Oculofacial and Orbital Surgery

• Blepharoplasty is the art of sculpting the extra skin, fat, and muscle of the upper or lower eyelids (dermatochalasis). This can improve one’s peripheral vision, decrease blepharitis, and even improve tension headaches in some patients as well as help one look their best. For cosmesis, the fat can be transferred in the upper and lower lids to provide more youthful contours, as your surgeon may discuss with you. Blepharoplasty can be done with a laser or a scalpel.  Upper lids require sutures while lower lids often do not. 
• Ptosis repair is necessary to tighten a loose tendon in the upper eyelid. Ptosis is a condition that causes the eyelid edge to drop over the pupil and can interfere with the upper field of vision. In cases of ptosis, surgical advancement of the eyelid tendon is needed to restore proper position of the lid and improve vision. Adjustments may be necessary in about 20 percent of patients to achieve symmetry. 
• Laser skin resurfacing is frequently used to tighten loose lower lid skin, smooth away wrinkles and increase collagen all while maintaining a natural shape to your eyes. This procedure requires 10 days with no makeup and frequent cleanings to achieve best results. The resurfaced area is often pink for 2-3 months in the average patient that has fractional ablative CO2 laser and possibly longer in patients that undergo a traditional CO2 laser resurfacing. Chemical peels may be used for similar purposes.  Your doctor will review which treatment is best for you. 

•  Entropion is a condition where the eyelids turn inward and the eyelashes rub against the eye.  This can cause irritation that leads to excessive tearing, infection, corneal damage and impaired vision. The eyelid can be repaired with a variety of different surgical techniques. Sometimes repair can be accomplished with an in-office procedure. In certain circumstances, entropion may also occur in the upper eyelid.
• Ectropion is a sagging downward or turning outward of the lower eyelid margin and lashes. This can cause significant discomfort because the affected eye is exposed and dry. The eyes may also tear because the tears spill over the lid margin instead of being properly pumped into the tear ducts. The eyelids may crust with excess mucus or appear red along the edge. Left untreated, ectropion can result in permanent eye damage such as infection and corneal scarring as well as permanent damage to the eyelid and eyelashes. Treatments include artificial tears and ointments for lubrication followed by corrective surgery. The surgery often involves a lid tightening procedure.. 
• Blepharospasm - a rare condition that causes muscle spasms and involuntary eyelid closure, which can be functionally and socially debilitating. Patients are often seen by a number of physicians before the diagnosis is finally made. This condition can sometimes affect other facial and neck muscles. The cause is unknown. The condition involves many areas of the brain and is related to patients who have brains that remodel themselves too easily.  There are several treatments to help control the spasm. So far, treatments do not target the source of the spasms in the brain. Most insurance companies require that patients first try oral medications. Your physician will discuss which options are best for you. Next, botulinum injections are recommended to soften the spasms.  In some cases, surgery to soften the muscles and nerves in the eyelids can be of great benefit.  In general, the condition is progressive and only regresses in a minority of cases. The oculofacial surgeons are the only physicians that are able offer all of these treatment options.  For severe refractory cases, neurosurgeons may offer deep brain stimulation surgery. 

Eyelid Cancer is usually painless, but very dangerous and is usually treated with surgery. Timely diagnosis usually results in minor surgery with excellent cosmetic outcomes. Your oculofacial surgeon has special skills to repair your eyelid to restore function and cosmesis, as well as to monitor the comfort of your eye and the health of your cornea during this process. 

Some common early signs of eyelid cancer are bumps, ulceration, red areas, missing eyelashes, scaly skin, or changing pigmented areas.   If indicated, your oculofacial plastic surgeon will perform a biopsy in the office.  Depending upon the result of the biopsy, you may be advised to have excision of the cancer by a Mohs surgeon (a specialized dermatologist) with a subsequent eyelid reconstruction by your oculofacial surgeon. The extent of the reconstruction cannot be determined until the Mohs surgery has been completed. It can range from a simple closure to more involved procedures.  Some cancers require reconstruction of the tear duct if this area is involved. This would involve placement of a stent in an attempt to maintain normal tear flow.. Your oculofacial surgeon will discuss predictions about your surgical repair depending upon the type of cancer that you have as well as the location.  In some cases, the affected eye might need to remain closed for several weeks to allow the repair to heal.  Stitches after such a procedure usually need to remain in place for 10 days, unless eyelid closure is recommended for a longer period. 

Eye injuries and facial traumas are usually treated by a team of physicians, including general ophthalmologists, cornea and retina specialists, facial trauma surgeons and oculofacial surgeons. Sports injuries, car accidents, or penetrating injuries can result in significant disability and dramatic alterations of one’s appearance. Timely repair of the injury is important to restore the proper function of the eyelids and of the eyes. The Duke Eye Center’s oculofacial plastic surgeons are experts on reconstruction of orbital fractures as well as periocular lacerations, in addition to care of the eye itself. 

Excessive watering or tearing of the eyes may in some cases be caused by blocked tear drainage ducts. This may be due to stenosis, stones, or previous trauma that hinder the drainage the system. Tearing may cause bothersome blurred vision and skin irritation from chronic dabbing. In some patients, an infection called dacryocystitis can be a serious complication of a blocked tear duct. 

First, your physician needs to determine the etiology of the tearing.  If it is due to an eyelid malposition problem, you may be advised to have an ectropion repair (see above). There are various treatments for blocked tear ducts depending on the location of the blockage and the severity of the situation. Partial obstructions may be treated with silicone tubes that are removed at a later date. These are placed in the operating room, although no cutting is involved.  Complete blockage may require a bypass surgery called a dacryocystorhinostomy (DCR), in which the tear duct is bypassed by making a small opening internally into the nose. The same Crawford stents are still placed. This is usually done with just 3-4 small stitches, but in some cases can be done endoscopically.  Lastly, if the obstruction is in the most superior part of the system, you may require a hollow glass tube called a Jones tube.

The orbit is formed by the bones of the eye socket and contains the eyeball, the optic nerve, the muscles that move the eye, and numerous critical vessels and nerves.   Orbital tumors can occur in any part of the orbit. They may present cause anything from a change in glasses prescription, to a decrease in visual field, to blurry vision, to pain, numbness, or a bluging eye. Imaging tests will be ordered as well as other possible tests. Usually, surgery will be necessary to obtain a biopsy; however, in some cases, your physician may recommend observation or other treatments. Depending upon the location of the tumor, surgery could be done through the thin tissues along the side of the eye, through the eyelids, or in some cases, in conjunction with neurosurgery by craniotomy. A pathology report is needed to determine if the tumor is benign or malignant.  Once the pathologist determines the diagnosis, a treatment plan can be made. 

Patients with an autoimmune thyroid disorder can develop a related condition called thyroid eye disease. Patients with this condition can have a variety of different presentations and symptoms, including eyelid retraction, redness, swelling, eye bulging, dry eye, tearing, double vision, and even vision loss from compression of the optic nerve, or from severe corneal exposure..

This eye condition can occur independent of the current hormonal status of the thyroid gland. It most commonly occurs in patients in their 40’s and in their 60’s.  The initial active inflammatory phase typically lasts up to 18 months, after which the swelling subsides and the condition ceases to be progressive. However, the changes to the eyes often do not return to normal. Therefore, surgical procedures are sometimes necessary to relieve pressure on the optic nerve, to minimize dryness that causes corneal damage, or to relieve feelings of discomfort and pressure and restore normal appearance.  Patients will need to determine the best plan for their eyes with their physician.  The treatment armamentarium includes treatment with anti-inflammatory medications such as steroids, orbital radiation, orbital decompression surgery, eye muscle surgery, and eyelid surgery. The proper order, timing, and necessity of the procedures can be determined by you and your doctor.

Duke Eye Center oculofacial plastic surgeons also perform a variety of cosmetic procedures to rejuvenate the face and skin.  

• Cosmetic blepharoplasty - can be accomplished solely with a laser with no knife needed.  This allows for elegant surgery with minimal bleeding and excellent results. Sutures are still used in the upper eyelids.
• Ablative laser skin resurfacing – smooths away wrinkles on the face with the strongest device to do so – the CO2 laser with both fractional and traditional techniques
• Facial fillers – are expertly injected to give facial rejuvenation with the most natural appearance possible. The artistry of the Duke oculofacial surgeons has been sought after by many continuing medical education conferences, to teach injection techniques in front of large audiences across the United States. Duke oculofacial surgeons can offer you the option of every filler that is FDA approved in the US to meet your individual needs.
• Neuromodulators – These chemicals are injected selectively and precisely into the facial muscles to decrease both standing wrinkles and wrinkles that occur with facial movement.  Duke offers all 3 neuromodulators: Botox, Dysport, and Xeomin. 
• Kybella Fat dissolution -  injected beneath the chin, to reduce submental fullness.  Duke physicians were among the 3 physicians in the state of North Carolina to be trained in the injection techniques. This alternative to liposuction technique often requires 3-4 treatments.
• Microfocused ultrasound (ultherapy)– provides non-invasive lifting of the jowls, neck, and brow often with very minimal downtime in a one-time treatment. 
• Microneedling with radiofrequency (Infini) – provides skin tightening of not only the face and neck but also other areas of the body.  This technique usually requires 3 days of social healing time. 3 treatments are generally recommended. The treatment is often planned by the physician with device settings and patient markings and then carried out by a physician extender.
• Vascular laser – provides rapid erasure of unsightly facial veins.  It is also an effective treatment for the generalized redness associated with rosacea.  
• Intense Pulsed Light (IPL) – This non-laser light treatment offers effective improvement of facial pigmented lesions, the redness associated with rosacea, and collagen tightening.
• General skin care – The oculofacial surgeons have a passion for taking care of your skin, with health and beauty as top priorities. These physicians have experience in working with the top researchers to make your skin its most radiant.  We offer a large variety of topical applications, including the most powerful antioxidants, retinoids, anti-pigment creams, growth factors, moisturizers, and sunscreens. Some of these products were actually invented at Duke and then acquired as the high-end physician line for L’Oreal. Other products were tested in clinical trials at Duke. The aestheticians can also provide skin care for rejuvenation, acne, and rosacea.