Cosmetic & Reconstructive
Eye, Eyelid & Facial
Aging & Facial Rejuvenation
Your eyes and area of the upper and midface are the focus of how the world sees you. During conversation there is more time spent looking in the area of the eyes than any other portion of the face. These areas can communicate your mood, demeanor and energy level to others. As we age, it is common for a number of changes to occur to the skin and the fat in this area. These changes lead to a deflation (loss of volume) and descent of the structures around the eyes. This may lead to the upper eyelids coming down over and covering the upper portion of the eye. This is often accompanied by the skin and soft tissue around your upper and lower eyelids stretching and further creating drooping or sagging of the eyelids. For some people this is made even more undesirable by orbital fat protruding through the lower eyelid resulting in “puffy bags” or dark circles on the lower eyelids. Others find that tissue volume around the eyes decreases to give the appearance of “hollowness.” These facial aging changes can occur as early as your twenties to early thirties and can become quite obvious in your forties, fifties and sixties.
If your eyes and forehead project the signs of aging due to overhanging skin and puffiness, dark circles under your eyes, crow’s feet, lines and wrinkles around your eyes or forehead, you may appear tired, older, less energetic and even sad or angry. This can be a problem in social and business settings. Conversely, if your eyes are more open and relatively free of creases and folds, you will probably seem more rested, alter and youthful. If your forehead shows signs of worry and stress, this too can make you appear fatigued. For these reasons, men and women of all ages, lifestyles and social groups, as well as those wishing to look ready, willing and able to perform well in the business setting, are interested in both surgical and non-surgical treatments for all types of facial changes.
BOTOX® Cosmetic, Injectable Gel Fillers & “Liquid Facelifts”
Wrinkles in the facial skin is due to contraction of the muscles that lie underneath. As the skin ages it loses elasticity allowing muscle contracture to produce wrinkles. BOTOX® Cosmetic Injections can dramatically improve your facial wrinkles by gently decreasing the contraction of the underlying muscle. During the BOTOX® Injection procedure, a small amount of BOTOX® is injected directly into the individual facial muscles that are responsible for creating wrinkles in the overlying skin to temporarily weaken them and prevent the pulling on the skin which helps to minimize diminish the wrinkles. Having BOTOX® Injections take only minutes and noticeable results can usually be seen within two to eight days. Our patients are able to return to work and wear makeup immediately after treatment. BOTOX® Cosmetic has the most dramatic effect on “expression wrinkles.” These are the frown lines or furrows found between the eyebrows, the horizontal forehead lines or furrows, and the crow’s feet around the eyes. The lines will be softened, but may not completely disappear. The effect of a single treatment will usually last three to four months, at which time another BOTOX® Injection may be required to continue seeing desirable results. The best way to find out if you are a good candidate for BOTOX® Cosmetic is to schedule a thorough evaluation and discussion so that we can determine if BOTOX® Cosmetic is right for you.
Injectable Gel Fillers
The aging face is also a result of loss of volume or deflation. Fat located beneath the skin (subcutaneous fat) decreases with age. This leads to sagging of the cheeks and prominent lines below the eyes. The volume lost with age can be replaced by gel fillers. These may be used either alone or in a layered approach with BOTOX® Cosmetic. Wrinkles may be grouped into two types: Dynamic wrinkles, which are formed when muscles contract, or Static wrinkles, which are lines or depressions that exist even when there is no muscle action or pull on the skin. Dynamic wrinkles are best treated with BOTOX® Cosmetic, whereas static wrinkles are best treated with substances that plump up and fill out the problem lines. These substances are known medically as “HA fillers” and include JUVÉDERM®, BELOTERO BALANCE® & Restylane®. These fillers are biodegradable and thus not permanent. They also have the added benefit of being reversible. Depending on your areas of concern we may suggest using only BOTOX® Cosmetic, JUVÉDERM®, BELOTERO BALANCE® or Restylane® or perhaps injecting a combination of the materials in order to achieve your desired results.
Liquid Facelifts for Facial Rejuvenation
The “liquid facelift” is an approach that blends the use of different non-surgical injectable facial rejuvenation treatments placed in the troublesome facial areas and layers to achieve a fresh, energetic more youthful appearance. A “liquid facelift” might include using BOTOX® Cosmetic to smooth dynamic wrinkles in the forehead area or to “lift” eyebrows slightly or even smooth crow’s feet and might also blend in the placement of gel fillers such JUVÉDERM®, BELOTERO BALANCE® & Restylane® to smooth fixed wrinkles and folds and “volumize” to add a firmer tighter look in the forehead, around the eyes or even in your cheeks or lips. Besides the quick and pleasing results, most men and women find the “liquid facelift” desirable because it is actually a “lunchtime” treatment so you can have it done on your lunch break with no downtime! We perform these treatments in the comfort, privacy and convenience of our office and you can be back to work and leisure activities almost immediately.
While the “liquid facelift” is effective for restoring, rejuvenating and maintaining a wide range of facial aging concerns, sometimes we might also recommend other types of treatment options including cosmetic eyelid surgery such as blepharoplasty “eye lifts” or forehead or eyebrow lifts to help you get the best results.
Blepharoplasty Eyelid for Droopy, Puffy, Saggy Eyelids
Blepharoplasty eyelid surgery is a popular type of cosmetic facial plastic surgery to help you look your best. In our society, looking your best and preserving your youthful features are important parts of who we are.
Upper Eyelid Blepharoplasty
Upper eyelid blepharoplasty involves the improvement of two characteristics of the aging upper eyelid area. The first is correction of excess skin of the upper eyelid, a condition referred to as “hooding of the upper lid.” The second condition that can be corrected is the puffiness that is seen in the inner corner and middle of the eyelid as a result of herniation or pushing forward of fat located in these areas above the eye.
Lower Eyelid Blepharoplasty
Lower eyelid Blepharoplasty is a procedure performed to improve the appearance of the lower eyelids, which is the anatomic area that extends from the lower lid eyelashes to the bony rim of the eye socket. If there is a herniation of fat present, there are two different surgical approaches to remove the fat. One technique utilizes an inconspicuous incision that runs just beneath the lash line. An alternative is to enter the fat pockets through an incision made in the inner lining of the lower eyelid. If excess skin needs to be removed, this can only be accomplished through an external approach. The procedure is long lasting and resets the clock decades.
Forehead & Eyebrow Lifts for Droopy Eyebrows, Frown Lines & Furrows
The normal aging process can affect the face in many areas-including the forehead and eyebrows. Forehead and eyebrow aging changes are sometimes hastened by a lot of sun and wind exposure or just by the pull of gravity. Aging of the forehead area and eyebrows can result in forehead furrows, “frown lines”, wrinkling across the forehead and a “heaviness” of the eyebrows making them a bit droopy. Sagging eyebrows can make you project a tired, sad or even grumpy appearance.
-About Forehead & Eyebrow Lifts
A forehead lift, or “browlift,” is a procedure that we use to restore a more youthful, refreshed look to the area above the eyes. The eyebrow is the foundation of the eyelid and as it descends it creates a fullness of the upper eyelid that may be unsightly. Some individuals with inherited low, heavy brows and deep set eyes with furrowed lines above the nose can also achieve a more alert and refreshed look with this procedure. A forehead or brow lift may be combined with eyelid surgery such as blepharoplasty to provide the best results for a more harmonious, youthful appearance. We find that sometimes patients who seek consultation for an upper eyelid blepharoplasty surgery find that a forehead lift better meets their personal appearance goals. The surgical objective of a browlift is to tighten excess loose skin, smooth forehead wrinkling and modify drooping brows in order to create a smoother brow and a more youthful expression. The primary goal, in most patients, is to rejuvenate the eyes, making them look more rested and youthful. Having a thorough and careful consultation will help us identify your areas of concern and personal goals.
When to Consider Forehead & Eyebrow Lifts
Patients who might find a brow lift beneficial are typically concerned about having a sad expression due to the outside of their brow sagging or those who have an angry expression because their central brow hangs or droops downward. Others who can benefit from brow lifts are unhappy with the presence of “frown lines” on their forehead, women who have difficulty applying makeup to their upper eyelid as the surface has been obscured by droopy skin and those who can see a pleasant improvement in appearance by gently lifting the skin above their eyebrows. For some, combining a brow lift with a blepharoplasty has a major benefit as it allows us to improve baggy tissue and crow’s feet providing a much happier overall look.
LATISSE® eyelash growth drop serum is an FDA approved treatment that can help you grow fuller, longer, darker lashes. Most people who are interested in their appearance know the value of having big, bright, beautiful eyes. While eye makeup alone may be able to help you achieve a fuller and longer look for your eyelashes, LATISSE® can actually help you grow fuller, longer eyelashes on your own! Your lashes are a big part of making your eyes more visible and adding that bright beautiful look to your appearance.
Lash enhancers have been used since ancient times to brighten the look of eyes. Today there are numerous eyelash cosmetics and treatments available to help you look your best. An option for those who want to fully benefit from these treatments is to make the most of their own natural lashes by enhancing their growth so that they are actually longer, fuller and darker. LATISSE® is a solution intended for use on the upper eyelid margins or the base of the eyelashes. It is a solution prescribed by a physician after an initial examination and consultation so that it can be determined if LATISSE® is a good choice for you. It is important to follow your physician’s instructions for LATISSE® use. You should make your physician aware of any side effects that may occur in a small number of patients so that they can be addressed. These can include itching and redness of the eye itself, eye irritation, darkening of the skin around the eye, dryness or redness of the skin around the eye. Make sure that you keep the appointments for follow-up visits with your physician so that they can be sure you are getting the results you desire and not experiencing any of the side effects mentioned.
LATISSE® is available from many physicians. Our eye physicians and surgeon are specialists in understanding your eyes and the delicate tissue around your eyes including your lashes, eyelid margins, and eyelids. They are specifically trained and experienced in the examination and treatment of these of these areas for your eye health and cosmetic appearance-and we are here to help you look your best!
Reconstructive Eye Surgery
Ectropion & Entropion Eyelid Position & Turning Problems
Ectropion is an eyelid position problem characterized by the eyelid turning outward interfering with the normal tear film functioning. Most often, ectropion results from the effects of aging and gravity so that lower eyelid stretches and become lax, no longer sitting in the proper position and rolling outward or drooping downward, so the white part of the eye may show beneath the cornea. Symptoms of ectropion can include irritation associated with drying out of the corneal surface as the tear film is no longer in the proper location and even excessive tearing. This can lead to further irritation and scarring of the tear drainage system. Fortunately, ectropion can most often be corrected with an outpatient eye surgery procedure by tightening the eyelid with a same-day surgical technique. Entropion is an eyelid position problem characterized by the eyelid turning inward causing the eyelashes and the skin of the eyelid can rub against the surface of the eye and cornea causing considerable irritation and even serious damage. The most common cause is a laxity of the lower eyelid as the aging process and effects of gravity occur. Most of the time, correction of this problem also requires a same-day surgical technique.
Eyelid Drooping & Ptosis
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. 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.
Facial Skin Tags & Lesions
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.
Eyelid & Facial 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.
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 & Drainage 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.
Thyroid Eye Disease
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.
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.
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.
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.