current trends in oculoplastics - matossian eye associates · current trends in oculoplastics cope...
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Current Trends
in
Oculoplastics
COPE #51615-AS
May 2017
Paul Johnson, MD
Matossian Eye Associates
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Financial Disclosures
• None
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Oculoplastics
• Reconstructive and
cosmetic surgery of
the orbit, eyelids, tear
ducts, and face
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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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
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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
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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
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Evaluation of Orbital Disorders
• CT vs. MRI
• Pathology
• Lab studies
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Anophthalmic Socket
• Trauma/
tumor/
blind painful
eye
• Sympathetic
ophthalmia
• Evisceration
• Enucleation
• ExenterationCopyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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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
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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
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Chalazion
• Caused by blepharitis
• Painful
• Warm compresses
• Injection of steroid
• Excision
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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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
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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
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Eyelid Reconstruction
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Eyelid Reconstruction
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Ectropion
• Involutional
• Cicatricial
• Paralytic
• Mechanical
• Congenital
• Cause chronic
tearing / irritation
/ exposureCopyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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Trichiasis
• Eyelashes turning inward and touching cornea
• Cause chronic irritation
• Epilation
• Electrolysis
• Cryotherapy
• Marginal
rotation
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Ptosis
• Aponeurotic
• Neurogenic
• Myogenic
• Traumatic
• Mechanical
• Congenital
• +/- dermatochalasis Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Ptosis
• Determine the correct
etiology
• Ptosis visual field
• Photos
• Repair either via anterior or
posterior approachCopyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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Lacrimal System
• Epiphora / Nasolacrimal
duct obstruction
• Canalicular lacerations
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Epiphora
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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Canalicular Laceration
• Laceration of the canaliculus
• Epiphora
• Repair with mini-Monoka tube
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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4 R’s of
Facial Rejuvenation
•Relaxing
•Refilling
•Resurfacing
•RedrapingCopyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Relaxing:
Neuromodulators
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Botox Brow Lift
(with Lower Lid Blepharoplasty)
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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“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
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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.
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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.
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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
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Refilling:
Dermal Fillers
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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Longer-Lasting
Temporary Fillers
• Restylane, Restylane Silk,
Restylane Lift
• Juvederm
• Belotero
• Voluma
• VolbellaCopyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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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
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1 month s/p 2 vials of Juvederm
to lower lids
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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7 weeks after 1 vial Juvederm
Ultra Plus to lower lids and
Botox to upper face
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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1 month after 1 vial Juvederm
Ultra Plus to Lower lids
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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Hyaluronic Acid Gel
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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Semipermanent
Fillers
•Radiesse
•Sculptra
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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Radiesse Longevity
• 9-15 months
• Most patients about 12
months
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
Radiesse –
Nasolabial Folds
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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
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Radiesse – Nasolabial Folds
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Midface Radiesse,
Periocular Juvederm
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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2 months after 2 vials of
Radiesse to upper cheeks
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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1 month after 2 vials of
Radiesse to upper cheeks
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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6 months s/p 3
treatments of 2 vials
of Sculptra
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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1 year after 4
treatments of Sculptra
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Resurfacing:
Chemical Peels
&
Intense Pulsed Light
(IPL)
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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Obagi Blue Peel
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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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
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IPL
(Intense Pulsed Light)
• Hair removal
• Acne
• Vascular lesions
• Photorejuvenation (sun spots, etc.)
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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Intense Pulsed Light
• Can also be used to treat dry eyes
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Redraping:
Surgery
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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Endoscopic Brow Lift
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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Relative
Contraindications
• Thyroid eye disease
• Severe dry eyes
• Narrow angles
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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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
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Upper Lid
Blepharoplasty
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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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
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Complications
• Retrobulbar hemorrhage
• Lower eyelid retraction
• Fat pad asymmetry
• Dry eyes
• Unmet expectations
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Lower Lid
Blepharoplasty
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Questions?
Copyright Paul Johnson, MD,
Matossian Eye Associates 2017
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Thank you!
Cell: (917) 648-7096
Email: [email protected]
Website: www.matossianeye.com
www.facebook.com/drpauljohnsonCopyright Paul Johnson, MD,
Matossian Eye Associates 2017