Eyelid Reconstruction

Quick Hits

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Soft tissue components

    • Layers of upper eyelid – skin, orbicularis (pretarsal, preseptal, orbital), orbital septum, upper lid fat compartments, levator muscle, muller muscle, conjunctiva. Whitnall ligament surrounds the levator as it becomes the aponeurosis.
    • Layers of lower eyelid – skin, orbicularis (pretarsal, preseptal, orbital), tarsus, lower lid retractors, capsulopalpebral muscle, inferior tarsal muscle. Lockwood ligament surrounds the retractors as they become the aponeurosis.
    • Lamella
  • Anterior lamella – skin and orbicularis
  • Posterior lamella – tarsus and conjunctiva
  • Middle lamella (septum) – holds eyelid position in place, emphasizes the orbital-malar depression so can release and transpose fat
    • Tarsal Plate: approximately 12-15mm in the upper lid, site of attachment for mullers muscle and levator; lower lid 4-10mm in height, inferior margin is continuous with the capsulopalpebral fascia
    • Tear trough ligament – osteocutaneous ligament between palpebral and orbital portions of orbicularis
      • Important to release (and fat redraping) during lower eyelid belpharoplasty if the patient has a tear trough deformity
    • Whitnall ligament (above) and Lockwood ligament (below) – fascial thickening that supports the globe and fuses with capsulopalpebral fascia (inserts into tarsus)
    • muscles
  • Levator – attaches to tarsal plate, normal excursion 12-16mm, innervated by CNIII (occulomotor nerve); in senile ptosis the levator muscle becomes detached or attenuated from its insertion into the tarsal plate, this can also be interrupted by retraction during cataract surgery 
  • Muller’s muscle (loss results in 2-3 mm of ptosis), innervated by sympathetic nervous system
  • Inner canthal orbicularis or pretarsal (Buccal V3) – blinking, lower lid tone, pumping lacrimal gland
  • Extracanthal orbicularis or orbital fibers (Zygomatic V3) – eyelid closure, squinting, animation

Fat compartments

    • Upper: ROOF (retroorbicularis oclulus fat) 2 compartments, medial (nasal – paler yellow) and central (darker yellow), separated by superior oblique tendon. the lacrimal gland takes up the space of what would be the lateral fat pad
    • Lower: SOOF (sub-orbicularis oculus fat) 3 compartments, medial, central, and lateral. Medial and central separated by the inferior oblique tendon.
      • Inf oblique tendon is the most common injury in a blepharoplasty

Sensory Innervation

      • Lacrimal nerve (V1) – superolateral upper eyelid
      • Infratrochlear nerve (nasociliary nerve) – medial upper and lower eyelid
      • Infraorbital nerve (V2) – lower eyelid

Trilayer tear components:

    • mucin from goblet cells (dispersion of the tears)
    • water/protein from lacrimal gland (antimicrobial)
    • lipid/oil layer from meibomian glands (prevents evaporation)

Normal Eye Measurements

    • Malar Vector – position of the cheek relative to the globe. Can measure eye prominence with hertel exophthalmometer
      • Negative vector (when eye sticks out farther than cheek) (>18mm exophthalmos) at higher risk for ectropion/lagophthalmos, scleral show, dry eyes
      • Consider lower lid elevating procedure – release capsulopalpebral fascia or spacer placement
    • Canthal tilt – (position of lateral canthus relative to medial canthus). Ideal is +5-8 degrees (lateral higher than medial) 
      • Ideal is positive canthal tilt

Specific exam findings/defects

    • Coloboma: congenital defect of eyelid, iris, retina, choroid, optic disk; can range from small notch to ocular cleft; localized growth disturbance vs optic fissure
  • Related to Tessier 6 or Treacher Collins Syndrome 
    • Horner syndrome – ptosis, myosis, anhidrosis
    • Von Graefe sign – lagopthalmos in downgaze 2/2 graves
    • Bell phenomenon – eye looks up and out during sleep. Bc of transient lagopthalmos after bleph, may get corneal ulceration if this reflex is not present
    • Epiblepharon – vertical eyelashes causing corneal irritation
    • Euryblepharon – shortage of eyelid tissue
    • Crypophthalmos – failure in embryonic development of lid fold
    • Hering test – elevate ptotic eyelid and observe whether the other eyelid becomes ptotic
      • Can also use phenylephrine. If you artificially elevate one side and the other side becomes ptotic you know both need repair
    •  ptosis covered in another lecture

Soft Tissue reconstruction 
Upper eyelid:

  • <1/3 eyelid – primary closure (older patients with significant laxity can undergo primary closure up to 40% 
      • If there is tension may perform a lateral canthotomy
  • 1/3-1/2 eyelid
      • tenzel semicircular flap (combining a lateral canthotomy can increase closure potential to 60%)
        • This is a rotational myocutaneous flap (provides anterior lamella only)
      • Mustarde flap (lower lid sharing), both anterior and posterior lamella for defects 30-60% of the CENTRAL lid, contains lashes, may need tenzel flap to close donor site
        • Based on medial palpebral artery
      • Sliding tarsoconjunctival flap- can provide medial and posterior lamella only. It is one stage composite flap and requires anterior lamellar coverage
  • >1/2 eyelid
      • cutler beard (lid switch from lower) flap (divide at 3-6 wk). This is a two stage procedure that provides both anterior and posterior lamella. There is no lash restoration, and will need tarsal plate replacement. 
      • Temporal forehead flap or fricke flap: anterior lamella coverage only (will need posterior). Only used when adequate tissue is unavailable
        • Risks injury to facial nerve (temporal branch)
      • Paramedian forehead flap: useful for extensive defects (anterior lamella only). Will need posterior lamella in the form of cartilage and mucosal grafts

Lower eyelid

  • <25% eyelid
      • primary closure, (remember elderly patients with significant laxity may undergo primary closure of up to 40%)
  • 25-50% eyelid
      • tenzels are good for partial thickness defects up to 60% but will require posterior lamella coverage
  • >50% eyelid
  • Hughes (posterior lamella only). This is a two-stage procedure can cover entire lid and can be combined with FTSG or tripier flap (anterior lamella) (lower lid defects). 
        • Taken from upper lid, should preserve 4mm of upper tarsus for stability
  • Tripier flap: bipedicled flap from upper lid for entire length lower lid defects (anterior lamella only, needs posterior lamella
  • Mustarde flap (cheek advancement flap when referring to lower eyelid reconstruction): for deep vertical defects of entire lower lid lid and requires posterior lamellar coverage
  • Temporal (Fricke) flap: defects of entire lid, requires posterior lamella
  • Vertical myocutaneous cheek lift (anterior lamellar only), one stage, requires posterior lamella
  • Other posterior lamellar graft options: 
        • Palatal mucosal graft can lead to keratinization and corneal abrasions
        • free tarsoconjunctival graft
        • nasal septum
        • buccal mucosa
        • periosteal flap
    • Lower eyelid ectropion after burn: FTSG and release of tissues even after early burn!!!; involutional ectropion (lax skin) treated with canthoplasty and wedge excision, 

Miscellaneous recon fact:

  • Gold weight should be placed superficial to the levator aponeurosis and tarsal plate, inferior portion of the plate just a few mm of the lash line
    • Placed centered over the junction of the medial and central one-thirds of the eyelid and medial limbus

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