Thursday, November 10, 2016

Doc, can you do something about my sausage lip?

Having a full lip can make a person more sensuous and attractive. However, an artificial pump-up lips which are not proportional to one's face can make one an object of ridicule.

Natural versus unnatural lips.

This woman had lip injection  in a beauty saloon two years ago to give her a better pout. She was told the injection consisted of hyaluronic acid. Two years later, the lips remained swollen and the upper lip had poor contour with the left side bigger than the right. She was depressed as people ridiculed her for having "sausage lips". 

Swollen upper lip with asymmetrical contour.

Side view of the lips

She consulted a few aesthetic physicians and had injections including steroid and hyalurodinase to reduce the swelling but to no avail. Examination showed the lips to be thickened and hard to touch, it was likely that she was injected with silicone rather than hyaluronic acid. The only treatment of choice is to surgically remove the granuloma. 

Surgical removal of the granuloma and to reshape the contour 
of the upper lip.

Excised lip tissue showing granuloma.

Post lip reduction with good contour.

Side view of the upper lip post lip reduction.

Sunday, September 11, 2016

Doc, Can You Straighten My Eyes? VI

Patients with high myopia may sometimes develop a very significant convergent squint which is not only cosmetic disfiguring but severely affect the vision. The mechanism is thought to be herniation of the globe outside the muscle cone usually between the superior and lateral rectus (as mentioned in previous post). Surgical correction is often complex as simple recession/resection technique is usually insufficient to significantly correct the malposition. One way of correcting this difficult squint is with muscle transposition. However, it is important to inform the patients that more than one operation may be needed for good outcome.

Surgical procedure showing transposition of muscles for myopic strabismus fixus. 
The medial rectus was released and allowed to hang back by 8mm. a. The superior 
rectus is isolated; b. the superior rectus is split into two equal halves; c. the lateral rectus 
is isolated and split into two equal halves; d e and f. a 5/0 silk is used to tie the upper 
half of the rectus at 15mm from its origin of insertion to the lateral half 
of the superior rectus. The technique strengthen the lateral rectus 
and push the globe back into the muscle cone.

Diagramtic presentation of the procedure shown in the photos.

This patient has residual convergent squint but is able to perform 
her daily activities without help. 

Despite the located lenses due to high myopia, this patient regains good vision after 
the surgery while awaiting surgical removal of the dropped lenses.

This patient has residual hypotropia but is pleased with his appearance.

Doc, Can You Straighten My Eyes? V

Most cases of squints are mild to moderate and involve the horizontal muscles. In such cases, simple techniques of recession/resection of the horizontal muscles (medial rectus and horizontal rectus) are all that are needed to restore the position of the eyes. However, there are occasionally difficult squints that call for special techniques and can only be treated by doctors who are proficient in performing challenging cases. 

Examples of challenging cases are these three patients who presented with severe convergent squints and high myopia of more than -12.00. Some of the eyes are so far pulled inward that the cornea became invisible. They all suffered from a condition called myopic strabismus fixus. In this condition, the eye globes were abnormally elongated and prolapsed between the superior and lateral rectus (as shown by the diagram and the MRI scans). Simple recession/resection would not be enough to restore the positions of these eyes.

A 35 year-old woman with  -15.00D both eyes and bilateral severe convergent 
squints. The left cornea was almost invisible. She had problems 
seeing due to the severe squints.

A 60 year-old man with bilateral severe convergent squints and dislocated lenses 
due to high myopia. He was referred for squint correction so that surgery 
could be performed to remove the dislocated lenses.

A patient with high myopia and a right severe convergent squint. The right vision 
has been poor since young and patient wished for restoration 
of the eye position for cosmetic reason.

MRI showing prolapse of the globes between the superior and lateral 
rectus in a patient with myopic strabismus fixus.

Diagram showing prolapse of the globe between the superior and lateral rectus 
so that the eye becomes severely inward turning.

Friday, August 19, 2016

Doc, Can You Straighten My Eyes ? IV

Squints are estimated to affect 1% of the population. After excluding any underlying conditions such as cataract and refractive errors, most patients wish to have their squints corrected. The benefits of squint surgery include:
  • improved appearance and eye positions
  • better eye co-ordination so that the eyes can be used simultaneously 
  • improved eye movement
While complicated squints are sometimes seen (as in the previous blog), most squints are fortunately straight forward and involves the horizontal muscles. Therefore, most operations will involve operating on a pair of muscles i.e. one is weakened and the other strengthened to make the eye straighter.
A child with a left convergent squint (eye turning inward) 
before and three days after squint surgery.

A man with a paralysed left convergent squint before 
and one month after correction.

A child with a severe left convergent squint, before and two months 
after the surgery. Three muscles were operated in this case: 
two on the left and one on the right.

A man with a left divergent squint (eye turning out). He had had previous 
surgery as a teenage in another centre but the eye remained deviated. 
The left eye was re-operated to straighten the eye.

A patient with constant divergent squint. Pictures showing 
before and one month after correction. 

A girl with intermittent exotropia (divergent squint) since young 
which progressed to constant exotropia. Pictures showing 
before and two months after the operation. 

Wednesday, August 17, 2016

Doc, Can You Straighten My Eyes? III

This middle-aged woman with a past history of hyperthyroidism presented with severe thyroid eye disease. Both eyeballs were constantly depressed due to fibrosis of the inferior rectus muscles (the muscles that are responsible for moving the eyes downwards). And she had severe dry eyes due to eyelid retractions.

Severe thyroid eye disease with both eyeballs being pulled 
download and lid retractions.

Inability to look up due to severe contracture 
of the inferior rectus.

The depressed eyeballs were corrected by releasing the inferior rectus muscles. Following the squint correction, she was able to see straight without having to constantly elevate her heads. The lid retractions were corrected with botox injection to the levator muscles.

Photos showing steps of inferior rectus recession. a. The eyeball was pulled 
upward using a 4/0 silk passed through inferior limbus; b. the inferior rectus 
was isolated using squint hook; c. the inferior rectus was released and 
d. hang back 4mm from its insertion.

Two days postoperative showing better eyeball position and 
reduced lid retraction.

8 units of Botox was injected into the levator via a posterior approach.

Appearance of the eyes 6 days postoperative.

Appearance of the eyes at two-month post-operative. There were some eyelid 
retraction. Mullerectomy was recommended but patient was happy to leave as 
the eyes were now comfortable. 

Monday, August 15, 2016

Doc, Can You Straighten My Eye? II

The eyes are the centre of attention during face-to-face interaction. Therefore, any imperfection of the eye like squints are immediately apparent. Squint affects about 1% of the population and can adversely affect other people's perception of the person. These two young persons were bothered by their squinting eyes since young but did not seek treatment until now. As they also narrow eyelid opening, double eyelid surgery was combined with the squint surgery. The operations were performed under general anaesthesia.

Right in-turning eye and narrow palpebral aperture (right more than left). 
The in-turning eye was corrected and double eyelids created simultaneously. 
The picture was taken 2 weeks after the operations. The patient had a
mild right ptosis as noted before the surgery.

Another person with left out-turning eye. Correction of the squint was done with 
double eyelid surgery at the same setting. The postoperative picture 
was taken 2 months later.

Friday, August 12, 2016

Doc, Can You Straighten My Eye? I

This middle-aged woman was involved in a road traffic accident 3 years ago resulting in trauma to the left eye. She underwent removal of the lens and blood from the back of the eye. The left eye had poor vision of hand movement and she was very much bothered by the position of the left eye which is constantly inward turning (convergent squint or esotropia). Squint surgery was performed by operating on the horizontal muscles that move the eye. The operation was done under local anaesthesia (using peribular and subtenon anaesthesia) with sedation. 

Left eye turning in caused by trauma.

Close-up view showing malpositioned pupil and absent lens. 
The macula is also damaged.

The muscles of the left eye were operated on to straighten the eyes. In this patient,
the medial rectus was moved back 7 mm and 8 mm of muscle was excised from the
lateral rectus.

The appearance of the left eye at one-day post-oprative. 
The left eye had been straightened.

Tuesday, August 2, 2016

Doc, Could You Balance My Eyes?

This 60 year-old woman presented with dermatochalasis (excess eyelid skin) and asymmetrical eyelids with the right eye appearing smaller. She sustained a right lateral eyelid trauma in a trauma one year ago. Unfortunately, the wound was not well reconstructed resulting in contracture with pulling of the upper eyelid skin over the lateral canthus. (See picture 1 and 2).

Figure 1. Excess skin in both upper eyelids and the right eye appears smaller 
due to wound contracture (red arrow) pulling down the upper lid (black arrow).

Figure 2. The scars (red arrows) are better seen the upper eyelid is lifted. 

She wanted her eyes to be made symmetrical and brighter. Bilateral upper blepharoplasty were performed together with reconstruction of the scars. The steps performed were shown in Figure 3.

Figure 3. a. Before the operation; b. Marking was done of the excess upper eyelid to be excised 
and a V-Y plasty planned for the contracted scar; c, d, e and f showing the construction 
of the V-Y plasty. g. At the end of the surgery. 

Figure 4. Appearance of the eye at 10 days postoperative.

Figure 5. Appearance of the lateral aspect of the eyelid at 10 days postoperative. 
10mg of triamcinolone and 4 units of botox was given over the lateral region of 
the eyelid at 5 days postoperative to prevent wound contracture.

Figure 6. Appearance of the eyelid at 4 weeks postoperative.

Figure 6. Appearance fo the eyelid at 4 weeks postoperative.