Oculofacial Plastic & Reconstructive Surgeries: "Functional" (Medically Necessary) and Cosmetic / Aesthetic
All evaluations and services are completely provided directly by Dr. Archer. There are no technicians, just one-on-one with Dr. Archer for that caring and personalized touch!
Brow Ptosis; (droopy eyebrows):
Direct Brow Ptosis Repair
Direct brow repair involves an incision directly above the upper row of eyebrow lashes, with the tissue to be removed measured beforehand in the office and then marked and removed at the time of surgery. There is a double layer closure: deep sutures that are reabsorbed by the body over 4+ months and skin sutures that are removed in the office 1 week after surgery. The forehead / scalp area is numb for 6-9 months following surgery. However, data shows that sensation nearly always returns, but as it is doing so the patient may experience a "tingling" sensation in the forehead or feel like an insect is crawling on the forehead. There is a scar directly above each eyebrow and extending out a bit. For most people, this settles in with time as natural remodeling of the scar occurs over 6-12 months and is usually barely visible. Makeup can be used to cover it.
Endoscopic Repair For Brow Ptosis
In this brow ptosis repair, the incisions are hidden inside the hair line and dissection is performed to the orbital rim. The endoscope is used in this area to prevent damage to nerves and blood vessels. The periosteum is released across the orbital rim from one side to the other. This allows the brow to be lifted up. Fixation devices are used inside the hair line and attached to the head to hold the newly repositioned forehead in place while healing. This procedure is more aesthetically appealing, but insurance companies do not cover it since there is no functional advantage to this approach, only cosmetic. This repair can handle up to 2 cm of brow ptosis (or sagging), but it works best for amounts less than 2 cm. This approach also improves heaviness in the area above the nose between the brows. There are no visible scars, unless the patient is bald, then scars tend to heal with minimal appearance in those areas.
Droopy Upper Lids (blepharoptosis):
To be covered by insurance, the amount of ptosis must impair the upper visual field to under 20 degrees from the horizontal midline, or the lid margin must sit barely above the center of the pupil. Bandages are worn overnight only, and skin sutures are removed in the office 1 week after surgery. There should not be any pain after surgery and there is usually only minimal bruising and swelling. It is very important for the patient to apply cold packs for either 10 minutes every hour while awake, or for 15 minutes every 2 hours on the day of surgery and for the following 3 days. While a very successful surgery, a recent study of ASOPRS members, who are specialists in this surgery, indicated a recurrence rate after surgery of up to 25%. Dr. Archer's success rate is over 95%, but unexpected recurrences can occur, and the reasons are not always clear. Sometimes, a neurologic evaluation is required before surgery to check for disease causing the ptosis, or if there are recurrences of ptosis after the surgery.
Dermatochalasis: (excess tissue upper eyelids)
To be covered by insurance, the skin needs to reach the lid margin, hang over the lashes, and interfere with peripheral vision when the eyebrows are in normal position. Any less than this and it is considered cosmetic, and not covered by insurance. Blepharoplasty is the surgical removal of excess eyelid skin. Bandages are worn overnight only, and the external sutures are removed in the office 1 week after surgery to minimize scarring. There should not be pain after surgery, but there may be some mild discomfort that responds to acetamenophen. The incision is placed in the lid crease which camouflages nicely and also creates the new lid crease.
Dermatochalasis: (lower eyelids)
Usually considered only cosmetic, rarely considered medically necessary unless the excess tissue is so severe that it balloons out and touches the bifocal portion of a patient's glasses, completely obscuring the bifocal. Pure dermatochalasis is treated by surgical removal of excess skin, with an incision placed just below the lower lid eyelashes. Sutures are removed in the office 1 week after surgery. This condition usually occurs in combination with protruding orbital fat and / or mid-face descent (SOOF). If the primary problem is orbital fat protrusion, Dr. Archer can remove the fat from an incision inside the lower lid. If the patient also has excess skin, then Dr. Archer removes the excess fat and skin from the front surface of the lower lid. With fat removal, it is important to watch for post operative scarring which causes the lid to retract and pull down. If the lower lid is loose, then the patient will need a lid tightening along with the blepharoplasty. If a patient has allergies that causes swelling in the lower lids, then an evaluation by an allergist, an internal medicine physician who has undergone additional fellowship training in allergy medicine, may be necessary to treat the underlying problem. Otherwise, correction of the excess lower lid tissue will not be maintained during an allergy attack with ballooning of the lower lid skin, and new/recurrent allergy bags can form.
Mid-Face Descent;(SOOF Descent)
This condition is best addressed by elevating the mid-face through an infraciliary incision (incision is placed just below the eyelashes of the lower lid). Entire mid-face area is freed up and mobilized upward. Permanent deep sutures are placed. This improves the sunken lower lid area and softens up the tear trough defect. It can lessen the "jowls" and nasolabial fold, but this is variable. External sutures are removed in the office 1 week after surgery. It may be tender to eat for a few weeks after surgery, due to manipulation of the masseter muscle of the cheek.
Elevation of the midface can be functional if there is shortage of tissue and the lower lid is turned out. Otherwise, it tends to be considered cosmetic.
Lower Lid Malposition
Entropion: (Lid turns inward)
This condition causes eyelashes to rub against the eye. Not only irritating, but has the potential to cause a corneal ulcer. Surgical treatment repositions the lid. Sutures are placed in the outer corner only, deep and surface, and the skin sutures are removed in the office 1 week after surgery.
Ectropion: (Lid turns outward)
This condition causes the eyelid to turn outward, causing watering of the eye, and exposure of the corneal surface with drying and breakdown. Surgical treatment repositions the lid. Sutures are placed in the outer corner only, deep and surface and the skin sutures are removed in the office 1 week after surgery.
With both procedures, the patient does not have pain, but will have bruising and swelling after surgery. Patient may not rub lids, as this may pull the deep sutures lose, or cause bleeding.
Cancer of the Eyelids
Suspicious lesions require a full thickness resection for pathologic evaluation. Usually, these are resected in the operating room, with a frozen section pathology analysis of tissue and additional resection until the lid margins are clear. Reconstruction depends on the amount of tissue resected and the location of the lesion. These options are discussed individually with each patient prior to any procedure being performed.
Tear Drainage Problems
Can be due to abnormal lid positions and treated as above (Entropion or Ectropion). Can also be due to a blockage in the tear outflow pathway (tear duct) and requires DCR (Dacryocystorhinostomy) to bypass the blockage. The tear sac is directly examined for any blockages. Tubes are placed at the time of surgery only if a membrane is found blocking openings in the tear sac. The tubes stay in place for 3-4 months. This surgery is performed under general anesthesia. Failure of the tear pump can be the underlying problem and cannot be diagnosed until abnormal lid position is corrected and blockage of the tear drainage system is corrected if needed. If watering of the eye persists after correction, then it means that the opening and closing of the eyelids is not adequately pumping the tears into the tear sac. The treatment is a conjunctival DCR, which requires placement of a special glass tube in the inner corner of the eye that allows the tears to drain from the inner corner of the eye directly into the nose. This surgery requires careful discussion with your surgeon as these tubes can shift and cause problems.
Thyroid Eye Disease
This is a complex and incompletely understood disease. Thyroid eye disease can occur completely separate (even by many years) from the original episode of hyperthyroidism. The body's immune system does not recognize the orbital tissue as it's own and mounts an antibody assault on the tissue; specifically, the extraocular muscles and orbital fat. These are both infiltrated with antibodies, which enlarges them. This in turn pushes the eyeball outward, causing proptosis (bulging eye). The disease also causes changes in the eyelid muscles and can cause lid retraction. Treatment depends on the stage of the disease. The goal is to protect the eye. Treatment can involve lid repositioning, removal of orbital fat (orbital fat decompression), bony orbital decompression, steroid treatment, radiation treatment and potentially drug treatment depending on the stage when diagnosed. Again, this depends on the need of the individual patient. If strabismus develops, then repositioning of the muscles of the eye may be necessary and could be more difficult due to thickened and tight eye muscles.
The best response is obtained in middle-aged women without thick skin. Elderly patients and men with thick skin are very poor candidates. After treatment, a special compression dressing is worn for several weeks to help the skin reattach and shrink properly. There is no to minimal pain, anesthesia is tumescent, which is a very dilute local anesthetic in fluid. The patient is awake for the treatment.
*All of the above procedures require evaluation and examination by Dr. Archer before a treatment plan can be determined. If the problem is "functional" (medically necessary) then the initial evaluation is covered by insurance. However, if the problem is cosmetic / aesthetic, then the cost of the initial evaluation is applied to any cosmetic treatment the patient chooses. Dr. Archer performs all evaluations, procedures and treatments herself.