. Once a female brow falls below the rim and a man’s well below the rim – brow elevation should be considered. If brow elevation is required but only the lids are done, the brows, postoperatively, may be pulled further downward into the lid. Many patients with low brows use their forehead muscles to keep the brows slightly elevated. Once the eyelid skin is removed the forehead muscles relax allowing the brows to fall. Some patients may complain following their upper eyelid surgery that there is little improvement post-operatively. What has actually happened is the eyebrows have fallen giving rise to a heavy eyelid appearance.

Is The Eyelid Surgery Covered By Health Insurance?

Health plans such as the Ministry of Health (OHIP) will only cover the eyelid skin removal on the upper lids if there is a 50% visual field restriction. The eyelid skin has to be covering the top of the pupil. Many people don’t get to this stage until their 70’s or 80’s. OHIP does not cover it simply because “it bothers you”, “you can see it in your field of vision”, or “it acts like a weight on the lid”. There must be a 50% visual field reduction for OHIP to cover it. OHIP will never cover eyebrow surgery even though the eyebrows are extremely low and may be contributing to a 50% visual field restriction.

What Is Involved In The Surgery?

Upper eyelid surgery is generally done under local anesthesia. The anesthesia is injected into the loose skin of the eyelid. Once frozen the excess lid skin ± fat is carefully removed. The incision is closed. The upper lids generally take 15 to 20 minutes per lid and it is not a painful procedure. The eyes are safe during the surgery.

Lower lids are slightly more involved and consume more time (average 1 to 1½ hours). The lower lids may be done under local anesthesia like the upper lids or may occasionally require intravenous sedation for nervous individuals. The eyes are safe during the procedure. Like the upper eyelids, the lower eyelid surgery is not painful.

What Is The Postop Care Routine And How Much Time Is Required Off Work Afterwards?

For upper and lower lids, rest with cool compresses placed over the eyelids every 3 to 4 hours are required to help with bruising and swelling in the first 3 days. In between these times the patient can be up but taking it easy. Thereafter, one can go out but should wear sunglasses as the lids will appear puffy and bruised. If one is too active in the first few days, bleeding could be stimulated which will prolong the recover and could have potential side effects to the eye. I generally recommend 1 week away from work or social gatherings when upper lids are done and 2 weeks when lower lids are done.

Is Cosmetic Eyelid Surgery Safe?

With any surgery there are risks and complications. If the surgery is being performed by an experienced individual preferably with a subspecialty in eyelid surgery, the chances of problems lessen significantly.

Anytime there is an incision in the skin there is a risk of infection. The risk is extremely small. Similarly, anytime there is a cut in the skin there is a risk of bleeding or bruising. This risk can be significantly decreased by avoiding Aspirin, blood thinners, anti-inflammatory medications,
Vitamin E, Ginko Biloba, etc. in the week before surgery as well as resting postoperatively with cool compresses over the lids. If bleeding occurs postoperatively for whatever reason and builds up in the eyelid, it may cause unsightly swelling, pain and potentially apply pressure to the eye which may then affect the vision if not attended to. Following postoperative instructions for rest and the use of cool compresses is extremely important. Scarring is uncommon and can be reduced by meticulous surgical techniques as well as careful post-op care with Vitamin E oil, topical steroid cream and silicone gel to the incision line. In most instances the upper lid incisions blends into the eyelid crease, while the lower lid incision hides just below the lashes. Slight asymmetry of the eyelids may occur if uneven amounts of skin are removed. This can be corrected easily with a small touch up performed generally at 3-4 months post-op. Vision should not be affected other than some mild blurring of vision post-operatively when ointment is being applied to the eyelid incision area and may get into the eye. Rarely, a change in glasses or contact lenses is required post eyelid surgery.

How Does One Avoid The “Wind Swept or Surprised Appearance”?

The best answer I can give is to have your eyelid surgery done by an experienced physician well trained in the eyelid area. In this day and age, there are many types of surgeons performing eyelid surgery including Ophthalmologists (Eye Doctors), Otolaryngologisrts (Ear/Nose/Throat surgeons), Plastic surgeons, General Practitioners, General surgeons, etc. Their training, however, is not the same. An Ophthalmologist with 1-2 additional years of subspecialty training in the eyelids is referred to as an Ophthalmic Plastic and Reconstructive Surgeon or an Oculoplastic Surgeon. An individual with training in this area generally does more eyelid surgery and has more knowledge of the eyelid anatomy than any of the other group of physicians doing this. Although this does not guarantee a lack of complications, it decreases the chance. Furthermore, Ophthalmologists are the only ones qualified to take care of the eye should the patient experience eye troubles following the eyelid surgery. It makes sense to have cosmetic eyelid surgery performed by the individual most qualified to not only do the eyelid surgery, but, also take care of the eye should any eye problems arise.

What Should You Look For In An Eyelid Surgeon?

A qualified individual who has many years of experience and who individualizes his eyelid surgery technique for each patient. Eyelids are not all the same and the surgeon that treats them this way is first one to avoid. Some people need skin removed, others skin and fat, others require brow elevation as well as skin and fat. Removing fat in lids that don’t actually require it will leave the eyelid area with a hollow appearance. Caucasian eyelids are different from Asian eyelids. If the Asian eyelid is treated like a Caucasian eyelid, the Asian patient develops a very unnatural appearance.

If you have any questions regarding the topics of this newsletter, or requests for future topics of InSight, please contact Dr. David R. Jordan office by telephone at (613) 563-3800.

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Cosmetic Enhancement in the Eyelid Area
Considerations and Possibilities

INTRODUCTION

As one ages, the upper and lower lid skin stretches, muscles weaken and fat pockets bulge. Aesthetically, such conditions may detract from the overall attractiveness of ones eyes and cause a “tired” or “older” appearance. This situation bothers some individuals more than others, and at different ages. There are a number of ways one can improve the appearance of the eye area, including surgical as well as non-surgical options.

What Are The Possibilities?

• Upper Eyelids – In a surgical procedure known as blepharoplasty, incisions are made in the natural fold of the eyelids to remove excess skin, muscle or fat. These incisions are then closed with very fine sutures so that, after healing, the surgical sites become virtually unnoticeable. This procedure relieves eyelid heaviness and unnecessary folds, leaving a smooth platform for makeup and a more youthful, energetic appearance.
• Lower Eyelids – blepharoplasty is also used to correct bulges, puffiness and wrinkles associated with the lower eyelids. Here the incisions are made directly below the eyelashes to remove excess skin. If only fat and no skin needs to be removed, the incisions can be made just behind the lower eyelids in a procedure known as transconjunctival blepharoplasty.
• Forehead Frown Lines – Vertical lines in the mid-forehead, usually called “frown lines”, can be eliminated or minimized through injection of minute quantities Botox™. Horizontal lines running across the forehead can also be treated in a similar fashion. Botox™ temporarily weakens the over-acting muscles that create these wrinkle lines for 3-9 months. A soft tissue filler such as Restylane is also beneficial to reduce the unwanted verticial lines between the eyebrows.
• Eyebrows – Droopy brows may be elevated through a procedure known as an eyebrow or forehead lift. Small incisions are made directly above the eyebrows or within the forehead creases. In a coronal brow lift, the incision is made at or just behind the hairline. In the endoscopic technique, several small incisions are placed in the scalp and the entire forehead is lifted using an endoscope. Botox™ may also be used to raise the eyebrows in selected patients.
• Sun Damage – The first step to treat photo damaged (sun damaged) skin is to stop the ongoing photo damage. It makes little sense to spend a lot of time and money to improve the quality of skin and then subject it to further damage from chronic ultraviolet (UV) light exposure. Your skin has the ability to repair itself if it is protected from continual damage. A sun blocker that protects from UVA (causes most of the aging and wrinkle changes) and UVB (causes skin cancer) is most beneficial. Most sun blocks have a rating for UVB protection but lack a rating for UVA protection. Study the label carefully or ask the pharmacist if there is UVA protection.

Skin damaged by the sun can be treated through the use of rejuvenative creams and lotions that minimize pigment spots and naturally thicken the skin to provide a more healthy and youthful appearance. A sun block started at any time in one’s life will help prevent further solar damage.

Cosmetic Eyelid Surgery – Should I Do It?

Removal of the excess skin and fat can restore a younger, more rested appearance but the surgery required is an individual decision. Patients should research the procedure through reading, internet, friends who have had it, as well as through consultation with a physician experienced in the field. It is important to then take some time and think over the advantages and disadvantages, risks, etc. The best time to consider cosmetic eyelid surgery is when the patient is truly ready and motivated to do it. It’s not a good idea if one is not sure, stressed out, going through a separation/divorce, or, experiencing another major life change. One shouldn’t feel outside pressure to have it.

Patient Expectations

Cosmetic eyelid surgery can remove some of the excess skin and fat and restore a more youthful and rested look. However, only so much tissue can be removed. It is important to leave enough skin behind to balance the rest of the face and most importantly allow proper eyelid closure. If the eyelids don’t close properly, eye irritation may occur which can be quite bothersome and lead to discomfort, tearing, photosensitivity, etc.

Choosing The Right Surgeon?

Eyelids are not the same. They are slightly different from person to person, race to race. One patient’s eyelids may require fat repositioning, while another patient may need fat resection, and a third may be in need of a special tightening effect of the lower eyelid. It is important to individualize the treatment plan for each particular patient’s needs.

Performing surgery in the area surrounding the eye requires a delicate hand, an artist’s vision and most importantly, extensive knowledge and specialized training. If you intend to see one or more surgeons before choosing one, there are questions you can ask to compare them. Examples:

What formal training have you had in cosmetic eyelid surgery

• A weekend course, a few cases as a resident?
• A formal, credentialed fellowship (usually 1 or 2 additional years), or other extended, advanced training in this area?
• A How long have you been performing cosmetic eyelid surgery?
• Are you credentialed by any recognized national organization?
• What are the complications of cosmetic eyelid surgery and are you trained to handle them or will you have to refer such complications to other physicians?
• If you need to refer, to whom do you send your patients?

For your information, Dr. Jordan served two additional years of fellowship training in Ophthalmic Plastic and Reconstructive Surgery with leading experts in the world in 1986 and 1987. This was after having fulfilled four years of medical school, a one-year internship and 3 years of residency training in Ophthalmology. Dr. Jordan has been performing cosmetic and reconstructive surgery in the eye region exclusively since 1986. He is credentiated by and is an active member of the American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) and is the only physician in the Ottawa area credentialed by this group.

Dr. Jordan will discuss with you all possible complications of your surgery. He is fully qualified to deal with any complications dealing with the eye or eyelid. Other surgeons routinely refer their eyelid complication cases to Dr. Jordan for management.

Tips For Successful Outcome:

1) Choose your surgeon carefully. Be sure he/she has lots of experience. Ideally they should have an additional training in the field of Ophthalmic Plastic and Reconstructive Surgery.

2) Review your concerns carefully with the surgeon and be sure the surgeon plans to individualize the surgery to your anatomy (i.e. not all eyelids are the same).

3) Follow post-op instructions carefully – give your body a chance to heal. Rest with ice packs in the first 48 hours is most important. If you are too active in the first few days, you may upset the healing process.

If you have any questions regarding the topics of this newsletter, or requests for future topics of InSight, please contact Dr. David R. Jordan office by telephone at (613) 563-3800.

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Blepharoplasty
For Functional and Cosmetic Indications

INTRODUCTION

Having eyelid surgery to remove excess skin and fat is referred to as a “Blepharoplasty”. Motivation for this type of procedure may be either functional or cosmetic.

Functional blepharoplasty

As one ages, the upper and lower lid tissues begin to relax. These nonspecific changes may be accelerated by sun exposure, allergies or recurrent swelling and consist of stretching or senile elastosis of the skin. In some individuals, this process may be hereditary. The result is an excess of eyelid tissue referred to as “dermatochalasis”. Stretching and relaxation of the orbital septum will allow prolapse of the orbital fat into the eyelids. As a result, a “fullness” to the lid develops which increases over time. This excess lid tissue creates a tired look, may cause the patient to look older than they actually are, and may cause a heavy feeling or weight on the lid. With time, the excess lid tissues in the upper lid may hang over the lid margin and cause a visual field restriction. Patients may describe it as “something sitting there”, “like wearing a baseball cap”, or “like a shadow at the side”. In the lower lid, the excess skin and fat do not cause as much of a problem but can occasionally affect the bifocal portion of the glasses. Patients with excess skin in the upper lids causing a visual field restriction or in the lower lid affecting the bifocal segment have a functional defect that can be alleviated by surgical removal of the skin, and fat, leading to an improved and more comfortable field of view.

Top figure – 48 year old female pre-op.

Bottom figure – Post 4 lid blepharoplasty.

Top figure – 70 year old male pre-op.

Bottom figure – Post 4 lid blepharoplasty

Cosmetic blepharoplasty

Your eyes are often the first thing people notice about your face and are an important aspect of facial attractiveness. Unfortunately, with age, the upper and lower eyelids become “droopy” or “baggy” in appearance. Aesthetically, such conditions may detract from the overall attractiveness of ones eyes and cause a “tired” or “older” appearance. This situation bothers some individuals more than others (female > male) and at different ages. Removal of the excess skin and fat can restore a younger, more rested appearance.

Preoperative consideration

A preoperative ophthalmologic examination is essential, to document the visual acuity, baseline tear function, tear film stability, strength of lid closure, symmetry of palpebral aperatures, previous lid incisions, etc. The pre-existence of dry eyes, residual facial palsy, lid closure problems from previous surgery or ptosis will have a definite bearing on the extent of the lid surgery.

For those considering surgery for functional reasons, a visual field test is required. If the visual field shows a reduced peripheral field of view, the surgery may be covered by OHIP. Preoperative photos may also be required for preauthorization.

In the cosmetic patient, it is essential to establish what they find bothersome in their appearance and what they expect surgery to accomplish. This process can be aided by handing the patient a mirror and asking them to point out what they would like corrected. Patients may point out skin discoloration, deep creases, cheek fullness and other features that may not be correctable by eyelid surgery alone.

Blepharoplasty is able to remove the bulges created by fat herniation and excess skin that is becoming redundant. Patients need to know they have to have some skin available to allow proper eyelid opening and closing. Enough skin has to remain to allow this. Many patients want “all” the fine lines removed on their lids (especially lower lids and crows feet). With skin removal by scalpel, the fine lines will diminish in their appearance but to remove them all, may prevent normal eyelid closure. Laser skin resurfacing is more effective in removing the fine lines than scalpel but even with laser it may not be possible to remove all of them. This is especially so in the crows feet area which may display a lot of wrinkling, especially with facial expression.

The goal of surgery is to remove excess wrinkles and fat. The patients look more alert and healthy, less tired and generally have a younger, more rested appearance. Surgery should allow the eyelids to open and close properly without any distortion or change in the natural almond-shaped lid contour and, with incisions that remain hidden.

Top figure – 45 year old female pre-op.

Bottom figure – Post 4 lid blepharoplasty

Top figure – 35 year old oriental male pre-op.

Bottom figure – Post upper lid blepharoplasty with re-creation of Caucasian lid fold.

Surgery

Many different specialists (of varying qualifications) perform this type of surgery including Ophthalmologists, Plastic Surgeons, Otolaryngologists and Dermatologists. Cosmetic (and functional) eyelid surgery is commonly performed by Ophthalmic Plastic and Reconstructive Surgeons who are Ophthalmologists that have completed one or two additional years specializing in treatment of problems that involve the eyelids, lacrimal system, orbit and adjacent facial structures. The complications associated with Blepharoplasty are eye related. It makes sense to have the surgery done by someone who has a thorough knowledge of the eye and is able to manage those potential eye problems that occasionally occur.

Blepharoplasty surgery is an out-patient procedure performed under local anesthesia, with sedation if desired. During surgery, incisions are made in the natural folds of the eyelid so they are almost invisible after proper tissue healing.

If only fatty tissue needs to be removed from the lower lids and not any skin, the surgery can be performed from behind the eyelid. This is known as “transconjunctival blepharoplasty”.

In cases where the eyebrows are also droopy, a procedure to elevate the eyebrow may be appropriate. This procedure, known as a “brow lift”, may be done directly above the eyebrow within the forehead creases or by an endoscopic approach.

After surgery

Following surgery, cold compresses for 3 to 4 days and antibiotic ointment, followed by warm compresses are used to help the healing process. Eye patches are not required. Discomfort is usually minimal and handled by acetaminophen. Aspirin containing compounds should be avoided because of their tendency to increase bruising. Most individuals will have swelling and some degree of bruising that will settle over the first 1 to 3 weeks. Patient healing however, is variable with some healing much quicker than others. Complete tissue healing usually occurs by 2 to 3 months. For upper lid blepharoplasty, one week off work is average while 2 weeks is best in those having 4 lid blepharoplasty. Makeup can be applied to help hide residual bruising after one week.

Complications

After surgery, the patient may temporarily experience minor discomfort, tightening or numbness of the lids, swelling, bruising and dryness of the eyes. The eyelid blink rate temporarily slows down after the surgery and, as a result, the eyes may have a gritty or sandy feeling. Artificial tears during the day and lubricating ointment at night are commonly used to keep the eyes moist during the healing process. As the incisions heal and the eyelid mobility returns to normal, these symptoms will usually resolve. Excessive pain, bleeding, and infection are very uncommon. Blurry vision may occur during the healing period as a result of the decrease in eyelid blink rate or ointment getting into the eye but should return to normal in one to two weeks. Loss of vision has been reported following this surgery but fortunately is extremely rare and very few blepharoplasty surgeons will ever encounter it. The exact incidence is unknown but is probably in the order of 1 in 2,500, (0.04%). The cause is usually deep orbital hemorrhage likely secondary to excess traction on the fat.

Once the healing process has settled (average 2 to 3 months), if there is any lid asymmetry, a touchup procedure may be required in less than 5% of patients.

SCALPEL vs. LASER

Both have advantages and disadvantages. In general, for the upper lids, there is really not much difference in the end result as the same amount of skin is being removed. For the lower lids if there is a lot of redundant skin, scalpel is beneficial. If there are mainly fine lines, laser is more effective. Laser on the lower lids may however, have a longer recovery period, depending on the skin type and laser used.

SUMMARY

Blepharoplasty surgery can provide both functional and cosmetic improvement with minimal risk of serious problems. Most patients are quite pleased with the results of their eyelid surgery.

If you have any questions regarding the topics of this newsletter, or requests for future topics of InSight, please contact Dr. David R. Jordan office by telephone at (613) 563-3800.

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Assessment of the Patient with Droopy Lids

INTRODUCTION

Droopy eyelids are common in the aging population and may involve one or both lids. What one physician refers to as a “droopy eyelid” how-ever, is not always what another is referring to. The drooping appearance may be due to: true “eyelid ptosis”(levator aponeurosis thinning or disinsertion), “excess eye-lid skin” (dermatochalasis),“brow ptosis”, “contralateral eyelid retraction”, “enophthalmos” (sunken eye) or, a combination of the above. The treatments for these various problems are different and it is essential to sort out which of the contributing factors are present in each individual so that an appropriate management plan can be organized

Eyelid Ptosis

Ptosis (pronounced “toe-sis”) of the eyelids refers to a drooping of the upper eyelid as a result of a problem with the eyelid elevating muscle (the levator). The lid droop may be minimal or it may droop to partially or completely cover the pupil and restrict the superior visual field [Figure 1].

Ptosis may be congenital or acquired. Congenital ptosis is present at birth and is commonly due to a dystrophic levator muscle while acquired ptosis develops with age. The commonest type of acquired ptosis is due to a thinning and/or disinsertion of the levator aponeurosis (that portion of the levator muscle which inserts onto tarsal plate). Other types of acquired ptosis are mechanical (due to a stye, chalazion or eyelid tumor), traumatic (blunt or surgical i.e. post cataract surgery), myogenic (i.e. myasthenia gravis), or neurogenic (i.e. Horners syndrome).

The treatment for eyelid ptosis (with the exception of myasthenia) involves an advancement of the levator aponeurosis onto the tarsal plate, with a resultant lifting of the eyelid.

Figure 1– True eyelid ptosis as a result of levator thinning. The eyelids are covering part of the pupil.

Excess Eyelid Skin (Dermatochalasis)

Excess eyelid skin that hangs over the eyelid margin also gives the eyelid a droopy appearance, but for a different reason than true eyelid ptosis. With dermatochalasis, it is the skin hanging over the lid margin that is responsible for the drooping appearance [Figure 2a]. The underlying eyelid height may be normal or low depending upon whether any true eyelid ptosis exists. The way to assess this situation is to gently raise the excess lid skin off the eyelid [Figure 2b] and measure the lid height either with a ruler or by shinning a light at the eye from a distance of 2 feet or so. A normal eyelid fissure height is generally about 10 mm. By shinning a pen light toward the patient from a two foot distance a light reflex is created on the cornea. The distance between the light reflex and the upper lid margin is termed the “margin to reflex distance” or MRD. The MRD is usually 4 mm. A value of 1 or 2 is abnormal and indicates a true ptosis of the eyelid is also present.

Figure 2–Excess eyelid skin responsible for drooping appearance of lids.

Figure 3– When the excess eyelid skin on the patient’s right upper lid is gently lifted, the true eyelid height is found to be at a normal level.

Treatment of dermatochalasis involves removal of excess skin and fat on the eyelid (blepharoplasty). The levator aponeurosis is not touched unless of course the patient has a true lid ptosis as well. In this latter situation the appropriate surgery would then involve a levator aponeurotic advancement in conjunction with removal of excess skin and fat (blepharoplasty).

Brow Ptosis

A man’s brow is generally more full, straighter and rests at level of the orbital rim, while a lady’s brow is thinner, curved and generally sits above the orbital rim.

As we age the fibrous connective tissue structures within our facial tissue becomes lax and as a result tissues begin to sag due to gravitational forces pulling downward. A gradual migration of the eyebrow inferiorly is a result of these aging changes. As the eyebrow moves downward the excess eyelid skin appears to be more than it actually is and gives rise to a droopy eyelid [Figure 3a]. This phenomenon can be assessed by finding where the brow is in relation to the orbital rim. If the aging male or female brow is sitting below the rim, gently elevating it to the rim level or slightly above will elevate some of the excess eyelid skin (that component contributed by the droopy brow) so that one can get an appreciation of the true excess eyelid skin and true eyelid height [Figure 3b].

Figure 3a– Severe brow ptosis giving a droopy appearance to lids. The brows are below the orbital rims.

Figure 3b– When the patients right brow is elevated to a normal level, the true eyelid height is found to be normal and there is only a small degree of excess lid skin (dermatochalasis).

It is extremely important to sort out whether the brows are playing a role in the “droopy eyelid”. If the patient with brow ptosis and excess lid skin simply has the eyelid skin removed, the droopy eyelid may not be corrected as the brows will still be low and may appear to be sitting in the upper lid. In fact, the brow droop may even appear more noticeable following the eyelid skin removal since removal of the lid skin may pull the brow further downward (into the lid). Sometimes brow elevation on its own, by lifting the excess lid skin upwards, is all that is needed to correct the so called droopy eyelid. More commonly the patient with brow ptosis has a combination of brow ptosis and excess lid skin. In this case brow elevation on its own will only partially correct the excess lid skin, and a brow elevation with upper lid skin/fat removal (blepharoplasty) is more appropriate. It is also possible for the patient to have brow ptosis, dermatochalasis and true lid ptosis all at once. In this situation the patient requires brow elevation, blepharoplasty, and levator advancement surgery. Simply doing one will not correct the others.

Brow elevation surgery can either be done immediately above the brow hairline, in the mid-forehead, along the temporal hairline or endoscopically behind the frontal hairline, depending upon the patient’s facial features.

Contralateral Eyelid Retraction

Sometimes a patient presents with a drooping upper lid that actually has a retracted opposite upper eyelid. This situation is most commonly due to unrecognized Thyroid eye disease (Grave’s disease). The so-called droopy eyelid is only droopy in comparison to the opposite lid which is actually retracted superiorly. The lid retraction may be partially hidden by excess skin [Figure 4a] (dermatochalasis) and only becomes apparent if the lid skin is gently lifted [Figure 4b]. This type of patient requires a thyroid work-up including a medical history looking for systemic signs, family history of others with thyroid disease and a TSH test. If all are negative they need to be followed for several months as lid retraction is occasionally the initial sign of thyroid eye disease, despite a normal TSH test. Systemic hyperthyroidism may not show up for months or years later.

Figure 4a– Patient presented with ptosis of her right upper lid. It is actually the left upper lid that is too high (partially hidden by excess skin).

Figure 4b– The left upper lid retraction becomes more obvious as one gently lifts the skin on the left upper lid upward by manually elevating the left brow.

Enophthalmos and Droopy Eyelids

Enophthalmos refers to a sunkeness of the orbital tissue. It is not uncommonly seen following a blow to the orbit causing an orbital fracture. The fractured bones allow an increase in the orbital volume and as a result the eye moves posteriorly. As the eye moves posteriorly the upper lid may fall creating a droopy lid appearance.

The droopy lid appearance is a direct result of the expanded orbital volume. This situation is often referred to as a pseudo-ptosis (a false ptosis since the lid isn’t the problem).
To correct the false eyelid ptosis one needs to correct the enophthalmos. Correction of the enophthalmos requires restoration of the orbital volume. During floor fracture repair the orbital tissue that is herniated into the maxillary sinus, is repositioned into the orbit. A plate of some variety (supra-mid, Teflon, porous polyethylene, titanium mesh) is used to cover the bony defect, prevent re-herniation of the tissue and allow a restoration of the orbital volume.

Enophthalmos may have a more sinister problem associated with it. It is not uncommon for metastatic breast cancer to show up in the orbit 20 years later (even following appropriate treatment of the breast cancer), with a pseudo-ptosis as the result of enophthalmos. The matastatic breast cancer cells create a fibrosing reaction within the orbital tissue. As a result the eye is pulled posteriorly (enophthalmos) and the eyelid falls giving the appearance of an eyelid ptosis [Figure 5].

Figure 5b– Patient has a ptosis involving her right upper lid as a result of a metastatic tumor in the right orbit pulling the eye back (enophthalmos).

Summary Examination of the patient with a “droopy eyelid” should involve an assessment of the:

1. Eyelid height (true ptosis and contralateral eyelid retraction)

2. Brow position

3. Eyelid skin (dermatochalasis)

4. Enophthalmos

Appropriate treatment can only be performed if the surgeon knows the contributing factors and corrects them.

If you have any questions regarding the topics of this newsletter, or requests for future topics of InSight, please contact Dr. David R. Jordan office by telephone at (613) 563-3800.

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