Eyelid Reconstruction

Quick Hits

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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


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


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


    • 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


      • 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)

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