Cosmetic Eyelid Surgery
Your eyes are a focal point of your facial features and are often one of the first things people notice about you. Unfortunately, as we age, our eyelid skin can loosen and sag and our fat pads deep within the eyelid bulge forward and become more prominent. The droopy and/or puffy appearance can make you appear more tired or older than you are.
Blepharoplasty (pronounced “blef-a-ro-plasty”) eyelid surgery can give a more youthful, refreshed appearance by removing the excess loose skin and sculpting the deep bulging tissues. Cosmetic blepharoplasty surgery can be performed on the upper and/or lower eyelids. This is one of the most common eyelid and cosmetic surgeries performed.
Upper Eyelid Blepharoplasty
Upper eyelid dermatochalasis (extra loose skin and bulging fat) is addressed by blepharoplasty surgery. Dr Dal Canto will determine how much skin to remove and will contour the underlying fat through an incision which hides in the natural eyelid crease. The thin eyelid skin heals remarkably well and the incision is often hard to find after several months of healing.
Lower Eyelid Blepharoplasty
Lower eyelid blepharoplasty surgery primarily involves removal or repositioning of the herniated fat (the cause of “eyelid bags”) through an incision hidden on the inside surface of the eyelid. The eyelid is also sometimes tightened horizontally at the outside corner of the eye to create a pleasing eyelid contour and reduce fine skin wrinkling. Finally, if extra skin can be safely removed, a separate incision is made just below the eyelashes and closed with fine sutures.
As a Board certified Ophthalmologist and a Fellow of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS), Dr. Dal Canto has extensive training in ophthalmic plastic reconstructive and cosmetic surgery and understands the important interactions between the eyelids, the eyes, and facial aesthetics. While lower eyelid blepharoplasty surgery is always performed on a cosmetic basis, upper eyelid surgery may be cosmetic or may be covered by your insurance plan. Dr. Dal Canto will help determine whether you qualify for functional (insurance-based) surgery and his office will work on your behalf to obtain preauthorization when needed.
Droopy or Heavy Eyelids (Ptosis)
Patients often complain of droopy or heavy upper eyelids. It is important to distinguish between two different forms of droopiness. Ptosis (pronounced “toe-sis”) is the medical term for lowering of the upper eyelid margin, with the eyelid obstructing the pupil, at least in part. Dermatochalasis is the medical term for excess skin of the upper eyelid. The excess skin can, at times, hang over the eyelid margin and thereby block the pupil to a degree. With either condition, patients often raise their eyebrows in an effort to raise the drooping eyelids. In severe cases, people may need to lift their eyelids with their fingers to see. While surgery to correct mild cases of dermatochalasis is considered cosmetic, severe cases can potentially be covered by insurance.
Children can be born with ptosis of one or both upper eyelids. They may develop amblyopia (“lazy eye”) from visual developmental delay because of limitation of their vision. Their ptosis should be corrected at an early age to allow for normal visual development.
What Causes Ptosis?
The most common cause of ptosis is age related weakening or stretching of the major muscle that lifts the eyelid, the levator muscle. Relatively rare causes are neurologic diseases, trauma, or congenital weakness. Ptosis may also occur following lasik or cataract surgery as a side effect of some of the instruments used in surgery. Children may be born with ptosis or may acquire it due to trauma or neurologic reasons.
Can Ptosis Be Corrected?
Ptosis can be corrected surgically, usually by tightening either the levator muscle through a skin incision or a second deeper muscle within the eyelid through an incision on the underside of the eyelid. Other techniques can be used or in severe cases with poor eyelid muscle function. The goal is to raise the eyelid to allow for improved visual field and to obtain symmetry with the opposite upper eyelid.
What Causes Dermatochalasis?
The most common cause of dermatochalasis is age related decrease of skin elasticity, allowing the skin to loosen and sag. Sun exposure and heredity can contribute to this condition. Brow ptosis (or droopy eyebrows) can bring additional eyebrow skin to the eyelids, apparently worsening dermatochalasis.
Blepharoplasty surgery to correct Dermatochalasis
Dermatochalasis can be corrected by blepharoplasty surgery, which predominately involves the removal of excess skin. Removal and/or sculpting of underlying bulging fat is often performed to achieve the best aesthetic outcomes, resulting in a more youthful appearance.
Ptosis surgery and blepharoplasty surgery are the most common surgeries performed by Dr. Dal Canto. Part of you evaluation will help determine whether the procedures will be considered medically necessary and covered by your insurance company. His office will work on your behalf to obtain preauthorization when possible. While most patients only require one of the procedures, some will benefit from both surgeries performed simultaneously. These may be functional (insurance-based) or a combination of functional and cosmetic.
Surgical Correction of Eyelid Malposition
The eyelids must be in proper position, and with good tone, against the eyeball in order to function correctly. In some circumstances, eyelids can turn away from the eye (ectropion) or roll inwards toward the eye (entropion).
Ectropion is the most common lower eyelid malposition. It is often an aging change resulting in eyelid laxity allowing the lid to sag away from the eye. Mild cases may not visibly turn away from the eye but can cause tearing, irritation, and/or dryness of the cornea. More severe cases will result in the eyelid truly turned away from the eye. Symptoms may include excessive tearing, chronic irritation, redness, pain, a gritty feeling, crusting of the eyelid, mucous discharge, and breakdown of the cornea.
What Causes Ectropion?
Ectropion most commonly results from aging changes causing tissues to stretch and the eyelid to loosen. However, it may also occur from facial weakness (from Bell’s palsy, stroke, or other neurologic conditions), trauma, skin scarring, previous surgeries, or skin cancer.
Ectropion repair is geared to the underlying cause of the malposition. As an oculoplastic specialist, Dr. Dal Canto will determine the root cause of you eyelid malposition and perform the appropriate corrective procedure. Most commonly, the eyelid is tightened at the outside corner of the eye. The surgery is performed on an outpatient basis and often results in rapid resolution of the eyelid malposition. After your eyelid heals, your eye will feel comfortable and be protected from corneal scarring, infection, and loss of vision.
Although aging changes most commonly result in ectropion (above), the eyelid may turn inwards towards the eye, a condition called entropion. Once turned in, the eyelid and eyelashes rub against the eye, usually causing significant irritation, redness, and sensitivity to light and wind. If left untreated, chronic entropion can cause corneal scarring and loss of vision. If entropion exists, it is important to have it fixed before permanent damage to the eye occurs.
What Causes Entropion?
Like ectropion, the most common cause of entropion are aging changes. However, trauma, scarring, previous surgeries, and eyelid tumors can also result in entropion.
Entropion repair is geared to the underlying cause of the malposition. Most commonly, the eyelid and its attachments are tightened to restore and stabilize the eyelid in its normal position. The surgery is performed on an outpatient basis and often results in rapid resolution of the eyelid malposition. After your eyelid heals, your eye will feel comfortable and be protected from corneal scarring, infection, and loss of vision.
As an orbital and eyelid reconstructive surgeon, Dr. Dal Canto is experienced in the correction of a variety of eyelid malposition disorders, whether simply age-related or due to other rare causes.
Eyelid Tumor Removals & Reconstructions
The eyelid skin is the thinnest in the body and is often exposed to sunlight. As a result, it is often one of the first areas to show sign of aging and sun damage. Unfortunately sun damage, combined with genetics, can lead to skin cancers of the eyelids, including at the lid margin. Skin cancer of the eyelids is relatively common and several types exist. They rarely cause symptoms such as pain, itching or bleeding, so any unusual nodule or lesion that is growing should be evaluated. Bleeding and/or ulceration (skin breakdown) are strong indications of possible cancer but are seen in only a minority of cases. If in doubt, have the lesion checked out by Dr Dal Canto, which involves an examination and a possible biopsy.
Basal Cell Carcinoma
Basal cell tumors are the most common eyelid tumor. These skin cancers grow slowly over months to years, so often go unnoticed by patients. Basal cell tumors often grow as pearly nodules, potentially with a central depression. If left untreated, they can grow and infiltrate the surrounding tissue, eventually destroying it. Fortunately, they do not spread to distant areas throughout the body. They typically can be cured by full excision, followed by reconstruction of the defect created by the tumor removal.
Squamous Cell Carcinoma and Melanoma
These types of tumors are much less common than Basal cell tumors, but are more aggressive and require more involved care to ensure complete treatment. In addition to surgical removal, further testing may be needed to ensure the tumor has not spread anywhere else. This will be determined based on your examination and the biopsy results.
Removal and Reconstruction
Skin cancer needs to be removed surgically. Dr Dal Canto will often excise the tumor in the hospital operating rooms where a pathologist can immediately confirm that the entire lesion was removed. In certain cases, however, he will work in conjunction with a specialized dermatologist who uses a special technique known as Mohs surgery to remove the cancer. Dr Dal Canto will then reconstruct the defect the following day.
Eyelid reconstruction may be necessary for a variety of reasons besides tumors and their excision. Defects in the eyelid can also arise from trauma or scarring from previous surgeries.
Small defects can be directly sutured closed, even if they extend through the full thickness of the eyelid. Larger defects may require complex reconstructions, involving transfer of adjacent tissues (“flaps”) or skin grafts from other parts of the face or eyelids.
As a Board certified Ophthalmologist and a Fellow of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS), Dr Dal Canto is uniquely trained and experienced in lid reconstruction. His goals are to attain an aesthetic as well as functional result in order to reestablish the eyelid for it’s primary role of protecting the eyeball.
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Excessive tearing can cause blurred vision, skin irritation, and significant frustration for some patients. Tearing can be caused by blockage of the tear drainage system, eyelid malposition, or excess tear production.
Dr Dal Canto specializes in treating patients with tearing due to eyelid malposition and/or blockages of the tear drainage system. The external tear duct openings (puncta), eyelid ducts (canaliculi), or the tear drainage duct into the nose (nasolacrimal duct) can become obstructed resulting in constant or intermittent tearing. Dr Dal Canto will determine the cause of your tearing during you initial visit with him.
What Are the Causes and Symptoms of Obstructed Tear Drainage Ducts?
There are a variety of causes for tear duct obstructions. The most common is aging changes, although infection, inflammatory disorders, medications, and tumors can be at fault. Blockages of the tear drainage ducts can result in excessive tearing, mucous discharge, irritation, swelling, pain, and infection. Babies can be born with blocked nasolacrimal ducts, causing tearing, eyelash crusting, and mucous discharge. Many times, babies will outgrow the blockage in the first 9-12 months of life. If they remain obstructed, surgery is recommended at around 1 year of age.
How is an Obstructed Tear Duct Treated or Repaired?
Dr. Dal Canto will determine whether your blockage is severe enough for surgery and which procedure is most appropriate. The most common blockage is within the nasolacrimal duct, which normally drains tears into the nose. If the blockage is complete, dacryocystorhinstomy (DCR) surgery is performed to bypass the duct and create a new passageway from the lacrimal sac to the nose. Partial nasolacrimal duct blockages can be treated by dilating the duct and placing a temporary stent through the system. In a small percentage of patients, the blockage will be of the puncta or canaliculi. Depending on the severity and extent of the blockage, Dr. Dal Canto will perform a variety of different procedures to fix or bypass the tear ducts.
Lacrimal duct surgeries are performed as an outpatient procedure. Patients generally have minimal bruising or swelling and notice an improvement in their tearing within one to two weeks. DCR surgery has a greater than 90% success rate.
Specializing in diseases of the orbit, eyelids, and tear drainage system, Dr. Dal Canto can fully evaluate the cause of your tearing. As a Fellow of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS), he has extensive training in managing the tearing patient and performing lacrimal duct reconstruction surgery.
Treatment of Thyroid Eye Disease
Thyroid eye disease, more technically named Graves ophthalmology or Graves orbitopathy, is an inflammatory disorder of the tissues within the orbit or eye socket (i.e., including the orbital soft tissues, eye muscles, eyelids, and conjunctiva). Patients with this disorder often have a thyroid abnormality that may manifest itself either before, during, or after eye symptoms begin.
Signs and Symptoms
Graves ophthalmopathy can have a wide variety of presentations and severity. The disease can begin suddenly and progress rapidly over days to weeks or can start slowly and progress gradually. The majority of patients have mild symptoms, mainly with retraction of the upper and lower eyelids and bulging of the eyes (proptosis). More moderate cases have increased inflammation with visible redness of the eyes, eyelid swelling, and varying degrees of double vision (diplopia). A small percentage of patients have severe inflammation that can result in compression of the optic nerve ad permanent vision loss.
In most cases, the inflammation worsens over the first 6 months to a few years before subsiding spontaneously. Changes caused by scarring of the eyelid and orbital tissues may persistent, resulting in persistent proptosis, eyelid retraction, and/or diplopia.
Evaluation and Management
Patients should be evaluated by an ophthalmologist to assess the extent and severity of the eye disease as well as an endocrinologist to manage any thyroid abnormalities. Smoking has been proven to worsen thyroid eye disease, and quitting is the most important thing patients can do to help improve their outcome. Patients with mild ophthalmopathy can often be evaluated periodically and managed to reduce ocular symptoms. Patients with moderate to severe disease may require intervention to reduce inflammation and preserve vision. Once the inflammatory phase has subsided, patients with eyelid abnormalities, double vision, or proptosis may benefit from surgical intervention to improve their function and appearance. Dr. Dal Canto is specialized in evaluating and monitoring disease progression and in medical and surgical management of eyelid and orbital abnormalities resulting from Graves ophthalmopathy.
Orbital Disease and Fractures
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Orbital infection, or orbital cellulitis, is an aggressive and rapidly progressing process that can be vision and even life threatening. Although commonly arising from an adjacent sinusitis, orbital cellulitis often requires urgent orbital surgery to drain any abscesses and intravenous antibiotic treatment. Early intervention often leads to preservation of vision and successful outcomes. Orbital cellulitis can also result from trauma to the eyelid, eye, or orbit or innately in people with weakened immune systems or diabetes.
Orbital tumors can arise within the eye socket itself or as an extension from the eyelids, eye, or surrounding sinuses, bones, or brain. Some tumors grow slowly and largely unnoticed while others can cause rapid changes, vision loss, double vision, or changes in the eye’s appearance and position. Dr. Dal Canto will often evaluate potential tumors with CT or MRI scans and make treatment recommendations accordingly. Depending on the tumor in question, it may be removed with surgery, either by Dr. Dal Canto alone or in combination with other specialists, treated by oncologists with chemotherapy or radiation therapy, or observed carefully over time.
Orbital fractures are common after trauma to the face. The thin bones of the eye socket can “blow out” or break into the surrounding sinuses. These fractures can occur in isolation or combined with other facial bone fractures, eyelid lacerations, tear drain injuries, and bleeding within and around the eye. These injuries occur all to commonly from fist fights, car accidents, sporting activities, and even simple falls. Orbital fractures with significant tissue prolapsed into the surrounding sinuses, double vision, or numbness of the cheek and/or lips should be repaired in a timely fashion, usually within several weeks. Dr. Dal Canto’s research showed that surgery was still effective even after a month, albeit more difficult. Surgery performed at a later time may still be worthwhile, but may be less effective. As an oculoplastic specialist, Dr. Dal Canto is an experienced orbital surgeon and will evaluate the fracture to determine whether surgery is necessary. He performs the surgery through an incision along the inside of the eyelid, leaving little if any external scars from the fracture repair.
Enucleation and Evisceration
The removal of an eye (enucleation and evisceration) may be necessary after a severe, blinding injury to the eye, or as a result of diseases that render an eye blind, painful, and often disfiguring. Once the eye is removed, the socket is reconstructed to prepare it for a prosthetic eye. When the surgery is done by a specialist such as Dr. Dal Canto, the result can be quite natural and pleasing in appearance in addition to the benefits of removing the blinded or diseased eye.
The orbit is a complex, enclosed structure with vital nerves and tissues necessary for normal ocular function. Dr. Dal Canto’s training and membership in the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASROPS) indicates that he is an expert in orbital surgery and reconstructive techniques. As a sub-specialized, board certified ophthalmologist, he has a deeper understanding of the anatomy and structure of the eye and orbit than other facial plastic surgeons. In addition, he can better monitor the impact of the orbital disease and surgery on the eye and its function.
Surgical Repair of Pediatric & Congenital Eye Disorders
Children can be born with, or can develop, a number of problems best treated by an oculoplastic specialist. Children can have blockages of the tear drainage ducts, abnormalities of their eyelids and eye socket, tumors, or other birth defects.
Excessive tearing, eyelash crusting, and occasional discharge are all symptoms of a congenital blockage of the tear drainage duct, or nasolacrimal duct. This disorder is relatively common; about 5% of newborns are born with a blockage. Fortunately, the condition will resolve on its own 90% of the time by the child’s first birthday. Massaging the tear drainage system during this time may be helpful; topical antibiotic drops may be used for severe mucus discharge. Surgery is usually reserved for blockages that persist beyond the first birthday or, in rare instance, for severe infection during the first year of life. The surgery involves probing and opening the tear drainage duct and is highly successful. Occasionally, stents are placed for several months or a balloon catheter is used during surgery to stretch the tear drainage duct further. These additional procedures are more commonly needed and used in children who are not being treated until they are older.
The most common congenital eyelid abnormality requiring intervention is ptosis, or a droopy eyelid. In children, ptosis is caused by abnormal development and weakness of the muscles that raise the eyelid. Congenital ptosis may be unilateral (one sided) or bilateral (both sides). It can be mild and only noticeable when the child looks up or severe and interfering significantly with the child’s ability to use that eye. In moderate and severe cases the droopy eyelid can interfere with proper visual development, leading to permanent amblyopia (“lazy eye”). Surgery is required in order to lift the eyelid; the surgical technique and timing of how quickly to proceed with surgery will be determined by Dr. Dal Canto based on the severity of the ptosis and the degree of eyelid muscle function.
Other abnormalities of the eyelid include misdirected eyelashes, turning in or out of the eyelid, congenital defects of the eyelid, and growths deep within or superficially in the skin of the eyelid. Again, these problems may need to be addressed surgically to restore the eyelids normal function of protecting the eye and allowing for normal visual development.
The orbit, or eye socket, surrounds and protects the eye. The most common problem of the orbit in children is bacterial infection, or orbital cellulitis. This usually results from bacterial infections spreading from the sinuses, though it can occur after trauma as well, and is thankfully relatively rare. Aggressive, prompt treatment with antibiotics and sometimes surgery is needed to treat the infection before it causes permanent vision loss.
Tumors can develop within the orbit or at the junction of the bones around the rim of the orbit. Some tumors, such as dermoid tumors, are benign (not spreading or invasive) but should be removed to protect from rupture and inflammation with trauma. Others, such as hemangiomas, grow over the first 1-2 years of life, but then regress, or shrink away, on their own. These may be simply observed as long as visual function and development are not impaired. Unfortunately, aggressive orbital tumors can develop in children as well, requiring surgery, chemotherapy, and sometimes radiation therapy to treat these life threatening problems.
Finally, trauma to or around the eye can result in fractures of the orbital bones or lacerations to the eyelids and tear drainage ducts. Depending on the extent of the injury, surgery may be required to correct the problem. Surgery may be urgently performed within several hours or delayed several weeks depending on the particular injury.
As a member of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS), Dr. Dal Canto has extensive training in problems that involve the eyelids, tear drainage system, and orbits in children as well as in adults. As a board certified ophthalmologist, he not only is an expert in dealing with the eyelids and orbits but is keenly aware of the need for appropriate visual development, which often is tied to eyelid and orbital function.
Fillers & "Botox® Cosmetic"
As an oculoplastic surgeon, Dr. Dal Canto is not only expert in facial anatomy but has a deeper understanding of the interaction between the deeper muscles and soft tissues and the different aesthetic units (cheeks, eyelids, mouth, etc) compared to many other physicians or spa technicians who may offer fillers and botox. Understanding these interactions is key in formulating the most effective treatment plan consisting of fillers, botox, or both in combination.
By far the most commonly used fillers in Dr. Dal Canto’s practice are the hyaluronic acid fillers, such as Juvederm® , Restylane® , and Hydrelle® . These are all part of the “next generation” of FDA approved dermal fillers. They are made of hyaluronic acid, a naturally occurring substance in your skin that helps add volume and hydration to your tissues. Besides being safer than collagen, they provide a smooth, natural contour and feel. They are gently injected under the skin into the mid to deep dermis to smooth away facial wrinkles and folds. They are particularly good with “static” wrinkles, or ones which are present even when the face is relaxed and not talking, smiling, frowning, etc. The effects of hyaluronic acid fillers generally last 9-12 months.
Fillers are commonly used for treatment of wrinkles and folds or for “plumping” the following areas:
- Nasolabial folds (the lines from the nose to the outside corners of the mouth)
- Marionette lines (the lines just below the corners of the lips)
- Tear trough (the area of the “dark circles” along the orbital rim)
While the “bags” and “dark circles” under the eyes are sometimes treated by surgical sculpting of the prolapsed fat creating the “bags”, some patients are better served or temporized by adding fillers to the hollow areas of the tear trough. By filling out the area along the orbital rim, the dark circles are often less prominent and the bulging fat is masked as well, resulting in a pleasant more youthful appearance. Since the area being injected is adjacent to both the orbit (eye socket) and eye, many doctors and spas will not treat the tear trough area. However, with Dr. Dal Canto’s extensive oculoplastic training and experience, these injections can be safe and effective in the right patients.
Botox® is commonly used for “dynamic” wrinkles, or wrinkles that become apparent or worsen with facial expression. Botox® is used to weaken the offending muscles resulting in a more relaxed, refreshed look with smother skin. The “Botox face” or “frozen face” appearance is a result of overly aggressive treatments that block not only the unwanted movements causing wrinkles but also all facial expression. Dr. Dal Canto strives for a natural appearance in his patients with the ability to maintain facial expressions, but with a softer, rejuvenated underlying appearance.
The most commonly treated areas are the forehead wrinkles, crow’s feet wrinkles (around the eyes) and frown lines (between the eyebrows). A series of small injections with a very fine needle are given just under the skin into specific muscles. Discomfort and downtime are minimal. The effect is generally noticeable after 7-10 days and lasts about 3-4 months, at which point the injections can be repeated. The lines and wrinkles often appear less severe after repeat treatments because the muscles are being trained to relax.
Dr. Dal Canto also uses Botox® for the treatment of blepharospasm (uncontrolled blinking and spasms of the eyelids). Patients with blepharospasm often also have dry eye syndrome and poor tear film quality due to blepharitis. It is important for patients to be evaluated and treated for these conditions in addition to the Botox® therapy.
As a member of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS), Dr. Dal Canto has extensive training and experience in the use of cosmetic fillers and Botox® . He will evaluate your aesthetic concerns and recommend the most appropriate approach, whether it be injection of fillers and/or Botox® or surgery, such as blepharoplasty surgery. He prides himself in personal service and does not relegate the task of the injections to a technician.