Cosmetic Orbital Surgery

Chair
Oculofacial Clinic

Cosmetic Orbital Surgery

Cosmetic orbital surgery is new concept in Oculoplastic region.

It refers to the treatment of patients who are bothered by protruding or sunken eyeballs due to disease, accident, or congenital reasons.

Director of
Oculofacial Clinic

Tomoyuki
Kashima

MD, PhD Instagram

Career

Exophthalmos and Enophthalmos

There are
two types of cause for each.

One is condition from illness and the other is by nature.
Cosmetic orbital surgery treats these patients cosmetically.

4 types of conditions

So there 4 types of conditions.
We are treating those patients respectively.

Exophthalmos

For exophthalmos,
3 types of condition.

1. Orbital tumor
2. Thyroid eye disease
3. Congenital exophthalmos

Orbital fat decompression
for thyroid eye disease
and congenital exophthalmos

Let’s move on to
orbital fat decompression.

Orbital bone decompression

From orbital anatomy the four walls surrounding orbital tissue (lateral /medial /floor /roof) can be decompressed.

The decompression of each 4 walls have each benefit and risk.

The risks
of BONE decompression

We must think about the risk of Bone decompression. It is the damage to surrounding tissue outside and inside of bone, such as, brain, nerves, vessels and nasal cavity.

The most serious problem is brain injury. The surgeons feel fear for fatal event.

And this method have relatively high probability of new onset diplopia.

But…

Bone doesn’t play any role in TED

Increasing volume of fat (and/or muscle) have important role for proptosis

Ideally, the target should be something different.

Fat decompression is 5th wall decompression.
He reported new onset diplopia occurs 2.5% of cases.

Advantage of
FAT decompression
compared to
BONE decompression

1. Natural
2. No skin Scar
3. Short recovery
4. Predictable and adjustable

So, why I changed my first choice from bone to fat?

Fat decompression have 4 advantage comparing with bone decompression. It can create Natural form, without Skin Scar, Recovery time is short and the result is predictable and adjustable.

However…

However, Posterior orbit is so dense with muscle, nerves and vessels.

Removing only fat seems like an impossible task.

So, I will tell you how I remove orbital fat without damaging those important tissue.

To avoid the complication we use 2 tools

Microscope(Leica M320)

We always use microscope for orbital fat decompression. Leica M320 is made for dentists. It is so good for oculoplastic surgery and also cheap.

It costs about 30,000 US. One fifth of normal microscope for ophthalmologists.

The microscope is necessary for orbital fat decompression especially for intraconal fat resection.

Spatula

And spatula is good tool for invading deep orbit without damaging important organ.

Categorize orbital fat

1.Extraconal fat

The role of extraconal fat is the structure supporting eyeball and muscle cone. So, it is relatively hard and strongly adhering bone, tendon and muscle.

2.Intraconal fat

The role of intraconal fat is the cushioning material for intraconal nerves, vessels during eye movement. It is very soft, loose and indefinite.

To avoid complication

To avoid complication, we should know about those important structure well.

To remove orbital fat, we must consider about muscle, nerves and arteries.

It is not necessary to consider about veins, because rupture of veins never damage visual function.

The first,
how I avoid damaging muscle?

Muscles are relatively hard tissue.
strongest of orbital tissue for damage.
With spatula, it is not so hard to avoid damaging muscles.

The second,
How I avoid damaging nerves?

1. Optic nerve
2. Sensory nerve
3. Motor nerves of extraocular muscles
4. Short ciliary nerve and ciliary ganglion

We should consider 4 nerves in the orbit.
Optic nerve, sensory nerve, motor nerves of extraocular muscles, short ciliary nerve and ciliary ganglion.
Needless to say, optic nerve is most important for visual function. Then, damaging the optic nerve is the worst complication.

Because Sensory nerve plays no role for visual function, it is not so important for this surgery.
Therefore, during orbital decompression surgery, we must pay attention to those two types of nerves.
Motor nerves of extraocular muscles and short ciliary nerve and ciliary ganglion.

motor nerves of
extraocular muscles

• Distribution of 4 rectus nerve is located optic nerve side of rectus.
• Avoid operating the optic nerve side of muscle.

Short posterior ciliary nerve and ciliary ganglion

• Intraconal fat is soft, loose and indefinite tissue.
• loosen the fat, avoiding tearing off the tiny fibers.

What we should consider to avoid damaging short posterior ciliary nerve and ciliary ganglion.

The intraconal fat is soft, loose and indefinite tissue, so loosen the fat, avoiding tearing off the tiny fibers which may be the branch of oculomotor nerve.

3.Avoid damaging Arteries

Most important tissue for avoiding visual loss is orbital vessels.
Because Veins are not important for visual function, I will talk about arteries only.

Blood Supply for Vision

We must think about blood supply for eyeball.

Which is more responsible for vision loss after orbital fat decompression?
Central Retinal Artery(CRA) or Posterior Ciliary Arteries(PCAs).

Answer: Posterior Ciliary Arteries (PCAs)

• Central retinal artery (CRA) is so close to optic nerve that CRA rupture is possible but rare.
• Rupture of PCAs is more probable. It must cause Anterior Ischemic Optic Neuropathy(AION).

Which area of orbital fat can be removed?

Fat removal from 4 quadrant

Of course, Orbital fat can be removed from 4 quadrant avoiding 4 rectus muscles.

And last, just behind lacrimal caruncle.

Orbital fat of lower quadrant can be removed from inferior fornix and upper quadrant can be removed from upper eyelid crease.

Schema of orbit

1. 1. Removing fat must be posterior to equatorial part of eyeball.
2. 2. The more posterior you go, the more effective it is.

Now I explain the basic concept of orbital fat decompression. The first, removing fat must be posterior to equatorial part of eyeball. Anterior part of orbital fat play no role for protrusion.

The second, The more posterior you go, the more effective it is. The cross-sectional area of orbit changes depending on the position. So, posterior fat removal is more effective, but it is also dangerous.

How I remove it?

1.Extraconal fat

You can just remove it roughly under adequate knowledge of orbital anatomy.

2.Intraconal fat

You must remove intraconal fat gently. Using 2 spatula, push aside 2 rectus muscles for each quadrant, then intraconal fat will pop out from the intermuscular septum.

The fat should be loosened before removing. And only loosened fat can be removed. Intraconal fat contains tiny but important nerves and arteries.

You must pay maximum attention for removing.

Intraconal and Extraconal
Fat decompression fornix approach

This is the movie of fat decompression. You can see this video in my youtube channel.

With the transconjunctival approach, fat tissue can be removed. At first, we remove blepharoplasty fat, and extraconal fat.

Then we remove intraconal fat from the space of muscles, between inferior rectus and lateral rectus, and between inferior rectus and medial rectus.

CASES

30 years old Female

40 years old Female

This is the result after fat decompression. We performed both upper and lower fat decompression for this case.

30 years old Female

For congenital enophthalmos

Case1.30 years old Male

Orbital fat decompression can treat congenitally proptotic patient.

However, from the side, you can understand the change.
Comparing the top of eyelid and eyebrow, it is remarkable eyeball position changed Different from thyroid eye disease, congenital proptosis do not have increasing volume of fat.
So there is limitation to remove the fat.

Case2.Explaining orbital decompression using case photos

Compare photos
before and after treatment

Please take a look at the pre-surgery photos. She has beautiful eyes with double eyelids, but the whites of her eyes are exposed a lot, and her upper eyelids look a little swollen, so she came to our clinic hoping to have these things corrected.

Next, please take a look at the photos taken 1 month after surgery.

There are still traces of bleeding on the lower eyelids and whites of the eyes. It usually takes 3-4 weeks for the bleeding to subside. You can see that the sunken eyes give a gentler impression.

Easy to understand and enlarge

Next is a photo taken from an angle.

Please pay attention
to your left eye

Compare photos before and after treatment

Comparing the left upper eyelid in an oblique photo, you can see that the puffiness has disappeared and the upper eyelid, which used to protrude more than the eyebrows, has become more depressed than the eyebrows after surgery.

In this way, you are born with large eyes (protruding eyes), and our clinic also performs corrections for this. If you have a similar problem, please feel free to contact us.

Risk

Cases of congenital bulging eyes

Case3.If the patient need to remove fat more…

Explaining a case of
congenital exophthalmia

Deepening of orbital sulcus cause completely different appearance which may bring impression of aged person.

Compare photos before and after treatment

Pre

The eyes are large and give the impression that they stand out too much. The area of the whites of the eyes is large, making them look like Sanpaku eyes. It also looks like the eyes are a little far apart.

Post

This is a photo taken the day after surgery. You can see that the eyes are sunken and the area of the whites of the eyes has decreased. The distance between my eyes has become closer and my balance has improved. The black lower eyelid is due to internal bleeding.

Easy to understand and enlarge

Pre

I have enlarged the photo for clarity. The area of the white of the eye is large, and there is also the white of the eye between the cornea and lower eyelid.

Post

This is a photo taken the day after surgery. You can see that the upper eyelids are sunken and the area of the whites of the eyes is reduced. The white of the eye between the lower eyelid and cornea is gone, and the tripaku has resolved. The black lower eyelid is due to internal bleeding.

Next, let’s take a look
at the photo from an angle.

Pre

It is noticeable that the eyes are very large. I think people with small eyes would be envious of them, but having them too big can also be a problem.

Post

In the photo taken the day after surgery, the area of the whites of the eyes has decreased and the impression that the eyes are large no longer appears. It has changed to a calmer impression.

Enlarge the photo
of the right eye

Again, we may remove fat as much as possible if patient demands, but it may result worsening of impression.

Pre

The position of the eyebrows and the position of the eyeballs are approximately the same height.

Post

It’s the day after surgery. As the eyeballs become sunken, the upper eyelids become sunken, and as a result, the area of the whites of the eyes becomes smaller.

Case4.40 years old male

Orbital tumor resection

The two main approaches to the ORBIT are

• Transcutaneous approach
• Transconjunctival approach

I prefer transconjunctival approach for cosmetic reason.

About
the extraorbital approach

The approach to the orbit began with avoiding intraorbital injury leading to loss of visual function.

However, the extraorbital approach is highly invasive.

10 approaches to the orbit

This is an illustration from the American Academy of Ophthalmology.

Many approaches have been developed and there are more than 10 approaches as shown here.

• A. Classic Stallard-Wright
  lateral orbitotomy.
• B. Eyelid crease lateral orbitotomy.
• C. Lateral canthotomy/
  cantholysis orbitotomy.
• D. Transcaruncular medial orbitotomy.
• E. Frontoethmoidal (Lynch)
  medial orbitotomy.
• F. Upper eyelid crease
  anterior orbitotomy.
• G. Vertical eyelid split
  superomedial orbitotomy.
• H. Medial bulbar
  conjunctival orbitotomy.
• I. Subciliary inferior orbitotomy.
• J. Transconjunctival
  inferior orbitotomy.
• K. Lateral bulbar
  conjunctival orbitotomy.

Different approaches are used depending on the location of the tumor in the orbit.

Minimally invasive as technology advances

This is the classic
transcutaneous approach that has been practiced for decades.

This approach leaves a scar formation on the skin, is far from the orbit, and is highly invasive, so it is gradually being phased out in modern times.

The Lynch incision approach has been replaced by the less invasive trans-caruncular approach.

If the approach is superomedial, lid crease incision approach is also possible.

The superolateral orbital approach has shifted to an approach from the lid crease incision approach.

The subciliary approach is shifting to conjunctival incisions, lateral canthotomy incision, or a combination of both called swinging eyelid approach.

This is a list of my preferred approaches.

I vary my approach depending on where in the orbit the tumor is located.

Specifically, the approach I choose depends on where in the four quadrants of the orbit and whether it is Extraconal or Intraconal.

The Lateral canthotomy approach

Now, I would like to move on to each of the topics.

First, the Lateral canthotomy approach.

Orbital tumor

70 years old Female
Right huge intraconal
orbital tumor
Operation refused
by neurosurgeon

This patient is approximately 70-year-old woman. She had been seeing a neurosurgeon, but because there’s a risk of blindness, she has not been able to undergo surgery until now. Gradually, the protrusion of right began to interfere with daily life, not only in terms of function but also in terms of appearance. She came to our hospital looking for a medical institution that could treat her right eye

Intraconal tumor
bigger than eyeball

MRI shows a tumor larger than the eye in the posterior part of the eye; both T1 and T2 have similar signal intensity as the vitreous cavity. The border is clear. The diameter of the tumor is about 35 mm. How would you remove this tumor?
I chose to approach through a lateral canthotomy incision.

I started from lateral canthotomy. Cut into until periosteum, and then removed lateral wall of orbit.
The key of orbital tumor removal is how to use the malleable retractors.
Using 2 malleable retractors, separate the tumor from orbital tissue, and then, remove it.

3 month post-operation

The tumor was successfully removed and vision was restored.
Because of the very large tumor, the eye is rather concave after removal.

Comparison of before
and after surgery.

The upper row is preoperative and the lower row is postoperative. You can see that the huge tumor was removed and no scar remains on the skin. Compared to before, the protrusion of the eyeball has improved and the vision, which was almost blind, has recovered to almost normal. Obviously, her quality of life improved due to cosmetic change.

Surgery video

Explanatory video of myocone intraorbital tumor removal
Occulofacial Clinic Tokyo
Dr. Tomotaka Kashima

*This is an explanatory video of the actual surgery, so if you are not comfortable with surgical videos, please do not watch it.

Swinging eyelid approach

Next is the swinging eyelid approach. This is a technique in which an incision is made at the lateral canthus and the conjunctiva is directly incised to secure a large surgical field below the orbit.

50 years old Female
Left extraconal orbital tumor

She is approximately 50 years old. A left orbital tumor is present below the eyeball. The increased size of the tumor has caused upward pressure on the eyeball, resulting in deviation.

This surgery was done with swinging eyelid approachIn Inferolateral quadrant, there is no important tissue, so I finished it in 18 mins. . I put this video on Youtube.

Postoperatively, differences in left and right eyelid shape and eye position have been resolved.
After surgery she regained symmetrical eyes cosmetically.

Upper eyelid crease

The next approach is upper eyelid crease incision.

Approximately 70 years old Male
Right lacrimal grand tumor

The right eye is compressed by the tumor, causing not only ocular protrusion but also downward deviation of the eyeball.

Right Lacrimal gland tumor

MRI shows a tumor in the lacrimal gland area of the right orbit, compressing the eye.

I choose lid crease approach. Dissecting into the periosteum and expose bone.
And then, after bone removal, I removed lacrimal gland tumor.
Lacrimal gland tumor have loose adhesion laterally and superiorly, so you should start with that area.
It has tight adhesion inferiorly and medially, I recommend to loosen posterior side of lacrimal gland and dislocate it.

After tumor resection, ocular protrusion and downward deviation of the eyeball improved. But he developed and blepharoptosis.

Comparison of before and after surgery.

It can be seen that the preoperative protrusion of the eyeball has cosmetically improved. The tumor has stretched the levator aponeurosis, resulting In a blepharoptosis. This will be fixed by aponeurotic repair.

Please feel free to contact us first.

Our hospital strives to perform surgeries that minimize the burden on patients, such as post-operative pain and scars, more than any other medical institution in Japan. Please do not hesitate to contact us.

Contact

Enophthalmos

For enophthalmos

• Orbital Fracture
• Enophthalmos after inadequate fracture repair
• Congenital exophthalmos (by nature)

The cause of enophthalmos is Orbital Fracture, Enophthalmos after inadequate fracture repair and Congenital exophthalmos (by nature).

Orbital fracture

Enophthalmos with Orbital strut fracture

This patient have severe Enophthalmos with Orbital fracture

Enophthalmos with Orbital strut fracture

And this patient has enophthalmos with Orbital fracture too.

Surgeon must think about Orbital strut

• Orbital strut is a supporting structure between medial wall and floor.
• Break of orbital strut cause severe enophthalmos.
• Must check the location of orbital strut before surgery.

In the A, orbital strut remains although medial wall and floor is broken.

But in B, orbital strut, medial wall and floor, all structure is broken.

Key for preoperative assessment

• Consider whether the shape of the right and left orbit is symmetrical with the nasal septum as the center.
• Especially, you need to check the location of orbital strut.

Check the location of orbital strut, medial wall and orbital floor.

Assessment of orbital reconstruction by ENT surgeon.

This is another case after orbital reconstruction by ENT surgeon.

The surgeon removed orbital bone, so orbital strut disappeared.

We use
transconjunctival approach
for all cases.

1. No.1 No scarring on skin
2. No.2 Only 1-2 stiches for closure
3. No.3 Totally short operating time

For reconstruction of orbital strut,
we release muscle tendon of inferior oblique muscle.

For reconstruction of orbital strut, we always release muscle tendon of inferior oblique muscle.

After this, you can see medial wall and floor in the same view and insert big plates.

Conversely, without releasing inferior oblique, you cannot see both walls in the same view and cannot insert big plate.

Paper model of reconstructing medial wall and floor

This is paper model of reconstructing medial wall and floor by one plate.

We also use the other supporting plates if needs.

Orbital fracture CASES

CASE.1

Severe enophthalmos
on the left

This patient has severe enophthalmos on the left. He was just observed until being this condition.

Orbital strut fracture

He had orbital fracture including orbital strut and medial wall and floor. Postoperatively, the position of orbital strut become symmetrical also medial wall and floor too.

The left enophthalmos was recovered to the normal after surgery.

CASE.2

Left enophthalmos on left

This patient has left enophthalmos on the left

Orbital strut fracture

On CT scan, orbital strut including medial wall and floor was broken. So we performed repairing surgery. Postoperatively, the position of orbital strut become symmetrical.

Before surgery, enophthalmos and superior sulcus exists on the left, but it disappeared after surgery.

30 years old female

Revision after
ENT surgeon’s repair

This case had severe enophthalmos because ENT surgeon removed all orbital bones before using balloons.

Her right orbit has enlarged due to lack of supporting tissue. So I dissect between orbital tissue and nasal mucosa and inserted the plates. After surgery, the position of orbital strut become symmetrical.

When you look at her right eye, it is very symmetrical after surgery although it was asymmetrical before surgery.
Also She can put make up after surgery, he cannot do it before surgery.

For congenital enophthalmos

Filler injection into DEEP orbit

Aesthetic hyaluronic acid is a drug injected primarily into the face.

Complications include arterial occlusion, which can cause skin atrophy and necrosis. Rarely, it flows back into the ophthalmic artery, causing central retinal artery occlusion, or into the internal carotid artery, causing cerebral infarction.

Although such complications discourage the use of hyaluronic acid injections into the orbit, our clinic specializes in orbital surgery, and based on our knowledge, we have been injecting hyaluronic acid deep into the orbit for patients who wish to have it done.

The mechanism of OAO
after filler injection is…

It is caused by filler mistakenly injected into the angular ophthalmic artery or other arteries that goes against the flow of the artery and reaches the deepest part of the orbit, entering the ophthalmic artery.

So, the filler was injected into some artery mistakenly, and then, filler go deep inside the artery retrogressively, and at the junction of ophthalmic artery, the filler turned toward eyeball progressively in ophthalmic artery.

However, this is not a problem of ORBIT

So I think, To treat congenital enophthalmos, Is there any technique safely inject filler into deep orbit.

What we should consider is Anatomy and technique.

1. Anatomy
2. Technique

About anatomy

About anatomy, I had 2 questions.

1. Where is the location of ophthalmic artery?
2. How far is the orbital apex?

How far is it?

The depth of orbital apex is reported to be 42 mm. It is so far.

Actually, you do not have a sharp needle which can deliver the filler into the apex even it is very big needle.

If it can reach…

If it can reach, it can make damage to ophthalmic artery, central retinal artery and optic nerve.

Technique

• How difficult it is to get into the retrobulbar space.
• If the eyeball is perforated, there is a great possibility of blindness.
• There are techniques that can anesthetize the eyeball with a blunt needle
• Recently, ophthalmologists avoid retrobulbar injection with a sharp needle.

My method

To deliver hyalonic acid gel into deep orbit safely.

Use a 24-gauge cannula needle. Remove the outer casing and cut away the plastic part at the base of the needle.

Return the needle and insert the cannula needle into the skin. Stop at a point shallow enough not to pierce the eyeball, and remove the injection needle, leaving the outer casing in place.

A cosmetic 40 mm blunt needle is then placed inside to penetrate deeper, safely reaching a depth of approximately 40 mm.

Congenital enophthalmos cases

You can see the change of two eyes. The eye looks more natural and severe enophthalmos reduced.

The patient was pleased very much because our clinic is the only one which cosmetically treat congenital enophthalmos.

Case1：　42y.o. female 1.5cc for each orbit

The first case is 42 y.o. female.

I injected 1.5cc hyalonic acid gel into the deep orbit from 3 locations.

Obviously, shadow in upper eyelid decreased after the injection.

You can see the change of two eyes. The eye looks more natural and severe enophthalmos reduced.

You can see the change of two eyes. The eye looks more natural and severe enophthalmos reduced.

The patient was pleased very much because our clinic is the only one which cosmetically treat congenital enophthalmos.

Case２：　34y.o. female.　1.1cc for both orbit

The second case visit us also complaining about congenital enophthalmos.

Actually, I do not think she have enophthalmos, but she eager to do filler injection.

After the injection of 1.1cc hyalonic acid gel into the orbit, the eyes become bigger, and the sulcus of both eyes disappeared.

Comparing case 1, the amount of filler is less, so the change is less too.

The eyes become bigger, and the sulcus of both eyes disappeared.

The eyes become bigger and the sulcus of both eyes disappeared.