Ophthalmic Plastic & Reconstructive Surgery | Orbital Oncology
Tear Duct Surgery
> Ophthalmic Plastic & Reconstructive Surgery | Orbital Oncology
Our ophthalmic plastic & reconstructive surgeons have undergone specialized training to perform a broad spectrum of eyelid, facial, tear duct and orbit (eye socket) surgeries in adults and children. Goals of these procedures include restoring normal function, treating diseases and injuries affecting the soft tissues and bones around the eyes, and improving cosmetic appearance with both surgical and non-surgical techniques.
Dermatochalasis (excess eyelid skin & fat)
With age, the upper eyelids can become loose and baggy, causing a reduction in the field of vision and interfering with important activities such as driving. This may be addressed with a type of surgery called blepharoplasty, which involves removing this excess tissue via small incisions hidden in the natural eyelid creases. Most insurance companies will require obtaining tests to demonstrate the degree of visual field restriction before authorizing this procedure. We also frequently perform a variation of this procedure for cosmetic purposes when the visual field is not obstructed.
There are many types of eyelid lesions, some can be observed safely while others should be biopsied or completely excised. Based on the appearance in consultation and your particular medical history, a decision can be made whether to observe, biopsy or remove the lesion. Some of the most common benign eyelid lesions are chalazion (stye), cysts, skin tags, and nevi (moles).
Eyelid Malposition (eyelids “turn in or out”)
The eyelids need to be in a normal position to ensure eye protection, for good tear production and drainage and to allow the eyelids to close properly with each blink. When the lids are malpositioned, they can be very irritating to the eye and result in tearing, pain, and chronic discharge. Entropion is a condition in which the eyelid is "turned in" toward the eye. Ectropion is a condition where the lower eyelid is “turned out” away from the eye. Both can be repaired with surgical procedures designed to return the eyelid to its natural position.
Eyelid Reconstruction (after cancer or trauma)
Eyelid reconstruction is often required following trauma or tumor excision. Depending on the degree and location, reconstruction can be performed using a variety of tissue flaps and grafts. In some cases, eyelid cancers are best removed surgically by a Mohs surgeon (dermatologist with additional training and expertise) who would be able to spare the greatest amount of normal tissue while maintaining the lowest rate of tumor recurrence. We have close relationships with Mohs surgeons in the area and would coordinate each patient’s care based on the specific circumstances of the case.
Facial Nerve Weakness (Bell’s Palsy)
Weakness of the facial nerve will lead to weakness on one side of the face. Depending on the severity of the weakness, the eyelids and eye itself can be affected. There can be weakness in blinking and closing the eyelids that can result in irritation, pain, and a potential risk for infection. Surgical and non-surgical techniques are available to protect the eye and provide symptomatic relief and functional improvement.
Ptosis (droopy eyelids)
Ptosis is the medical term for droopy eyelids. Drooping of the upper eyelid(s) can cause a reduction in the field of vision when the eyelid obstructs the visual axis. Children can be born with ptosis, while adults develop ptosis as a result of aging, prior surgery, or long term contact lens use. There are various methods of correcting ptosis depending on the type, degree and severity of ptosis. Recovery from ptosis surgery is usually quite rapid, and patients find themselves returning back to work within a few days.
Orbital (Eye Socket) Tumors
A variety of tumors can occur in the eye socket in both adults and children. In some cases these tumors can be biopsied or removed entirely with outpatient surgery. More aggressive tumors, however, may require coordination with other surgical specialists.
Thyroid Eye Disease (also known as Graves’ Disease) is an autoimmune inflammatory disorder of uncertain origin that affects the tissues of the orbit (i.e. eyelids, eye muscles muscles and other soft tissues around the eyes.) Thyroid Eye Disease can develop and affect patients with varying degrees of severity. Surgical and non-surgical treatments exist to manage the complications of this condition including eyelid malposition or retraction, ocular proptosis (bulging eyes), and double vision.
Evisceration & Enucleation (removing blind painful eyes)
Despite great advances in ophthalmic care, eyes that are blind, painful and disfiguring may be removed when the eye cannot be salvaged. Reconstruction of the eye socket is prepared for a prosthetic eye that leads to a cosmetically acceptable result.
Eye Socket Reconstruction
The surgical reconstruction of an eye socket can be required when a ocular prosthesis no longer fits well or causes discomfort.
Orbital Trauma & Fractures
Trauma to the orbit can result fractures of bones of the orbit. When these fractures cause symptoms such as double vision or when the fracture is large, surgical repair is normally recommended. The surgical repair is typically performed within a few weeks of the injury.
TEAR DUCT SURGERY
Dacryocystorhinostomy [DCR] (tear duct bypass surgery)
In cases where the tear drainage system is completely blocked, a new drain is surgically created in order to permit natural elimination of excess tears so that they do not run down the face or blur the vision. This surgery is also performed after infections of the tear drainage system in order to prevent them from coming back.
Punctoplasty and Stents (natural tear duct opening)
In cases where the tear drainage system is narrow but not completely blocked, minimally invasive procedures may be performed in order to improve symptoms by enlarging the openings and passages of the system. These include punctoplasty (a procedure to open narrow tear drain entrances) and stent placement (a procedure to enlarge the tear drainage tubes, which involves temporarily inserting a tiny silicone tube).
Treatment of Tearing in Infants and Children
A significant number of children are born with the tear drainage system only partially formed. While the system often completes its development within the first year of life, some will require a procedure in order to eliminate tearing and mucus discharge/crusty eyelashes, as well as prevent infection. Required treatments range from a one-time procedure to dilate the drain to stent placement to DCR.
Blepharoplasty: Upper & Lower Eyelid
The tone and shape of eyelids can loosen and sag with time. Surgical repair of this condition can give the eyes a more youthful look by removing excess skin, bulging fat, and lax muscle from the upper or lower eyelids. In the upper eyelids, excess skin can result in a tired appearance or can result in difficulty seeing in the top segment of your visual field. As a result, some forms of blepharoplasty surgery are considered cosmetic eyelid surgery while in some other cases it is medically necessary to allow the patient to see better. Lower eyelid blepharoplasty is almost always a cosmetic procedure to improve the shape, contour and appearance of loose skin, bulging fat, and irregular shape.
Double Eyelid Surgery
Eyelid crease enhancement can be performed surgically and is customized to the lid anatomy of each individual patient.
Forehead & Brow Lift - Forehead/Brow lift (endoscopic, external, and internal)
Forehead and brow lifting addresses eyebrow position and loose or wrinkled forehead skin. There are several surgical techniques available to address this condition that will be discussed with you at the initial consultation. Brow shape differs between males and females; males have relatively minimally arching brows that rest right above the bone of their orbit. Females tend to have a more pronounced arch to their brows and they tend to rest above the bone of their orbit. Brow lifting can be done at the same time as a blepharoplasty and is covered by insurance in some cases. The benefit of combining a brow lift with a blepharoplasty is that the brows are repositioned to a more natural and youthful position thereby reducing the amount of upper eyelid skin required to be removed.
Cosmetic Ptosis (droopy lids)
When drooping of the upper eyelid(s) is noticeable but not causing a reduction in the field of vision, surgery can be performed to elevate the lids to a more desirable height or create better symmetry between the sides. Recovery from ptosis surgery is usually quite rapid, and patients find themselves returning back to work within a few days.
NON-SURGICAL OCUPLASTIC PROCEDURES
Dermal Fillers (eg Juvederm, Restalyne & Belotero)
Hyaluronic gels, a naturally occurring sugar molecule normally found in the skin, like Restylane, Perlane and Juvederm, can be used to replace the volume lost from the area around the eyes as well as other regions of the face. These fillers are ideal for addressing wrinkles due to volume loss and typically will last between 6-12 months.
Neuromodulation (eg Botox, Xeomin)
These injectable neuromodulators (eg Botox, Xeomin) act to temporarily weaken overactive muscles around the eye and can be used for functional conditions such as blepharospam and hemifacial spasm. They can also be used to address more cosmetic conditions such as wrinkles in dynamic areas such as near the eyelids ("crows-feet") or on the forehead.
Fat can be removed from your abdomen and re-injected to sculpt and re-inflate regions of the face that has lost volume due to aging (or trauma). The most common locations of injection include the upper and lower eyelids, the eyebrows, the temples, and tear trough (fold between the lower eyelids and nose). Transferred fat can last indefinitely.
Lips can be re-inflated and sculpted with dermal fillers or fat grafting to improve appearance. Duration of the filler will depend on the type used, but typically last 6-12 months.
Latisse (eyelash growth stimulation)
This is an FDA approved medication for increasing the fullness of eyelashes. It is applied to the upper eyelid margin (where the lash grow) and can have a dramatic effect in about 3-4 months.
Under Construction, But Coming Soon
Oculofacial Plastic and Orbital Surgery Fellowship (ASOPRS Even Year)
Fellowship Program Director: Peter Levin, MD, Adjunct Clinical Professor, Ophthalmology
Clinical Faculty: Andrea Kossler, MD; Albert Wu, MD; Ben Erickson, MD
Affiliated Clinical Faculty: ENT Sinus & Skull Base Surgery (Peter Hwang, MD; Jayakar Nayak, MD; Zara Patel, MD); ENT Facial Plastic Surgery (Sam Most, MD); OMFS/Trauma Surgery (Stanley Liu, MD)
Stanford Ophthalmology offers a two-year fellowship in oculofacial plastic, orbital, cosmetic and reconstructive surgery. Our fellowship program is accredited by the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). The goal of this fellowship is to provide the fellow in depth exposure to all aspects of functional, reconstructive, and aesthetic ophthalmic plastic and reconstructive surgery, as well as to orbital oncology. Successful completion of the fellowship qualifies the physician to apply for membership in the ASOPRS Society.
• To provide comprehensive training in oculofacial plastic & reconstructive surgery and orbital surgery.
• To develop the fellow’s skills in clinical and laboratory research in preparation for a leadership role within the ASOPRS community.
• To assist the fellow in becoming an effective teacher, surgeon, and clinician
The fellowship is structured to provide an intensive, well-supervised oculoplastic and orbital surgery training experience over two years. It will prepare the fellow for practice in either an academic or private setting through the following training experiences:
1) primary preceptor training; 2) caring for Oculoplastics patients as the primary caregiver in his/her own clinic; and 3) supervising and attending the residents in oculoplastics clinic and surgery. A comprehensive surgical experience encompasses the full spectrum of lacrimal, eyelid and orbital reconstructive surgeries due to disease or injury, as well as aesthetic and rejuvenative procedures. There is frequent collaboration with other subspecialties, including dermatology, head and neck surgery, endoscopic sinus and skull base surgery, pathology, general plastic surgery, facial plastic surgery, oral/maxillofacial surgery, neurosurgery and neuroradiology in a busy tertiary care setting with a level one trauma center.
Several specialty clinics add to the experience. The fellow may participate in the Stanford Health Care Thyroid Eye Disease Center clinic, a multidisciplinary clinic staffed by ophthalmic plastics, endocrinology and radiation oncology specialists, a monthly skull base multidisciplinary conference and a weekly multidisciplinary head and neck tumor board.
During the second year, the fellow will have protected time to conduct research, study independently, or seek elective experiences in facial plastic surgery, plastic surgery, cosmetic dermatology, Mohs surgery, oral maxillofacial surgery, neurosurgery, endoscopic and skull base surgery.
Clinics are located at the Byers Eye Institute, Stanford University School of Medicine in Palo Alto, California. Surgery is performed at the Byers Eye Institute Outpatient Surgery Center, Byers Eye Institute Procedure Room, Stanford Hospital Ambulatory Surgery Center, Stanford Hospital Main Operating Room and Stanford Children’s Hospital.
The fellow holds an appointment at the Stanford University School of Medicine as Clinical Instructor and is an integral part of teaching in the Department of Ophthalmology. The fellow actively participates in quarterly research meetings, case conferences, journal clubs and other local and regional oculoplastics related conferences. The fellow provides instructional lectures to the residents, and spearheads various educational initiatives from suture workshops to cadaver dissection.
Research is expected of all fellows and strongly supported by the preceptors and program. This research will form the basis for the thesis required for membership in the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). In addition, the fellow is encouraged to participate in several other research projects within the division and to present these findings at Annual AAO and ASOPRS meetings. The fellow will additionally participate in the Annual Stanford Ophthalmology Resident & Fellow Research Day.
The fellow receives a PGY scale salary adjusted for the cost of living in the Bay Area. Malpractice insurance and health benefits for the fellow and dependents are provided. Limited funds are available for travel to national scientific meetings in each year of training if the fellow is a first author. Additional funding is available for research. The fellow receives three weeks of vacation in each year of training.
Upon successful completion of training, the fellow will be awarded a fellowship certificate by Stanford University School of Medicine and is eligible to apply for membership in ASOPRS.
Basic Application Requirements:
- Completion of training in an ophthalmology residency program sanctioned by the ACGME prior to the initiation of fellowship. Exceptional foreign medical graduates are welcomed to apply if eligible for full California licensure.
- Eligibility for a California Medical License with prompt initiation of the application process upon acceptance of a fellowship position (can take up to 12 months for processing).
- Eligibility for academic and professional credentials at the Stanford Hospital Center and Children’s Hospital Center.
All applications to ASOPRS fellowship programs will be made through an online Centralized Application Service (CAS) via the San Francisco Match (SF Match) website (www.sfmatch.org). The following supportive documentation is required:
• Current Curriculum Vitae
• Medical School Transcript
• At least three independent letters of recommendation including one from your Program Director or Department Chair
• USMLE Scores
• Personal Statement
• Documentation of Immigration Status or US Citizenship
Additional required information:
• Current OKAP Scores
Our application deadline is December 31.
Supplemental material should be emailed to:
Danielle N. Ghasemieh
2452 Watson Court Palo Alto, CA 94303
Telephone: (650) 724-9981
Applicants invited to interview will be contacted individually by the Oculoplastic Fellowship interim program coordinator, Rosangel Garcia. For questions regarding oculoplastic fellowship interviews please contact:
Danielle N. Ghasemieh
2452 Watson Court Palo Alto, CA 94303
Telephone: (650) 724-9981
Clara Jiayun Men, MD, is a clinical instructor of Ophthalmology and the Ophthalmic Plastic & Reconstructive Surgery, Orbital Oncology Fellow with the Byers Eye Institute.
Clara graduated from Troy High School in Fullerton, California, where she was awarded the Bank of America Plaque of Achievement in Science and Mathematics and the Bausch and Lomb Science Award. She was also a semifinalist in the prestigious Siemens Westinghouse Competition, a National Merit Finalist, and took second place at the National Science Olympiad for Chemistry.
Clara graduated cum laude from Yale University, where she majored in molecular biophysics and biochemistry. During her time at Yale, Clara developed computational methods for genome analysis and was a co-author of publications in Science and Nature Genetics. She was also a volunteer and eventually president of, the Yale chapter of Unite for Sight, which developed her interest in ophthalmology.
After her undergraduate studies, Clara attended Harvard Medical School, graduating with her MD cum laude. At Harvard, Clara conducted research on the genetics of inherited retinal degenerations and potential novel genetic treatments for these diseases in the lab of Dr. Eric Pierce as a Research to Prevent Blindness Fellow.
Following a transitional internship at Cambridge Health Alliance, Clara completed her ophthalmology residency with the Shiley Eye Institute at University of California, San Diego. There, she continued her clinical development and shifted her research to focus on improvements on current surgical techniques within ophthalmic plastic and reconstructive surgery, including orbital decompression for thyroid eye disease and surgical intervention for periocular infantile hemangiomas. At Stanford, Clara will continue her clinical and surgical practice with research aimed at advancing the field of oculoplastics and improving patient care.
1) Before Your Visit
2) Surgery & Treatment Information
3) Patient Education Forms
FAQ Oculoplastic Surgery
1) What should I expect at my initial consultation?
Prior to any surgical or non-surgical procedure, we will carefully review your concerns as well as your other medical conditions and all your medications. Once we arrive at the appropriate intervention the procedure will be discussed and all your questions will be answered. You will receive written instructions detailing pre-operative requirements, medications to avoid, and directions to the surgical center. Prior to receiving any anesthesia, you will likely be required to see your primary care doctor who will perform a full pre-operative examination.
2) What should I expect on the day of surgery?
You will asked to arrive between one to two hours prior to surgery for the nursing staff to greet and prepare you for the operating room. Normally you will be called the day before to confirm the time of arrival. The staff will review your medical history and medications. The anesthesiologist will also meet with to review the anesthesia plan and to answer any questions you may have. Finally, the surgical team will greet you in the preoperative holding area to confirm the surgical plan, answer any questions and the mark the surgical site.
Immediately after your surgery, you will recover in the post-operative area of the surgical center. You may have a cold compresses and ointment in your eyes so don’t be alarmed that your vision is blurred or obscured. While you recover a nurse and recovery team will be available at all times. Once you are fully recovered you will be able to have something to light to drink and eat. Please have bags of frozen peas or cold compresses at home ready for use. And please review the FAQ Cosmetic Eyelid Surgery PDF above that has more specific details.
Final note to smokers: please reduce or stop smoking 2-3 weeks before and after surgery to allow accelerate healing, reduce risk of infections, and improve your surgical outcomes.
3) What should I expect during the post-operative period?
For a few days your vision may be blurry due to the ointment that is used on your eyes, as well as normal post-operative swelling. Have someone reliable assist you the night after surgery.
Recovery is usually well tolerated by most patients. Pain is normally mild to moderate and can be controlled with over the counter pain medications or stronger prescription strength medications.
Remember to use ice packs for the first 2-3 days after surgery as this reduced swelling and helps with any pain. And please review the the FAQ Cosmetic Eyelid Surgery PDF above that has more specific details.