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: [email protected]
Website: www.matossianeye.com
www.facebook.com/drpauljohnsonCopyright Paul Johnson, MD,
Matossian Eye Associates 2017