Plastic surgery: When specialties overlap

(Image Credit: AdobeStock/puhhha)

The disciplines of ophthalmology and plastic surgery can frequently intersect. One such area is blepharoplasty, a surgical procedure for correcting defects, deformities, and disfigurations of the eyelids, and for aesthetically modifying the eye region of the face.

Kay Durairaj, MD, FACS, known as Dr Kay, is an internationally renowned facial plastic surgeon located in Pasadena, California, who specializes in faces, including surgery for eyelids, rhinoplasties, facelifts and neck lifts. She also has expertise with Botox and other neurotoxins, facial injectables, and fillers. Durairaj discussed blepharoplasty and the collaboration between facial plastic surgeons and ophthalmologists in a conversation with Ophthalmology Times.

“[These procedures can] take 10 years off their appearance by just giving the eyes a wide, more open, less heavy-lidded look,” she said. “So they get some [lift. It’s] an entry point for people to feel like themselves without major interventions.”

As Durairaj also pointed out, many patients also seek the procedure because they don’t feel that it is changing their identity.

“If they are getting a rhinoplasty or a facelift or a bigger procedure, they are worried about how they may look [afterward],” she explained.

But when it comes to eyelid surgery, it’s almost intuitive that an individual’s eyes don’t change. Durairaj noted that during the procedure, it’s just the heavy skin that goes. Educating patients about the procedure can help patients to have reasonable expectations about its results.

Durairaj explained that having important midface support is critical to performing a successful blepharoplasty.

“When we see patients who have cheek ptosis are heavy [in the] mid face, where they don’t have good facial fat support in the medial cheek pads or lateral cheekbones, they just have very droopy, heavy skin,” she said. “These are the patients who need plastic surgery and concomitant [treatment].”

The approach, Durairaj explained, should be collaborative, with the surgeon fixing the midface and the lower face at the same time as the blepharoplasty.

“That removes a lot of drag on the face, and that removes a lot of drag on the eyes when we position the apex and the cheek where [they belong],” she said.

Patients can have issues with skin elasticity, which Durairaj said would be important to tighten. They also can have very heavy festooning or laxity of the cheek skin, which ultimately can impact the surgical blepharoplasty result.

It also is important for ophthalmologists to be aware of some of the surgical and nonsurgical options for eyelid heaviness.

“Nonsurgical [treatment begins with] neurotoxins that we can [use to] improve eyelid position with very accurately finessed placement,” she said. “We can finesse [the placement of] Botox or neurotoxin, and I think that placing filler in the temples is kind of overlooked. We have the ability to lift the lateral brow and the temple by placing temple filler, and that improves the eyelid position mildly.”

Durairaj pointed out that these nonsurgical options can provide from 1 to 2 mm of eyelid support. She also has placed brow threads, which help improve eyebrow and eyelid position indirectly. On rare occasions, she will use some upper eyelid filler, because when the brow bends, the fat pad under the brow causes some dissent.

“Some patients have been over-resected or over-thinned from their blepharoplasty,” she said. “So we are doing interventions like upper and lower eyelid filler as well as fat transfers to those areas.”

Kay Durairaj, MD, FACS

These less invasive nonsurgical approaches can offer some positive results. Moreover, midface cheek support, according to Durairaj, should be done prior to working on the eye.

“Accurate positioning of the midface will remove the gravity of the weight of the face from the delicate eyelid,” she said. “It can be done at the same time as blepharoplasty or prior. Sometimes, we will do that nonsurgically with cheek filler and sometimes we’ll do that with surgical placement, such as sutures suspension. Cheek threads is an option…midface threads is an option for people who want the nonsurgical approach.”

When surgery is the desired option, a mid-facelift or mini-lift procedure can be a starting point, and depending on the degree of skin laxity, rare cases may require a full facelift and neck lift. Durairaj noted that cheek implants would be a very rare choice.

For patients, a successful blepharoplasty can provide immediate benefits, including feeling less tired and immediately looking 10 years younger.

“Blepharoplasty in combination with midface support is ideal,” Durairaj said. “I’ve seen many cases where people are offering just skin excision of the upper and lower eyelids without addressing the droop and drag of the mid face and the lower face. And when we have heavy jowling and cheek ptosis, if we don’t treat that, we don’t have a more youthful-looking patient.”

Durairaj explained that a patient who only undergoes simple skin excision of the upper and lower eyelids may not be satisfied with the final results. They may not look rested and could still exhibit an older appearance.

“It is important to recreate the heart-shaped youthful face position versus the heavy inverted position…an inverted pyramid of aging. It’s very important to correct that,” she noted.

On follow-up, it is important for the patient to return to the surgeon who performed the procedure and to seek treatment from an ophthalmologist if vision issues arise.

“Your primary surgeon would always love to see you, but certainly we would want the vision assessed by an ophthalmologist,” she added.

Red flags can arise for ophthalmologists, and in these instances, Durairaj said it is important to know when to refer a patient to an ocular plastic surgeon.

“I think an ophthalmologist should refer to a facial plastic surgeon when they see significant cheek ptosis,” she explained, “when they see heaviness and skin laxity that’s beyond several millimeters. In blepharoplasty surgery, we’re going to take only millimeters of skin, generally speaking.”

As a result, when a patient has extreme skin laxity, very sun-damaged skin, or photo-damaged skin that’s not going to bounce back and heal well, Durairaj said she will sometimes perform interventions such as full-face laser resurfacing or a concomitant at the same time as eyelid surgery.

“Other situations would be when there is fat that requires repositioning, or we have fat that has fallen into the wrong position,” she pointed out. “We may want to use existing fat and reposition it so that it can improve the teardrop appearance of the eye.”

Durairaj pointed out that referring the patient to an ocular plastic surgeon also would be necessary when a fat transfer is needed and the ophthalmologist is experienced in face fat transfers. Any patient who has major festoons would also be a candidate for referral.

Ophthalmologists who are treating patients who have had previous injections of fillers or other materials that may affect the eyelid may want to consider referring them to an ocular plastic surgeon for additional treatment when vision is not immediately threatened.

“Sometimes, we can see instances where there have been excess injections with hyaluronic acid because we can assist with dissolving that preoperatively,” Durairaj noted. “Sometimes, there is silicone or illegal materials that have been injected, and the assessment of that would be helpful.”

Durairaj also noted there has been an increase in issues in patients stemming from overfilled teardrops, Tyndall effect, and filler that becomes encapsulated under the eyes, which can prove to be difficult to pinpoint and remove.

Another issue arises in patients who have received injections whose filler has migrated into areas where it shouldn’t be, which could pose a problem for patients of both plastic surgeons and ophthalmologists.

Durairaj also suggested that ophthalmologists develop a relationship with a plastic surgeon whom they can work with when the specialties overlap.

“There can be instances where they work together with a patient, [to offer] 2 layers of expertise,’ she said. “While it can be difficult to coordinate, every time I have done a collaborative case, with an ophthalmologist and myself in the room as a facial plastic surgeon, the 2-way teaching has been incredible. Our tips and pointers to each other really helped.”

The interaction between the specialists can provide a positive outcome for the patient with the 2 experts. Durairaj has also worked on cases with her brother, Uday Devgan, MD, an ophthalmologist based in Los Angeles, California.

“It was great. It was really good fun,” she said. “I taught him tips and tricks from my end, and he [did] the same for me.”