Soft Tissue

• Anterior lamella – skin and orbicularis
• Posterior lamella – tarsus and conjunctiva
• 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.
  • 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
• Sensory
  • Lacrimal nerve (V1) – superolateral upper eyelid
  • Infratrochlear nerve (nasociliary nerve) – medial upper and lower eyelid
  • Infraorbital nerve (V2) – lower eyelid
• Motor
  • Levator – attaches to tarsal plate, normal excursion 12-16mm, innervated by CNIII (occulomotor nerve)
  • 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 lacrimla gland
  • Extracanthal orbicularis or orbital fibers (Zygomatic V3) – eyelid closure, squinting, animation
• Whitnall ligament (above) and Lockwood ligament (below) – fascial thickening that supports the globe and fuses with capsulopalpebral fascia (inserts into tarsus)
• 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
  • Trilayer tears
• mucin from goblet cells (dispersion of above layers)
• water/protein from lacrimal gland (antimicrobial)
• lipid/oil layer from meibomian glands (prevents evaporation)
• 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

• 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 our previous lecture

Soft Tissue recon (divided into <25%, 25-50% and >50%)

• 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 –
• tenzel semicircular flap (combining a lateral canthotomy can increase closure potential to 60%)
• This is a rotational myocutaneous flap (provides both 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 –

• 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%

• primary closure, (remember elderly patients with significant laxity may undergo primary closure of up to 40%)

25-50%

• tenzels are good for partial thickness defects up to 60% but will require posterior lamella coverage

>50%

• Lower lid defects
• 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, neurogenic treated with gold weights
• Skin graft from c/l eyelid best option especially in elderly patients; retroauricular/supraclavicular too thick

Miscellaneous:

• 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
• 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

Nasoorbitoethmoid fractures

• Anatomy – disruption of medial canthus, lacrimal system, nasofrontal duct
• Classic sxs of medial canthal disruption is telecanthus, ptosis, epiphoria
• Treatment (within 2wk)
• Approach
• Coronal incision
• upper eyelid medial incisions
• transcaruncular/retroaurunceal approach
• Technique
  • Frontomaxillary – can use load bearing plates across frontomaxillary buttress to support compressive forces of mastication
  • Nasal base – closed reduction w/ splints may cause later widening of base. Single buttress spanning plates may prevent this. K stitch
  • Medial canthal fixation – transnasal wiring vs mini plates vs mitek anchoring, osteosyntehsis screw anchoring. Vector should be posterosuperior and overcorrected (do this last)