Foundations of oculofacial plastic surgery

Introduction

Oculofacial surgery is a unique specialty that combines aspects of ophthalmology, general plastic surgery, head and neck surgery, dermatology, neurological surgery, and craniofacial surgery. With advances in endoscopic and small incision techniques, many oculofacial procedures can now be performed safely and effectively with minimal scarring and excellent aesthetic results.

Evaluation

Oculofacial surgery encompasses both functional and aesthetic goals. As such, the evaluation of the oculofacial patient requires a complete history and physical examination with particular attention to medical, functional, aesthetic, and psychosocial details.

A complete medical history should be elicited, with particular attention to hypertension, diabetes, liver disease, immune status, current or prior cancer, and trauma. Surgical history should include any previous facial surgery, ophthalmic surgery (such as refractive surgery), use of neurotoxins and dermal fillers, and chemical- or energy-based skin treatments. Medications, including anticoagulants, tobacco, and alcohol, should be documented. A history of implanted cardiac devices should also be noted since this determines which types of cautery can be safely used. The use of medications, tobacco and alcohol should be documented.

The physical examination should focus on the areas of patient concern and the proposed surgical procedure. The entire face should be examined and the patient can be allowed to point to areas of concern using a handheld mirror. For most eyelid, facial, and orbital procedures, documentation of visual acuity, pupillary function, color vision, slit-lamp examination, intraocular pressure, eyelid position and closure, and tear film are minimum requirements. Dilated fundoscopic examination may be required in select cases if there is any evidence of optic nerve compromise. Ocular motility in nine positions of gaze ( Figure 1.1 ) and globe position by exophthalmometry ( Figure 1.2 ) should be carefully documented for any orbital procedure. The Naugle exophthalmometer is useful for measuring proptosis or enophthalmos when prior surgery has been performed to remove the lateral orbital rim. Vertical and horizontal globe displacement should be noted as well. Evaluation of lacrimal diseases requires functional and anatomic testing. Both dye disappearance testing and lacrimal probing and irrigation are useful.

Ancillary testing for oculofacial surgery may include visual field testing for functional eyelid conditions, dacryoscintigraphy for lacrimal obstructions, and imaging studies for orbital diseases. Computed tomography (CT) is useful for evaluation of bony structures and general screening for orbital disease. Magnetic resonance imaging (MRI) is better suited for soft-tissue lesions and optic nerve diseases. Angiography is indispensable for evaluating vascular malformations.

Photography is an essential component of the oculofacial examination. Ideally, photographs should be taken during all aspects of patient care from the preoperative evaluation, intraoperatively when indicated, and at postoperative visits. Many third-party insurance carriers require photographic documentation prior to authorization of functional oculofacial surgeries. Additionally, photographs are important for the aesthetic patient to document changes after treatment and for medical legal protection. Photographs should be taken in the frontal, side, and three-quarter views. For orbital diseases, eye movements in the nine positions of gaze are taken. Additionally, a worm's eye view ( Figure 1.3 ) is used to document globe position and closure of the lids to document the presence or absence of lagophthalmos ( Figure 1.4 ).

Modern digital single lens reflex (DSLR) cameras are ideal in the oculofacial setting. These DSLRs allow for rapid sequence photography with excellent resolution and dynamic range compared to pocket-sized cameras with smaller imaging sensors. Uniform lighting can be difficult and variable depending on the clinical situation. In general, flash photography is used to normalize lighting. A dedicated photo room with a blue backdrop and diffuse lighting is ideal, but for most surgeons, a DSLR using the pop-up or external flash will suffice. The use of a 50 mm macro lens is ideally suited for full-time use. Using the macro function, this lens allows close-up photography of small lesions on the face. Furthermore, with its fixed focal length, facial photographs will appear square and consistent, avoiding the barrel distortion seen when the camera is too close to the subject. Finally, to achieve uniform focus across the entire photograph, a small aperture (at least greater than f/10) should be set to allow for a deep depth of field.

Anesthesia

The choice of anesthesia depends on patient age, medical condition, as well as physician and patient preference. Patient safety and comfort are an absolute priority, and intraoperative patient cooperation may be needed during certain oculofacial procedures. A combination of various anesthetic modalities is frequently utilized to provide an optimal surgical experience.