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.
Injecting drops of neosynephrine (2nd photo) causes the muscle to contract and the eyelid to lift, making it possible to distinguish this type of ptosis from those linked to a loss of muscle contractibility. The procedure, usually performed for aesthetic purposes, is a delicate one, as even the slightest imperfection is highly visible. The aim is, of course, to lift the eyelid, but also to give it a regular, harmonious curvature, and to reposition the palpebral crease and orbital fat to eliminate the hollow-eye appearance.
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.
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.
Dog bite injuries to the eyelids result in torn tendons and crush wounds that heal poorly.
In this child's case, a first suture had been made in the local emergency department (first photo), the antomic structures were not concordant, the tear of the deep layer of the eyelid not reconstructed.
The operation involved :
- restore the natural shape of 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.
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.
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 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.
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.
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.
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.
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).
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.
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.
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.
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.
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.
If there is an excess of lower skin, it can be used by making a flap rather than a skin graft.
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.
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:
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.
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.
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.