current trends in oculoplastics - matossian eye associates · current trends in oculoplastics cope...

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

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Orbit

• Orbital Anatomy

• Evaluation of Orbital Disorders

• Orbital Cellulitis

• Thyroid Eye Disease

• Orbital Tumors

• Orbital Fracture

• Retrobulbar Hemorrhage

• The Anophthalmic Socket

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Orbital Anatomy

• Bony cavity that contains:

– Globes

– Extraocular muscles

– Nerves

– Fat

– Blood vessels

• Pear-shaped

– Tapers posteriorly to the apex and optic canal

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Orbital Cellulitis

• Preseptal vs.

orbital cellulitis

• Large majority

from direct spread

of adjacent

sinusitis

• Status-post

trauma

• Bacteremic

spreadCopyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Anophthalmic Socket

• Trauma/

tumor/

blind painful

eye

• Sympathetic

ophthalmia

• Evisceration

• Enucleation

• ExenterationCopyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Chalazion

• Caused by blepharitis

• Painful

• Warm compresses

• Injection of steroid

• Excision

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Periocular Malignancies

• Basal cell carcinoma

(most common)

• Squamous cell

carcinoma

• Sebaceous gland

carcinoma

• Melanoma

• Merkel cell

carcinoma

• Check for eyelash

lossCopyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Eyelid Reconstruction

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Eyelid Reconstruction

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Ectropion

• Involutional

• Cicatricial

• Paralytic

• Mechanical

• Congenital

• Cause chronic

tearing / irritation

/ exposureCopyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Entropion

• Involutional

• Cicatricial

• Spastic

• Congenital

• Eyelashes rub

against globe

causing chronic

irritation

• Repair via lateral

tarsal strip +/-

Quickert sutures Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Trichiasis

• Eyelashes turning inward and touching cornea

• Cause chronic irritation

• Epilation

• Electrolysis

• Cryotherapy

• Marginal

rotation

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Ptosis

• Aponeurotic

• Neurogenic

• Myogenic

• Traumatic

• Mechanical

• Congenital

• +/- dermatochalasis Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Ptosis

• Determine the correct

etiology

• Ptosis visual field

• Photos

• Repair either via anterior or

posterior approachCopyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Epiphora

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Canalicular Laceration

• Laceration of the canaliculus

• Epiphora

• Repair with mini-Monoka tube

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

4 R’s of

Facial Rejuvenation

•Relaxing

•Refilling

•Resurfacing

•RedrapingCopyright Paul Johnson, MD,

Matossian Eye Associates 2017

Relaxing:

Neuromodulators

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Contraindications

• Neuromuscular junction

disorders (myasthenia gravis,

Eaton-Lambert syndrome)

• Allergy to botulinum toxin,

human albumin, saline

• Pregnancy

• BreastfeedingCopyright Paul Johnson, MD,

Matossian Eye Associates 2017

Glabella

• Corrugator muscle causes

vertical glabellar (11) lines

• Procerus muscle causes

transverse wrinkles in the region

of the nasion

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Crow’s Feet

• Produced by orbicularis oculi

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

orbital rim

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Botox Brow Lift

(with Lower Lid Blepharoplasty)

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

“Bunny Lines”

• Caused by nasalis muscle

• Inject on both sides of the nasal

dorsum

• Avoid lip asymmetries by

avoiding the nasofacial groove

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Refilling:

Dermal Fillers

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Longer-Lasting

Temporary Fillers

• Restylane, Restylane Silk,

Restylane Lift

• Juvederm

• Belotero

• Voluma

• VolbellaCopyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

1 month s/p 2 vials of Juvederm

to lower lids

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

7 weeks after 1 vial Juvederm

Ultra Plus to lower lids and

Botox to upper face

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

1 month after 1 vial Juvederm

Ultra Plus to Lower lids

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Hyaluronic Acid Gel

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Semipermanent

Fillers

•Radiesse

•Sculptra

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Radiesse Indications

• Nasolabial folds

• Cheek augmentation

(especially in HIV-associated

lipodystrophy)

• Hands

• Do not use in the lips or tear

troughsCopyright Paul Johnson, MD,

Matossian Eye Associates 2017

Radiesse Longevity

• 9-15 months

• Most patients about 12

months

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Radiesse – Nasolabial Folds

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Midface Radiesse,

Periocular Juvederm

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

2 months after 2 vials of

Radiesse to upper cheeks

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

1 month after 2 vials of

Radiesse to upper cheeks

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

6 months s/p 3

treatments of 2 vials

of Sculptra

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

1 year after 4

treatments of Sculptra

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Resurfacing:

Chemical Peels

&

Intense Pulsed Light

(IPL)

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Obagi Blue Peel

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Post-Peel Care

• Patient should expect edema,

erythema, and eventual

desquamation.

• Oral narcotic

• Bland emollient 3-4x/day

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

IPL

(Intense Pulsed Light)

• Hair removal

• Acne

• Vascular lesions

• Photorejuvenation (sun spots, etc.)

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Intense Pulsed Light

• Can also be used to treat dry eyes

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Redraping:

Surgery

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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.

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Endoscopic Brow Lift

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Relative

Contraindications

• Thyroid eye disease

• Severe dry eyes

• Narrow angles

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Post-Op Care

• Cold compresses for 24-36

hours

• Sleep with head elevated

• Antibiotic-steroid ophthalmic

ointment

• Follow-up within 1 week

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Complications

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

• Lagophthalmos

• Dry eyes

• Milia

• Unmet expectationsCopyright Paul Johnson, MD,

Matossian Eye Associates 2017

Upper Lid

Blepharoplasty

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

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,

Matossian Eye Associates 2017

Complications

• Retrobulbar hemorrhage

• Lower eyelid retraction

• Fat pad asymmetry

• Dry eyes

• Unmet expectations

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Lower Lid

Blepharoplasty

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Questions?

Copyright Paul Johnson, MD,

Matossian Eye Associates 2017

Thank you!

Cell: (917) 648-7096

Email: johnson.paul.b@gmail.com

Website: www.matossianeye.com

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

Matossian Eye Associates 2017