A look back: 20 years in oculoplastic surgery

Significant advances have been made in every area of the field. Part of an ongoing retrospective series.

Issue: May 1, 2002

ByMark R. Levine, MD, FACS

The field of oculoplastic and orbital surgery has changed dramatically over the past 20 years. The American Society of Ophthalmic Plastic and Reconstructive Surgery has increased its numbers through fellowship programs that have grown from 1 year to 2 years long. Oculoplastic surgeons who have passed the rigorous oral and written exam and submitted a thesis for publication now number well over 300 physicians in the United States. The logical evolution of our expertise and skills has led us to become more involved in periorbital surgery such as endoscopic brow lifts, cheek lifts and many aspects of facial plastic surgery.

Much has changed in the field of oculoplastics. Anatomy of the orbit and eyelids has been much better defined. Awareness of the levator aponeurosis regarding dehiscences and disinsertions causing acquired ptosis has been very sharply defined. This also holds for inferior aponeurosis of the capsulopalpebral fascia with involutional entropion.

Great advances have been made in enucleation and evisceration surgery. The integrated orbital implant has become firmly entrenched in our modern armamentarium. We use hydroxyapatite and polyethylene implants that vascularize and become incorporated as integrated implants, allowing better motility.

Diagnostic imaging

In radiology, sophisticated computed tomography and magnetic resonance imaging have revolutionized the diagnosis and treatment of retrobulbar tumors. CT gives detailed information about the location, size and shape of retrobulbar lesions and their involvement with bone and adjacent periorbital structures. The use of contrast medium helps the physician appreciate the internal characteristics of the lesion.

The MRI provides soft tissue and bone marrow resolution superior to CT and is particularly useful in evaluating tumors of the cavernous sinus and skull base, including optic nerve tumors that enter the cranial cavity. It is best for evaluating lesions of the central nervous system that relate to the orbit. The two modalities together give optimum diagnostic and therapeutic approaches to the orbit, thus reducing the mystery of retrobulbar and apical tumors.

Fractures

Treatment of blowout fractures and trimalar fractures has improved significantly, with micro- and macroplating systems to realign the orbital bones and fix implants in the orbit. These plating systems are light and inert and prevent rotation of bone fragments. They help stabilize trimalar fractures, which were difficult to treat with traditional wiring methods.

Aesthetic surgery

Regarding aesthetic surgery, there has been a shift from doing external lower eyelid blepharoplasty to transconjunctival blepharoplasty with sculpting and repositioning of eyelid fat. This gives a softer appearance to the lower lid and avoids ectropion and vertical lid shortening. It can be done with the traditional No. 15 Bard-Parker blade approach or with a CO₂ laser as the cutting modality. Blepharoplasty results have been augmented with the use of botulinum toxin for rhytids and laser resurfacing to smooth out and soften lines of facial expression.

Botulinum toxin has revolutionized the treatment of facial dystonias from essential blepharospasm and hemifacial spasm to cervical dystonias. The number of patients needing orbital myectomies for essential blepharospasm has diminished significantly.

Personal note

This is just a thumbnail sketch of some of the advances. It has been a privilege to have been associated with such a bright, energetic and enthusiastic group of oculoplastic surgeons who have contributed so much to patient care and to the science and art of oculoplastic and orbital surgery.

For Your Information:

Mark R. Levine, MD, FACS, can be reached at University Suburban Health Center, 1611 South Green Rd., Suite 306A, South Euclid, OH 44121; (216) 291-9770; fax: (216) 291-0550.