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Reconstructive

Reconstructive Procedures with Malena Amato, MD

Dr. Amato has extensive experience in all facets of orbital and reconstructive eyelid surgery for all ages and continues to research and train students in the field. She offers minimally invasive endoscopic techniques with a personalized plan. Procedures can range from office procedures to general anesthesia depending on the needs and complexity of the patient’s problem.

Patient Experiences

Dr Amato performed amazing surgery on my eyelids for a complicated issue. I had minimal downtime considering the procedure. She not only resolved the issue that I originally presented but also additional improvements.

The staff is extremely friendly and proficient. I have visited multiple plastic surgeons in Austin area and my experience with Dr Amato far exceeds my other experiences

J.S. - Google

Eyelid/Eye

A chalazion is a blocked eyelid gland that can become enlarged, red and painful. It can occur spontaneously but can be more prevalent in patients with blepharitis or rosacea. The eyelid has hundred’s of oil glands, and sometimes there is a disruption of their normal pathway, resulting in a blocked gland that is red, and swollen.  

  • What is the treatment of a chalazion? It is typically treated by warm compresses a few times a day and time and usually resolves on its own in a few weeks. Occasionally, secondary cellulitis or infection can result in requiring antibiotics. If chalazia do not resolve, or continue to worsen or cause pain, the chalazion can be removed in a 15-minute office procedure called an incision and drainage. A chalazion can recur, though rare.

Dermatochalasis is the condition whereby excess upper eyelid tissue can cause upper visual obstruction to the point that surgery to improve this condition is medically necessary. Typically, blepharoplasty is performed, whereby excess skin and sometimes fat is removed from the upper eyelid with a hidden incision at the natural eyelid crease, and the edges are brought together with dissolving stitches (See page on eyelid lift).

Dry Eyes are a significant cause of eye irritation in adults. Dry eyes occur when your eyes do not make enough or the right type of tears or tear film. Symptoms include blurry vision, irritation, foreign body sensation, mucous discharge, burning, and eye fatigue. The cause of dry eye is often related to age, as well as medical conditions such as pregnancy, menopause, rheumatoid arthritis, rosacea, Sjogren’s disease, Bell’s palsy, and vitamin A deficiency. Patients may have low tear production, poor quality of tear production or oil gland/meibomian gland deficiency. Environmental factors including smoke, allergens, dust, and dry conditions may contribute to dryness.

The treatment goal is to keep the surface of the eye lubricated with artificial tears and ointment. Other treatments include the use of oral supplements such as omega-3 oils, fish oil or flax seed oil. Other environmental aids include avoiding ceiling fans, air conditioner or heat vents, and wearing glasses or sunglasses. If this is not sufficient, patients may require additional medications that improve the quality of tear production and reduce inflammation such as Restates or Xiidra. Often, plugging of the lacrimal puncta, or permanent closure of the lacrimal ducts. There are in-office or laser procedures performed by a dry eye specialist that may also help in restoring your tear film and improve dry eye symptoms. Dr. Amato often works closely with your eye doctor to ensure that the patient receives optimal dry eye care, especially when considering eyelid surgery. Conservative eyelid surgery may be necessary for the severe dry eye patient.

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Removal of an eye, or enucleation or evisceration, is often necessary due to injury, tumor, or disease. Patients can develop a painful blind eye after injury, surgery, or conditions such as glaucoma or diabetes or retinal problems. Patients with ocular tumors such as melanoma may require removal of the eye. The loss of an eye is significant and often a tough time for a patient. A prosthetic eye can often replace a nonfunctioning eye, look very natural, and movement can usually be maintained. Though people can wear a prosthetic eye for several years without complications, some side effects may need surgical and medical attention. Poor fit of the prosthesis, sagging of the eyelids, loss of shape of the eye socket, or migration or infection of the implant may require revision or replacement.

  • What is the surgery for eye removal? Surgery may entail removing the entire eye called enucleation or removing the inside contents of the eye and leaving the outer lining of the eye called evisceration. Surgery to remove the eye is typically an outpatient procedure and usually lasts about an hour. The patient is often under general anesthesia, and the eye is removed and replaced with an orbital implant to add volume to the socket and improve fitting of an ocular prosthesis. Patients usually take postoperative pain and nausea medicine to minimize those side effects. Some patients choose to stay n the hospital for pain or nausea control for 1-2 days. A patient who has had an ocular prosthesis but who already has a poorly fitting prosthesis due to sagging of the eyelid or scar tissue of the socket may be improved with eyelid procedures.
  • When would I get my prosthetic eye? Once healed after about a month following orbital or eyelid surgery, the patient will be referred to the ocularist who will fit or create a beautiful artificial eye that has a realistic appearance. Usually, the final results are aesthetically pleasing to the patient.

Eyelid malposition includes a variety of conditions such as in turning (entropion) or outward turning (ectropion) of eyelids, inward-turning eyelids (entropion) misdirected eyelashes irritating the eye (trichiasis), and eyelid laxity or inability to close the eyelids (lagophthalmos). These conditions can result from age, inflammation, scarring, facial paralysis, trauma, congenital malformation, or disease. Eyelid malposition can cause chronic eye irritation, poor eyelid closure and dry out of the eye, mucous discharge, blurred vision, excessive tearing, infection, corneal damage, and impaired vision.

Ectropion is turning out or drooping of the eyelid that can result from aging, scarring of the eyelid skin, (cicatricial ectropion), mechanical pulling downward of the skin, congenital defect, or facial paralysis (Bell’s Palsy).  Medical treatment usually involves lubrication or treatment of the underlying inflammation or infection. Eyelid malposition is often addressed surgically to reposition and tighten the eyelid as needed to protect the eye. The type of entropion or ectropion associated with aging is best corrected surgically by shortening or tightening the lower eyelid through an incision at the outer corner of the eye (near the eyelid) and some sutures below the eye (Quickert) to rotate the eyelid. Sometimes there are scars following trauma or following the surgical removal of skin cancers, and your surgeon may need to use a skin graft taken from the upper eyelid or from behind the ear to repair the ectropion. On occasion, cicatricial ectropion repair involves the formation of a flap of tissue from the upper eyelid to the lower eyelid through an incision at the outer former of the eye (nearest the ear). Trichiasis treatment may involve office treatments to remove the lash follicles or a lash rotation surgery. Lagophthalmos may include a release of scar tissue or tight muscles, placement of a gold weight to help the eyelid close, or grafting.

  • What should I expect at the time of surgery? Eyelid repair is usually performed as an outpatient procedure under local anesthesia and with the patient lightly sedated with either oral or intravenous medications.  Your eye may be patched overnight.  Once the patch is removed you will use an antibiotic ointment on the stitches for about one week.  Occasionally, your eyelids may have to be stitched together or have a prolonged patch placed for up to one week to allow the eyelid to heal underneath the bandage.  Your doctor can advise you whether this will be necessary.  After your eyelids heal, your eye will feel more comfortable.

  • What are the risks and complications of surgery?  Bleeding, infection, scarring, and recurrence of the condition, which are potential risks with any surgery, are very uncommon.  As with any medical procedure, there may be other inherent risks that you should discuss with your surgeon.

  • What should I expect after surgery? After surgery, pain is usually minimal, bruising and swelling may be expected and will likely go away within one to two weeks.  We encourage ice packs regularly especially the first 2 days after surgery and pain medication as needed. The results of surgery are usually permanent, and recurrence is rare. After your eyelids heal, your eye should feel more comfortable, and you will no longer have the risk for corneal scarring, infection, and loss of vision.

Ptosis is the term for droopy, sagging eyelids. There are several causes of eyelid ptosis including age, injury, muscle or nerve disorders, and congenital defects. Droopy or baggy eyelids not only can falsely portray an aged or tired appearance but often it can affect vision. Patients often complain of a brow or forehead ache and fatigue at the end of the day as they continually lift their brows to see. Eyebrow ptosis can also occur with aging and be visually significant.  It can cause the skin below the brow to overhang over the eyelids/lashes and block vision, especially if the forehead falls below the brow bone. Since there are many causes of ptosis, it is vital to undergo evaluation by a qualified physician who can properly evaluate and treat a patient with ptosis. Surgery is usually necessary to correct ptosis and is performed on an outpatient basis.

Skin and eyelid cancer is common in many races and ethnic groups, especially in Caucasians and in patients exposed to the sun. Basal cell carcinoma is the most common type of eyelid skin cancer. Other eyelid skin cancers include Squamous cell carcinoma, melanoma, and less commonly sebaceous cell carcinoma or Merkel cell carcinoma.  Eyelid skin cancer frequently occurs on the lower eyelid, and usually starts as painless elevations or nodules, with some loss of eyelashes or distortion of the eyelid margin.  Skin cancer may present as a lump or area of the eyelid or face that continues to ulcerate or bleed and distort the eyelid architecture. It is essential to have these lesions examined early on to avoid large excisions necessary to remove all the cancer cells. Frequent follow-up visits to your dermatologist are necessary for monitoring.

  • What is the procedure for Mohs surgery and eyelid reconstruction? The surgeon can remove the eyelid cancer and reconstruct the eyelid and restore function and cosmesis with various techniques including wedge resection, or advancement flaps or skin grafts. Dr. Amato often works with a MOHS cancer surgeon who will remove the eyelid cancer while Dr. Amato performs the reconstruction.  Larger skin cancers may involve more than one surgery such as Hughes flap and Culter Beard techniques. It may or may not require assistance with a multispecialty team of oncologists, dermatologist, ENT surgeons or plastic surgeons. Dr. Amato has extensive experience in the treatment of eyelid and orbital cancers.

A variety of neurologic conditions can affect facial animation. Benign essential blepharospasm is one such disorder causing uncontrolled spasms around the eyes and face. Hemi-facial spasm affects one side of the face. Sequela of Bell’s palsy creating fundamental facial weakness can result in long-term spasms, and it can be progressive.

  • What is Bell’s Palsy? Bell’s palsy is a hemifacial paralysis whose cause is unknown, or possibly thought to be a virus, that mimics a stroke. Patients should seek immediate medical attention at the onset of facial paralysis. Bell’s palsy causes drooping on one side of the face and can cause problems with eyelid closure, tearing, and drying out of the eye along with drooling and trouble speaking and eating. Typically, Bell’s palsy can improve on its own, but sometimes the effects are permanent. Oculoplastic surgeons are highly qualified to treat the impact of facial spasm or paralysis from Bell’s palsy, stroke or after surgery or trauma. Treatments include Botox®, gold weight to close the eyelid, eyelid tightening/ectropion repair or midface lift/ sling are various treatments. Botox® treatments usually last 3-6 months and require repeat surgery. Myectomy is eyelid surgery to partially remove the muscles that cause spasm when Botox or other neurotoxin injections are ineffective.
  • What is the treatment or surgery for facial or eyelid spasm? Treatment for facial spasms entails Botox® Cosmetic or other neuromodulators every 3-6 months typically. If this is not sufficient, Dr. Amato performs a procedure called a partial Myectomy that is an outpatient procedure to partially remove the eyelid muscles contributing to the spasms. This in conjunction with Botox® can be an excellent complimentary treatment for this chronic disease. There may be a surgery to decompress the nerve performed by a neurosurgeon for hemifacial spasm if you are a candidate. For new onset hemifacial spasm, brain imaging is critical to look for a mass or cause of nerve compression. If the facial spasms progress to the neck or beyond the face, Dr. Amato will work with a neurologist for optimal treatment.
  • What is the treatment for bell’s palsy? Facial palsy can result after an injury, tumor resection or Bell’s palsy. If the condition does not improve on its own after several months during which time it is imperative to protect the eye surface by taping of the eyelid or continuous ocular lubrication.  Several outpatient procedures can be performed to improve eyelid closure (lagophthalmos) and facial function including an upper eyelid gold weight, ectropion repair of the lower eyelid, midface and brow lifting. There may be a nerve decompression surgery that can be performed by a neurosurgeon if you are a candidate. For more information on BEB, look here and here.

Pterygium is a benign growth on the eye that begins on the surface of the eye or conjunctiva. It can grow aggressively to start to cover the cornea and visual axis, causing eye irritation, astigmatism, or blocked vision. Most pterygia can be a result of sun exposure or heredity and are typically treated with the use of sunglasses and artificial tears.

  • How can a pterygium be removed? Advanced or symptomatic pterygia can be surgically removed as an hour outpatient procedure, but the risk of recurrence is high. Sometimes, the defect remaining after the excision of the lesion can be covered with an amniotic membrane graft, but despite these efforts, they can still return. Learn more

Tearing, or epiphora can result from dry eyes, inadequate tear drainage into the lacrimal tear ducts or overproduction of tears from the lacrimal gland.

  • What causes  tearing? The most common causes of tearing are dry eyes, which can trigger a reflex tearing from the tear gland. Another common cause is blockage of the lacrimal (tear) ducts (nasolacrimal duct obstruction) located within the drainage pathway from the tear drain in the eye into the nose, which may result from inflammation, injury, tumors, sinus infection or other reasons.
  • Who can get a blocked tear duct?Blocked tear ducts can occur in infants, which can often resolve on their own, or can be acquired as an adult. Excess tearing can be a nuisance, and can also cause an infection that may threaten vision if untreated.
  • What is the treatment for tearing? If tearing occurs from dry eyes, Dr. Amato will work closely with a dry eye specialist to with ocular lubrication and other treatments to improve the tear film and health of the eye surface.
  • What is the treatment for tearing in children? Tearing can frequently occur in infants, and with medical therapy and message, the obstruction often resolves.  If tearing persists after one year of life, probing and irrigation of the lacrimal system are recommended. If there is a recurrence, frequently children will require a small silicone stent to be placed into the tear drainage system.
  • What is the treatment of tearing in adults? For dry eyes, there is a procedure that can permanently close the tear drains. Tear duct surgery can vary from office procedures to widen or open or close the punch or opening, to nasal probing, or intranasal operations such as DCR (dacryocystorhinostomy) or CDCR with Jones tube to open a blocked tear duct. All of these procedures are typically outpatient procedures performed usually under general anesthesia and last about an hour. Patients are often asked to stop blood thinners for 2 weeks before surgery to avoid the risks of bleeding.  For blocked tear ducts in adults, nasolacrimal duct obstruction often requires a procedure called dacryocystorhinostomy, or DCR, which creates an opening from the tear duct into the nose. Dr. Amato is one of few surgeons in Austin to offer endoscopic, or no scar DCR (dacryocystorhinostomy) whereby the tear duct blockage is opened from the nasal side, and a stent is placed temporarily in the tear drain system until healing occurs. This stent is easily removed in the office. If there is a recurrent blockage or if the tear duct is too damaged, a Jones tube can be offered, which is an artificial tear duct implant.

Thyroid eye disease can occur as a result of Graves’s disease, or hyperthyroidism and much less common as hypothyroidism. Infiltration of the muscles and tissues surrounding the eye can cause poor eye movement, proptosis, or bulging of the eyes, eyelid malpositioning, and visual loss. Patients can present with a single eyelid retraction, or mild proptosis, or have a dramatic change in their appearance, which can also be a sight-threatening disease if not treated correctly. Thyroid disease and other autoimmune diseases can be physically and emotionally debilitating to the patient.

  • How do you treat thyroid eye disease? Management of patients with this disease is often multidisciplinary and includes endocrinologists, internists, strabismus surgeons, ophthalmologists, and oculoplastic surgeons. Patients with severe sight-threatening progression of the disease often require high-dose steroid treatment, radiation therapy, or surgery to decompress the eye and preserve sight.
  • What is the surgery for thyroid eye disease? The surgery to correct sequela of thyroid eye disease can vary from eyelid retraction surgery to orbital decompression. Surgery is usually outpatient or overnight stay and can take a few hours per eye. Patients may also require surgery to straighten the muscles that move the eye and eyelid surgery to remove extra tissue.
  • What is the recovery process for surgery after thyroid orbital decompression? This process of eye and orbit rehabilitation after a diagnosis of thyroid eye disease can take years, but the majority of the post-operative bruising and swelling will occur for the next weeks after surgery. Dr. Amato and the team of specialists work closely together and are there to explain the process to you and help you through it every step of the way. Other autoimmune disorder can cause eyelid inflammation including inflammatory orbital syndrome, IgG4 inflammation, and others. For more information, refer to Graves Eye Disease, American Thyroid organization or www.thyroid.org.

Scar tissue can result from injury or surgery, which may be unsightly or deforming to the eyelid. Scarring can cause poor function and closure of the eyelid, notching of the eyelid margin, drooping eyelids, misdirected lashes, and ultimately irritation to the eye or affect vision. Repair of facial injuries or eyelid lacerations is essential to avoid unnecessary problems with healing and the best cosmetic result. It is essential to have an eyelid specialist evaluate, and property repair the many intricate layers and structures of the eyelid for the best cosmetic and functional result. Tear duct injuries can commonly result with lower eyelid lacerations, in which a specialist should reconstruct the duct for proper function of the tear drain to avoid tearing. Scar revision can be addressed surgically to improve these problems. Dr. Amato has repaired hundreds of patients of all ages with orbital-facial traumas for the past 18 years.

Facial

Orbital tumors can be malignant or benign and occur in all ages. Patients often present with proptosis, or bulging of the eye, and possibly vision problems or double vision. Benign orbital tumors can occur more commonly such as cavernous hemangiomas, and luckily today there are many treatment options for orbital tumors depending on the cell type and stage at presentation. For some cancers in other parts of the body, it can spread to the orbit around the eye or the tumor can originate in the orbit. If the tumor extends into the brain or sinuses, a team approach to remove the tumor by Oculoplastic surgeons, Neurosurgeons and ENT surgeons is often necessary. Dr. Amato has been involved in hundreds of cases of orbital tumor removal and reconstruction. Several factors regarding type and location of the orbital tumor will determine the treatment, follow up and prognosis. Surgery can often be outpatient or a few days in the hospital, usually under general anesthesia. Dr. Amato has treated hundreds of patients with orbital tumors for the past 18 years.

Orbital trauma often results from car accidents, a fall, a fight or sports injuries where there is a direct impact to the eye or orbital bones. The most common type of orbital fractures around the eye is a blowout or orbital floor fracture, which results from direct impact, causing the floor of the orbit to collapse.  This may create double vision, inability to look up or down and a sunken appearance of the eye over time.  Restoring the bony orbit around the eyes is vital for eye positioning and vision.  For facial fractures, patients usually undergo a CT scan to evaluate the bony structures and typically an orbital or facial implant, and plating is performed often in the same day procedure.

  • What can happen with orbital trauma in children? Children often present after injury with a normal appearing eye after orbital trauma but can demonstrate nausea, inactive behavior, or are unable to look up. This can be a concern for a green-stick fracture whereby an eyelid muscle is entrapped in the fracture site and requires immediate repair. Dr. Amato is experienced in the repair of complex orbitofacial trauma and fractures.
  • What can happen with orbital trauma in children? Children often present after injury with a normal appearing eye after orbital trauma but can demonstrate nausea, inactive behavior, or are unable to look up. This can be a concern for a green-stick fracture whereby an eyelid muscle is entrapped in the fracture site and requires immediate repair. Dr. Amato is experienced in the repair of complex orbitofacial trauma and fractures.

Trauma to the eyelids and bony orbits often require surgical repair by an oculoplastic specialist for an optimal functional and aesthetic result.

Ready to book your procedure?

If you are ready to take the next steps, or simply want more information about a procedure, please contact our team! Dr. Amato looks forward to speaking soon.