Reconstructive Eyelid Surgery
Reconstructive eyelid surgery covers the restoration of the form and function of the eyelids. This can include repairs after lacerations from trauma, or the recreation of an entirely new eyelid following the removal of an eyelid afflicted with skin cancer. It also includes elevation of upper eyelids that droop to the extent where vision is impaired or tightening of lower eyelids that pull away from the eye and fail to offer adequate protection to this vital structure. Dr. Yohai is fellowship trained in Ophthalmic Plastic, Lacrimal and orbital reconstructive plastic surgery and has performed literally thousands of eyelid reconstructions. The specific areas of eyelid reconstruction are as follows:
Upper eyelid problems.
- Blepharoptosis or ptosis. This is where the upper eyelid droops to the point where it is blocking some or all of the pupil. This will cause a limitation of upper peripheral vision. The most common repair for this condition is a tightening of the eyelid lifting muscle, the levator palpebrae. The procedure is commonly called a levator resection. In this operation an incision is made in the upper eyelid crease. The loose upper eyelid lifting muscle is identified deep in the eyelid, trimmed and advanced lower in the eyelid so that it is effectively tightened resulting in an elevation of the upper eyelid well above the pupil. In cases where there is no function of the levator muscle, we will often run a silicone band from the eyebrow down to the eyelid. Thus when the patient raises their eyebrow, the eyelid will also be elevated. This is often necessary for congenital ptosis.
- Upper and lower eyelid skin cancers. When these cancers are on the skin, away from the margin of the eyelid, then the tumor is widely excised and the defect (the area missing the skin) is reconstructed with either grafts, flaps, or combination of the two. In a flap, the skin is rearranged locally to move skin into the defect. A graft is performed when skin is removed from a distant side such as the opposite upper eyelid. When the cancer involves the margin of the eyelid, then a full thickness removal of eyelid must be performed to assure complete removal of the cancer. There are various methods combining both flaps and grafts that allow reconstruction of even an entire eyelid. While lower eyelids are easier to reconstruct than upper eyelids, advance techniques can allow for acceptable cosmetic and functional results even in these unfortunate circumstances.
Lower eyelid abnormalities
Lower eyelid abnormalities are relatively more common than upper eyelid abnormalities.
- Ectropion. This is when the lower eyelid turns outward. It exposes the inner layer of the eyelid called conjunctiva. The conjunctiva is designed to stay moist. When it is out in the air, it often becomes beefy red and inflamed. Lower eyelid ectropion can be caused by a combination of factors. Most commonly the tendon holding the eyelid to the bone becomes loose. Tightening the lower eyelid will often improve the ectropion. Sometimes, however, the skin becomes tight, or it is removed for a skin cancer causing a tightness of the skin which pulls the eyelid down. In this case, the repair can be performed by grafting skin from another portion of the body. Alternatively, by lifting the mid face, we can recruit skin from the cheek and bring it into the eyelid. Sometimes these techniques are combined. Ectropion can also cause tearing in the eyes because the tear drain in the lower eyelid is turned away from the tears. The tears then pool in the space between the lower eyelid and the eye and will often run out when a person leans over. Ectropion can also cause irritation, although, often the symptoms are less pronounced than one would expect from the appearance of the eye.
- Entropion. This is when the lower eyelid rolls inward. This is quite irritating because the eyelashes rub on the eye. Patients typically complain of a foreign body sensation and tearing. This occurs due to horizontal laxity of the lid as well as a loss of the eyelid retractors which tend to pull the eyelashes outward when we look down. This is repaired with a combination of horizontal tightening of the eyelid combined with a re-advancement of the eyelid retractors to pull the skin backward preventing the inward rolling of the eyelid margin.