Thyroid Eye Disease (Eyelid Surgery)
Eyelid Retraction Repair and Blepharoplasty
The inflammation that occurs in thyroid-related eye disease can cause swelling, fatty infiltration/degeneration, and scarring of the eyelid muscles resulting in eyelid retraction (the eyelids being pulled away from the front of the eye). In mild cases, individuals will experience dry, gritty eyes that feel “sandy”, "gritty", or irritated. In more severe cases, some people may have impaired eyelid closure and experience dry spots on the cornea. This can lead to severe eye infections and scarring with vision loss. Eyelid surgery can help reduce eye exposure so that the eyelids are more adequately able to protect the front of the eye. Additionally, thyroid-related eye disease may result in significant swelling of the fat in the upper or lower eyelids making the eyelids appear puffy and unsightly. Surgery can improve these problems as well.
Upper Eyelid Surgery
To improve upper eyelid retraction, surgical loosening of the upper eyelid retractor muscles (levator muscle and Mueller’s muscle) and release of fibrotic (scar-like) tissue in the muscles can allow the upper eyelids to come down to a more normal level. This surgery is typically performed with local injections and minimal IV sedation in order to permit patient cooperation during the surgery. Patients are placed in a sitting upright position at the end of surgery to ensure adequate surgical correction. Adjustments made during surgery diminish the risk of asymmetry following surgery. Despite meticulous attention to eyelid height during surgery, the eyelids may heal differently resulting in eyelid asymmetry. Frequently, the asymmetry is not bothersome and further surgery can be avoided. In up to 10-15% of patients, additional “touch-up” surgical procedures may be needed to correct significant asymmetries. Significant upper eyelid retraction repair is typically considered medically necessary and is usually covered by most commercial insurance carriers. Mild cases of eyelid retraction repair may be considered cosmetic, non-covered services.
At the time of upper eyelid retraction repair, patients may elect to have excessive fatty tissue and redundant skin folds excised. Upper Eyelid Blepharoplasty is frequently considered cosmetic and not covered by most commercial insurance carriers.
Lower Eyelid Surgery
The same puffiness and tissue response that occurs in the upper eyelids may also develop in the lower eyelids. Lower eyelid retraction may result in exposure of the white portion of the eye, referred to as inferior scleral show. This may contribute to eye exposure, dryness, and irritation. Surgical procedures can improve the protection of the eye and the appearance of the lower eyelid. With lower eyelid surgery, the fibrotic (scar-like) muscle can be loosened and spacer material inserted to help boost the eyelid upward. Spacer grafts used might include ear cartilage or hard palate (upper mouth) mucosa. To be able to reposition the outer edge of the lower eyelid upward, the outside tendon must be tightened. Despite meticulous measurements of spacer materials, the eyelids may heal differently resulting in eyelid asymmetry. Frequently, the asymmetry is not bothersome and further surgery can be avoided. Additional “touch-up” procedures are occasionally indicated to correct significant asymmetries. Surgical correction of significant lower eyelid retraction is typically considered medically necessary and is often covered by most commercial insurance carriers.
At the time of lower eyelid retraction repair, patients may elect to have excessive fatty tissue and redundant lower eyelid skin folds excised. Lower Eyelid Blepharoplasty is frequently considered cosmetic and not covered by most insurance carriers.
Expectations of Eyelid Surgery for Thyroid Eye Disease Patients
Bruising and Swelling
There is usually more bruising and swelling with surgery for thyroid eye problems than the typical “baggy eyelid operation” (Blepharoplasty). In thyroid-related eye disease, the arterial and venous vasculature to the eyelids and orbit is often more prominent. This results in a greater tendency to develop postoperative swelling. This also makes surgery more challenging and tedious than ‘standard’ eyelid surgery. Oral corticosteroids, ice packs, rest, and head-of-bed elevation may help to limit postoperative bruising and swelling.
Postoperative Stiffness of the Eyelids
Even though the eyelid position is improved following surgery, stiffness caused by scar tissue may persist after surgery. It is impossible to remove or loosen every bit of fibrosis ("scar tissue") due to the underlying thyroid-eye disease process.
Most patients with thyroid-related eye disease have some degree of upper and/or lower eyelid asymmetry prior to reconstructive surgery. A mild amount of eyelid asymmetry should be expected after surgery. Significant amounts of asymmetry can occur in up to 15% of patients. Further reconstructive surgery may be indicated in these individuals.
Anesthesia During Surgery
If a person is having surgery limited to the upper eyelids, then local injection with mild IV sedation is performed. Patient cooperation is critical to ensure adequate eyelid height adjustment. Patients are placed in the upright, sitting position during surgery to assess the degree of eyelid correction. If lower eyelid surgery is also necessary, then deeper anesthesia is frequently employed.
Surgery is performed as an outpatient and patients will frequently go home within an hour after the operation is completed. Ice packs, rest, head-of-bed elevation, topical antibiotic ointment, and a tapering dose of prednisone is recommended the first week after surgery. Most patients will take 5-10 days off of work to recover. Full recovery may take 3-6 months.
What is Blepharoplasty?
Eyelid surgery to remove or reposition redundant tissues in the upper or lower eyelid is referred to as “blepharoplasty”. Upper eyelid blepharoplasty involves removal skin, muscle, and/or fat and is one of the most common cosmetic surgical procedures performed in the United States today. Functional upper eyelid blepharoplasty is performed to help restore the field of vision that is impaired by the redundant upper eyelid tissues. Lower eyelid blepharoplasty is nearly always considered cosmetic and emphasizes removal and/or repositioning of the lower eyelid fat (“fat bags”). Blepharoplasty surgery is different than Ptosis surgery which is performed to raise a droopy eyelid.
Why Consider Surgery to Elevate the Eyebrow and Forehead?
The downward positioning of the eyebrow can lead to full upper eyelids and contribute to excess skin in the upper eyelid area. This fullness may actually interfere with the superior visual field. Often times, downward descent of the eyebrow is the major contributor to upper eyelid skin redundancy and fullness and with surgical elevation of the eyebrow minimal eyelid skin may actually need to be removed. If significant eyebrow ptosis is present, eyelid surgery alone may not adequately improve eyelid fullness or expand the lateral or superior visual field (see Droopy Eyelids).
Elevation of the eyebrow and forehead can be an important procedure in reversing some of the aging changes of the upper face. An eyebrow or forehead lift can improve the “tired” look that may result from the degenerative changes of aging.