Oculofacial Plastic Surgery

Plastic surgery can be used to correct problems or to enhance appearance.  At Concord Eye Center in New Hampshire, our board certified oculofacial plastic surgeon, Dr. David Weinberg believes that a physician and surgeon should:

  • listen and be attentive to your concerns
  • answer all of your questions
  • perform a careful assessment of your situation / needs
  • individualize your treatment to your needs and wishes
  • be meticulous and attentive to detail during surgery
  • do his or her best to ensure patient satisfaction
Dr. Weinberg specializes in all aspects of oculofacial plastic surgery, including cosmetic and reconstructive eyelid surgery, lacrimal (tear duct) disorders, and orbital diseases and surgery.  Concord Eye Center also offers cosmetic procedures including BOTOX® and dermal filler injections, blepharoplasty and forehead and mid-face lifts.
To schedule a consultation at Concord Eye Center, call 603.224.2020 today.
 
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Ptosis

Ptosis refers to an upper eyelid position that is too low (droopy eyelid).  There are many causes of this condition, but it is most commonly due to weakness or stretching of the muscles that raise the upper eyelid.  Ptosis repair may be performed externally (through a skin incision) or internally (from the inside of the eyelid), and the goal is usually to tighten the muscles that raise the eyelid.  Infrequently, if the ptosis is severe and muscle function is weak, a sling may need to be placed between the brow and the eyelid (frontalis sling procedure).

 

Dermatochalasis

Dermatochalasis refers to excess eyelid skin.  When there is significant upper eyelid dermatochalasis, the skin may overhang the lashes and potentially interfere with vision. Corrective surgery involves removing the excess skin and sometimes fatty tissue (blepharoplasty).

 

Entropion

Inward rotation of the eyelid (entropion) often results in eyelashes rubbing against the surface of the eye.  This condition may cause significant eye irritation.  There are a number of potential causes of entropion, and it is important to understand the basis of the entropion before proceeding with corrective surgery.

 

Trichiasis

In certain cases, even though the eyelid is in normal position, there are misdirected eyelashes that are turned inward toward the eye (trichiasis), which may be quite painful.  Simple epilation involves individually pulling out the inturned eyelashes, but those lashes usually grow back.  Electrolysis or cryotherapy (where electrical current or freezing treatment is used to destroy the misdirected eyelashes) may provide a more permanent solution.

 

Ectropion

Outward rotation of the eyelid (ectropion) may result from eyelid laxity and/or tight eyelid skin. Symptoms include a watery eye (due to malposition of the opening of the tear duct) or redness and irritation of the eye (due to exposure of the inside of the eyelid and the surface of the eye). Surgical repair typically involves tightening the lax eyelid, and occasionally it is necessary to place a skin graft, use a skin flap, or raise the cheek to address the tight eyelid skin.

 

Eyelid retraction

Eyelid retraction refers to an upper eyelid that is too high or a lower eyelid that is too low.  Potential causes of this condition are thyroid eye disease (Graves’ disease), eyelid scarring, or simply an eye that is prominent (proptosis).  Eyelid retraction may cause the eye to feel dry and irritated.  It is correctable with surgery, which may occasionally require placing a tissue graft on the inside of the eyelid.

 

Lumps and bumps around the eye

There are many benign and cancerous growths that occur on the eyelid and face, including the same skin cancers that appear elsewhere on the body, such as basal cell and squamous cell carcinomas and melanomas.  Most growths are benign and display slow growth over months to years.  These include cysts, papillomas (such as seborrheic keratoses), warts, hemangiomas (reddish vascular lesions), moles, etc.  These lesions can usually be easily removed in the office.

Certain features are suggestive that a lesion may be malignant: rapid growth, irregular shape (rather than round with a smooth surface), ulceration (breakdown of skin overlying the lesion), or spontaneous bleeding.  With pigmented (darkly colored or brownish) lesions, one should monitor the lesion for the following features (the “ABCDE’s”) that may suggest a lesion could be a melanoma:
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A = asymmetry (irregular shape rather than round or oval)

B = border (the edges of the lesion are irregular or jagged rather than smooth)

C = color (the lesion displays different colors rather than being one single color)

D = diameter (larger than 6mm in size)

E = evolving (changing in size, shape, color, elevation, or other features over time)

If there is suspicion that a growth may be cancerous, then a biopsy or removal of the lesion should be performed. If the lesion is found to be malignant and it was not completely excised, further surgery will usually be necessary to remove the remainder of the tumor, which may involve the assistance of a Mohs surgeon (a dermatologist specializing in removal of skin cancers).

Blepharitis and Chalazia

Blepharitis (crusting of the eyelashes and/or dysfunction of the oil glands of the eyelid) is a very common condition.  It may cause soreness, itching, and redness of the eyelids.  Blepharitis is typically treated with daily warm compresses, eyelid scrubs (to clean off the eyelashes), and oral flax seed oil and omega 3 fish oil.  In certain cases, oral doxycycline and antibiotic eye drops or ointment are prescribed. Blepharitis may increase the risk of developing a chalazion or stye (also known as a hordeolum). This is a blocked and inflamed oil gland in the eyelid, which often manifests as a tender, inflamed bump on the eyelid. Chalazia and styes are initially managed with frequent warm compresses, and they will often resolve spontaneously.  If they don’t go away, they can usually be removed in the office.

Lacrimal disease includes problems with tear production and tear drainage.

 

Dry eye syndrome

Inadequate tear production is a major cause of dry eye syndrome that tends to develop as we age.  Certain oral medications, such as antihistamines, may contribute to dry eyes.  Symptoms include eye discomfort (burning, aching, or a scratchy feeling) and blurring of vision.  One may also develop reflex tearing, where the eye periodically produces a flood of LacrimalSystemImagetears in response to the dryness, and such patients often report alternating periods of dryness and wetness of the eye.  In fact, a large percentage of patients who present with tearing are found to actually have dry eye syndrome.  Dry eyes therapy includes artificial tears, gel or ointment in the eye(s) at bedtime, oral flax seed oil, and topical cyclosporine (Restasis).

Tearing (Wet Eye)

Tears on the surface of the eye drain through the tear duct, as follows. Tears flow into the puncta (small openings along the edge of the upper and lower eyelids near the nose), then through the canaliculi (narrow drainage channels in the eyelids) to the lacrimal sac (on the side of the nose), and then down the nasolacrimal duct into the nose.  A blockage anywhere along that pathway may cause tearing and potentially infection.   Infection in the lacrimal sac (dacryocystitis) causes redness, swelling, and tenderness on the side of the nose, often with pus training from the eye.

A blocked tear duct is relatively common at birth (congenital nasolacrimal duct obstruction), but usually resolves spontaneously over the first year of life.  If it fails to resolve and it is symptomatic (tearing, crusting, infections), treatment options include probing of the tear duct and sometimes placement of a temporary silicone tube stent, both of which carry a very high success rate. A blocked tear duct may also develop later on in life (acquired nasolacrimal duct obstruction) for many possible reasons, e.g. facial trauma.  While placement of a silicone tube stent is sometimes successful in adults with a partial tear duct blockage, a severe obstruction usually requires dacryocystorhinostomy (DCR), which involves creating a new drainage pathway from the lacrimal sac into the nose to bypass the blockage.  This can be done either through a small skin incision (external DCR) or through the nose (transnasal endoscopic DCR).  The skin incision usually heals quite nicely, leaving a minimal scar in most cases.  When there is complete blockage of the upper and lower canaliculi (in the eyelids), placement of a Jones tube (a permanent glass tube which drains tears from the inner corner of the eye into the nose) may be necessary to alleviate the tearing.

A wide variety of conditions may affect the orbit (the eye socket), including inflammation, infection, trauma (e.g., fracture of the orbital bones), and tumors.  The orbit contains numerous muscles, nerves, and blood vessels involved in function of the eye.  Consequently, orbital disease may result in pain, double vision, and occasionally visual loss.  Swelling or the presence of a mass behind the eye may push the eye forward, which is called proptosis or exophthalmos.  On the other hand, an orbital fracture may cause the eye to recede in the eye socket, becoming “sunken in” (enophthalmos).  In addition, a small, or “trapdoor”, fracture may cause restriction of eye movement and double vision as a result of an eye muscle getting caught in the fracture (entrapment).  Only certain orbital fractures require surgical repair.  There are many other potential reasons for orbital surgery, such as biopsy or removal of a tumor or orbital decompression surgery for thyroid eye disease.

A number of facial and eyelid changes occur with aging and sun damage.

 

Skin changes:

  • Dry skin
  • Fine lines and deeper wrinkles (rhytids) including “crow’s feet,” frown lines (“the 11’s”), and forehead creases
  • Brown spots (dyschromias)
  • Benign and cancerous growths

 

Other eyelid and facial changes:

  • Loss of facial fullness (volume loss)
  • “Baggy” upper and lower eyelids, with loose, excess skin (dermatochalasis) and protruding orbital fat
  • Droopy upper eyelids (ptosis)
  • Sagging of the brows and cheeks (Gravity takes over!)
  • Deeper nasolabial folds (“parentheses”) and “marionette lines”
  • Double chin

Sun damage is likely responsible for many of the aging changes of skin, and smoking augments that damage.  Protecting your skin from sun exposure with a broad-spectrum sunscreen (wtih both UVA and UVB block), with a SPF of at least 15-30, is very important.  That will also reduce your risk of developing skin cancers.  Many skin care products are available to treat sun-damaged skin, including moisturizers, retinols, exfoliants, vitamins, antioxidants, peptides, growth factors, and lightening agents.  We carry SkinMedica, a comprehensive line of skin care products.

Botulinum Toxin and Dermal Fillers

Botulinum toxin, such as BOTOX®, is a prescription medicine that may be injected into muscles of the face to temporarily reduce dynamic facial creases, such as crow’s feet and frown lines, with the effect typically lasting about 3-4 months. Dermal fillers are injectable products, usually a gel, that can temporarily reduce static facial creases and folds and correct volume loss. These fillers include Juvederm, Voluma, Restylane, Belotero, and Radiesse, with some lasting up to 1-2 years. Common filler injection sites include the nasolabial folds (the “parentheses” between the nose and the corners of your mouth), marionette lines (below the corners of your mouth), lips, lower eyelids and cheeks. Botulinum toxin and dermal filler injections are a great way to nonsurgically rejuvenate your face. These injections are administered by Dr. Weinberg, not a nurse or assistant.

 

Facial Peels

Facial chemical peels, such as the SkinMedica and TCA peels we offer, exfoliate (remove) the surface layer of damaged skin cells, allowing the skin to regenerate with a healthier appearance.  These treatments may rejuvenate your skin, improving skin texture, fine lines, age spots and skin discoloration, mild scarring, and some forms of acne.

 

Cosmetic Eyelid and Facial Surgery

Blepharoplasty (“lid lift” surgery), by addressing excess eyelid skin and fat in the upper and lower eyelids, can restore a more alert and youthful appearance.  Sometimes excess upper eyelid skin is related to a low position of the eyebrow (brow ptosis), and browlift surgery may be recommended.  Midface (cheek) lift can restore the youthful shape of your face, reversing the effects of gravity.  Conservative surgery is one of the keys to achieving a natural-appearing surgical result.  You should choose an experienced, board-certified surgeon to perform your facial and eyelid surgery.

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