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JCAHPO Regional Meetings 2017

Aesthetics

&

The Ophthalmic Patient

David A. Kostick, M.D., F.A.C.S.

[email protected]

www.FloridaEyeSpecialists.com

Aesthetics and the Ophthalmic Patient

OutlineSkin Types

Skin Care

Fillers

Surgery


Healthy skin

(firm, smooth, even color)


Aging Skin

(loose, lines, discoloration)


Fitzpatrick Skin Type

(ARCH DERMATOL 1988; 124: 869-871)

I Very White Always Burns

II White Usually Burns

III Light Brown Rarely Burns

IV Dark Brown Dark Tan

V Black Never Burns, Very Dark Tan


Skin Care

Cleanser

Sunscreen (UVA, UVB)

Antioxidant (topcial Vitamin C)

Exfoliant (alpha-hydoxy acids)

Pigment Therapy (hydroquinone)

Retinoids (Retina-A, Renova)

Don’t Smoke!


Fillers / Injections

Botulinum Toxin (Botox ®, Xeomin ®)

Autologous Fat vs. Hyaluronic Acid (HA)


botulinum toxin

Purified botulinum toxin

Edward J. Schantz, PhD ~ 1944

Alan B. Scott, MD

late 1960’s – strabismus research

1977 – 1st volunteer

FDA approval, 1989


Botox ®

Inhibits Acetylcholine release XEOMIN® Selected Important Safety Information

WARNING: DISTANT SPREAD OF TOXIN EFFECTPostmarketing reports indicate that the effects of XEOMIN and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia, generalized muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening and there have been reports of death. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults treated for spasticity and other conditions, particularly in those patients who have underlying conditions that would predispose them to these symptoms. In unapproved uses, including spasticity in children and adults, and in approved indications, cases of spread of effect have been reported at doses comparable to those used to treat cervical dystonia and at lower doses.

XEOMIN® (incobotulinumtoxinA) for injection, for intramuscular use Prescribing Information. Greensboro, NC: Merz Pharmaceuticals, LLC; April 2013.

Please see other Important Safety Information at the end of this presentation.Please see provided full Prescribing Information, including Boxed WARNING, also available at XEOMIN.com.

CONTRAINDICATIONSXEOMIN is contraindicated in patients with a known hypersensitivity to the active substance botulinum toxin type A or to any of the components in the formulation and in the presence of infection at the proposed injection site(s).

http://www.fda.gov/fdac/features/2002/ldbotox.html

http://www.fda.gov/fdac/features/2002/ldbotox.html



Botulinum Toxin (Botox ®, Xeomin ®)





Cosmetic Eyelid Surgery


outline Introduction

Anatomy

Evaluation

Eyebrow

Upper lid

Lower lid

Summary

West Side Story

Sharks versus Jets


anatomyUnderstanding periorbital anatomy is the most

important aspect of being an oculoplastic surgeon.

“Normal anatomy” varies widely

especially with appearance

it’s what makes us unique


anatomy

Upper lid Lower lid

Oculoplastic anatomyUpper lid


medial canthal defect

Intra-op Post-op


medial canthal defect

Intra-opPost-op


pre-op evaluation Medical History

Prior surgery

Bleeding

Scarring

Motivation

Occupational

Emotional

Marital trouble

Depression

Ocular History

Vision

Contact Lens wear

Prior ocular surgery

Lid

Refractive

Trauma

Dry Eyes

Glaucoma


pre-op evaluationPrior Eye History

Check Vision

Know what you’re getting into!!

B A D

DO A COMPLETE EYE EXAM

KNOW WHAT YOU’RE GETTING INTO


3 causes of “eyelid droop”, “heaviness”

Brow Position

Dermatochalasis

Lid droop (true blepharoptosis)

Weakness of levator / aponeurosis

Brow Ptosis

I D E A L B R O W

Brow Ptosis

Surgical Options

Botulinum Injection

Direct brow

Mid-forehead

Bicoronal

Temporal hairline

Endoscopic (sub-periosteal)

DIRECT BROW

MID-FOREHEAD LIFT ENDOSCOPIC BROW LIFT

PTOSIS REPAIR

Ptosis Repair

surgical optionsExternal Ptosis Repair

(levator surgery)

Internal Ptosis Repair

(conj-muller, Fasanella-Servat)

Frontalis suspension

(banked, autologous, synthetic)

(not really considered cosmetic)

Ptosis Repair

levator function / surgical optionsExcursion (mm) Levator function

0 – 4 Poor / Frontalis suspension

5 – 10 Fair / External levator

11 + Good / External or Internal

PTOSIS REPAIR: External Approach

BE AWARE OFUNILATERAL PTOSIS

PTOSIS REPAIR: Internal Approach

Conjunctival-Muller Resection

phenylephrine test

Before Drops After Drops

(OS only)

Instrument Tray

Conjunctival-Muller Resection

post-operativeNo Patch

Ophthalmic ointment BID & prn

Cool – Ice compress:

(10 minutes q hour while awake)

Prn acetaminophen, ibuprofen & diphenhydramine

Follow-up visits:

(1 day, 1 week, 6 – 8 weeks)

BLEPHAROPLASTYchange the shape of the eyelid

Pseudoptosis Upper Blepharoplasty

Lower Blepharoplasty


summaryKnow anatomy

Restore anatomy

Everyone is unique

Less is more

Understand patient expectations

Be Aware of Unilateral Ptosis

“Know what you’re getting into”

Aesthetics

&

The Ophthalmic Patient

David A. Kostick, M.D., F.A.C.S.

[email protected]

www.FloridaEyeSpecialists.com

jcahpo regional meetingsdocuments.jcahpo.org/.../regionalmeetings/2017/florida/kostick.pdf ·...

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