Anatomy
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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