Current Trends in Oculoplastics - Matossian Eye Associates · Current Trends in Oculoplastics COPE #51615-AS ... –Grasp lateral lower eyelid with forceps ... with Alloderm or

Current Trends

in

Oculoplastics

COPE #51615-AS

May 2017

Paul Johnson, MD

Matossian Eye Associates

Financial Disclosures

• None

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Oculoplastics

• Reconstructive and

cosmetic surgery of

the orbit, eyelids, tear

ducts, and face



Training

• Undergraduate training (4 years):

Johns Hopkins University

• Medical school (4 years):

Jefferson Medical College

• Internship (1 year): St. Barnabas

Medical Center

• Residency (3 years): New York

Eye & Ear Infirmary

• Fellowship (2 years): Wills Eye

InstituteCopyright Paul Johnson, MD,


Orbit

• Orbital Anatomy

• Evaluation of Orbital Disorders

• Orbital Cellulitis

• Thyroid Eye Disease

• Orbital Tumors

• Orbital Fracture

• Retrobulbar Hemorrhage

• The Anophthalmic Socket



Orbital Anatomy

• Bony cavity that contains:

– Globes

– Extraocular muscles

– Nerves

– Fat

– Blood vessels

• Pear-shaped

– Tapers posteriorly to the apex and optic canal



Orbital Anatomy

• Orbital walls comprised of 7 bones

• Border the 4

paranasal sinuses

• Periorbita

• 7 extraocular

muscles

• Optic nerve

• Lacrimal gland Copyright Paul Johnson, MD,


Evaluation of Orbital Disorders

• 6 Ps: pain, proptosis, progression,

palpation, pulsation, periorbital changes

• Globe displacement

• Proptosis (as measured by Hertel’s

exophthalmometry)

• Decreased EOMs

• Eyelid changes

• Palpable mass

• Audible bruit

Evaluation of Orbital Disorders

• CT vs. MRI

• Pathology

• Lab studies



Orbital Cellulitis

• Preseptal vs.

orbital cellulitis

• Large majority

from direct spread

of adjacent

sinusitis

• Status-post

trauma

• Bacteremic

spreadCopyright Paul Johnson, MD,


Orbital Cellulitis

• Obtain CT to rule

out abscess

• Compartment

syndrome rare but

must be ruled out

• Warning sign: If

patient cannot open

eyes at all

• Infectious Disease

consult

• ENT consult Copyright Paul Johnson, MD,


Thyroid Eye Disease• Most commonly

hyperthyroid (90%)

but can also be

euthyroid or

hypothyroid

• Loss of vision from

optic neuropathy or

exposure keratitis

• Diplopia from EOM

involvement

• Eyelid retraction

• Cosmetic deformity

• Loss of self esteem

• Pain / photophobiaCopyright Paul Johnson, MD,


Thyroid Eye

Disease• CT scan showing

characteristic EOM

enlargement (inferior >

medial > superior >

lateral rectus) +/-

crowding at apex

• TFTs (T3, T4, TSH)

• Thyroid stimulating

immunoglobulins (TSIs)

• Clinical diagnosis

• Rule out optic nerve

involvement by

checking for an afferent

pupillary defect



Thyroid Eye

Disease

• Therapies include:

– Control thyroid function

– Quit smoking

– Periocular steroid

injections

– Oral steroids

– Radiation

– Bony and fatty orbital

decompression

– Strabismus surgery

– Eyelid retraction

surgery

– Psychological support

Orbital Fractures

• Blunt trauma from an object

larger than the orbit (fist,

dashboard, softball)

• Must rule out injury to the

globe (ruptured globe,

hyphema, vitreous

hemorrhage, retinal

detachment)

• At times associated with

traumatic optic neuropathy

• CT orbits

• Floor / medial wall / roof

• Lateral wall / ZMC Copyright Paul Johnson, MD,


Orbital Fractures

• Indications for emergent repair: White-

eyed blowout fracture, especially in a

child (extraocular muscle entrapment)

– clinical diagnosis

• Indications for timely repair: Diplopia

in primary or downgaze, enophthalmos

>2mm that is cosmetically

unacceptable to the patient, large

fractures (>50% of floor)

• Release of prolapsed tissues with

insertion of orbital implant

• Late repair with hydroxyapatite

granulesCopyright Paul Johnson, MD,


Retrobulbar Hemorrhage

• Commonly seen on CT

• Compartment syndrome is a clinical

diagnosis

• Warning sign: If patient cannot open eyes

at all

• Less likely to cause compartment syndrome

if associated with orbital fracture

• Can lead to blindness



Retrobulbar

Hemorrhage

• Lateral canthotomy/

cantholysis:

– Inject about 3 cc of

lidocaine 2% with

epinephrine

subcutaneously to lateral

canthus

– Cut with Westcott or

Stevens scissors

laterally from the globe

– Grasp lateral lower

eyelid with forceps

– Strum the canthal

tendon and cut

– Feel “blow for freedom”

• Admit

• IV steroidsCopyright Paul Johnson, MD,


Anophthalmic Socket

• Trauma/

tumor/

blind painful

eye

• Sympathetic

ophthalmia

• Evisceration

• Enucleation

• ExenterationCopyright Paul Johnson, MD,


Anophthalmic Socket

• Globe is surgically

removed

• Plastic conformer and

tarsorrhaphy placed

• About 3 months later,

patient referred to

ocularist for

prosthesis

• Psychological

support

• Lead normal lives

• Can driveCopyright Paul Johnson, MD,


Eyelids

• Eyelid Anatomy

• Chalazion

• Floppy eyelid

syndrome

• Periocular

malignancies

• Eyelid trauma

• Eyelid and

canthal

reconstruction

• Ectropion

• Entropion

• Trichiasis

• Ptosis/Dermato

chalasis

• Eyelid

retraction

• Facial dystonia



Eyelid Anatomy

• 2 fat pads / 1 lacrimal gland upper eyelids

• 7 layers in the upper eyelid:– Skin

– Orbicularis

– Orbital septum

– Preaponeurotic fat

– Levator muscle aponeurosis

– Muller’s muscle / tarsus

– Conjunctiva

Eyelid Anatomy

• 3 fat pads

• 7 layers:

– Skin

– Orbicularis

– Orbital septum

– Orbital fat

– Capsulopalpebral

fascia

– Inferior tarsal

muscle / tarsus

– Conjunctiva Copyright Paul Johnson, MD,


Chalazion

• Caused by blepharitis

• Painful

• Warm compresses

• Injection of steroid

• Excision



Floppy Eyelid Syndrome

• Almost 100% association

with obstructive sleep

apnea

• Sleep study

• Eyelids evert during sleep

and rub against

pillowcase causing severe

irritation

• Associated with ptosis,

dermatochalasis, and lash

ptosis

• Excise tarsal wedge

• Correct ptosis/dermatochalasisCopyright Paul Johnson, MD,


Periocular Malignancies

• Basal cell carcinoma

(most common)

• Squamous cell

carcinoma

• Sebaceous gland

carcinoma

• Melanoma

• Merkel cell

carcinoma

• Check for eyelash

lossCopyright Paul Johnson, MD,


Periocular Malignancies

• Risk factors: Fair individuals with blue eyes and blonde or red hair / UV exposure / family history / smoking history

• Can invade orbit leading to the need for exenteration and can rarely metastasize (3% mortality rate of periocular BCCA)

• Goal is complete tumor eradication while maintaining the structure and function of the eyelids and ocular surface and providing the best aesthetic outcome possible

• Frozen sections

• Mohs micrographic surgeryCopyright Paul Johnson, MD,


Eyelid Trauma• Extramarginal: Skin

closure (6-0 plain)

• Marginal: Tarsal

closure with 5-0 Vicryl,

margin closure with

vertical mattress 6-0

silk left long and

incorporated into 6-0

silk skin suture. Close

rest with 6-0 plain

• Canaliculus-involving

• Levator-involving (fat

in field) Copyright Paul Johnson, MD,


Eyelid Reconstruction



Eyelid Reconstruction



Ectropion

• Involutional

• Cicatricial

• Paralytic

• Mechanical

• Congenital

• Cause chronic

tearing / irritation

/ exposureCopyright Paul Johnson, MD,


Ectropion Repair

• Mild –

lateral tarsal strip

• Moderate –

posterior support

with Alloderm or

buccal mucosa +

lateral tarsal strip

• Severe –

full-thickness skin

graft + lateral tarsal

strip +/- Hughes

procedureCopyright Paul Johnson, MD,


Entropion

• Involutional

• Cicatricial

• Spastic

• Congenital

• Eyelashes rub

against globe

causing chronic

irritation

• Repair via lateral

tarsal strip +/-

Quickert sutures Copyright Paul Johnson, MD,


Trichiasis

• Eyelashes turning inward and touching cornea

• Cause chronic irritation

• Epilation

• Electrolysis

• Cryotherapy

• Marginal

rotation



Ptosis

• Aponeurotic

• Neurogenic

• Myogenic

• Traumatic

• Mechanical

• Congenital

• +/- dermatochalasis Copyright Paul Johnson, MD,


Ptosis

• Determine the correct

etiology

• Ptosis visual field

• Photos

• Repair either via anterior or

posterior approachCopyright Paul Johnson, MD,


Eyelid Retraction

• Most common causes:

thyroid eye disease /

CN VII palsy

• Can cause chronic

exposure – foreign

body sensation,

corneal ulceration,

corneal scarring, loss

of vision, loss of eye

• Surgical approach

depends on etiology

• Gold weight

• Levator aponeurosis

recessionCopyright Paul Johnson, MD,


Blepharospasm Hemifacial Spasm

• Due to overaction of the muscles of facial

expression due to overstimulation by CNVII

• Rule out pontine glioma in hemifacial spasm

via MRI (1%)

• Treat with Botox® or Anderson procedure

Lacrimal System

• Epiphora / Nasolacrimal

duct obstruction

• Canalicular lacerations



Epiphora



Epiphora

• Probe and irrigate to

determine level of

obstruction

• Nasolacrimal duct

obstruction: external

or endoscopic

dacryocystorhinosto

my (DCR) with

Crawford tube

• Conjunctivodacryocy

storhinostomy

(CDCR) with Jones

tube Copyright Paul Johnson, MD,


Canalicular Laceration

• Laceration of the canaliculus

• Epiphora

• Repair with mini-Monoka tube



Cosmetic Oculoplastics

• Neuromodulators (Botox®, Dysport®, Xeomin®)

• Dermal fillers (Juvederm®, Radiesse®, Belotero®, Voluma®, Volbella®, Restylane®)

• Chemical peels

• Intense Pulsed Light

• Browplasty

• Upper eyelid blepharoplasty

• Lower eyelid blepahroplastyCopyright Paul Johnson, MD,


4 R’s of

Facial Rejuvenation

•Relaxing

•Refilling

•Resurfacing

•RedrapingCopyright Paul Johnson, MD,


Relaxing:

Neuromodulators



Botulinum Exotoxin A

• First used in 1973 by Allen

Scott, an ophthalmologist,

to treat strabismus

• Currently used in

oculoplastics in the

treatment of

blepharospasm and

hemifacial spasm

• FDA approved in 1992 for

cosmetic treatment in the

glabellar region Copyright Paul Johnson, MD,


Pharmacology

• Blocks the release of acetylcholine

at the neuromuscular junction at

the presynaptic level

• Denervation paralysis of the

injected muscle is first noted 24-72

hours after injection and usually

lasts 3-4 months

• No deaths have been reported

• A maximum dose of less than 400

units per treatment session at 3-

month intervals is safe in humans.Copyright Paul Johnson, MD,


Available Botulinum Toxin Products

• Botox (US – Allergan), Dysport (UK – Ipsen),

Xeomin (US – Merz)

• Botox is available in 100-unit vial which is

frozen until reconstituted

• Dysport is available in 500-unit vial

• 1 Botox unit equals about 3 Dysport units



Side Effects

• Systemic reactions (rare): Nausea, fatigue, malaise, flulike symptoms, rashes

• Local reactions: Bruising, swelling, pain, erythema, headache

• Reduce discomfort with EMLA cream or ice packs

• Decrease bruising by stopping vitamin E, ASA, NSAIDs for about 1-2 weeks before injection

• Contracting treated muscles for a few hours after injection can help uptake toxin



Eyelid Ptosis

• Caused by diffusion through the

orbital septum to the levator

muscle

• Lasts 3-6 weeks

• Reversible

• Treat with Iopidine 1% tid

(stimulates Muller’s muscle)Copyright Paul Johnson, MD,


Contraindications

• Neuromuscular junction

disorders (myasthenia gravis,

Eaton-Lambert syndrome)

• Allergy to botulinum toxin,

human albumin, saline

• Pregnancy

• BreastfeedingCopyright Paul Johnson, MD,


Glabella

• Corrugator muscle causes

vertical glabellar (11) lines

• Procerus muscle causes

transverse wrinkles in the region

of the nasion



Horizontal Forehead Rhytids

• Caused by frontalis muscle

• Inject in 4 locations across the center of the

forehead

• 10 units is sufficient for most – may need

more in men



Crow’s Feet

• Produced by orbicularis oculi

• Inject at 2 to 3 sites 1 cm lateral to the bony

orbital rim



Brow Elevation

• Frontalis elevates the brow

• Orbicularis oculi, corrugator,

procerus, and depressor

supercilii depress the brow.

• Elevate the medial brow by

treating the glabella.

• Do not inject lateral frontalis

muscle as this will elevate the tail

of the eyebrow.Copyright Paul Johnson, MD,


Botox Brow Lift

(with Lower Lid Blepharoplasty)



“Bunny Lines”

• Caused by nasalis muscle

• Inject on both sides of the nasal

dorsum

• Avoid lip asymmetries by

avoiding the nasofacial groove



Platysmal Bands

• Ask patient to contract platysma and mark

each band

• Inject each band evenly at 2-cm intervals

• Begin at the jawline and place every 2 cm until

the banding ends (usually 3-4 injections)

• Inject just the

band. Deep

injections can

cause dysphagia,

neck weakness,

and changes in

voice pitch.

Chin Dimpling

• Caused by mentalis muscle

• Causes cobblestone appearance of the chin

• Inject at a point halfway between the lower

vermillion border and the edge of the mentum,

and 5-10 mm medial to the oral commisure.

• Don’t inject too close to the lip.

Follow-up

• Ask patients to contract injected muscle after injection

• Return to the office 8-10 days after injection

• Persistent hyperfunctional lines can be injected with additional toxin.

• Actinic lines or deep creases can be treated with soft-tissue fillers, lasers, or chemical peels.

• Reinject about every 4 months.Copyright Paul Johnson, MD,


Refilling:

Dermal Fillers



Dermal Fillers

• Today’s patients want less

surgery, less downtime, and less

risk.

• Can be used alone or in

conjunction with surgery.

• Success depends on the

patient’s anatomy and

expectations and the individual

surgeon’s experience.Copyright Paul Johnson, MD,


Choice of Filler

• Product’s biocompatibility

• Anatomical site to be addressed

• Thickness and quality of the

patient’s skin

• Patient’s concerns about

longevity and cost



Longer-Lasting

Temporary Fillers

• Restylane, Restylane Silk,

Restylane Lift

• Juvederm

• Belotero

• Voluma

• VolbellaCopyright Paul Johnson, MD,


Longer-Lasting

Temporary Fillers

• Most are derived from hyaluronic

acid

• Most last 6-12 months

• Product should be used at the

time of treatment or thrown away

• Do not overcorrect

• Overcorrection can be reversed

with the injection of 10 units of

hyaluronidaseCopyright Paul Johnson, MD,


Restylane

• FDA approved in 2003

• Moderate to severe facial lines

and wrinkles around nose and

mouth

• Also available in Restylane Silk

(lower density) and Restylane Lift

(higher density)

• 6-9 months

• Patients tend to retain some

volume after each injectionCopyright Paul Johnson, MD,


Juvederm

• FDA approved in 2006

• Juvederm Ultra and Juvederm

Ultra Plus (more viscous)

• Ease of injectability

• Lower incidence of

posttreatment edema than other

hyaluronic acid fillers

• 9-12 months

• Juvederm Voluma

• Juvederm VolbellaCopyright Paul Johnson, MD,


1 month s/p 2 vials of Juvederm

to lower lids



7 weeks after 1 vial Juvederm

Ultra Plus to lower lids and

Botox to upper face



1 month after 1 vial Juvederm

Ultra Plus to Lower lids



Hyaluronic Acid Gel

Indications

• Lip augmentation

• Effacement of vertical perioral

lines

• Nasolabial folds

• Also: periorbital rejuvenation,

effacement of glabellar lines,

facial volume enhancementCopyright Paul Johnson, MD,


Hyaluronic Acid Gel



Complications

• Mild to moderate inflammatory

response for first 24-72 hours

• Mild to moderate bruising

(especially if patient is on

NSAIDs, vitamin E, herbal

supplements, or anticoagulants)

• Tyndall effect if injected to

superficially

• Bumps/asymmetryCopyright Paul Johnson, MD,


Semipermanent

Fillers

•Radiesse

•Sculptra



Radiesse

• 30% calcium hydroxylapatite

microspheres and 70% gel

• Gel dissolves after injection by

microspheres remain which

provide a scaffold for soft tissue

deposition

• FDA approved in 2006 for

treatment of facial wrinkles/folds

and correction of HIV-associated

facial wastingCopyright Paul Johnson, MD,


Radiesse Indications

• Nasolabial folds

• Cheek augmentation

(especially in HIV-associated

lipodystrophy)

• Hands

• Do not use in the lips or tear

troughsCopyright Paul Johnson, MD,


Radiesse Longevity

• 9-15 months

• Most patients about 12

months





Radiesse –

Nasolabial Folds

Radiesse Complications

• Swelling and bruising most

common

• Nodules when used in the lips

(10% of cases)

• White discoloration of the

tissue when injected too

superficiallyCopyright Paul Johnson, MD,


Radiesse – Nasolabial Folds



Midface Radiesse,

Periocular Juvederm



2 months after 2 vials of

Radiesse to upper cheeks



1 month after 2 vials of

Radiesse to upper cheeks



Sculptra

• Major component is poly-L-lactic

acid

• Requires sterile water for

reconstitution before injection

• FDA approved in 2004 for HIV-

related facial atrophy

• When product degrades, acts as

scaffold for collagen productionCopyright Paul Johnson, MD,


Sculptra Indications

• FDA approved in 2004 for HIV-associated lipoatrophy

• Correction of nasolabial folds

• Results take weeks to months to develop

• More volume enhancing than wrinkle reducing

• Take special care in reconstitution and administration to avoid papules

• Multiple administrations spaced every 3-4 weeks

• Lasts 12-24 monthsCopyright Paul Johnson, MD,


6 months s/p 3

treatments of 2 vials

of Sculptra



1 year after 4

treatments of Sculptra



Resurfacing:

Chemical Peels

&

Intense Pulsed Light

(IPL)



Chemical Peel Candidates

• Ideal: Fair skin, blue eyes, shallow rhytids

• Contraindications: History of cutaneous radiation, smoking, frequent HSV infections, diabetes, hypertrophic scar, keloids

• Risk of hyperpigmentation with OCPs, exogenous estrogens, and photosensitizing drugs, pregnancy

• Absolute contraindication: Isotretinoin (discontinue 12-24 months before peel)Copyright Paul Johnson, MD,


Prep

• Sunscreens which block both UVA and UVB should be started 3 months before the peel to decrease melanocyte activity.

• Tretinoin should be started 6-12 weeks before the peel because tretinoin has a synergistic effect with TCA and has been shown to sustain the effects of the peel. Aids in reepithelialization and increased melanin distribution.

• Hydroquinone 4%Copyright Paul Johnson, MD,


Obagi Blue Peel



Post-Peel Care

• Patient should expect edema,

erythema, and eventual

desquamation.

• Oral narcotic

• Bland emollient 3-4x/day



Evolution of a Peel

• Hours 0-12: Inflammation increases

• Hour 13 – Day 3: Epidermis becomes

leathery and separates from dermis.

Underlying dermal injury becomes necrotic

and sloughs. Emollient helps in clearing

necrotic tissue.

• Days 4-7: Desquamation

• Days 7-10: Reepithelialization. Skin

changes from bright red to light pink.Copyright Paul Johnson, MD,


Post-Peel Care

• Strict avoidance of direct,

prolonged sun exposure

for 12 weeks

• Avoid OCPs or pregnancy

(increased circulating

estrogens can cause

hyperpigmentation)Copyright Paul Johnson, MD,


IPL

(Intense Pulsed Light)

• Hair removal

• Acne

• Vascular lesions

• Photorejuvenation (sun spots, etc.)



IPL

(Intense Pulsed Light)

• Good for Fitzpatrick skin types I – IV

• Start at 8-8.5 J/cm2 and titrate up

from there

• We use cooling gel and ice for

patient comfort

• Around 20 J/cm2 the pain level

increases and the risk of

hypopigmentation and burning

increases

• Men must shave the night beforeCopyright Paul Johnson, MD,


Intense Pulsed Light

• Can also be used to treat dry eyes



Redraping:

Surgery



Analysis of Upper Face

• Upper 1/3 of the face is the first area where the signs of aging become apparent.

• Sun exposure / gravity / genetics cause brow ptosis which gives a tired, sad, or angry appearance.

• Brow ptosis can sometimes interfere with vision.

• Patients often notice dermatochalasis of both upper lids before they notice brow ptosis.

• Correction of brow ptosis alone may fix both problems.



Brow Aesthetics

• Ideal female brow should rest at or above the supraorbital rim.

• Medial female brow should be full but taper gracefully as it moves laterally.

• Male brow should sit at or just above the supraorbital rim.

• Male brow should be straight in configuration.

• Male brow is thicker and flatter than female brow and should only taper slightly as it traverses laterally.Copyright Paul Johnson, MD,


Endoscopic Brow Lift



Upper Eyelid

Blepharoplasty

• Dermatochalasis (too much skin)

• Steatoblepharon (herniated orbital

fat)

• Incision is made in upper eyelid

crease

• Crescent-shaped area of skin and

orbicularis are removed

• A conservative amount of

preaponeurotic fat is removed

• Running closure with 6-0 nylonCopyright Paul Johnson, MD,


Relative

Contraindications

• Thyroid eye disease

• Severe dry eyes

• Narrow angles



Post-Op Care

• Cold compresses for 24-36

hours

• Sleep with head elevated

• Antibiotic-steroid ophthalmic

ointment

• Follow-up within 1 week



Complications

• Retrobulbar hemorrhage 1 in 2,000 (vision threatening: 1 in 10,000)

• Lagophthalmos

• Dry eyes

• Milia

• Unmet expectationsCopyright Paul Johnson, MD,


Upper Lid

Blepharoplasty



Lower Eyelid

Blepharoplasty

• Indications: rejuvenating the

aesthetic appearance of the eyes,

desire for a less tired look,

minimizing lower lid redundancy,

correcting eyelid asymmetries.

• Transcutaneous skin flap

approach

• Transcutaneous skin-muscle flap

approach

• Transconjunctival approach Copyright Paul Johnson, MD,


Complications

• Retrobulbar hemorrhage

• Lower eyelid retraction

• Fat pad asymmetry

• Dry eyes

• Unmet expectations



Lower Lid

Blepharoplasty



Questions?



Thank you!

Cell: (917) 648-7096

Email: [email protected]

Website: www.matossianeye.com

www.facebook.com/drpauljohnsonCopyright Paul Johnson, MD,


Documents

Current Trends in Oculoplastics - Matossian Eye Associates · Current Trends in Oculoplastics COPE #51615-AS ... –Grasp lateral lower eyelid with forceps ... with Alloderm or