Doc, can you stop tears from running down my face?

This 68 year-old has been troubled by constant watering of the right eye for the past three years. She has seen many eye doctors but despite applying different eyedrops the condition fails to improve. Syringing of the nasolacrimal duct reveals blockage of the nasolacrimal duct. This condition typically affects elderly woman and thought to be a type of degeneration.  

Figure 1. Normal tear drainage system.

Figure 2. Diagram showing blocked nasolacrimal duct 

causing watering eye. 

Figure 3. Diagram showing how the blockage can be by-passed 

by creating an alternative passage for the tear. 

To bypass the blockage, an alternative passage is created by creating a connection between the lacrimal sac and the nasal cavity. The procedure is called dacryocystorhinostomy (DCR). The steps of the procedure done on this patient are shown in the photos below. The procedure is carried out under general anaesthesia.

Figure 4. a. Marking is done nasal to the right eye; 

b. incision is made and the skin and muscle are pulled away; 

c. an incision is made along the periosteum and peeled away from the bone; 

d. a hole is created by breaking the bone of the nose (rhinostomy); 

e. once the bone is removed the underlying nasal mucosa can be seen; 

f. the nasal mucosa is cut to create an anterior flap; 

g. the lacrimal sac is identified by inserting the lacrimal probes through the nasal puncta; 

h. the lacrimal sac is also cut to create an anterior flap; 

i. to improve the success rate of DCR, silicone tubing is inserted; 

j. the tube is passed from the punta through the lacrimal sac and nasal cavity and out through the nostril; 

k. after the tubing is passed, the anterior flaps of the lacrimal sac and nasal cavity are sutured; 

l. at the end of the procedure, the tubing is removed 6 weeks later. The new passage allowed the tear to bypass the blocked nasolacrimal duct. 

Doc, what are these swellings in my upper eyelids?

This 60 year-old woman is bothered by swellings in her upper eyelids near the nose. Examination shows these swellings were soft to the touch and can be pushed inwards (see figure 1). The features suggest these swellings were caused by prolapse of the medial fat pad. 

Figure 1. The patient is concerned by the swellings in her upper lids 

near the nose (areas circles in blue).

Anatomically, the upper eyelid contains two fat compartments: medial and central and the lower eyelids three: media, central and lateral (see figure 2). In young people, the fats are not visible but with age, the fat may become protruded due to weakness of the overlying structures such as muscles and septum (the fibrous tissue that separates fat from the muscles). 

Figure 2. Picture showing the right eye of a 70 year-old man with severe fat prolapse.

A = medial fat pad; B = central fat pad; 

1 = medial fat pad, 2 = central fat pad and 3 = lateral fat pad.

The swellings are easily removed through a limited incision along the skin creases (double eyelids). To get to the fat pad, the incision needs to go to through 3 layers namely: skin, orbicularis oculi muscle and the orbital septum. The fat needs to be handled with care to avoid bleeding into the back of the eye. After enough fat was taken the wounds are closed with sutures which are removed in one week.  

Figure 3. The patient shown in figure 1 undergoes fat incision under local anaesthesia.

a. marking along the skin crease (double eyelid); 

b. the fat is teased out from the medial fat compartment; 

c. the fat was clamped with a pair of artery forceps to prevent bleeding; 

d. the fat is excised and cauterized (burnt); 

e. at the end of the fat excision; 

f. the wound is sutured with 6/0 nylon. 

PDF articles from Cosmetic Surgery and Beauty Magazine

Click on the pictures to download the free articles.

Click here for the English version.

Click here for the Chinese version

Postoperative Review

Just done clinic including reviewing 12 operations I did yesterday. Some of the pre-and post-operative pictures are shown below with patients' permission. 

The top picture shows a patient with right ptosis preoperative which was corrected with posterior approach conjunctivomullerectomy. The swelling is minimal. 

The second picture shows a patient who had had suture technique for double eyelids some years ago, a limited incision techniques and epicanthoplasty were done to widen and lengthen the eyes. 

The last picture shows a patient who developed right ptosis following cataract surgery 10 years ago. Again the right ptosis was done with posterior approach conjunctivomullerectomy with minimal swelling. 

一切從眼睛開始 translated article from Cosmetic Magazine.

Did 4 cataract surgery today and received this article from Cosmetic Magazine.

Learning a New Word: "Pulchronomics"

A quiet day without clinic, so went to see my accountant about the GST. Afterward, went to Starbuck and read a book I bought in Kinokuniya. The book is titled "In Your Face" with the subheading "The hidden history of plastic surgery and why looks matter". Although written for the public, it was an entertaining and educational read for any doctors who perform aesthetic facial surgery. In page 124, I learnt a new word "pulchronomics". The term can be defined as the economic advantages of looking attractive. Pulchronomic appears to be a key factor in the mushrooming of aesthetic procedures in the last decades. With the increased competition in marketplace, looking attractive and young allow ones to get more customers and retain jobs these are especially true for those working in the beauty lines. No surprisingly, quite a number of my patients are either beauticians or cosmetic sale persons. 

Picture 1. A beautician before and after upper and lower blepharoplasty. 

Picture 2. A sales woman of a cosmetic counter. 

Before and after upper and lower blepharoplasty. 

 

A Patient with "Kissing" Naevus

Kissing naevus, also known as divided naevus, is a rare form of congenital anevus that usually occurs on adjacent parts of the upper and lower eyelids of one eye. When the eyelids are closed the eye appears to be covered by one large nevus. It may cause functional and aesthetic problems. This 60 year-old woman had had this lesion since birth and for the past three years there was an increase in size causing problem with eye opening. Examination shows no signs of malignant transformation. The patient was keen to have the lesion for both cosmetic and functional reasons. 

Picture 1. Left kissing naevus causing problem with

left eye opening and lower lid ectropion. 

The next series of photos show how the lesions were excised and the lids reconstructed. Before the operation, eye examination shows loose lower eyelid from chronic stretching of the lesion, so excision with direct closure was planned. The upper eyelid also showed lid stretching but it was thought the amount of excision may required additional steps to close the defect so reversed Tenzel's flap was planned. 

Picture 2. a. Drawings showing site of planned excision and reversed Tenzel flap. 

b. The lower lesion was excised in pentagon fashion. 

c, d and e. To facilitate direct closure, canthotomy and cantholysis of the lower eyelid were performed. 

f. Pentagon excision of the upper eyelid lesion.

Picture 2. g. At the end of excision; h. Layered closure of the lower eyelid; 

i. The cut edges of the upper eyelids can be apposed without tension so Tenzel flap was not done. 

j. Layered closure of the upper eyelid.

Picture 3. Appearance of the eyelid at the end of the operation. 

The excised lesions were sent for histopathologic study. The eyelid is expected to open in a few weeks time when the swelling subsides. (To be continued.