Oculoplastic Surgery

What is oculofacial plastic surgery?

Oculofacial plastic surgery is specialized plastic surgery that treats the eyelids and the area around them. Reconstructive oculofacial plastic surgery, considered medically necessary, restores obstructed vision. It is usually covered by insurance. In contrast, cosmetic variations are performed for appearances only and are generally not covered by insurance. Most surgeries are performed as outpatient procedures.

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Oculoplastic Surgery

What are the various procedures?


Blepharoplasty is the surgical procedure to remove excess eyelid tissue (skin, muscle, or fat) around the eyes. The delicate skin around the eyes can appear puffy or saggy as we age. The skin stretches, muscles weaken, and the deposits of protective fat around the eye bulge.

Blepharoplasty is performed on the upper eyelid, lower eyelid, or both lids. Sometimes excess upper eyelid tissue obstructs the upper visual field or can weigh down the eyelid and produce tired-feeling eyes. People often choose blepharoplasty to improve their appearance by making the area around their eyes firmer. When blepharoplasty is performed to improve vision, it may be covered by insurance rather than for cosmetic reasons only.

Blepharoplasty for the lower lid removes the large bags under the eyes. It is unusual for insurance to cover lower lid blepharoplasty.

The outpatient surgery is performed in one to three hours. Upper lid incisions are made in the lid's natural crease, and lower lid incisions are made just below the lash line. A procedure for lower lid blepharoplasty, called transconjunctival blepharoplasty, removes excess fat through an incision inside the lower lid. Incisions are closed with fine sutures.

Swelling, bruising and blurry vision are common after blepharoplasty. Stitches are removed three to five days after surgery, except in the case of transconjunctival blepharoplasty, where self-dissolving sutures are used.

The possible complications of blepharoplasty include bleeding and swelling, delayed healing, infection, drooping of the upper or lower eyelid, asymmetry, double vision, and dry eye. It is important to note that the puffiness of the fat pockets may not return, but normal wrinkling and aging of the eye area will continue.

Brow lift (Or Forehead Lift)

Sun, wind, and gravity affect the skin and muscles of the face over time. One of the most noticeable aspects of aging is a progressive drooping of the eyebrows. This can cause wrinkling of the forehead from raising one's eyebrows and vertical wrinkles or furrows between the eyebrows. Sometimes the eyebrows or excess eyelid tissue can obstruct vision.

A brow lift or forehead lift elevates the brow and smooths forehead skin, removing the vertical lines between the eyebrows. Incisions are made in inconspicuous places, either behind the hairline, in one of the forehead wrinkles, or immediately above the eyebrows. If an endoscope (a small tube with a fiberoptic light) is used, tiny incisions are made. After the muscles are tightened and excess skin is removed, the incision is closed with sutures. The operation is usually an outpatient procedure that can take several hours.

Swelling and bruising, typical after a brow lift or forehead lift, subside in seven to 14 days. Numbness and itching are expected during the healing process. Sutures are removed within seven to ten days after surgery. Incisions in the hairline may damage hair follicles and result in some hair loss.

Ectropion and Entropion

Ectropion is an outward turning of the lower eyelid, most commonly caused by aging, eyelid burns, or skin disease.

Usually, the eyelids help lubricate and cleanse the eye during blinking. Drooping eyelids can cause dry eyes, excessive tearing, redness, and sensitivity to light and wind.

Entropion is an inward turning of the eyelid and lashes toward the eye, usually caused by relaxation of the eye muscles and tissue due to aging.

Entropion usually affects the lower lid. The skin and eyelashes rub against the eye and cause discomfort and tearing. The irritated eye can produce mucous and become red and sensitive to light and wind. If entropion is not treated, the rubbing of the skin and eyelashes may cause infection or scarring of the eye, leading to vision loss.

Surgery is performed to tighten the eyelid and return it to its normal position. The eyelid then protects and lubricates the eye properly to reduce irritation and other symptoms.

Eyelid surgery is usually performed outpatient using local anesthesia to repair ectropion or entropion. After surgery, an eye patch is generally worn, and antibiotic ointment is prescribed.

Eyelid Tumors

A tumor is an abnormal growth of any tissue or structure. It is either benign or malignant. A tumor can affect any part of the eye, such as the eye socket, eyeball, eye muscles, optic nerve, fat, and tissues. Sometimes tumors grow into the eye area, or tumors from other parts of the body travel to the eye. Most tumors of the eye are benign.

Basal cell carcinomas are the most frequent type of malignant tumor to affect the eyelid (85-95% of all malignant eyelid tumors). The most frequent location is the inner portion of the lower eyelid, particularly in elderly fair-skinned people. Prolonged exposure to sunlight seems to be a risk factor for developing this form of tumor.

There are many different basal cell carcinomas, but the nodular variety is most common. It appears as a raised, firm, pearly nodule with tiny, dilated blood vessels. Some lashes may be missing if the nodule is in the eyelash area. The nodule may have superficial ulceration and crusting like chalazion or stye. While these tumors are malignant, they rarely spread elsewhere in the body. For most of these tumors, surgery is the most effective treatment. In severe cases, when the tumor has been neglected for a long time, it can spread into the eye socket, which may ultimately require the removal of the eye and adjacent tissue.

Squamous cell carcinoma is the next most frequent malignant eyelid tumor (occurring in approximately 5% of malignant eyelid tumors.) As with basal cell carcinoma, the lower eyelid is the most common, particularly in elderly, fair-skinned people. This tumor also appears as a raised nodule that can lead to loss of eyelashes in the involved area. When detected and treated early, the outcome for this type of tumor is excellent. However, if the tumor is neglected, it can spread to the lymph nodes in the neck. Surgery is the most effective treatment.

Sebaceous cell carcinoma originates in glands of the eyelid in elderly individuals. It is relatively rare but still accounts for 1 to 5% of malignant eyelid tumors. These highly malignant tumors may recur, invade the eye socket, or spread to lymph nodes. The tumor may look like a chalazion or stye, making it difficult to diagnose. Surgery is usually necessary for this type of tumor.

Malignant melanoma makes up almost 1% of all malignant eyelid tumors but accounts for many deaths from malignant eyelid tumors. As with any other type of malignant melanoma, these tumors on the eyelid can arise from a pre-existing nevus or mole or may appear with no other pre-existing cause. Again, these tumors tend to occur in sun-exposed areas of elderly fair-skinned people. Any pigmented area should be examined, especially if it grows or changes color. Surgical removal is usually the recommended treatment.

Lacrimal Drainage Dacryocystorhinostomy (DCR)

Keeping the eyes moist and healthy requires tears. Tears are produced in the lacrimal gland, located under the upper eyelid. Tears drain from the eye into the nose through the nasolacrimal duct or tear duct. A blockage of this drainage duct can cause wet eyes or excessive tearing. A blocked tear duct can also cause mucus buildup in the eye or ongoing infections in the lacrimal sac where tears collect. Infections are noticeable as a swelling of the inner corner of the lower eyelid.

Nasolacrimal duct obstructions can happen with no apparent cause. Sometimes previous sinus or nose surgery, or facial trauma with broken facial bones, can obstruct the tear duct.

Lacrimal drainage surgery is called dacryocystorhinostomy (DCR) and can be performed differently. One type of operation is an external DCR where an incision is made on the side of the nose, where eyeglasses might rest. A small amount of bone is removed, permitting a new connection between the lacrimal sac and the inside of the nose. Small plastic tubes are inserted during surgery to keep the newly created opening from scarring shut during healing. The tubing is removed a few months after surgery.

Another type of operation uses a unique instrument called an endoscope. The endoscope is a small tube with a fiberoptic light that facilitates the creation of a new opening into the nose. Various types of lasers have also been used to perform the DCR operation.

In extreme cases where the tear duct can't be reopened or repaired, an artificial tear duct is implanted. The artificial tear duct is called a Jones tube and is implanted behind the inner corner of the eyelid to drain tears into the nose.


Ptosis is drooping of the upper eyelid. The lid may droop only slightly or cover the pupil entirely. In some cases, ptosis can restrict and even block normal vision.

Congenital ptosis, or ptosis present at birth, requires treatment for normal visual development. Uncorrected congenital ptosis can cause amblyopia or lazy eye. If left untreated, amblyopia can lead to permanently poor vision.

Except in mild cases, the treatment for childhood ptosis is usually surgery to tighten the levator muscle that lifts the eyelid. In severe ptosis, when the levator muscle is fragile, the lid can be attached or suspended from under the eyebrow, so the forehead muscles do the lifting. Whether they have had surgery or not, children with ptosis should be examined annually by an ophthalmologist for amblyopia, refractive disorders, and associated conditions.

Ptosis in adults is commonly caused by the separation of the levator muscle from the eyelid due to aging, cataract or other eye surgery, an injury, or an eye tumor. Adult ptosis may also be a complication of diseases involving the levator muscle or nerve supply, such as diabetes.

If treatment is necessary, it is usually surgical. Sometimes a slight tuck in the levator muscle and eyelid can raise the lid sufficiently. More severe ptosis requires reattachment and strengthening of the levator muscle.

The risks of ptosis surgery include infection, bleeding, and reduced vision, but these complications occur very infrequently. Although improvement of the lid height is usually achieved, the eyelids may not appear perfectly symmetrical. In rare cases, the entire eyelid movement does not return.

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