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Examples Before / After

Ptosis: levator muscle resection by a conjonctival approach

Ptosis is a drooping of the upper eyelid related to a dysfunction of the eyelid lift muscle. In the case described below, the muscle contracts normally but its attachment to the eyelid has relaxed (ptosis of the aponeurotic type). This phenomenon may be related to aging, an inflammation of the surrounding area or prolonged lens wear.

The injection of neosynephrine drops by causing the muscle to contract and the eyelid to rise makes it possible to distinguish this type of ptosis from those linked to a loss of muscle contractibility. The operation, usually performed for aesthetic purposes, is delicate because the slightest imperfection is very visible. The objective is of course to raise the eyelid but also to give it a regular and harmonious curvature, as well as to reposition the palpebral fold and the orbital fat in order to eliminate the appearance of sunken eyes.

The operation is done under potentiated local anaesthesia (with a supplement given by the anaesthetist which allows to be destresssed). Both sides are operated on at the same time. There is no scar because the eyelid is turned over and the muscle is approached from the inside. The thread at this level is resorbable and will be uncomfortable for about 4 weeks (foreign body sensation). The main risk is an aesthetic imperfection (asymmetry, inharmonious curvature) which would lead to a retouch this time with a skin approach. There is no risk of palpebral malocclusion here as the shortening is moderate.

Pre-operative appearance
Appearance after instillation of neosynephrine
Immediate post-operative appearance
Appearance 2 months after surgery

Ptosis: frontalis suspension

Ptosis is a drooping of the upper eyelid due to a dysfunction of the eyelid lift muscle.

When this muscle no longer functions at all, as in the case described below, the eyelid is suspended from the frontal muscle which, by contracting, will lift the eyelid. A strip (here made of silicone) is used which will be placed very precisely to give a harmonious shape to the palpebral opening, place the palpebral fold in the right place and orient the eyelashes horizontally.

The strip will limit the closing of the eyelids, the more it will be stretched, the wider the opening will be (and the better the aesthetics will be) but the more the closing will be limited with risks of drying out the eye. The tension applied to the strips during the operation therefore seeks a compromise which is the maximum tolerable opening.

It may sometimes be necessary to replace the strip in 3 situations: satisfactory aesthetic result but the eye does not tolerate the opening, aesthetically imperfect result (under correction or inharmonious form), spontaneous rupture of the strip.

Before the operation
Immediately after the procedure
Immediately after surgery: eyes do not close completely
2 months after surgery
2 months after surgery

Lower conjunctival blepharoplasty

The lower palpebral pockets are related to excess fat volume in the orbit, which protrudes anteriorly from the bony orbital rim.

In this example, this defect is isolated: indeed, there is no ring (which is a hollow along the orbital rim), nor is there any loosening of the skin and the orbicularis muscle. Pockets can therefore be removed conjunctivally (through the inside of the eyelid) as there is no excess skin to remove.

No skin scars are thus created and the risk of scar retraction is avoided, which can lead to deformation of the palpebral opening (round eye), a complication that is dreaded because it degrades the expression of the eyes.

Before intervention
Before Intervention
After intervention

After Intervention

                                                                             

Conjunctival lower blepharoplasty with lipostructure to fill dark circles and facial hollows

Combination of pockets and dark circles in the lower part / internal pockets and lateral hollows in the upper part
Face and eye analysis :

The lower eyebrows are one of the first signs of ageing of the eyes.

They correspond to fat in the orbit that protrudes and becomes prominent. They are all the more visible as, at the same time, a hollow forms immediately underneath: the ring.

It is linked to a loss of fatty volume located in front of the orbital bone margin and continues downwards in the form of a furrow in the middle of the cheek.

The ensemble gives the impression that the eyelid has lengthened vertically and that the orbital bone frame has widened.

In this example, there is no excess skin on the underside of

On the upper level, bags also appear, in this case only internally, while on the contrary, externally, the eyelid is hollow due to a low volume of fat, which may have always existed (as in this case) or appear with age.

This is associated with a slackening of the skin which appears wrinkled.

The intervention will seek to restore the initial volumes and correct the sagging by :
  • Removing the lower peaks conjunctivally (through the inside of the eyelid, which does not leave a scar and avoids the risks of retraction and round eyes)
  • Remove excess skin from the upper and lower eyelids
  • Remove the upper internal fatty spots
  • Correct the lack of volume by micro fat grafting (lipostructure) in: the dark circles, the top of the naso genial fold, the medio jugal fold and part of the cheek

Areas where fat has been placed
Appearance a few hours after the operation

1 year post-op
pre op

post op
Intervention :

The operation must be performed under general anaesthesia to avoid the injection of a local anaesthetic, which by swelling the tissues prevents the correct assessment of volumes.

The fat is removed from the inside of the knees by lipo-aspiration and then centrifuged to concentrate the fat cells (adipocytes)

Stem cells and growth factors are also concentrated, which will have a regenerative effect on the quality of the skin (improvement of skin radiance).

Some of the grafted volume will reabsorb and therefore needs to be slightly overcorrected.

This overcorrection is very prudent and we want to avoid excess volume in the long term, as it would be difficult to correct.

After this initial resorption, the result is long-lasting and the injected fat will evolve like the natural fat that surrounds it.

As with any surgery, there are risks:
  • Placing the fat in the wrong place or in the wrong amount will severely impair the result. For the surgeon, there is a long learning curve and it is essential to have a solid experience before engaging in the use of fat in the peri-ocular region.
  • The survival rate of fat cells varies from one individual to another, the fraction that is resorbed (resorption) varies from 10 to 30%. Since we want to avoid excess volume, we always anticipate the lowest resorption. As not all patients have the same resorption rate, it is accepted that in some cases 10 to 20% of the volume that was intended to be placed may be missing. This is totally accepted, as this lack will not compromise the aesthetic result, unlike an excess, even if minimal.
  • Persistent lymphatic oedema phenomena (from a few weeks to a few months) are possible. This occurs in patients who already have a tendency to lymphatic stasis with variable oedemas, generally maximum in the morning on waking, even before the operation. Similarly, patients who have had injections of hyaluronic acid (a volumising product that fixes water) are more exposed to postoperative oedema. It is sometimes preferable to eliminate the hyaluronic acid beforehand with hyaluronidase.
  • Very exceptionally, cases of serious complications (blindness, stroke) have been described due to injection inside a vessel (embolisation). This can happen with all types of products but it is mainly cases of needle injection of hyaluronic acid that have been published. This complication can be avoided by the use of cannulas (needle with a rounded end and a lateral orifice) of large diameter which will mechanically push the vessel rather than penetrate it.

Lipostructure is a huge step forward, it is a breakthrough technique in eye surgery, I have been practising it in the peri-ocular region since 2007.

Inferior blepharoplasty and lipostructure of dark circles and face

Blepharoplasty will correct excess skin, slackening of the orbicular muscle and excess fat in the orbit.

Lipostructure is a recent technique that also allows to correct hollows by performing micro fat grafts using cannulas (foam needles, i.e. not pointed so as not to be aggressive).

Fat is removed from the inner side of the knees, centrifuged to take only the fat cells (adipocytes) which are then deposited in the form of multiple small clusters in all the areas where volume is desired. A film is visible to visualize the technique.

These grafts also provide stem cells that will improve tissue quality and skin radiance.

An overcorrection is voluntarily sought at the time of the operation to take into account a partial resorption of 30 to 40% of the graft volume in the 6 months post-operatively.

This technique is a huge advance in eye surgery, especially when the face has become thinner overall or when the dark circles are very pronounced.

Pre-operative appearance
Appearance at age 20
Appearance at D 1
Appearance at 6 months

Superior blepharoplasty

With an excess of skin gradually appears on the upper eyelids, making the palpebral fold go down and then disappear.

At this stage, the skin touches the eyelashes which gives a closed look to the eyes and often leads to a feeling of heaviness of the eyelids. To compensate, the forehead muscles contract, which raises the eyebrows abnormally and creates wrinkles on the forehead.

The procedure removes excess skin and fat and replaces the palpebral fold.


Pre-operative appearance at age 59
Appearance of the eyes at the age of 20 (eyebrows in normal position)
Immediate post-operative appearance
Post-operative appearance at 3 months

Ectropion

Ectropion is a malpositioning of the eyelid that tilts outwards. The conjunctiva will be exposed to the air and become red, tears will run down the cheek instead of being evacuated in the nose, the eye is no longer well protected with a more or less important discomfort (sensation of foreign body, redness, crusts, burns).

This tilt can be related to a simple relaxation of the tissues supporting the eyelid with age, but also to a retraction of the skin as in the case described below. Retraction can be caused by tearing, chronic inflammation, retraction of a scar, dryness of the skin aggravated by sun exposure etc...

The treatment is surgical and consists of tightening the slack tissue (reattachment to the orbital rim) and lengthening the retracted tissue (skin graft or skin and muscle flap).

Before intervention
Before intervention
Immediately after intervention
Immediately after intervention
2 Months after intervention

Ectropion without cutaneous retraction with malar pad

Ectropion is an outward tilt of the eyelid. It is related to a relaxation of the tissues supporting the eyelid.

In the case described below, the skin and the orbicular muscle are not retracted (which would aggravate the rocking motion) but, on the contrary, relaxed, which produces a slight deformation above and outside the cheekbone called malar pad .

The operation consisted of tightening the posterior lamella in its 2 axes (refixation to the external bone edge and refixation of the retractor muscle) and raising the anterior lamella (skin, orbicular and suborbital fat) also fixed to the bone edge (mesolift or "cheeklift"). An initial over-correction is deliberately sought to take into account the slackening within 6 months post-operatively.

Aspect before the operation
Aspect before the operation
Immediate post-operative appearance
Appearance 2 months after surgery
Appearance 2 months after surgery
Aspect 2 Years after surgery

Involutional entropion (by release)

Entropion is a bad position of the eyelid which turns inwards, this leads to a rubbing of the eyelashes on the eye which causes discomfort (sensation of foreign body, redness, glare, pain).

Most often, as here, eyelid instability is due to sagging with age (involutionary form). The treatment is surgical and consists of tightening the eyelid in its different axes by reattaching it to the external orbital rim and recreating a palpebral fold.

Before intervention
After intervention

Upper Cicatricial Entropion (with retraction)

The scarring entropion is due to a retraction of the deep part (posterior lamella) of the eyelid which turns inwards, causing the eyelashes to rotate and rub the eye, which then becomes damaged (keratitis).

The treatment is surgical with a separation of the anterior and posterior lamellae that make up the eyelid, and an ascent of the anterior lamellae in relation to the posterior one. To do this, the levator muscle must be moved backwards.

An initial overcorrection is sought to take into account the healing process. The objective is to bring the eyelashes back to the horizontal without modifying the shape of the opening between the 2 eyelids.

Before intervention: rotation of the free edge towards the back, the lashes rub the eye.
Before intervention: rotation of the free edge towards the back, the lashes rub the eye.
Before surgery: retraction of the deep lamina
Immediately after the procedure
2 months after surgery
2 months after surgery

Lower eyelid reconstruction: graft + flap

Cutaneous carcinomas are frequently localized on the eyelids and frequently diagnosed late because these lesions are painless and not very visible. The fall of the eyelashes and the perception of an indurated cord to the touch should make you think of this diagnosis and consult your doctor.

The malignant nature of the lesion will lead to a safety margin of 4 to 10 mm depending on the location and nature of the carcinoma. Reconstruction is complex for the eyelids because 2 layers have to be reconstructed with a combination of flap (neighbouring tissue that remains blood-fed) and grafts (tissue removed elsewhere and replaced over the flap). The objective is to protect the eye while recreating a natural and aesthetic shape of the opening between the 2 eyelids.

Before the operation
Boundary drawing
After removal of the lesion
Final appearance

Lower eyelid reconstruction: Kollner Technique

An eyelid consists of two flaps, one posterior which must be non-abrasive because it is mobile in front of the eye, the other anterior made of the orbicular muscle and the skin which must not be in contact with the eye at the free edge.

When almost the entire eyelid is missing but the corners are still present, the posterior flap is reconstructed with a flap (tissue that is displaced but still supplied with blood) from the deep part of the upper eyelid . The anterior flap is recreated with a skin graft taken from the other upper eyelid.

15 days later the flap is cut, the upper eyelid lift muscle is pulled back (to prevent the upper eyelid from being too high) and the free edge is sutured. This technique is very efficient because it rebuilds an eyelid with tissue that comes from an eyelid itself, giving a natural final appearance with good mobility. Its limitations are the absence of eyelashes,, sometimes redness of the free edge and asymmetry in the shape of the eyelid opening.


Before surgery: Misleading form of carcinoma
Before the operation
J 1 After the operation
J 8 After release of the flap
3 months after surgery

If there is an excess of lower skin, it can be used by making a flap rather than a skin graft.


Aspect of the carcinoma before the operation
Drawing of limits and safety margins (5 mm)
Immediate post-op appearance, you can see the flap passing in front of the eye.
Final appearance 2 months post op

Palpebral wound (dog bite)

Dog bite injuries to the eyelids result in torn tendons and crush wounds that heal poorly.

In this child's case, a first suture was done in the local emergency department.

A second operation then sought to

- to give a natural shape to the palpebral opening,

- reconstruct the lower eyelid, the deep part of which had been torn off (with the eyelashes) and was reconstructed with a graft taken from the deep part of the contralateral upper eyelid

- reposition the external angle.

Facial paralysis: Resuscitation of the eyelid with an intra-palpebral implant

If the facial nerve is affected, the contraction of the orbicular muscle that closes the eyelids is compromised and the eye remains open at night (lagophthalmos) with absent or incomplete blinking during the day. When this leads to deterioration of the eye (keratitis, corneal ulcer, decreased vision, pain etc...), resuscitation of the eyelid can be achieved through gravity by placing a gold implant under the eyelid lift muscle. A test is performed before the operation to choose the most suitable weight. The definitive gold implant will be placed in such a way as to maintain a harmonious shape at the palpebral opening.

If there is a retraction of the eyelid (which is the case here), the weight will correct both the retraction and the lagophthalmos.

In the absence of retraction, it will result in a slightly lower position of the eyelid in relation to the opposite side, which can be aesthetically disturbing. Therefore, the minimum weight capable of achieving eyelid closure is always chosen.

Preoperative appearance with a retracted eyelid and significant lagophthalmos
Preoperative appearance with a retracted eyelid and significant lagophthalmos
Pre-operative weight testing
Final appearance 2 months after surgery
You can guess the rectangular implant

Dysthyroid orbitopathy (Graves' disease)

Some thyroid diseases, notably Graves' disease, cause an increase in the volume of the orbit and a retraction of the levator muscle.

This leads to a complex transformation of the gaze with abnormally exposed bulging eyes.

Several interventions were necessary here:

  • Firstly, a decompression of the bony orbit by removing the inner and outer walls and part of the floor. By giving more volume to the orbital fat, the eyeball recedes
  • in a second step, the levator muscle was moved back to place the free edge at the level of the upper edge of the cornea

Reconstruction of the orbital cavity: Evisceration and placement of a spherical implant

When an eye stops functioning, for example as a result of trauma or retinal detachment, it may atrophy (i.e. get smaller and smaller) and become painful and unsightly.

In order to eliminate pain and restore a more natural look, it is possible to perform an evisceration that removes the cornea (the transforming part in front of the iris) as well as the contents of the eyeball. In order to restore a normal anatomy, it is essential to compensate for the loss of volume with a spherical implant of a size close to that of a normal eye.

In this case the implant used is made of acrylic (plastic), the white wall of the eye (called the sclera) has been retained and used to cover the implant. The oculo-motor muscles extend from the sclera, so there will be movement of the implant when the sighted eye is in motion. Surgical techniques now allow implants to be placed large enough to compensate for the entire volume loss.

This will recreate a natural palpebral opening, a curved upper eyelid and a palpebral crease at a near-normal height.

The whole is covered by a prosthesis which is a fairly thin lens that looks like an eye. This lens will be mobilised by the movement of the implant, but this mobility will remain lower than that of the normal eye.

Painful, atrophic and unaesthetic right eye
Volume defect with a prosthesis deeper in the orbit than the left eye
Final appearance

Reconstruction of the orbital cavity after loss of the eyeball: dermal fat grafting

Removal of the eyeball results in an orbital volume defect. If this has not been corrected by the insertion of an orbital implant, or if this implant is of insufficient size, the volume defect will cause significant aesthetic damage.

To compensate for this, the prosthesis (which is a kind of large lens that looks like an eye) will be abnormally thick. Over time this will cause the lower eyelid to droop with the development of a deep hollow in the upper eyelid.

To recreate volume, a graft of both dermis and fat was taken from the buttock (the area where the fat is densest). The volume is close to that of an eyeball, the oculomotor muscles are reattached to the dermal part of the graft to give mobility.

A fraction of about 20-50% of the graft volume will resorb. The mobility of the prosthesis will be present, which is essential for aesthetics, but will always be significantly less than on the normal side.

The objective is to restore the most natural look possible, with a harmonious palpebral opening, a well-placed crease and an absence of offset of the prosthesis with the contralateral eye.

Orbital reconstruction after expulsion of an orbital implant: Dermofat grafting

When the eye must be removed (enucleation which is a complete removal, or evisceration where the globe wall is retained) the loss of volume is compensated by the insertion of an intra-orbital implant.

Sometimes it can be rejected and become externalized, leading to infection and abundant and embarrassing secretions. The dermofat graft taken from the buttocks will then allow volume to be recreated after removal of the infected marble. The graft also makes it possible to reconstitute the conjunctiva which will reform on the white dermal part left bare.

The graft takes about 15 days and the conjunctiva will reform in about 6 weeks. A prosthesis with the appearance of an eye is then custom-made by an ocularist. Partial resorption of the graft (about 30%) will occur in the first 6 months. This is anticipated by voluntarily placing a graft that is too large at the beginning.

Abundant secretions and exteriorization of the ball which becomes visible when the prosthesis is removed.
Abundant secretions and exteriorization of the ball which becomes visible when the prosthesis is removed.
A dermofat graft is taken from the buttocks...
Appearance after 15 days
Final appearance 6 months after surgery with and without prosthesis
Final appearance 6 months after surgery with and without prosthesis