Dr. Nicholas J. Schmitt MD, Oculoplastic Surgeon

Treating Static and Dynamic Wrinkles There are two different types of rhytids (wrinkles): static and dynamic. Static wrinkles are those lines in the face that persist after muscle tension is relieved. Examples include, glabellar lines (vertical lines between the brows), perioral lines (upper lip and smile lines), nasolabial folds, dimples at the outer corners of the mouth, and frown lines (marionette lines). Static wrinkles do not respond to treatment with Botox, but rather, to hyaluronic acid fillers (Restylane and Juvederm). Dynamic wrinkles are those that are present only with muscle contracture. Examples include forehead ‘worry ‘lines, periorbital lines (‘crow’s feet’), ‘bunny lines’ around the bridge of the nose and occasionally glabellar creases. Dynamic wrinkles respond very well to Botox treatments. Often, dynamic wrinkles can become static lines through many years of muscle contraction and the thinning of skin that naturally occurs with aging the effects of sun damage. The glabella and upper lip lines are good examples of this. Thus, pre-treatment with Botox is required to prevent muscle contraction from deepening the creases further. Multiple treatments of Botox before filler is best, as often these persistant lines soften with time, obviating the need for filler in this region. Another example of pre-treating a static wrinkle with Botox is the softening of the depressor anguli oris action at the outer corners of the mouth. This elevates the outer corners of the mouth as well as making the melomental fold (frown line) appear less depressed. Dermal filler can then be injected to fill-in remaining marionette (frown) lines. Static and Dynamic Wrinkles There are two different types of rhytids (wrinkles): static and dynamic. Static wrinkles are those lines in the face that persist after muscle tension is relieved. Examples include, glabellar lines (vertical lines between the brows), perioral lines (upper lip and smile lines), nasolabial folds, dimples at the outer corners of the mouth, and frown lines (marionette lines). Static wrinkles do not respond to treatment with Botox, but rather, to hyaluronic acid fillers (Restylane and Juvederm). Dynamic wrinkles are those that are present only with muscle contracture. Examples include forehead ‘worry ‘lines, periorbital lines (‘crow’s feet’), ‘bunny lines’ around the bridge of the nose and occasionally glabellar creases. Dynamic wrinkles respond very well to Botox treatments. Often, dynamic wrinkles can become static lines through many years of muscle contraction and the thinning of skin that naturally occurs with aging the effects of sun damage. The glabella and upper lip lines are good examples of this. Thus, pre-treatment with Botox is required to prevent muscle contraction from deepening the creases further. Multiple treatments of Botox before filler is best, as often these persistant lines soften with time, obviating the need for filler in this region. Another example of pre-treating a static wrinkle with Botox is the softening of the depressor anguli oris action at the outer corners of the mouth. This elevates the outer corners of the mouth as well as making the melomental fold (frown line) appear less depressed. Dermal filler can then be injected to fill-in remaining marionette (frown) lines. Static and Dynamic Wrinkles There are two different types of rhytids (wrinkles): static and dynamic. Static wrinkles are those lines in the face that persist after muscle tension is relieved. Examples include, glabellar lines (vertical lines between the brows), perioral lines (upper lip and smile lines), nasolabial folds, dimples at the outer corners of the mouth, and frown lines (marionette lines). Static wrinkles do not respond to treatment with Botox, but rather, to hyaluronic acid fillers (Restylane and Juvederm). Dynamic wrinkles are those that are present only with muscle contracture. Examples include forehead ‘worry ‘lines, periorbital lines (‘crow’s feet’), ‘bunny lines’ around the bridge of the nose and occasionally glabellar creases. Dynamic wrinkles respond very well to Botox treatments. Often, dynamic wrinkles can become static lines through many years of muscle contraction and the thinning of skin that naturally occurs with aging the effects of sun damage. The glabella and upper lip lines are good examples of this. Thus, pre-treatment with Botox is required to prevent muscle contraction from deepening the creases further. Multiple treatments of Botox before filler is best, as often these persistant lines soften with time, obviating the need for filler in this region. Another example of pre-treating a static wrinkle with Botox is the softening of the depressor anguli oris action at the outer corners of the mouth. This elevates the outer corners of the mouth as well as making the melomental fold (frown line) appear less depressed. Dermal filler can then be injected to fill-in remaining marionette (frown) lines. Static and Dynamic Wrinkles There are two different types of rhytids (wrinkles): static and dynamic. Static wrinkles are those lines in the face that persist after muscle tension is relieved. Examples include, glabellar lines (vertical lines between the brows), perioral lines (upper lip and smile lines), nasolabial folds, dimples at the outer corners of the mouth, and frown lines (marionette lines). Static wrinkles do not respond to treatment with Botox, but rather, to hyaluronic acid fillers (Restylane and Juvederm). Dynamic wrinkles are those that are present only with muscle contracture. Examples include forehead ‘worry ‘lines, periorbital lines (‘crow’s feet’), ‘bunny lines’ around the bridge of the nose and occasionally glabellar creases. Dynamic wrinkles respond very well to Botox treatments. Often, dynamic wrinkles can become static lines through many years of muscle contraction and the thinning of skin that naturally occurs with aging the effects of sun damage. The glabella and upper lip lines are good examples of this. Thus, pre-treatment with Botox is required to prevent muscle contraction from deepening the creases further. Multiple treatments of Botox before filler is best, as often these persistant lines soften with time, obviating the need for filler in this region. Another example of pre-treating a static wrinkle with Botox is the softening of the depressor anguli oris action at the outer corners of the mouth. This elevates the outer corners of the mouth as well as making the melomental fold (frown line) appear less depressed. Dermal filler can then be injected to fill-in remaining marionette (frown) lines.

2009-12-13T13:55:00.000-08:00

There are two different types of rhytids (wrinkles): static and dynamic. Static wrinkles are those lines in the face that persist after muscle tension is relieved. Examples include, glabellar lines (vertical lines between the brows), perioral lines (upper lip and smile lines), nasolabial folds, dimples at the outer corners of the mouth, and frown lines (marionette lines). Static wrinkles do not respond to treatment with Botox, but rather, to hyaluronic acid fillers (Restylane and Juvederm).

Dynamic wrinkles are those that are present only with muscle contracture. Examples include forehead ‘worry ‘lines, periorbital lines (‘crow’s feet’), ‘bunny lines’ around the bridge of the nose and occasionally glabellar creases. Dynamic wrinkles respond very well to Botox treatments.

Often, dynamic wrinkles can become static lines through many years of muscle contraction and the thinning of skin that naturally occurs with aging the effects of sun damage. The glabella and upper lip lines are good examples of this. Thus, pre-treatment with Botox is required to prevent muscle contraction from deepening the creases further. Multiple treatments of Botox before filler is best, as often these persistant lines soften with time, obviating the need for filler in this region. Another example of pre-treating a static wrinkle with Botox is the softening of the depressor anguli oris action at the outer corners of the mouth. This elevates the outer corners of the mouth as well as making the melomental fold (frown line) appear less depressed. Dermal filler can then be injected to fill-in remaining marionette (frown) lines.

What is Ptosis (Droopy Eyelid) and How is it Treated?

2009-11-07T10:23:00.001-08:00

Ptosis (pronounced to'sis) simply means droopy eyelid. It is one of the most common eyelid problems. The lid may droop slightly, or cover the entire pupil, which can restrict and even block normal vision. It can be present in children and adults, and is usually treated with surgery.

There is a difference between a droopy eyelid and a baggy eyelid. A droopy eyelid is low. A baggy eyelid (dermatochalasis) has excess skin and fat. The two often occur at the same time in adults.

Ptosis can be inherited, be present at birth, occur later in life, and affect one or both eyelids. Signs and symptoms include: the drooping lid itself, looking up underneath drooping lids (a "chin-up posture"), raising the eyebrows in an attempt to lift the lids, loss of interest in reading due to forehead muscle fatigue, and headaches due to forehead muscle fatigue.

The most common cause of ptosis in adults is the separation of the levator muscle from the eyelid. This may occur due to aging changes, after an injury to the eyelid, after eye surgery such as cataract surgery, or with an eyelid tumor. Less commonly, ptosis in adults may occur with neurological disorders. Additional testing is performed to help diagnose these conditions.

Treatment is usually surgical and involves tightening of the levator (lifting) muscle within the eyelid (external levator advancement). This is performed as a same day surgery with light sedation and local anesthesia. If necessary, a blepharoplasty is performed first. Otherwise, a small incision is made in the natural upper lid skin crease. The levator muscle is tightened using a small, permanent suture. The patient is asked to open her eyes so that lid height, symmetry, and contour can be assessed.

It is important for the patient to be alert during this part of the surgery to give the best results. Further adjustments are made, if necessary. The incision is closed using a fine absorbable suture. The patient is seen for a postoperative visit 1 week later. Sometimes, the lid height will need adjusting at that visit, which is comfortably performed in the office under local anesthesia.

Causes and Treatment of Tearing of the Eye

2009-11-07T10:20:00.000-08:00

Tearing can be a difficult problem for both patient and doctor alike. Tearing, which is the actual spilling of tears down the cheek, differs from "watering," where tears well up without spilling down the cheek. The distinction between tearing and watering is important, because tearing implies a partial or complete blockage somewhere along the tear drainage system, such as a nasolacrimal duct obstruction (a plumbing problem). Watering implies a problem with the eyelids or the tear film. Watering eyes can be caused by eyelid malpositioning, such as ectropion (out-turned lid) and entropion (in-turned lid). In either case, the lower punctum (opening in the lower eyelid to collect tears) is not in the proper position to collect the tears.

It is important to understand that multiple factors can simultaneously contribute to tearing: tear film abnormalities, eyelid malposition, and nasolacrimal duct obstruction. Thus, a thorough exam in the office is necessary to determine which factors contribute to a patient's tearing problem.

The tear film is composed of three layers: outer (oil) layer, middle aqueous (water) layer, and inner layer (mucin) layer. The oil layer serves to keep the middle aqueous layer from evaporating. The mucin layer acts as a lubricant on the ocular surface. A deficiency in any or all of these layers can lead to eye irritation and watering.

Tears are primarily made from the lacrimal gland, which is located in the outside corner of the orbit (eye socket). Tears are distributed over the ocular surface with each blink, much like a windshield wiper on a car's windshield. The tear film is an important component of the eye's optical system. Thus, an abnormality of the tear film can cause blurry vision as well as irritated, dry eyes and reflex tearing.

The tear drainage system begins at the inner corner of the upper and lower eyelids. Small openings called puncta on the inner margins of the lids collect the tears, which then drain through passageways called canaliculi into the nasolacrimal sac. The sac is located between the inner corner of the eyelids and the bridge of the nose. The nasolacrimal sac empties in the nasolacrimal duct, which is a bony passageway into the nose. Tears are then swallowed.

A blockage can occur anywhere along the drainage system, from the puncta to the canaliculi, to the nasolacrimal sac and finally the nasolacrimal duct into the nose.

If only the punctal openings are blocked, a simple procedure called a punctoplasty is performed in the office under local anesthesia. More often, though, a blockage exists further downstream, usually in the nasolacrimal duct.

Examination in the office is used to determine where along this pathway a blockage may exist in a patient with tearing.

Dacryocystitis (infection of the tear sac) may occur with a nasolacrimal duct obstruction. Symptoms can range from mild redness and irritation on the inside corner of the eyelids to a severe cellulitis requiring emergent care. Antibiotics are used in the short term, but ultimately a dacryocystorhinostomy (DCR) is necessary to prevent the infection from recurring.

A procedure called a dacryosystorhinostomy, otherwise known as a DCR, is used to alleviate tearing caused by a nasolacrimal duct obstruction. Dacryocysto means "tear sac", and rhinostomy means "opening to nose." The purpose of a DCR is to create a new pathway for the tears to enter the nose directly from the nasolacrimal sac, effectively bypassing the blocked nasolacrimal duct. This is accomplished through a small incision near the inside corner of the eyelids. The incision is hidden in a skin crease, and scarring is rarely an issue. A new connection is made between the nasolacrimal sac and the nose, thus allowing tears to directly enter the nose. A DCR is a same-day surgery under local with sedation and local anesthesia.

Recent Advances in Cosmetic Eyelid Surgery (Blepharoplasty)

2009-11-07T10:19:00.000-08:00

Blepharoplasty (Blepharo- means "eyelid", and -plasty means "change") is the most commonly performed facial plastic surgery procedure. This is because the eyelids account for a large part of the expressiveness of the face. When you look at someone, you look at his or her eyes. If the eyelids are sagging, droopy, or puffy, the face will look fatigued, sad, and tired despite good health and adequate rest. If the eyes look bright and alert, an otherwise aging face will appear rejuvenated. Thus, blepharoplasty is a procedure that can rejuvenate the face as well as the eyes.

Years ago, treatment focused on aggressive skin and fat removal on every patient. This approach lead to unnecessary complications, such as lid retraction after excessive skin removal, causing chronically irritated eyes, and a sunken (skeletonized) appearance to the eye socket after excessive fat removal. These results, unfortunately, created a more aged appearance - the direct opposite what was intended.

Today, blepharoplasty is tailored individually for each patient. The right combination of skin removal, skin resurfacing, fat removal, fat repositioning, and lid tightening is applied to achieve a more rejuvenated and youthful appearance in each individual patient. Sometimes, less is more.

Modern day upper lid blepharoplasty is typically performed as a same day surgery under light sedation and local anesthesia. An incision is made in the natural upper-lid skin crease, across the lid. Excess skin is removed using an advanced electrocautery device with the precision of a laser. Bulging orbital fat may be removed, sculpted, or repositioned. Lateral sub-brow fat that contributes to upper lid fullness may be removed and/or sculpted. The incision is closed using a fine, absorbable suture.

Modern day lower-lid blepharoplasty is performed to soften the puffiness of the lower eyelids caused by prolapsed orbital fat. An incision is made across the length of the inside of the lower lid to remove or sculpt the fat (transconjunctival blepharoplasty). Fat may be repositioned to improve a tear trough deformity. Excess skin is removed, if necessary. Lower lid laxity or droop may be simultaneously corrected. Blending of the lid-cheek junction is performed with a lateral canthoplasty and orbicularis muscle suspension.

What is Non-Specific Orbital Inflammation (NSOI)

2009-11-07T10:12:00.000-08:00

Nonspecific orbital inflammation (NSOI), also known as psuedotumor, is disease of the eye that not uncommonly presents to the emergency room or ophthalmologist. Typically, its onset is acute and manifests with severe orbital pain, swelling around the eyes, limitation and pain with eye movements, and even loss of vision. It is easily confused with infection (pre-septal or post-septal eyelid cellulitis) and may be treated initially --and unsuccessfully-- with antibiotics.

Computed tomography of the orbits may reveal thickening of the extraocular muscles, stranding of the orbital fat, a poorly defined mass (hence the name "pseudotumor"), thickening of the sclera, soft tissue inflammation in the eyelids, or even nothing at all. NSOI can affect children as well as adults. Typically, it responds very quickly to high dose corticosteroids. In fact, this rapid response usually confirms the diagnosis. Atypical presentations warrant further testing, including blood tests and tissue biopsy.

NSOI is so named because of the way a biopsy of affected tissue appears microscopically. There is a scattering of plasma cells, lymphocytes, neutrophils, and histiocytes with no particular pattern. The differential diagnosis for pseudotumor includes the following: thyroid-associated orbitopathy (Graves' disease), non-infectious granulomatous inflammation (specific orbital inflammation such as Wegener's granulomatosis and sarcoidosis), infectious orbital inflammation (bacterial, fungal, and parasitic), lymphocytic inflammation (Sjogren's syndrome and Kimura's disease), xanthogranulomatous and histiocytic inflammations (non-Langerhans cell histiocytosis and Langerhans cell histiocytosis), fibrotic inflammation (idiopathic sclerosing orbital inflammation and chronic dacryocystitis), and amyloid deposition.

The treatment for NSOI is immunosuppression. Typically, high dose oral prednisone at 60-80 mg a day is tapered over a long period of months. Occasionally, patients may become steroid dependent and unable to be weaned from the prednisone without relapses. Alternative treatments include other forms of immunosuppression, such as methotrexate and immunomodulators such as infliximab. Irradiation of the orbit is also an option, although a tissue diagnosis should be obtained before pursuing radiation treatment. Irradiation is contraindicated in patients with diabetes, due to potential worsening of diabetic retinopathy.

Ptosis in Children

2009-10-08T00:10:00.000-07:00

Ptosis (pronounced to'sis) simply means droopy eyelid. It is one of the most common eyelid problems. The lid may droop slightly, or cover the entire pupil. Ptosis can restrict and even block normal vision. It can be present in children and adults, and is usually treated with surgery.
When ptosis is present at birth, it is called "congenital ptosis." For moderate to severe cases, treatment is necessary to allow for normal vision development. If congenital ptosis is not corrected, amblyopia (lazy eye) may develop, which, if left untreated, can lead to permanent loss of vision.
Congenital ptosis is often caused by poor development of the levator muscle (the muscle that lifts the eyelid). It is usually an isolated problem, but may also be associated with eyelid tumors, muscular diseases, strabismus (eye movement abnormalities), neurological disease, or refractive error (need for eyeglasses).
Congenital ptosis is treated differently depending on severity and the strength of the levator muscle. If the ptosis is severe, the levator muscle is tightened when the levator muscle's strength is fair to good. When the levator muscle is extremely weak, the eyelid can be suspended from under the eyebrow (frontalis suspension) so that the forehead lifting muscles can do the lifting. If the ptosis is mild to moderate, surgery is usually not needed early in life, and may be delayed until the child is older.
Ideally, ptosis correction is best performed with the patient awake with mild sedation and local anesthesia (monitored anesthesia care), as apposed to being asleep (general anesthesia). This is because real-time adjustments can be made after asking the patient to open his eyes and assessing the eyelid height. Otherwise, post-operative adjustments require another trip to the operating room. If the ptosis is mild enough, delaying surgery until the patient is old enough to have it under monitored anesthesia care is often recommended.

How Are Ectroprion and Entroprion of the Eyelid Different and How Are They Treated? How Are Ectroprion and Entroprion of the Eyelid Different and How Are They Treated?

2009-10-08T00:09:00.000-07:00

Ectropion refers to an out-turned lower eyelid and can occur for three different reasons. The most common is age-related involutional ectropion, where there is excessive laxity in the bottom lid. The next most common type is paralytic ectropion, where there is partial or complete paralysis of the facial muscles, such as after a stroke or from Bell's palsy. The third type is cicatrial (scarring) ectropion, caused by trauma related scarring or skin diseases with tightening of the skin. Symptoms include tearing, mattering of the lashes, irritation, and erythema (redness) of the eye's bottom lid.
Involutional (age-related) and paralytic ectropion are repaired by tightening. A small incision is made in the outer corner of the bottom lid, which is tightened and reattached just inside the lateral orbital rim -- like a "nip and tuck." This is performed as a same day surgery with light sedation and local anesthesia. Cicatricial ectropion is a bit more complicated to repair. Sometimes, a skin graft is required.
Entropion refers to an in-turned bottom lid, where the lashes are rubbing against the eyeball. This can be quite irritating to a patient, and, if left untreated, can cause permanent damage to the cornea and loss of vision. Involutional (age related) is the most common type of entropion. This is caused by vertical laxity in the lower lid retractors (muscles that pull the lower lid down and back) combined with horizontal laxity in within the lower lid.
Symptoms include chronic redness, irritation, tearing, foreign body sensation, and loss of vision.
Entropion repair is performed as a same-day surgery with light sedation and local anesthesia. Treatment is aimed at tightening the lower lid retractor muscles through a small incision just beneath the lower lashes. An additional lower lid tightening procedure is performed through a small incision at the outer corner of the eyelids. The incisions are closed with fine absorbable sutures.
Ectropion refers to an out-turned lower lid. Ectropion can occur for three different reasons. The most common is age-related involutional ectropion, where there is excessive laxity in the lower lid. The next most common type is paralytic ectropion, where there is partial or complete paralysis of the facial muscles, such as after a stroke or from Bell's palsy. The third type is cicatrial (scarring) ectropion, caused by trauma related scarring or skin diseases with tightening of the skin.
Symptoms include: tearing, mattering of the lashes, irritation, and erythema (redness) of the lower lid
Involutional (age-related) and paralytic ectropion are repaired with a lower lid tightening procedure. A small incision is made in the outer corner of the lower eyelid, and the lower eyelid is tightened and reattached just inside the lateral orbital rim. Think of it as a "nip and tuck" for the lower eyelid. This is performed as a same day surgery with light sedation and local anesthesia. Cicatricial ectropion is a bit more complicated to repair. Sometimes, a skin graft is required.
Entropion refers to an in-turned lower eyelid, where the lashes are rubbing against the eyeball. This can be quite irritating to a patient, and if left untreated, can cause permanent damage to the cornea and loss of vision. Involutional (age related) is the most common type of entropion. This is caused by vertical laxity in the lower eyelid retractors (muscles that pull the lower lid down and back) combined with horizontal laxity in within the lower eyelid.
Symptoms include, chronic redness, irritation, tearing, foreign body sensation, and loss of vision.
Entropion repair is performed as a same-day surgery with light sedation and local anesthesia. Treatment is aimed at tightening the lower lid retractor muscles through a small incision just beneath the lower lashes. An additional lower lid tightening procedure is performed through a small incision at the outer corner of the eyelids. The incisions are closed with fine absorbable sutures.

What is Thyroid-Associated Orbitopathy (Graves Disease) And How is it Treated?

2009-10-08T00:07:00.000-07:00

Thyroid-associated orbitopathy (TAO), also known as thyroid eye disease (or Graves' eye disease) is the most common specific inflammatory condition affecting the orbit (eye socket) and periorbital tissues. The management of TAO involves both surgical and medical components.
TAO is associated with Graves' thyroid disease, and can present at any time in the course of the disease, whether the patient is in a euthyroid (normal thyroid), hypothyroid (underactive), or hyperthyroid (overactive) state.
The cause of TAO is unknown. In theory, the immune system promotes inflammation directed at the structures around the eye. Extraocular muscles (muscles that move the eye) are the primary site of inflammation. Orbital fat and eyelid muscles are also commonly involved.
Demographically, TAO is most prevalent among middle-aged Caucasian women, though it occurs in all races. It is particularly rare among Asians. Though less often affected, men tend to have a more severe course than women.
There are two phases of thyroid-associated orbitopathy. The active, inflammatory phase may last from 6 months to 5 years. Signs and symptoms change or progress over weeks to months. The non-active, post-inflammatory phase begins once the signs and symptoms have remained stable for at least 6 months.
Signs and symptoms of active thyroid-associated orbitopathy include: eyelid retraction (particularly lateral flare) causing "thyroid stare", dry eye syndrome, periorbital edema (swelling), conjunctival swelling (boggy, wet eyes), restrictive strabismus with double vision, proptosis (bulging eyes), and vision loss due to compressive optic neuropathy (damage to the optic nerve - the optic nerve connects the eye to the brain).
The active phase of thyroid associated managed by corneal lubrication (artifical tears), oral corticosteriods (prednisone), corticosteriod injections to the orbit, orbital radiation, and, in the rare case of optic nerve compression, orbital decompression.
Generally, surgical management is reserved for the post-inflammatory or non-active phase of the disease, except when vision-threatening disorders (e.g., optic neuropathy or severe corneal exposure) are present.
The signs and symptoms of the non-active phase include eyelid retraction, exposure keratopathy, restrictive strabismus (tightness and pulling sensations when moving the eyes causing double vision), proptosis and compressive optic neuropathy with vision loss.
If mild to moderate, management may only require artificial tears. If more severe, then surgery is usually required. Surgical management of TAO must follow a staged sequence of procedures:

Orbital Decompression
Strabismus Correction
Correction of Eyelid Retraction

Because of the variable nature of TAO, surgery to correct disease-related functional abnormalities is carefully timed and individualized. Though not all stages are necessary for every patient, orbital decompression is performed first, followed by strabismus correction, and, finally, correction of lid retraction.

1. Orbital Decompression
Orbital decompression, if required, is performed first in the surgical staging of TAO. There are several indications for orbital decompression in patients with TAO: compressive optic neuropathy, exposure keratopathy due to proptosis, orbital pain, elevated intraocular pressure, and cosmetic deformity.
Orbital decompression in TAO is achieved by removal of orbital bony wall and/or orbital fat. Removing portions of one or more of the bony walls of the orbit expands the volume available to the orbital fat and extraocular muscles.
Typically, a balanced orbital decompression is performed, which involves removal of the lateral orbital wall (outside wall) and medial orbital wall (inside wall), along with orbital fat. An orbital surgeon removes the lateral wall through a superior eyelid crease incision, and an otolarygologist removes the medial wall by an endoscopic approach through the nose. Usually, both procedures are during the same surgery. This is a major operation requiring general anesthesia and usually an overnight hospital stay.
2. Strabismus Correction
The goal of surgical therapy is not to eliminate double vision entirely, but, rather, to move the region of single binocular vision into a more functional area (straight ahead and down). Because of the unpredictable nature of restricted extraocular muscles, surgery is usually performed with adjustable sutures. Adjustable sutures allow the alignment of the eyes to be fine-tuned in the postoperative period -- when the patient is awake and alert, thus improving the final surgical outcome.
3. Correction of Eyelid Retraction
Upper lid retraction can cause dry-eye symptoms and corneal exposure, and may even induce a corneal ulcer due to inadequate lid closure. It also contributes significantly to cosmetic disfigurement. Due to the tendency for spontaneous improvement, surgery for isolated upper lid retraction is usually performed only after at least one year of observation.
Eyelid retraction surgery is performed after decompressive and strabismus surgeries have been completed and the lid position has been stable for six months or more.
Upper lid retraction is corrected with a levator recession operation. The levator muscle (muscle that lifts the eyelid) is lengthened, thus allowing the upper lid to cover more of the eye. One can think of this operation as the opposite of a ptosis (drooping eyelid) repair.
Lower eyelid retraction is a common problem in TAO' patients. Patients with lower eyelid retraction complain of tearing, dryness, and foreign-body sensation. They frequently have evidence of exposure keratopathy. The most commonly used method of elevating the lid involves placing a tissue spacer within the back surface of the eyelid, thus effectively elongating the lower lid.

How does the face age?

2009-09-06T21:12:00.000-07:00

How does the face age?

The face ages through what I call the “3 D’s – decent, deflation, and demarcation. UV damage to the skin, loss of collagen in the dermis, loss of subcutaneous fat, and loss of bone density contribute to the 3 D’s. It is important to understand what is wrong before beginning a treatment regimen. A therapeutic technique must address the underlying anatomic basis for the cosmetic problem.

It is useful to break the face down into 3 aesthetic regions. The upper third includes the hairline to the glabella (brows), the middle third includes the glabella to the nose, and the lower third from the nose to the chin.

Aging changes in the upper third include brow ptosis (droop), glabellar creases between the brows, and forehead rhytids (wrinkles). A surgical brow lift is often needed to correct brow ptosis. However, in mild cases of brow ptosis, Botox can provide an excellent brow lift without the down-time of surgery. Botox works very well for forehead and glabellar creases. Sometimes, a dermal filler such as Restylane or Juvederm is needed to fill in persistent glabellar creases.

Aging changes in the middle third of the face include baggy and excessive eyelid skin, eyelid ptosis (droop), puffy or sagging lower lids. These changes are best addressed surgically through an upper and lower lid blepharoplasty. In some patients, hollowing of the lower lids occurs with demarcation of the lower rim of the orbit (eye socket) or a depression near the side of the nose called a tear trough deformity. These patients are best served by adding volume to this area with dermal fillers. Prominent nasolabial folds (laugh lines) are also treated very effectively with dermal fillers. Nasal tip ptosis (downward pointing of the nose) develops due to loss of structural support around the nasal alae. Again, dermal fillers work very well at correcting this deformity by increasing volume and support in this area.

Aging changes to the lower third of the face include jowls (pronounced melolabial folds) and loss of lip volume. Loss of lip volume presents as lip ptosis (curling in of the lips) with loss of the vermillion (red) border, a poorly defined “cupid’s bow”, and loss of the upper and lower “pillows”. Fine vertical lines become more prominent. Dermal fillers are ideal choices for correcting both melolabial folds and lip enhancement.

What are dermal fillers and how do they work?

2009-09-04T16:35:00.000-07:00

Dermal fillers are injectible, soft tissue implants that can be permanent, semi-permanent, and temporary. They are used to replace lost volume after age or disease-related bone, fat, and collagen loss. They can be used in many different aesthetic regions throughout the body, especially the face and hands. This discussion will focus on the application of dermal fillers to the face.

Permanent fillers, such as silicone, are rarely used in the face. At first it may seem like the most economical way to go. However, a well placed filler today becomes a not-so-well placed filler years later as the face changes shape. A permanent filler is not easy to remove.

Semi-permanent fillers can last 1-2 years and have some important uses in the face. Examples include Radiesse and Sculptra. Radiesse is a calcium hydroxylapetite in an aqueous carrier. It is used for precise placement in deep tissues where bone loss has occurred. It is particularly effective along the jaw bone, nasolabial folds, and along the inferior rim of the orbit (eye socket). Sculptra is polymerized lactic acid, similar to the material used for skin sutures (Vicryl). It is the opposite of Radiesse, in that it is used for non-precise large-area volume enhancement. It does have a small, but real risk of allergic reaction.

Temporary fillers are by far, the most commonly used fillers in the face today. Collagen filler was quite popular for awhile,but only lasts 3-6 months and has a risk of allergic reaction. Collagen has largely been replaced by the hyaluronic acids (HAs). Hyaluronic acid is a naturally occurring substance and is found in the eye, joints, and skin. HAs are safe, have a very low incidence of allergic reaction, and typically last 6-12 months. Restylane/Perlane and Juvederm Ultra/Ultra Plus are examples of HAs. Restylane and Juvederm Ultra have smaller molecular structures, which is more effective in filling in finer lines, and building volume and definition in the lips. Perlane and Juvederm Ultra Plus have larger molecules, and thus more “horsepower” in building volume and filling deeper lines.

What are the different types of anethesia used for dermal filler injections?

2009-09-03T08:28:00.000-07:00

Dermal filler injections are second only to Botox in popularity for non-surgical facial rejuvenation. There are a number of different ways to provide anesthesia during dermal filler injections. These include ice, topical anesthetic, dental blocks, and local anesthetic mixed with the filler itself. The choice of anesthetic depends on the type of filler used and the area of injection. This discussion will focus on the hyaluronic acid fillers, namely Restylane/Perlane and Juvederm Ultra/Ultra Plus.

Topical anesthetics include 2% lidocaine gel and a triple anesthetic gel composed of 20% benzocaine, 6% lidocaine, and 4% tetracaine, (BLT gel). I find the BLT gel is more effective that the lidocaine gel alone. Dental blocks with 3% Polocaine are painlessly given with a tiny 30 gauge needle to anesthetize the upper and lower lips and peri-oral region. Recently, clinicians have started mixing small amounts (0.2-0.3 cc) of 2% lidocaine with epinephrine with the hyaluronic acid gels with high patient satisfaction. Medici, the maker of Restylane/Perlane has introduced a pre-packaged mixture of 0.3% lidocaine with Restylane/Perlane in Europe. It is not available in the US, yet.

Glabellar creases, lateral sub-brow fat augmentation, nasolabial folds (laugh lines) and melolabial folds (frown lines) respond well to either pre-injection icing or topical anesthetic gel. Tear trough (depressions on the inside corners of the lower lids) injections typically require anesthetic to be mixed with the filler in addition to icing. Lip augmentation and injections to the outer corners of the mouth almost always require a dental block for adequate analgesia.