Thank
you for
your question.
You submitted your question with two photos.
And you describe in your question that you had issues with discomfort in one eye.
And that in 2014, you were diagnosed with thyroid eye disease and you underwent a fat
removal or orbital decompression surgery by an oculoplastic surgeon at that time.
You still felt concern about the appearance of your eyes and so you underwent eyelid surgery
in 2016.
Now currently, you state from your question that you hate the appearance of your eyes
and you’re considering another decompression surgery and you’re looking for additional
opinions based on the photos that you submitted.
Well, I can certainly share with you my approach to dealing with patients with thyroid eye
disease.
A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon.
I have been in practice in Manhattan and Long Island for over 20 years.
Thyroid eye disease has been a very big part of my practice.
And I perform the full gamut of procedures, everything from orbital decompression to eyelid
surgery.
And I can certainly understand your challenges that you’re dealing with in terms of your
desire to improve you appearance.
So to begin with, I think that one thing to be sure of is that if you’ve been going
to an oculoplastic surgeon who has been doing this work in a stepwise way, I think that
your doctor will be the best person to guide you as to what the next steps are.
And I’ll explain a little bit further.
When we talk about the concept of what happens with thyroid eye disease and understanding
that there are two phases: there’s the active inflammatory phase and there’s the fibrotic
phase.
And generally speaking, you try to avoid operating during the inflammatory phase unless there
is a very clear indication such as visual threatening disease that requires surgical
intervention at that time.
Typically, the active inflammatory stage where there’s this autoimmune process and variability
of the eye appearance, you can expect that it can last about 2 years.
In the medical literature, it can last up to 5 years but that’s really the rare instances.
Basically determining where someone’s in the fibrotic stage is contingent mostly on
the clinical appearance based on the stability of the eye appearance.
And of course, from that point, you do surgeries to help people improve their eye function
and eye appearance.
So with the fat decompression, it was likely done because you had an issue with the proptosis
or the prominence of the eye being pushed forward.
And that approach can be very effective in reducing the volume that is behind the eyes
since in thyroid eye disease, there is an increase in certain types of thyroid eye disease
proportionally in the amount of fat behind the eye.
Now the question at this point is what do you want to see change?
If you want to see projection of the eye change, well it’s important you discuss with your
doctor what are your other options.
It is likely your doctor probably did as much fat decompression as is safely possible from
your initial surgery which leaves you with a procedure called bony orbital decompression.
And in bony orbital decompression, you’re actually removing parts of the bone in the
orbit such as the bones of the ethmoid sinus above the maxillary sinus.
And even further, you can actually reduce the bone in the lateral aspect in the lateral
part of the orbit or the greater wing of the sphenoid.
This is more of a technical jargon but it basically means that you are doing a more
aggressive operation and with that comes certain risks that you need to be aware of.
Now if you are more concerned about the appearance of the eyes in terms of the retraction, well
I think that it is likely you can do additional eyelid surgery which can address the eyelid
retraction.
This includes surgery to address lower eyelid retraction as well as upper eyelid retraction.
Now you mention that you did have this surgery or eyelid surgery and you weren’t exactly
specific.
But nonetheless, as long as you have an understanding as to the risks and benefits, I would probably
say, coming from a conservative perspective that, again, without a physical examination
but at least understanding how I counsel my patients, I ask them how much does the prominence
of the eyes bother you.
And very often, if I show them that the eyelid being brought down, let’s say in the case
of the upper eyelid and brought down a little bit, it’s remarkable how it can really change
the perception of prominence.
Basically, if the eyelids are retracted, the eyeball looks more prominent.
And so, it’s basically both an optical illusion but at the same time, it is also functionally
more comfortable for the patient to be able to close their eyes.
You know, with fat decompression, I’ve observed that even if you don’t get that much of
a retrusion of the eyeball, the eyeball does move a little bit more easily and the blinking
actually becomes more comfortable.
Again, this is clinical experience.
But I think that when I present to a lot of my patients what their options are, they tend
to shy away from bony orbital decompression because of the extent of the procedure.
It’s not saying that it’s not a good procedure.
It’s actually a very effective procedure but I think it’s best reserved for more
severe cases of proptosis.
So that being said, I think it’s very important that you speak to your oculoplastic surgeon
about your situation.
What differentiates your doctor’s perspective from someone else is their familiarity with
your anatomy.
Now certainly, as a specialist, as someone who sees patients and takes care of patients
from around the world, I have been in a position to do revision eyelid surgery whether it’s
for eyelid retraction or eyelid ptosis and other eyelid situations.
Certainly, it’s okay to have other opinions and have at least an understanding but I think
that you should have this discussion first with the surgeon who has done the surgery
for you already.
Now if they feel that they’ve done as much as they could and they don’t want to do
anything more, then seek additional opinions.
But at the meantime, I think that it is important for you to understand and have this discussion
about bony decompression versus additional eyelid surgery.
And although there’s no examination here, I suspect, based on your photos, that you
might find a middle ground of compromise with the eyelid surgery over the decompression.
I think that one of the things that I have counseled on my patients who have thyroid
eye disease which very often affects young to middle aged women and the significant impact
of this disease on their physical appearance can be quite devastating and very emotionally
impactful.
And so understanding that it is accepting a change that is very difficult to restore
to the pre-thyroid disease appearance but nonetheless, having a natural aesthetic appearance
is possible and that, I think, is important to at least just get comfortable with.
It’s never ideal but it is, unfortunately, just the physical realities of these long-term
anatomic changes from this autoimmune disease.
So I hope that was helpful, I wish you the best of luck and thank you for your question.