EYELID RECONSTRUCTION

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2 EYELID RECONSTRUCTION James F Thornton MD and Jeffrey M Kenkel MD ANATOMY AND PHYSIOLOGY Surgery of the eyelids requires a thorough knowledge of the periorbital anatomy. The complexity of the eyelids as well as the importance of each component to the function of the eyelid must be appreciated. A detailed description of eyelid anatomy and the lacrimal apparatus was given by Jones 1 in The reader is also encouraged to peruse Zide and Jelks s 2 Surgical Anatomy of the Orbit for a complete description and excellent illustrations of the periorbital anatomy. Blood Supply The rich vascular supply of the eyelids is through marginal and peripheral arcades. 2,3 Medially a rich superficial network is formed via anastomoses from both the internal and external carotid artery systems (Fig 1). Fig 1. Blood supply of the eyelid. ADT=anterior deep temporal artery; DN=dorsal nasal artery; F=facial artery; IO=infraorbital artery; L=lacrimal artery; OA=ophthalmic artery; SO=supraorbital artery; ST=supratrochlear artery. (Reprinted with permission from Tucker SM, Linberg JV: Vascular anatomy of the eyelids. Ophthalmology 101:1118, 1994.) The upper marginal arcade is initially quite tortuous and then straightens out as it passes further laterally. Its vascular supply is primarily via the ophthalmic artery. The marginal artery of the eyelid courses approximately 3 3.5mm above the lid margin. 2 The inferior marginal arcade is supplied predominantly from branches of the facial artery in addition to a branch from the superior marginal vessel. These arcades travel just anterior to the tarsus. The marginal artery courses 1mm superior and anterior to the base of the lower tarsus. 3,4 Laterally the superficial network of the skin is supplied primarily by branches of the superficial temporal artery and the lacrimal artery. The extensive collateralization that exists between branches of the internal carotid artery mainly the ophthalmic artery and branches of the facial artery accounts for reversal of flow seen when the internal carotid artery is obstructed. 2 Innervation Sensation to the periorbital area is via the first and second branches of the trigeminal nerve. The motor supply to the orbicularis oculi muscle is from the temporal and zygomatic branches of the facial nerve, which enter the muscle from its deep surface. Ouattara and coworkers 5 find three common patterns of innervation of the orbicularis (Fig 2). In the most common variant, present in 63.3% of their cases, the muscle is innervated by a superior plexus fed by temporal and superior zygomatic branches and an inferior plexus fed by inferior zygomatic and superior buccal branches. In the lower lid, Mendelson et al 6 describe the situation as follows: The zygomatic branches of the facial nerve that innervate the orbicularis oculi enter the pars orbitalis at or near its periphery and seem to do so in four distinct locations [Fig 3].... Ultimately, the several branches become more superficial as they enter the suborbicularis oculi fat on the underside of the orbicularis. The [zygomatico-facial] nerve, previously considered the main innervation of the orbicularis oculi, separates from the zygomatic nerve well

3 Fig 2. Common anatomical variations in the innervation of the orbicularis oculi and their relative prevalence. T = temporal branch of facial nerve. SZ = superior zygomatic branch. IZ = inferior zygomatic branch. SB = superior buccal branch. a, 63.3%; b, 16.7%; c, 13.3%. (Reprinted with permission from Ouattara D, Vacher C, Accioli de Vasconcellos JJ, et al: Anatomical study of the variations in innervation of the orbicularis oculi by the facial nerve. Surg Radiol Anat 26:51, 2004.) before the latter passes deep to the zygomaticus major. [The zygomatico-facial nerve] continue[s] its directly horizontal course over the outer surface of the zygomaticus major, within a centimeter of the upper edge of the muscle origin. This orbicularis branch courses immediately outside the prezygomatic space as it passes on the inferior surface of the same zygomatic ligament forming part of the inferior boundary of the prezygomatic space,... [and] continues medially onto the surface of the zygomaticus minor,... where it abruptly changes course, from transverse to vertical, to enter the suborbicularis oculi fat overlying the zygomaticus minor. It remains in this layer, in the ceiling of the space, as it ascends toward the lid margin [Fig 4]. Mendelson et al (2002) In the upper lid, Hwang and colleagues 7 follow the course of the temporal branch of the facial nerve in the orbicularis oculi muscle and designate a hazard zone where injury to the temporal branch is likely to occur. On the basis of a study on 20 cadavers, the authors found the temporal branch of the facial nerve coursed horizontally along the fibers of the orbicularis oculi muscle with interconnections, but did not cross over the superior orbital rim. The location of the supraorbital and infraorbital nerves can be predicted by palpating for the supraorbital notch. Cadaver studies by Wilhelmi and associates 8 place the vertical course of the supraorbital and infraorbital nerves approximately 16 17mm from the medial canthus along the medial one third of the orbit. Fig 3. Pattern of innervation of the orbicularis oculi of the lower lid. The branches at 6 o clock and 7 o clock course from deep to the parotid-masseteric fascia to become superficial into the sub-orbicularis oculi fat near the retaining ligaments. The dark arrows indicate the three common surgical approaches to the prezygomatic space. (Reprinted with permission from Mendelson BC, Muzaffar AR, Adams WP Jr: Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 110:885, 2002.) Skin and Subcutaneous Tissues Eyelid skin has only 6 to 7 cell layers and averages <1mm thick. The upper eyelid is even thinner than the lower lid in most people. Sebaceous glands are more numerous on the medial half of the lids, contributing to smoother, oilier skin on the nasal side. 9 Eccrine sweat glands are found throughout the eyelid, while apocrine glands (Moll) are more commonly found near the lid margin. The sebaceous glands of Zeis are associated with the eyelashes. 9 2

4 Fig 4. The temporal approach to the prezygomatic space passes deep to the lower temporal branches of the facial nerve (TFN) to the orbicularis. The zygomatico-facial nerve (ZFN) is the only structure crossing the space, and lies directly cephalad to the zygomaticus minor muscle. (Reprinted with permission from Mendelson BC, Muzaffar AR, Adams WP Jr: Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 110:885, 2002.) In the Western upper eyelid, fascial bands from the levator palpebrae pass through the orbicularis oculi muscle and insert into the skin from the ciliary margin to the level of the palpebral furrow (Fig 5A). The skin superior to the furrow is nonadherent and relatively mobile; this transition from adherent pretarsal skin to mobile preseptal skin forms the upper eyelid fold, which typically runs along the superior border of the tarsus. Asians usually lack a palpebral fold because the levator expansions do not penetrate the orbital septum. In the lower eyelid of Europeans, fibrous bands from the orbital septum pass through the orbicularis oculi and insert into the skin, forming an inferior palpebral furrow. As in the upper lid, Asians lack these fascial extensions and therefore show no palpebral crease (Fig 5B). Fig 5. A. Sagittal section of upper eyelid in left, Westerners and right, Asians. The levator expansions penetrate the orbital septum and orbicularis muscle to attach to the skin in Europeans. These extensions are lacking in Asian eyelids. (Adapted from Sheen JH: Supratarsal fixation in upper blepharoplasty. Plast Reconstr Surg 54:424, 1974.) Fig 5. B. Sagittal section of lower eyelid in left, Westerners and right, Asians. The capsulopalpebral fascia in the lower lid corresponds to the levator in the upper lid. (Reprinted with permission from Wolfort FG, Kanter WR, eds: Aesthetic Blepharoplasty. Boston, Little Brown, 1995.) 3

5 Orbicularis Oculi Muscle The orbicularis oculi consists of palpebral and orbital portions, with the palpebral portion further subdivided into pretarsal and preseptal portions. Medially, the orbital portion of the muscle originates directly from the bony orbital rim and the medial canthal tendon. Superiorly, the orbital portion of the muscle overlies both the frontalis and corrugator muscles. Inferiorly, the orbicularis muscle attaches indirectly to the orbital rim by means of the orbicularis retaining ligament (Fig 6), overlying the origins of the levator muscles to the upper lip. The orbicularis retaining ligament separates the prezygomatic space from the preseptal space (Fig 7). Laterally, the ligament merges into the lateral orbital thickening. 10 The upper and lower portions of the preseptal orbicularis converge at the lateral canthal raphe. 2 Fig 7. The orbicularis retaining ligament (ORL) indirectly attaches the orbicularis oculi (OO) to the periosteum of the orbital rim and separates the prezygomatic space from the preseptal space. (Reprinted with permission from Muzaffar AR, Mendelson BC, Adams WP Jr: Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 110:873, 2002.) Fig 6. Attachments of the orbicularis oculi in the lower lid. Medially, the muscle originates directly from the orbital rim above the origin of the levator labii superioris (LLS). More centrally, the orbicularis has an indirect attachment to the orbital rim by means of the orbicularis retaining ligament (ORL), which courses directly on the orbital side of the zygomatico-facial nerve (ZFN). At the lateral orbital rim, the ligament merges into the lateral orbital thickening. Sub-orbicularis oculi fat (SOOF) lines the undersurface of the prezygomatic orbicularis. (Reprinted with permission from Muzaffar AR, Mendelson BC, Adams WP Jr: Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 110:873, 2002.) The preseptal portion of the orbicularis muscle originates medially from an extension of the orbital periosteum that stretches across the lacrimal fossa, simulating a diaphragm. Lateral movement of this diaphragm produces negative pressure in the tear sac, while medial movement produces positive pressure and is responsible for the lacrimal pump. The pretarsal muscle is closely adherent to the tarsal plate. The pretarsal muscle is an integral component of lid closure and helps to maintain the structural integrity of the tarsal plate. 11 Medially the pretarsal muscles insert on the medial orbital wall both anterior and posterior to the lacrimal sac. Laterally the pretarsal muscle forms a common lateral canthal tendon inserting on the lateral orbital tubercle. This is typically found 7 10mm from the zygomaticofrontal suture. 2 Orbital Septum The orbital septum extends from the arcus marginalis the bony margin of the orbit toward the tarsus. In the upper lid the septum inserts onto the levator aponeurosis 2 5mm above the superior portion of the tarsus. In the lower lid the septum attaches to the inferior border of the tarsus and fuses with the periorbita at the bony rim (Fig 8). 4

6 Along the lateral half of the orbital rim, the septum originates just inferior to the orbital margin, resulting in a potential space the recess of Eisler. 2 Medial Canthus Zide and McCarthy 12 describe the medial canthus as tripartite: The upper superficial preseptal and pretarsal portions of the orbicularis oculi... inserted into the medial canthal tendon and adjacent bone.... In each instance a vertical or slightly oblique component of thick tendinous fascia arose from the transverse tendon at a point nasal to the junction of the limbs that form the tendon [Fig 9]. The fibers... were clearly oriented in a vertical direction and were inserted firmly into an ill-defined portion of the medial orbital rim just at, inferior to, or slightly superior to the nasofrontal suture. Zide & McCarthy (1983) Fig 8. Anatomy of the upper and lower eyelids and periorbital structures. Medially the septum attaches to the lower end of the anterior lacrimal crest and passes from lower to upper lid under the orbicularis muscle. Laterally the orbital septum passes just anterior to the lateral canthal tendon. 9 Zide and Jelks 2 emphasize the following key anatomic points: Laterally the orbital septum lies in front of the lateral canthal tendon. Superomedially the arcus marginalis forms the inferior portion of the supraorbital groove. Medially the orbital septum passes in front of the superior oblique trochlear pulley and then runs posterior to the deep heads of the orbicularis oculi muscle to insert onto the posterior lacrimal crest. Inferomedially the septum attaches to the anterior lacrimal crest and the inferior orbital rim. Fig 9. The suture surrounds the strong vertical component of the medial canthal complex. (Reprinted with permission from Zide BM, McCarthy JG: The medial canthus revisited an anatomical basis for canthopexy. Ann Plast Surg 11:1, 1983.) Zide and McCarthy 12 believe that the vertical component of the medial canthal tendon is responsible for suspension and fixation of the medial canthus, while the horizontal components are relatively weak and contribute little to medial canthal stability. 12 Lateral Canthal Tendon The lateral canthal tendon is more difficult to define than the medial canthal tendon. It attaches to both the upper and lower tarsal plates, the 5

7 orbicularis muscle, and the fibrous portion of the septum. 11 The relative contributions of these various components to the lateral canthal tendon are still unclear. Its fibers insert onto the lateral orbital tubercle of Whitnall s approximately 5mm behind the rim. 2 Tarsal Plates The superior tarsus measures approximately 10 12mm vertically from the lid margin. Anteriorly it is covered by the pretarsal orbicularis and posteriorly it is adherent to the underlying conjunctiva. It is composed of thin sheets of connective tissue which maintain structural integrity of the upper lid while accommodating the contour of the globe. Within the tarsus meibomian glands can be found that are responsible for secretion of oil. Whitnall 13 observed that the tarsus was not a solid plate of connective tissue, but rather consisted largely of meibomian glands. Furthermore, the tarsus splays out at the lid margin and becomes a flange that is roughly triangular on sagittal section. The lower tarsal plate measures approximately 3.7mm vertically, 4 and with the pretarsal orbicularis maintains the support of the lower lid. Mustardé 14 discusses the characteristics of the tarsal plate that dictate the choice of reconstructive method. While admitting that the flange effect is responsible for the rigidity at the lid margin, Mustardé felt that the source of permanent support for the lower lid was the orbicularis oculi muscle. His belief is reinforced by the drooping of the lower eyelid that is seen when the orbicularis oculi muscle is paralyzed or anesthetized, despite an intact lid margin. Preaponeurotic Fat The preaponeurotic fat is located posterior to the orbital septum and anterior to the levator aponeurosis in the upper lid. In the lower lid the fat is located anterior to the inferior retractors. The upper lid contains two fat pads, a nasal and a central. The lower lid contains three fat compartments (Fig 10). The inferior oblique separates the nasal and central compartments, while a fascial sheath separates the central and temporal compartments. 15 Fig 10. Preaponeurotic orbital fat. (Reprinted with permission from Putterman AM: Cosmetic Oculoplastic Surgery, 2nd Ed. Philadelphia, WB Saunders, 1993.) Eyelid Retractors Upper eyelid. The upper eyelid is responsible for 90% of the eye-opening action. This action is mediated by the levator palpebrae superioris and Müller s muscle. The levator palpebrae originates under the lesser wing of the sphenoid just anterior to the optic foramen. At the level of the superior transverse ligament of Whitnall s the levator muscle divides into an anterior aponeurotic layer and a posterior muscular layer. Anteriorly the aponeurosis attaches to the lower 7 8mm of the anterior tarsus (Fig 11) and is densest 3mm above the lid margin. The levator aponeurosis also sends fibers through the orbicularis to the skin of the lid in the pretarsal zone. The attachment of the levator to the skin in this region forms the superior tarsal fold of the upper eyelid. The total length of the levator muscle is approximately 40 45mm, with a 10 15mm aponeurotic extension. Posteriorly Müller s muscle attaches 10mm away from its origin to the upper margin of the tarsal plate. Müller s muscle consists of smooth muscle fibers which are under sympathetic control. It is normally responsible for 2 3mm of lid lift; however, with sympathetic stimulation an additional 1 2mm of lift above baseline is possible. When sympathetic tone is lost at twilight or in Horner s syndrome, 2 3mm of ptosis may be seen. 6

8 Fig 11. Anatomy of the levator muscle and aponeurosis. (Reprinted with permission from Iliff CE, Iliff WJ, Iliff NT: Oculoplastic Surgery. Philadelphia, WB Saunders, 1979.) In contrast to Müller s muscle, the levator is a striated muscle innervated by the third cranial nerve. The levator changes from horizontal to a more vertical position at Whitnall s ligament, which serves as a fulcrum for the muscle. 2,9,11 The total excursion of the levator muscle is 10 15mm. Lower eyelid. The lower lid retractors take their origin from the capsulopalpebral head of the inferior rectus muscle. The muscle then splits around the inferior oblique muscle to rejoin anteriorly as Lockwood s ligament. The capsulopalpebral fascia extends anteriorly from Lockwood s ligament and then fuses with the orbital septum and the tarsal plate. Like its counterpart in the upper lid, the capsulopalpebral fascia sends anterior projections that penetrate through the orbicularis muscle to insert on the skin of the lower eyelid to create a transverse crease. 16 Just posterior to the capsulopalpebral fascia is Müller s muscle, which fuses with the fascial layer approximately 2.5mm below the inferior border of the tarsal plate. Conjunctiva The conjunctiva spans four discrete regions. The marginal conjunctiva joins the anterior skin at the lid margin. The tarsal conjunctiva is adherent to the tarsus. The orbital conjunctiva lies just posterior to Müller s muscle in the upper and lower lids. The bulbar conjunctiva extends posterior to the fornix. 4 Lacrimal System The lacrimal system is responsible for tear production, distribution, and appropriate drainage. The secretion of tears is the function of the basic and reflex secretors. The basic secretors consist of exocrine accessory glands and provide lid lubrication and the precorneal film necessary for proper corneal protection. Under normal circumstances the entire volume of tears produced by the basic secretors evaporates from the surface of the cornea. 2,17 Three sets of glands comprise the basic secretors. The conjunctival, tarsal, and limbal mucinsecreting goblet cells are responsible for producing a mucoprotein layer that forms the innermost layer of the precorneal tear film. This layer allows the overlying layers to spread more uniformly over the cornea. 2 The second group of basic secretors consists of the accessory lacrimal glands lying within the subconjunctival tissues. They are responsible for producing an intermediate, aqueous layer. 2 The last group of basic secretors are the oil-producing meibomian glands, located within the tarsal plate, and the glands of Zeis and Moll at the root of the eyelashes. They produce the outermost layer of the precorneal tear film, which helps stabilize the tear film and retards evaporation. 2 The main lacrimal glands are reflex secretors, meaning that they respond to sudden changes in our physical or emotional environment. The lateral horn of the levator palpebrae superioris divides the lacrimal gland into an orbital and a palpebral lobe (Fig 12). Although only about one third the size of the orbital lobe, the lateral palpebral lobe of the gland is prone to prolapse and may be visible externally. The orbital lobe sends tears through the palpebral lobe, which in turn empties into the superolateral conjunctival fornix via six to twelve tear ductules. 2 Tears secreted from the gland pass from the ducts into the upper lateral cul-de-sac and sweep across the cornea to empty into the lacrimal drainage system. The excretory portion of the lacrimal system consists of lacrimal lake, puncta, canaliculi, sac, and nasolacrimal duct. The puncta carry tears from the lacrimal lake into the ampulla and canaliculi. 18 The upper and lower puncta are 5 7mm lateral to the canthal angle, and the lower punctum is often lateral to the upper. 7

9 Fig 12. The main lacrimal glands are divided into an orbital lobe (Lo) and a palpebral lobe (Lp) by the lateral horn of the levator palpebrae superioris (LA). (Reprinted with permission from Zide BM, Jelks GW: Surgical Anatomy of the Orbit. New York, Raven Press, 1985.) The canaliculi are about 1cm long and join to form a single duct that opens into the lacrimal sac (Fig 13). The lacrimal sac extends inferiorly for approximately 1cm and gives rise to the nasolacrimal duct, which consists of an intraosseous portion and a meatal portion. The duct usually opens just below the anterior end of the inferior nasal turbinate. 18 As the flow of tears moves from lateral to medial with blinking and movement of the eyelids, the tears either evaporate from the surface of the eye or enter the excretory system. Movement of tears through this system is the result of capillary pull by the vertical portion of the canaliculi, pumping action of the orbicularis muscle, and negative pressure on inhalation. 1,2 EYELID LACERATIONS Eyelid lacerations with no loss of tissue should be minimally debrided and closed primarily. It is necessary to meticulously align the anterior, middle, and posterior lamellae properly. Malalignment of the wound edges must be avoided, and care should be taken to keep the knots away from the globe. Eyelid defects <25 30% of the lid substance can frequently be closed primarily (Fig 14). If undue Fig 13. Average lengths of the lacrimal excretory passages. (Modified from Jones LT: An anatomical approach to problems of the eyelids and lacrimal apparatus. Arch Ophthalmol 66:111, 1961.) tension is encountered on approximation of the raw surfaces, 5 8mm of additional lid length can be gained by performing a lateral canthotomy and cantholysis (Fig 15). 19,20 While medial canthotomy and cantholysis for eyelid repair has been described, 22 it should be reserved for those defects requiring more radical measures. Complications of this technique may include telecanthus, epiphora (due to transection of the canaliculus), notching, and ectropion. 22 PARTIAL-THICKNESS DEFECTS Skin Defects involving skin of the upper lid and medial canthal area are best repaired with thin full-thickness skin grafts. The skin of the contralateral upper lid is the best donor site for upper lid skin defects. Posterior auricular skin is a good donor source for reconstruction of the lower lid, while supraclavicular grafts are well suited to the repair of combined lower lid and cheek defects. 8

10 Fig 14. Direct closure of a defect of the lower eyelid. (Reprinted with permission from Leatherbarrow B: Oculoplastic Surgery. London, Martin Dunitz; distributed in USA by Fulfillment Center, Taylor & Francis, Independence, KY; 2002.) Fig 15. Lateral relaxing incision and cantholysis to allow primary closure. (Reprinted with permission from Ross JJ, Pham R: Closure of eyelid defects. J Dermatol Surg Oncol 18:1061, 1992.) Conjunctiva Defects of conjunctival lining that cannot be repaired by advancing the conjunctiva from the sulcus require the use of free grafts. Free conjunctival grafts from the same or opposite eyelid undergo considerable contraction and are difficult to handle. Care must be taken to avoid compromising the donor fornix. When fornix reconstruction is performed using conjunctival grafts, a conformer is required. 23,24 The mucosa of the mouth is an alternative source of donor graft for conjunctival replacement. While 9

11 buccal mucosa is abundant and simple to harvest, it tends to contract to approximately 50% of pregraft volume. On the other hand, nasal mucosa is relatively thick and more easily handled and contracts much less than buccal mucosa, so that graft size must be only about 20% larger than the defect for adequate coverage. 23 Approximately cm of mucosa can be harvested from a normal adult nose. Skin cannot be used to replace conjunctiva in a seeing eye because tiny hairs and the squamous layer of epidermis are highly irritating to the sensitive cornea. 23 Tarsal Plate Losses of tarsal plate are commonly seen in composite lid defects involving either lining or skinorbicularis in addition to tarsus. If possible, primary repair should be performed. When the defect is too large for primary closure, the tarsus must be replaced by either a composite free graft or a flap. Alternatives for reconstruction include chondromucosal grafts from the nasal septum 23 or upper lateral nasal cartilages, 25,26 full-thickness grafts from the contralateral lid, mucosal grafts from the hard palate, 32 conchal cartilage grafts, and assorted flaps. 33,34 Nasal chondromucosal grafts have been recommended because of the strong hyaline cartilage of the nose, which is closely associated with the mucussecreting lining of the nasal mucosa. To prevent corneal irritation, a small fringe of nasal mucosa must be turned anteriorly over the cartilage to meet the remaining skin of the eyelid so that squamous epithelium does not come into contact with the globe. Mustardé 23 favors septal mucosal grafts because of the long-term stability of this cartilage. Werner, Olson, and Putterman 30 describe their use of tarsal-conjunctival composite grafts for eyelid reconstruction. In their retrospective review of 51 patients, they note that 91% had postoperative symmetry of the palpebral fissure within 2mm. Little change was noted between the preoperative and postoperative photographs in both donor and recipient eyelids. The most common postoperative complication was mild punctate staining of the cornea, but this did not lead to ulceration or persistent epithelial defects. Only 14% of grafts maintained their cilia. Hawes and Jamell 31 discuss their complications in 44 tarsal-conjunctival grafts. Five patients (11%) had major complications requiring reoperation. These problems included upper lid retraction, wound dehiscence, cicatricial ectropion, and excessive lower lid laxity. Thirty-two patients (73%) had minor complications such as notching of the donor or recipient lid margin (most common). The authors conclude that while their patients frequently manifested minor complications, free tarsoconjunctival grafts were a useful technique in eyelid reconstruction. Cohen and Shorr 32 reported their results with hard palate mucosal grafts for conjunctival-tarsal losses in 18 patients. In their opinion, hard palate grafts are superior to other sources of graft tissue because, in addition to mucous membrane, they contain a collagen matrix that provides ample support for the eyelid. Hard palate grafts also bring an abundance of tissue that may be used to reconstruct the entire length of the eyelid. In their experience, hard palate grafts undergo minimal shrinkage and are much more pliable than grafts of ear or nasal cartilage. Biopsy results postoperatively show that the keratinized palatal mucosal grafts undergo metaplasia to nonkeratinized mucosa over the first 6 months. In conclusion, they found that hard palate mucosal grafts are quite versatile for eyelid reconstruction. Tarsal reconstruction with acellular human dermis (AlloDerm) has been described. 35 Either thick or thin AlloDerm grafts can be placed in the posterior eyelid as spacers to correct lower eyelid retraction. In Taban s series, the results achieved with thick AlloDerm grafts were comparable to those with hard palate grafts and perhaps superior to thin AlloDerm grafts. 35 The advantages of AlloDerm are lack of donor site morbidity, ready availability, and predictability of the graft material. Chondroplast (beta-irradiated bovine cartilage) has also been described for tarsal replacement, again with uniformly good results. 36 Implants 1mm thick are fixed to the remaining tarsal plate or canthal tendon and inserted in a preformed pocket between the orbicularis muscle and skin. No loss of implant or complications were reported in Mullner s series. 36 The advantages of Chondroplast for tarsal restoration are availability in large pieces, no need for graft harvest, and good biocompatibility. 10

12 Composite grafts for replacement of skin and tarsus are taken mainly from the concha of the ear. 37 These grafts have the advantage that the donor wound can be well concealed and easily controlled. Disadvantages include the risk of graft failure or only partial take, and subsequent shrinkage of the graft with scarring around the wound. Naugle, Levine, and Carroll 38 describe a technique that mobilizes the orbicularis muscle to improve free graft viability and appearance by enhancing its blood supply. Composite grafts to the eyelid frequently show contraction, discoloration, poor healing, depression, and immobility. In 7 patients who required complex primary or secondary reconstructive techniques for difficult eyelid defects, the authors mobilized the orbicularis muscle into the recipient site before grafting. The muscle provides an improved vascular bed for placement of both skin and composite grafts. FULL-THICKNESS DEFECTS Upper Eyelid Composite grafts Composite grafts coupled with local flaps may be used to repair full-thickness defects of the eyelid. Putterman 27 divides full-thickness losses into two components, one of the skin and one of tarsusconjunctiva. The tarsus-conjunctiva component of the defect is repaired with a composite eyelid graft. This graft is then covered with a vascularized skin flap. Budenz and associates 39 report on two patients undergoing upper eyelid reconstruction with contralateral tarsoconjunctival grafts and ipsilateral upper eyelid skin flap. Histologically, the healed grafts showed a scarred tarsus and absent meibomian glands, with one of the patients completely losing cilia. Despite the apparent reduction in lubricating glandular elements, there were no clinical problems with the tear film. Marks and coworkers 40 report posterior lamella rreconstruction with large composite auricular grafts. The cartilage graft is secured between the remaining orbicularis muscle and tarsal plate and the orbital septum posteriorly. The graft is stabilized with sutures to the tarsus anteriorly and the orbital rim inferiorly. The posterior auricular skin fills the eyelid skin defect. According to the authors, auricular composite grafts are too thick to be considered perfect for eyelid replacement; 2 patients in their series required secondary thinning of their grafts. Avram and colleagues 41 describe their technique of composite autografting for eyelid avulsion injuries. They remove the skin and orbicularis from the graft while leaving the lid margin intact. The posterior lamellar graft is then sutured precisely into the defect, the levator aponeurosis is sutured to the anterior surface of the graft, and a flap of skin and orbicularis is used for interior lamellar reconstruction and to provide vascularity to the underlying graft. A lid margin suture between the upper and lower lids stretches the aponeurosis for a few days and counteracts the tendency of the eyelids to retract. From their experience the authors stress the importance of attention to tetanus and rabies vaccinations wound culture and prophylactic antibiotic therapy irrigation and minimal debridement of the wound careful layered closure when attempting autograft repair of eyelid avulsion injuries using the retrieved tissue Goldberg and others 42 describe a case report in which the patient lost approximately 75% of his upper eyelid. The entire full-thickness of the avulsed eyelid tissue including skin and orbicularis was replaced as a true composite autograft. This resulted in a functional upper eyelid with adequate contour; however, the lid was short, without cilia, and had decreased mobility. The authors studied various methods for preserving the avulsed eyelid tissue and concluded that 1) it should not be immersed in saline and 2) it could be preserved in a moist environment at 4 C for up to 6h or 3) in a specialized tissue-culture medium for up to 24h. Sakai 43 reported the use of composite skinmuscle-mucosal grafts from the lower lid for marginal defects of the upper eyelid. This method allows for one-stage reconstruction but lacks the middle layer cartilaginous support. Flaps Full-thickness defects of the upper lid that cannot be closed primarily are often repaired with flaps of 11

13 local tissue. Flaps carry their own independent blood supply and therefore contract less than grafts after transfer. Unfortunately, flaps tend to be bulky and less pliable than grafts and may produce a secondary scar deformity. Lower eyelid flaps are of two basic types: advancement flaps and switch flaps. Cutler and Beard 44 introduced the lower lid advancement flap in The flap as it is classically described involves advancement of a rectangular segment of fullthickness lower lid into the upper lid, preserving the lower lid margin and tarsus (Fig 16). Approximately 6 8 weeks later the flap is divided and returned to the lower border of the intact lid margin. The upper lid margin is then fashioned from the divided edge of the flap. 45 The major disadvantages of the Cutler Beard technique are the necessary occlusion of the eye and the lack of support of the reconstructed lid margin. area and is used for interior lamellar coverage. Leone s modifications add support to the margin of the upper lid while avoiding full-thickness donor site loss of the lower eyelid. As described, this technique is best suited for shallow losses of the upper lid margin. Mauriello and Antonacci 47 describe a similar technique whereby a tarsoconjunctival flap is raised on the lower lid (Fig 17). They performed the reverse modified Hughes procedure in 10 patients with full-thickness upper lid defects. Fig 17. A tarsoconjunctival flap from the lower lid is sutured to the tarsal remnants of the upper lid and covered with a skin graft. The flap pedicle is divided 5 to 8 weeks later. (Reprinted with permission from Mauriello JA Jr, Antonacci R: Single tarsoconjunctival flap (lower eyelid) for upper eyelid reconstruction [ reverse modified Hughes procedure]. Ophthalmic Surg 25:374, 1994.) Fig 16. The Cutler-Beard technique for reconstruction of large upper lid defects. (Modified from Cole JG: Reconstruction of large defects of the upper eyelid. Am J Ophthalmol 64:376, 1967.) In response to these problems, Leone 46 modified the Cutler Beard flap by creating a double advancement rotation. Following resection of the lesion, an upper lid tarsoconjunctival flap is designed and elevated from the remaining tarsus and advanced toward the lid margin. This flap is then sutured to the lower lid tarsoconjunctival flap, creating support along the upper lid margin. A full-thickness skin graft is then harvested from the retroauricular Like Leone s flap, it involves an incision 1.5 2mm below the lower eyelid margin. In contrast, the Cutler-Beard procedure requires an incision 4 6mm below the lid margin to preserve the marginal artery. 44,46,47 The entire vertical height of the tarsus was excised in 8 of 10 patients in Mauriello s series. Follow-up was 6 24mo. The authors report excellent results with minimal complications. Jordan and colleagues 48 described a technique in which shallow defects of the upper lid may be repaired with a tarsoconjunctival flap fashioned from the superior tarsal remnant and advanced inferiorly to the upper lid margin. This technique is limited to defects involving the margin where at least a 3mm section of upper tarsus remains, and seems to be best suited for central upper eyelid defects. They report excellent results in 13 cases. Three patients had corneal irritation from eyelid retraction lasting 1 3mo. Two of these patients ultimately required surgical revision. 12

14 A semicircular (Tenzel) flap 21,49 or one of its modifications can be pivoted on the lateral canthus (Fig 18) to reconstruct the upper or lower lid. Defects up to 70% of lid length can be repaired with this semicircular flap of skin and muscle as long as some tarsus remains on either side of the wound. Fig 18. Semicircular (Tenzel) flap used in closure of an upper lid defect. The Tripier flap was originally described as a bipedicled flap, but it can also be carried on one pedicle. If unipedicled, however, it will not cross the pupil reliably. Flaps raised from the lower lid require full-thickness skin grafts for closure of the donor defect. When taken from the upper lid, primary closure of the donor site is often possible (Fig 19). Van der Meulen 50 discusses the usefulness of the bipedicled Tripier flap combined with buccal mucosa for lining when reconstructing the upper eyelid. The subsequent reconstructed lid requires tension on the closure to avoid sagging of the lid and retraction of the flap margins. Moschella and Cordova 51 describe a method for functional reconstruction of the upper eyelid in large full-thickness lid defects. Buccal mucosal grafts are used to reconstruct the conjunctiva. A bipedicled musculocutaneous flap is designed from the preseptal or orbital portion of the lid (the superior aspect of the defect). This flap serves as the lid margin and the levator muscle is then approximated to it. The donor defect is closed by transposing a temporofrontal flap. While this reconstruction lacks marginal support, it may be useful in shallow marginal defects and for patients who are interested in single-stage reconstruction. Esser 52 described a lower lid switch flap in The flap was based on the marginal artery and rotated 180 into the upper eyelid, as in the Estlander-Abbe flap used for lip reconstruction. McCoy and Crow 53 reported reconstruction of the Fig 19. Tripier flap used in the upper lid. 13

15 lower lid with a switch flap from the upper lid. Later Mustardé 14,33,43,54 pioneered the modern technique of a switch flap from the lower lid to repair upper lid defects (Fig 20). Fig 20. Mustardé s laterally based (left) and medially based (right) flaps for upper eyelid reconstruction. (Modified from Mustardé JC: Reconstruction of eyelids. Ann Plast Surg 11:149, 1983.) Lower lid switch flaps can be based either laterally or medially. Laterally based switch flaps trace a smoother arc than medially based flaps when rotated to the upper eyelid. The lower lid is restored by advancing cheek tissue medially. Most of the reconstruction is completed in a single operation, so that only a short operative session is subsequently needed for division and inset of the hinged pedicle. However, laterally based switch flaps suffer from uncertain vascularity because the pedicle is based on the temporal and canthal portions of the cheek advancement flap, whose blood supply is random. Both partial and total flap losses have been reported when lower lids are transferred with the pedicle based laterally. In contrast, medially based switch flaps from the lower lid are more difficult to rotate and set into place than laterally based switch flaps, but maintain excellent vascularity via the marginal artery and offer a better chance of a successful reconstruction. The second stage of flap transfer involves division and inset of the switch flap as well as lower lid reconstruction with the cheek advancement flap. There are considerable advantages to lower lid switch flaps in upper eyelid reconstruction, namely switch flaps bring like tissue to replace the missing eyelid large horizontal defects with significant vertical components can be repaired the upper lid margin is duplicated precisely in the transferred margin of the lower lid, for a continuous, smooth line at the leading edge of the lid the period of occlusion is minimized. The foremost disadvantage of lower lid switch flaps is the deliberate sacrifice of the lower eyelid for reconstruction of the upper eyelid. In addition, an extra reconstructive procedure is required to repair the donor defect in the lower lid. Mustardé 55,56 discusses flap design and dimensions as well as placement of the hinge or pivot point of the flap according to the size and location of the defect. He emphasizes the following principles: The width of a defect in the upper lid can be reduced by one-quarter of the upper lid length. The remainder of the defect should be closed using the switch flap. The key to flap success is an appropriate hinge point for the flap. The reconstructed upper lid must protect the cornea during sleep and must be capable of elevation. Mustardé 56 avoids using the contralateral upper lid for fear of donor site morbidity and prefers to transfer tissue from the lower lid to reconstruct the upper lid. Because defects of the upper lid up to 25% of lid length may be closed primarily, the reconstructed lid needs to be only three fourths as long as the original. Borman and Özcan 57 anchor the levator muscle to the reconstructed upper eyelid using a modified adjustable suture technique. They find that predicting final lid height with the patient under general anesthesia often results in under- or overcorrection, but a secondary lid-adjustment procedure under local anesthesia achieves a functional and esthetically pleasing result. Kersten and colleagues 58 described a tarsal rotational flap designed from the lid remnant. The tarsus of the central upper lid at the edge of the defect is dissected free from Müller s muscle and conjunctiva for approximately 4mm along its proximal superior border. Cuts in the tarsus within 2 14

16 3mm of the eyelid margin create a vertical tarsal strip 3 4mm wide and 7 10mm high. This is then rotated 90 so that it lies horizontally and is affixed to the remnant of the medial canthal tendon or periosteum. At least a third of the lid remnant is required for either medial or lateral wounds. Kushima et al 59 described total upper eyelid reconstruction with a free radial forearm flap and hard palate mucosal graft. The patient had complete avulsion of the superior levator palpebrae muscle and the superior orbital fat. The right superior rectus muscle was exposed and no orbital fat was seen between the muscle and the orbital roof. The gliding surface was reconstructed with an adipofascial flap from the forearm lined with a mucosal graft from the palate. Levator function was mimicked by the superior rectus muscle without frontalis suspension. Follow-up at 18 months showed a cosmetically good result with essentially no ptosis and only slight lagophthalmos. Lower Eyelid Full-thickness lower eyelid reconstruction is a hotly debated topic. Mustardé 23 advocates using tissues other than the upper lid to reconstruct the lower lid, reasoning that the absence of part or even the whole of the lower lid may be tolerated reasonably well as long as the upper eyelid remains fully functional, but that loss or dysfunction of even part of the upper lid may result in corneal exposure with possible ulceration and visual impairment. Still others 30,60,61 describe techniques borrowing from the upper eyelid, which they feel can safely be used to reconstruct the lower eyelid. Grafts of cartilage or periosteum Matsuo and associates 62 feel that conchal cartilage is ideally suited for lower eyelid reconstruction, as it is thin and supple and resembles the curvature of the globe. 40,63 They report using conchal cartilage grafts alone when eyelid support and lining are needed, placing the graft in such a way that the graft perichondrium forms the posterior lamella. Epithelialization from the surrounding mucosa is noted in 3 4 weeks. Reports by Marks and associates 40 and Jackson, Dubin, and Harris 63 show good stability of large conchal cartilage grafts for lower eyelid reconstruction after follow-ups averaging 16 and 21 months, respectively. Marks and coworkers 40 find that for each millimeter of lid retraction they must bring in 2 2.5mm of conchal cartilage. They insert the grafts to face the bulbar conjunctiva between the tarsus and the contracted lid retractors. The posterior surface of the graft is left to reepithelialize. Jackson and colleagues 63 suture the conchal grafts to the tarsal plate above and the periosteum of the infraorbital rim below to prevent graft displacement. They report no loss of lid support at almost 2 years postoperatively. Hurwitz, Corin, and Tucker 64 used free periosteal grafts for posterior lamellar reconstruction in cases of extensive lower lid losses extending beyond the confines of the lid. The periosteal graft is harvested from the lateral orbital rim through the same wound as the cheek advancement flap. The graft may be covered with a second local flap for anterior lamellar reconstruction. Like others, Hurwitz 64 reports reepithelialization of the periosteum by 3½ weeks postgrafting. Leone 65 reported a variation of this technique in which lateral canthal defects are repaired with a rectangular flap of periosteum from the lateral orbital rim. This periosteal flap is then used as a sling and sutured to the free edge of the lower lid. A temporal skin flap is designed for anterior lamellar coverage. As described, no conjunctival or lining tissue is replaced; rather, the periosteum is left to epithelialize (Fig 21). Conjunctival flap plus skin graft Moss and colleagues 66 believe, as does Mustardé, 54 that the upper lid should not be used as donor tissue for lower eyelid reconstruction. They describe their 25-year experience and review 43 patients who underwent lower eyelid reconstruction with a conjunctival flap covered by a full-thickness skin graft. The flap is divided 2 weeks later. Although the published illustrations show acceptable cosmetic and functional results, most surgeons would question the long-term stability of a lower lid reconstructed without tarsal or cartilaginous support. 15

17 Fig 21. Technique of lower eyelid reconstruction with a periosteal flap. Top, the lateral orbital rim is exposed and a 5mm wide periosteal flap is dissected and sutured to the tarsus of the remaining eyelid. Bottom, a temporal skin flap is raised, undermined, and rotated into the defect. (Reprinted with permission from Leone CR Jr: Periosteal flap for lower eyelid reconstruction. Am J Ophthalmol 114:513, 1992.) Cheek advancement flaps Rotation-advancement flaps of the cheek are ideal for reconstruction of the lower lid, whose skin is thicker overall than the upper lid s. Defects involving the lateral canthus are well suited to this reconstructive technique because the skin is not only thicker temporally but also more visible. Cheek advancement flaps were originally described for lower eyelid reconstruction by Professor Imre 67 of Hungary in It was further popularized by Mustardé. 23,56,68 Mustardé incorporates the cheek advancement into defects >25% of the lower lid up to total lower lid losses. If the middle and posterior lamellae are deficient, he prefers a free composite graft of nasal septum covered by the flap. As defects become larger, the flap is extended superolaterally and inferiorly in front of the ear. The flap is elevated in a subcutaneous plane. Mustardé states that in every case the final extent of the incision can only be determined after undermining the cheek flap in the layer of subcutaneous fat and repeatedly testing to see whether further extension of the incision and rotation of the cheek is necessary. 56 Tension is taken off the reconstructed lid by anchoring the deep surface of the flap to the inferior margin of the orbit. At the region of the lateral canthus a deep suture is placed in the subcutaneous tissues, anchoring them to the periosteum of the orbital margin just above the attachment of the canthal ligament. Callahan and Callahan 69 provide an excellent review of the Mustardé flap based on experience with 55 lower eyelid reconstructions followed for an average of 7 years. Their most frequent complication was inferior descent or retraction of the flap associated with ectropion of the lid margin which did not manifest for approximately 2 3 years after surgery. The authors described occasional trichiasis, lateral symblepharon, rounded canthus, and a marginal notch. Only 13 patients required subsequent surgical revision. They conclude that the two most influential factors determining the outcome of reconstruction were the design of the flap and the composition of the graft for internal lining and support. They recommend a modification of the Mustardé flap to incorporate temporal skin from well above the lateral canthus instead of the traditional lower rotational arc passing immediately lateral to the outer canthus. Composite grafts of nasal septal mucosa and cartilage proved superior to free buccal mucosal grafts in all cases, and the added structural support helped minimize postoperative collapsing of the flap. Callahan and Callahan conclude that the use of a high-arc flap, composite nasal cartilage-mucosal grafts, and hitching sutures allowed for the best postoperative results. 69 Although Callahan and Callahan did not list flap loss as a complication of the Mustardé flap, there is a definite risk of tissue loss when elevating these large cheek flaps to repair composite lower lid and upper cheek defects. Compromised flap tissue is usually seen at the apex of the flap, where it extends into the temporal skin, the principal part of the lid reconstruction. Inclusion of the superficial musculoaponeurotic system (SMAS) in the flap will enhance the blood supply to this area. Similarly, when large medial defects of the upper eyelid require a lower lid switch based on a lateral cheek flap, subsmas dissection of the flap seems prudent. 16

18 McGregor s combined flap repair 70 adds a lateral Z-plasty to Mustardé s cheek advancement flaps for defects <60% of the lower lid (Fig 22). 71 An incision lateral to the eyelid is slanted gently upward and carried into the temple for 1.5 to 2.5X the width of the defect. A backcut is made at the temporal end of the incision and angled medially approximately 30. Since the lateral 40% of the flap serves as Z-plasty, a second backcut is made parallel, medial, and superior to the first backcut to create a second Z-plasty. This method successfully recruits vertical laxity from the lateral periorbital region to correct horizontal defects of the lower eyelid. Fig 22. Combined flap consisting of a horizontal rotation and a temporal Z-plasty for repair of moderate-sized lower eyelid defects. (Reprinted with permission from Khan JA, Garden VS: Combined flap repair of moderate lower eyelid defects. Ophthalmic Plast Reconstr Surg 18:202, 2002.) Semicircular flap Tenzel 72 first described the semicircular flap in 1975 for reconstruction of both the upper and lower eyelid. The procedure is a modified lateral advancement rotation flap from the outer canthus that can be used to reconstruct up to three fourths of the eyelid. 73 Transection of the lower limb of the lateral canthal tendon and attachments of the orbital septum is performed first, then a 1 2cm skin-muscle flap is elevated and advanced medially and rotated into the defect (Fig 23). A full-thickness triangle is often resected from the base of the defect to facilitate flap inset, and the conjunctiva from this Burow s triangle may be used to line the lateral aspect of the reconstructed lid. The canthal angle is reconstituted with a through-and-through vertical mattress suture tied over a cotton bolster. The semicircular flap technique is most useful in near-total central defects of the upper and lower eyelid where at least 2mm of tarsus remains on either side of the defect. 73 Tenzel and Stewart 73 report satisfactory results in 35 of 41 eyelids reconstructed by this method. Other authors report using this flap for partial lid reconstruction. Jordan, Anderson, and Holds 76 describe a modification of the semicircular flap technique for eyelid reconstruction that uses a more vertical, temporal advancement flap. Dissection begins at the lateral canthus and then extends superiorly toward the lateral eyebrow. The authors bevel the incision to include more muscle than skin in the flap. They believe that the combination of a vertically oriented flap and a preponderance of muscle provide the upward force necessary to decrease sagging of the temporal lid, maintain a more normallooking lateral canthus, and provide enough tissue to reduce the chance of a lid notch. 76 They report good to excellent results in 22 of 28 patients. Six cases developed notching of the lid margin at the junction of the flap and lid remnant. Fig 23. Semicircular flap reconstruction of the lower lid. The technique requires lateral canthotomy, inferior cantholysis, and suturesuspension of the flap from the periosteum of the lateral orbital margin. (Reprinted with permission from Leatherbarrow B: Oculoplastic Surgery. London, Martin Dunitz; distributed in USA by Fulfillment Center, Taylor & Francis, Independence, KY; 2002.) 17

19 Tarsoconjunctival flap Although switch flaps from the upper lid have been proposed for lower lid reconstruction, 53 the standard technique of lower eyelid repair using upper lid tissue 77 involves the sliding of an upper lid tarsoconjunctival flap into the lower lid defect. Landolt 78 originally described this procedure in The technique was later expanded by Kollner 79 in 1911, Dupuy-Dutemps in 1929, 80 Hughes in 1937, 60 and Smith 19 in Hughes 60 reflects on his 40-year experience with the tarsoconjunctival flap procedure, during which time he modified the original technique by cutting obliquely through the tarsus beginning at the conjunctival margin and extending to the anterior surface of the tarsus approximately 3mm above the lid. This refinement seems to decrease the risk of upper eyelash loss and entropion of the lid margin. In a follow-up article, Hughes 81 describes a slightly different way of dissecting the tarsoconjunctival flap that frees the upper lid tarsus through an incision carried along the anterior surface of the tarsus to its upper border. At this point the incision is extended to the conjunctiva, cutting through the attachments of Müller s muscle, and the dissection is carried upward along a plane adjacent to the conjunctiva. Once the conjunctival flap is freed, the flap of mucosa is then draped over the lower eyelid margin and sutured to the skin of the reconstructed lower eyelid. 74,82,83 While this refinement is said to help prevent retraction of the upper lid, if dissection is not carried high enough or the attachments of the levator muscle or Müller s muscle are not severed, entropion of the lid margin and lid retraction are still probable. The maximal Hughes procedure combines oblique medial and lateral periosteal flaps with a Hughes flap for the repair of large defects of the lower lid (Fig 24). 84 In a series of 8 patients who had lower eyelid reconstruction by this method, Maloof and colleagues 84 report excellent eyelid contour and protection in all. One patient had mild lid retraction and a second patient developed medial ectropion that required subsequent revision. Rohrich and Zbar 85 reviewed the evolution of the Hughes tarsoconjunctival flap (Fig 25) for lower eyelid reconstruction. Central defects of the lower eyelid measuring 60 80% of the total lid length can be successfully repaired with this flap. Fig 24. Maximal Hughes procedure for lower eyelid reconstruction. Oblique medial and lateral periosteal flaps are reflected at the medial and lateral orbital margins. The flaps can be folded over to produce a straight horizontal attachment for the tarsus from an angled design. The extreme nasal and temporal aspects of the tarsus are not freed. (Reprinted with permission from Maloof A, Ng S, Leatherbarrow B: The maximal Hughes procedure. Ophthalmic Plast Reconstr Surg 17:96, 2001.) Over the years several practical modifications have also been reported, including the following: the tarsoconjunctival flap is raised at least 3 4mm above the lid margin Müller s muscle and levator aponeurosis are transected at the superior edge of the tarsal plate, with the dissection proceeding subadjacent to the conjunctiva a thin FTSG is used to cover the anterior surface of the tarsoconjunctival flap the flap is divided 3 6 weeks after inset and the mucocutaneous line is left to heal by secondary intention circulatory support is provided via the anterior lamella Other modifications of the tarsoconjunctival flap procedure include a step incision through the upper tarsus, with reattachment of the levator and Müller s muscle segments to the lower tarsal remnant, as suggested by Pollock et al. 86 Smith 19,77 and Macomber and coworkers 87 preserve the upper lid margin with an incision through the lower tarsus 3mm behind the upper border of the lid. 18

20 Fig 25. Left, the Hughes flap as originally described in Center, the Hughes flap as modified in The new plane of dissection creates a true transconjunctival flap. Right, modified Hughes flap in which the inferior edge of the flap is designed at least 4mm from the lid margin to ensure sufficient tarsal plate remaining for support in the donor lid. (Reprinted with permission from Rohrich RJ, Zbar RIS: The evolution of the Hughes transconjunctival flap for lower eyelid reconstruction. Plast Reconstr Surg 104:518, 1999.) Leibsohn and colleagues 88 intentionally buttonhole their tarsoconjunctival flaps to allow vision and to monitor the eye by slit lamp. The buttonholes extend vertically from the superior tarsoconjunctival edge of the flap to a point 12 15mm above the upper eyelid margin. McNab 89,90 divides the tarsoconjunctival flap pedicle at 2 weeks. In a prospective, randomized study of 60 patients, 32 had their flaps divided at 2 weeks and the rest at 4 weeks. All patients had fullthickness skin grafts placed on the anterior lamella of the reconstructed eyelid. There was no statistical difference in postoperative eyelid position between the two groups. Other complications were uncommon and spread evenly between the two groups. It was initially thought that the risk of corneal abrasion from keratinized skin decreased if the conjunctiva was advanced over the eyelid margin. This, however, results in persistent hyperemia of the exposed conjunctiva along the eyelid margin. Bartley and Putterman 91 divide the conjunctival pedicle at its origin from the upper eyelid flush with the reconstructed lower eyelid at the desired new eyelid margin. No excess conjunctival tissue is advanced to the eyelid margin, and the mucocutaneous junction is allowed to heal spontaneously. The authors have performed this technique in 70 patients, with satisfactory results. Doxanas 92 mobilizes the preseptal orbicularis oculi muscle over the tarsal flap and into the recipient beds of the skin grafts used for reconstruction of the anterior lamella. The transposed muscle is said to enhance mobility of the reconstructed eyelid and serves to correct cicatricial ectropion. Lowry, Bartley, and Litchy 93 studied the reconstructed lower eyelids of 6 patients after a modified Hughes procedure as described by Doxanas. 92 Electromyographic analysis demonstrated electrical activity in the orbicularis muscle of all reconstructed eyelids. Holmstrom and colleagues 94 reviewed 58 cases of lower lid reconstruction using the tarsoconjunctival flap. Their technique was similar to Kollner s, 79 sparing the upper lid margin and incorporating the levator and Müller s muscle complex into the pedicle. Division and inset were done 3 weeks after flap advancement. The authors report no significant deformities of the upper lid and state that this operation could be repeated if needed because of tumor recurrence. This purported benefit, of course, is also true of the cheek advancement flap. Cross-lid flap Some surgeons differ with Mustardé and try to uphold the principle of replacement of eyelid tissue with like eyelid tissue championed by Byron Smith. 77 They state that when the upper eyelid is used for reconstructing the lower lid, the result is more delicate and normal-appearing in contour and texture than if other facial tissues are used. This method also avoids additional scars on the cheek, nose, or forehead. In 1966 Jones 61 proposed a cross-lid flap of skin, tarsus, and conjunctiva as an alternative to tarsoconjunctival flaps for the correction of throughand-through marginal defects of the lower eyelid. This composite flap is elevated from the central 19

21 portion of the upper lid as a single-pedicle or bipedicled flap. The upper and lower margins of the tarsus are not taken in the flap. The donor eyelid is closed directly. Subsequent experience with the cross-lid flap procedure 95 has confirmed its applicability in long, narrow defects of the lower lid margin. As a unipedicled flap it may be based either laterally or medially, and for total marginal losses the flap can be transferred on a double-pedicle sling. Problems with the technique include postoperative retraction of the lower lid and, of course, no lashes, but the presence of lashes is not considered critical in the lower lid. Anderson and associates 96,97 suggest a modification of the composite flap technique that makes use of the entire upper portion of the tarsal plate and overlying tissues, preserving the microvascular blood supply to the upper eyelid margin. Flap reliability is enhanced by a persistent marginal vascular arcade. The levator aponeurosis and Müller s muscle are recessed to prevent postoperative lagophthalmos and eyelid retraction. The flap can be raised on a single or double pedicle. The authors admit to the necessity for meticulous dissection and thorough knowledge of the anatomy. The risk of injury to the more important upper lid must be weighed against the benefits of this method. In experienced hands the upper lid-tolower lid procedures are considered safe and pose no great technical difficulties. Tripier flap Another option in the repair of very narrow defects running as far as the entire length of the lower eyelid is the Tripier 49 bipedicled flap. The flap consists of upper lid skin and orbicularis muscle, and can be lined or left unlined. 55,98 The bases of the pedicles are revised approximately 2 weeks after initial transposition. The operative technique of the Tripier flap is simple, avoids facial scars, and does not interfere with vision. Levin and Leone 99 incorporate the pedicles of the Tripier flap into the wound. The incision for flap elevation in the upper eyelid crease is extended medially and laterally to meet the ends of the lower lid defect (Fig 26) and the donor site in the upper lid is closed primarily. Fig 26. Lower eyelid reconstruction with an extended, bipedicled Tripier flap. (Adapted from Levine ML, Leone CR: Bipedicle musculocutaneous flap repair of cicatricial ectropion. Ophthalmic Plast Reconstr Surg 6:119, 1990.) Elevated on one pedicle, the Tripier flap can be based either medially or laterally. In either case the predictably viable flap length is just short of the midline of the lower lid. 100 When the defect is less than one third the length of the lid, cartilaginous support is usually not required. The Tripier flap can be raised with a conjunctival flap after the method of Manchester 101 to bring skin cover or lining to the reconstruction. Leone and van Gemert 102 suggest yet another modification that essentially combines Jones s 61,95 composite flap with Tripier s musculocutaneous flap for one-stage fullthickness repair of the lower lid. The technique involves transposition of a flap of skin and orbicularis from the upper lid for reconstruction of the outer lamella of the lower lid. The tarsus-conjunctiva element is taken as a flap from the midtarsal area, 20

22 based at the lateral fornix, and is rotated into the lower eyelid defect where it is sutured to the tarsus of the remaining lid. The donor areas are step-cut to avoid a through-and-through defect. This is an excellent option for the correction of lower lid coloboma such as seen in the Treacher Collins syndrome 103 and for the repair of shallow horizontal defects of the lower lid. It successfully avoids hitching of the upper eyelid margin, a common sequela of full-thickness excisions of upper eyelid. Supratrochlear artery flap A two-stage flap based on the supratrochlear artery has been described by Duman and others 104 for lower eyelid reconstruction (Fig 27). The flap is most commonly transferred in combination with conjunctival grafts for the treatment of complex ectropion. Advantages of this method are excellent vascularity of the tissues, versatility of flap design, and good color match. Disadvantages are the slightly bulky and less pliable coverage and the need for a second stage to divide the flap pedicle. Fig 27. The supratrochlear artery flap for lower eyelid reconstruction. (Reprinted with permission from Duman H, Sengezer M, Semanpakoglu AN, Eski M: Supratrochlear artery flap for the repair of lower eyelid defects. Ann Plast Surg 44:324, 2000.) Fascial flaps Holt, Holt, and Van Kirk 105 report using a sling of temporalis fascia in the event of full-thickness lid losses requiring trilaminar reconstruction. The authors believe that the temporalis fascia provides static suspension, assists in proper globe opposition to the eyelid, and prevents sagging of the reconstructed elements. The temporoparietalis fascial flap is an option for orbital or eyelid reconstruction in the event of complex deformities when cheek advancement flaps are not available. The flap is thin, malleable, and its arc of rotation reaches all the periorbital structures. The temporoparietalis fascial flap has been used to enhance the blood supply of the orbit; 106 for reconstruction of the anatomic barriers between the orbit, intracranial cavity, and paranasal sinuses after exenteration; 107 and for lower eyelid and malar reconstruction. 107 Other methods Leone and Van Gemert 108 also describe reconstruction of the lower eyelid with a tarsoconjunctival free graft from the upper lid and a bipedicled skin orbicularis flap from the lower lid transposed superiorly. The procedure is recommended for patients who might be disabled by the modified Hughes technique, which obstructs the vision for 3 4 weeks eg, patients with only one seeing eye. In this unique situation, Leone and Van Gemert s technique may play a role, although horizontal scarring and muscle action pulling the lid down should be expected to produce superior rotation of the bipedicled flap, causing lid retraction and ectropion. The flap may also need to be back-grafted, which would mar the cosmetic appearance. Doermann and associates 109 use upper cheek skin advanced superiorly in a V-to-Y manner to reconstruct the lower lid. Concerns about this technique include the distance that a V Y flap can be advanced, the possibility of lid retraction and ectropion caused by downward pull of the cheek flap, and the potential cosmetic deformity of the cheek. The authors describe a V Y flap that will advance as far as it can be elevated out of its bed, and report only two instances of ectropion in 22 patients. This technique was also elaborated on by Kalus and Zamora, 110 who feel the V-Y advancement flap is suitable for reconstruction of the lower lid. Visible in both these reports is a trapdoor deformity, frequently seen when regional esthetic units are violated. Ito and associates 111 report their experience with total lower eyelid reconstruction in 4 patients using a hard palate mucoperiosteal graft combined with a 21

23 V Y subcutaneous pedicle flap. The curved triangular advancement flap is designed along the relaxed skin tension lines and the eyelid unit or subunit lines, so as to make postoperative scars inconspicuous (Fig 28). The flap width is slightly less than the horizontal span of the defect. Fig 28. Design of curved subcutaneous V-Y advancement flaps for eyelid reconstruction. Solid line, upper eyelid. Dashed lines, lower eyelid possibilities. The V-Y advancement is combined with a mucoperiosteal graft from the hard palate. (Reprinted with permission from Ito O, Suzuki S, Park S, et al: Eyelid reconstruction using a hard palate mucoperiosteal graft combined with a V-Y subcutaneously pedicled flap. Br J Plast Surg 54:106, 2001.) Despite the good results illustrated in this article, the technique drew a sharp rebuke from Van der Meulen, 112 who believes postoperative lid sagging is caused by overall laxity and can always be corrected by adequate redistribution of tissues without the insertion of supportive material such as periosteum. Van der Meulen lists the following disadvantages of the Ito technique: 1) in the orbital region the incisions terminate at right angles to the eyelid rim, inviting retraction; 2) the skin of the cheek is much thicker than eyelid skin; and 3) the facial scars will always remain visible. In our department we also enjoy using modifications of the paramedian forehead flap for total lower eyelid reconstruction, as suggested by Hughes. 113 The most distal aspect of the flap is tacked to the lateral orbital rim to help maintain adequate support of the reconstructed lower eyelid. Nakajima and Yoshimura 114 transfer a subcutaneous pedicled flap from the lateral paraorbital temple that pivots on the lateral canthus. The flap is lined with a palatal mucosal graft for one-stage reconstruction of the lower lid. Moschella and coworkers 115 use mutiple subcutaneous pedicled flaps of skin and orbicularis muscle from the lower eyelid area, supported underneath by a free chondromucosal graft. In their hands this technique yielded good functional results in 13 patients, without ectropion or lagophthalmos. Patients did experience temporary edema which resolved after 2 months. The use of an island chondromucosal flap and skin graft has been described by Scuderi and Rubino. 116 Their technique incorporates a strip of upper lateral cartilage and nasal mucosa to reconstruct the tarsoconjunctival plane, along with a skin graft. The donor defect is closed primarily. Härmä and Asko-Seljavaara 117 describe a temporal artery island flap combined with a mucosal or chondromucosal graft for reconstruction of the lower eyelid in 11 patients. The flap is based on the anterior branch of the superficial temporal artery. The flap was found to be particularly useful in cases of recurring lesions when other local means of reconstruction had been exhausted. Large composite defects of the lateral canthus, upper and lower lids can be repaired with a Y- shaped hard palate mucoperiosteal graft and V Y advancement flap, as suggested by Acikel and colleagues 118 (Fig 29). In this case report there was 100% survival of the graft and flap and excellent cosmetic results. Eyelid closure was satisfactory but symptoms of dry eye persisted and led to exposure keratopathy, which was later corrected with lateral tarsorrhaphy and punctum plug insertion. Porfiris and colleagues 119 report lower eyelid reconstruction by means of an island mucochondrocutaneous flap from the nasojugal fold (Fig 30). The flap is raised taking the full thickness of the lateral nasal wall. The raised flap contains mucosal lining, a cartilage framework consisting of part of the upper lateral cartilage with or without the accessory nasal cartilages, parts of the muscles levator labii superioris and nasalis, and the lateral nasal skin. The subcutaneous pedicle is thick (up to 0.5cm in diameter) and contains the periosteum of the nasal bone and the subcutaneous tissue with the vessels. Porfiris et al (1997) 22

24 Fig 29. A, the area of resection is outlined and the V Y advancement flap is designed. B, appearance of the defect after ablation. C, mucosal side of the Y-shape hard palate mucoperiosteal graft. The demucosalized part of the central limb is used for lateral canthal tendon reconstruction. (Reprinted with permission from Acikel C, Celikoz B, Yildiz TF: Y-shape hard palate mucoperiosteal graft and V Y advancement flap in the reconstruction of a combined defect involving lateral canthus and upper and lower eyelids. Ann Plast Surg 52:97, 2004.) Free flaps In severe cases of lower eyelid deficit, free tissue transfer has been described. Thai and associates 120 report the case of a severely burned patient who had both upper and lower eyelid reconstruction with a staged dorsalis pedis flap augmented by conjunctival flaps and septal cartilage grafts. Following successful transfer, secondary division of the flap to create an ostium for his vision was performed. Fig 30. Anatomy, design, and transfer of nasojugal island mucochondrocutaneous flap for total lower lid reconstruction. (Modified from Porfiris E et al: Island mucochondrocutaneous flap for reconstruction of total loss of the lower eyelid. Plast Reconstr Surg 100:104, 1997.) The flap pedicle is supplied by the dorsonasal vessels and the terminal branches of the ophthalmic vessels. Advantages of this method include trilaminar reconstruction in one stage and a donor site that is closed with minimal difficulty. Disadvantages include slight bulkiness and difficult dissection of the pedicle. Tissue expansion A few reports exist of successful eyelid expansion to repair ectropion and lagophthalmos 121 or full-thickness lid deficiencies. 122 An experimental study on pigs by Wieslander and Wieslander 123 explored the possibility of lower eyelid/cheek reconstruction with prefabricated, capsule-lined transposition advancement flaps from the adjacent cheek, using the expander capsule lining as conjunctiva/mucosa replacement. A tissue expander was inserted approximately 2 weeks before the surgical reconstruction and inflated to moderate skin tension. The expander was left in place but essentially unexpanded for 2 3 weeks, after which time capsule-lined cheek flaps were raised around the expanders and transferred to the surgically created defects in the lower lid. Histologic examination of the reconstructed eyelid specimens showed uneventful healing at several different intervals postoperatively. At 2 weeks the transposition flap lining had changed from an expander capsule to an eyelid conjunctiva with a stratified columnar epithelium containing mucussecreting goblet cells. Giant cells were noted and 23

25 some areas of dense fibrosis, but the pigs tolerated their eyelid reconstructions well. The authors conclude that the expander capsule acted as a temporary conjunctiva substitute providing a physical shield, an infection barrier, and a matrix for epithelialization simultaneously with a gradual capsular resolution. Clinical trials are pending. ECTROPION Ectropion is an eversion of the eyelid margin that commonly occurs in the lower eyelid from gravitational pull on the unsupported lid tissue. It may be mechanical (involutional or senile), cicatricial, or neurogenic. Involutional ectropion is the result of progressive laxity of the lower eyelid and disinsertion of the lower eyelid retractors or capsulopalpebral fascia from the inferior border of the tarsal plate. 124 Signs of involutional ectropion include scleral show that progresses to punctal eversion, keratinization, conjunctival hyperemia, and finally exposure of the globe. In contrast, cicatricial ectropion occurs secondary to scar contracture of the anterior lamella of the eyelid. It may be seen in dermatologic conditions such as icthyosis, atopic dermatitis, and extensive actinic exposure. It is common following burns, trauma, and overzealous lower eyelid blepharoplasty. 124 The position of the lower eyelid is determined by several different factors: the integrity of the tarsal plate, the ligamentous and tendinous attachments of the tarsus, and the forces exerted on these structures by the overlying skin and orbicularis layer. 124 Lower eyelid laxity can be evaluated by the snap-back test or the lower eyelid distraction test. 125 The snap-back test consists of placing traction on the lower lid, then releasing it and noting the speed with which the lower lid returns to its resting position. Lax lids tend to return slowly or remain away from the globe until the patient blinks. 126 The status of the lateral canthal tendon is assessed by measuring the distance between the lateral canthal angle and the lateral orbital rim. If this distance is >6mm, lateral canthal dehiscence is suspected. Assessment of the medial canthal tendon is done by distracting the lower eyelid laterally. If the punctum moves >5mm, then medial canthal tendon laxity exists. 125 Isolated medial ectropion results in eversion and lateral displacement of the punctum. This may progress to stenosis or occlusion of the punctum, thickening of the lower lid, and hyperkeratinization. Medial canthal tendon laxity can be best corrected by direct tightening of the tendon. 127 However, plication of the medial canthal tendon may result in occlusion of the canalicular system. If the lower canalicular system is occluded, then direct tightening may proceed. Patients with a patent punctum may undergo a medial spindle procedure or diamond-shaped excision of the conjunctiva, 124 plicating the eyelid retractors to the tarsus and inverting the lower punctum. Various types of wedge excision have been suggested for correction of severe ectropion. Smith 128,129 described the lazy-t operation, which adequately corrects punctal eversion but which may cause notching and leave an unsightly scar in the medial portion of the lid. O Donnell 130 combines a diamond-shaped excision to correct punctal eversion with either a pentagonal full-thickness excision or lateral tarsal strip to further shorten the lower lid horizontally. He feels that this technique can be performed with relative safety in patients who have medial ectropion of the lower eyelid without excessive canthal laxity. Sullivan and Collin 131 describe an aggressive approach for correction of medial ectropion. They propose resection of the medial canthus, including the tendon and inferior canaliculus. This procedure shortens the medial canthal tendon, stabilizes it to the posterior lacrimal crest, and marsupializes the cut end of the canaliculus to maintain patency of the lacrimal system. In their experience with 37 cases of severe paralytic or involutional medial ectropion managed by this technique, the deformity was totally eliminated in 19 patients and improved in 33. As modified by Fox, 132 the Kuhnt-Szymanowski procedure involves lid splitting and lateral wedge resection and offers improved cosmesis, hiding the scar in the lateral canthal area where it is often concealed by natural skin creases (Fig 31). The procedure may be combined with a diamond shaped excision near the medial punctum to correct punctal eversion. When further support of the lower lid is required, the reconstructed lid can be sutured to a flap of orbital periosteum

26 Fig 31. The modified Kuhnt-Szymanowski procedure for correction of ectropion. (Reprinted with permission from Fox SA: A modified Kuhnt-Szymanowski procedure for ectropion and lateral canthoplasty. Am J Ophthalmol 62:533, 1966.) Although wedge resection procedures tighten the lower eyelid, there is a tendency to create a more rounded lateral canthal angle, which may result in lid notching, phimosis, and further tension on the lateral canthal tendon without appropriate reinforcement. 124 Tse, Kronish, and Buus 133 report a similar technique using a transconjunctival approach for the treatment of tarsal ectropion due to disinsertion or dehiscence of the lower eyelid retractors. The lower lid retractors are sutured to the inferior tarsal margin without excision of palpebral conjunctiva. The looping suture pulls the tarsal plate downward to counteract any everting tendency of the lid margin. The absorbable suture also triggers an inflammatory reaction that helps to anchor the reattached structures with scar. Jelks et al 134 describe an inferior retinacular lateral canthoplasty that is said to address the problems associated with lower lid laxity or malposition. The technique incorporates the lower lid component of the lateral retinaculum, which is freed and then secured to the lateral orbital rim with a permanent suture (Fig 32). In the authors hands the procedure has been particularly useful in correcting a negative vector relationship (when the globe is anterior to the lower eyelid and malar eminence) and for prevention of rounding of the lateral canthus, bowing of the lateral lower lid, and scleral show. Procedures designed to deal with laxity of the lateral canthal tendon include the tarsal tuck 124,135 and the lateral tarsal strip techniques The tarsal tuck procedure is commonly combined with standard blepharoplasty and may be done through a subciliary incision. Two sutures are used to affix the lateral tarsus to the superolateral orbital rim. Placement of these sutures inside the orbital rim helps create a sharp canthal angle. 124,135 Fig 32. Technique of retinacular lateral canthoplasty. Left, the lower lid component of the lateral retinaculum (dotted line) is dissected from the bone. Center, a double-armed suture is passed through the free end of the lateral retinaculum and suspended to the periosteum of the lateral orbital rim. Right, after the suture is tightened, the retinaculum is fixed in its elevated position. The tissues bunched at the canthus will relax over the ensuing 2 4 weeks. (Modified from Jelks GW et al: The inferior retinacular lateral canthoplasty: a new technique. Plast Reconstr Surg 100:1262, 1997.) 25

27 When used in conjunction with transconjunctival lower blepharoplasty, 124 the internal tarsal tuck is carried through a transconjunctival incision, lysing the inferior crus of the lateral canthal tendon. The lateral portion of the tarsus is identified and a small portion of the conjunctiva is removed to prevent epithelial inclusion cysts. Two absorbable sutures are used to secure the lateral tarsus to the superolateral orbital rim. When there is significant horizontal lid laxity, a tarsal strip is preferred. Although the surgical technique is more complex than in tarsal tucks, tarsal strip reattachment is among the most useful and effective corrective procedures in lower eyelid surgery. 139 A lateral canthotomy is performed, followed by an inferior crus cantholysis and exposure of the orbital periosteum. The anterior lamella overlying the lateral tarsus is then excised and the lateral lid is secured to the periosteum of the orbital rim (Fig 33). A canthus-sparing technique of ectropion repair is described by Lemke and coworkers. 140 An incision is made lateral to the lateral canthus and a periosteal flap is developed at the lateral orbital rim. The inferior crus of the lateral canthal tendon is attached to this periosteal flap and the sutures pulled in a lid-tightening maneuver (Fig 34). Cicatricial ectropion is secondary to skin or muscle deficiency and requires replacement of the missing elements for correction. Simply tightening the eyelid will not adequately correct cicatricial ectropion. Most often the anterior lamella is deficient, and can be replaced with a full-thickness skin graft. The management of paralytic ectropion and lagophthalmos is discussed in another issue of SRPS. 141 Various springs and encircling prosthetic devices 142,143 have been described for the treatment of upper lagophthalmos. The preferred method of many seems to be insertion of a gold weight implant, 143,144 which effectively prevents corneal exposure when the patient is in the upright position. At night the eye can be taped closed. Neuman 145 describes a 16-year experience with gold lid loads in lagophthalmos. Of the 71 patients treated, 56 had a satisfactory result and uneventful Fig 33. Technique of lateral tarsal strip for shortening the lower lid. (Reprinted with permission from Nesi FA, Waltz KL: Smith s Practical Techniques in Ophthalmic Plastic Surgery. St Louis, CV Mosby, 1994.) 26

28 Fig 34. Technique of canthus-sparing ectropion repair. Left, the inferior crus of the right lateral canthal tendon is grasped with a needle and suture. Right, the suture is passed through the periosteal flap and tightened. (Reprinted with permission from Lemke BN, Cook BE Jr, Lucarelli MJ: Canthus-sparing ectropion repair. Ophthalmic Plast Reconstr Surg 17:161, 2001.) outcome from the procedure, four had implant extrusion, three had improper position of the gold weight, three had persistent eyelid edema, two had keratitis from fifth nerve palsy, and two patients were still unable to close their lids after surgery, resulting in conjunctivitis. Severe lagophthalmos with exposure keratopathy can be improved with lateral tarsorrhaphy techniques. Temporary tarsorrhaphy relies on stripping the epithelium from the eyelid margin or creating intermarginal adhesions. This results in a defect of the lid margins or trichiasis when the tarsorrhaphy is taken down. A reversible tarsorrhaphy for corneal protection involves small pieces of red rubber catheters that are sutured to the upper and lower lids, 2 3mm from the margin. A silk suture is passed between the bolsters and tied to pull the eyelids closed. 146 Tanenbaum and coworkers 147 describe an alternative tarsal pillar technique that sutures strips of conjunctiva and tarsal plate from the upper lid into the lower lid to narrow the interpalpebral fissure. The technique was used successfully in 35 consecutive cases of keratopathy. Flowers and Caputy 148 report using a cartilage graft and fascial sling to correct the sagging punctum in laxity of the paralytic lower lid. Other measures to tighten the lower eyelid may be taken prophylactically at the time of blepharoplasty, and should be considered in patients over 40 years old or who show evidence of lower lid laxity. 149 These preventive maneuvers include wedge resection of the tarsal plate, tarsal tuck sutures, or a lateral tarsal strip reattachment. They also help secure the lower lid after lower lid laserabrasion, when transient cicatricial ectropion often develops. ENTROPION Entropion is a turning inward of the eyelid margin to the point where the lashes come in contact with the cornea. Entropion may be either involutional or cicatricial. Allen 150 lists the following causes of involutional entropion: 1) dehiscence or attenuation of the capsulopalpebral fascia, which allows the lower tarsal border to rotate outward; 2) horizontal lid laxity with or without laxity of the canthal tendons; or 3) overlapping of preseptal orbicularis muscle fibers on the tarsus, which makes the lid turn inward. 142 The management of entropion typically involves resection of a thin strip of infraciliary skin and tarsus and suturing the superior edge of the wound to the inferior border of the tarsus for anterior rotation of the lid margin 151 release of conjunctival adhesions and resurfacing with free grafts of buccal mucosa or conjunctival flaps lid margin splitting and rotation 152 incorporating a cartilage graft into the reconstructive flap 153 Charonis and Gossman 154 focus their attention on the overaction of the preseptal and pretarsal 27

29 Fig 35. Transverse tarsotomy and anterior rotation of the lid margin for entropion correction. The tarsal plate is transected at mid-level and a double-armed suture is passed through the proximal cut edge of the tarsal plate, orbicularis, and skin. (Reprinted with permission from Kersten RC, Kleiner FP, Kulwin DR: Tarsotomy for the treatment of cicatricial entropion with trichiasis. Arch Ophthalmol 110:714, 1992.) portions of the orbicular oculi muscle that is common in these patients. The authors cite previous studies demonstrating superior and forward migration of the preseptal orbicularis, which overrides the pretarsal part of the muscle and results in entropion. 155,156 They incorporate a subtotal orbicularis myectomy to eliminate this muscle as a source of recurrence. This, combined with a posterior lamellar tightening via a periosteal flap, has produced impressive results in 42 eyelids studied. There was no evidence of overcorrection in any case, and the esthetic result was described as good. Postoperative complications included one patient each with chemosis, asymptomatic trichiatic eyelash, and pyogenic granuloma requiring excision. Cicatricial entropion is related to trauma, chemical injuries, Stevens-Johnson syndrome, ocular pemphigoid, and other inflammatory conditions 129 that may cause symblepharon or abnormal adhesions of the palpebral and bulbar conjunctival surfaces. Entropion should be distinguished from trichiasis, where only the lashes are turned against the globe; distichisis, in which an extra row of lashes sometimes irritate the cornea; and epiblepharon, a redundant skin fold in the lower eyelid that rolls over the lower eyelid margin and causes an inversion of the lid margin. 129 Kersten, Kleiner, and Kulwin 157 recommend simple transverse tarsotomy followed by repositioning of the lid margin in slight eversion using a silk suture (Fig 35). The skin and orbicularis layers are left undisturbed. One year after surgery, 69/81 eyelids (85%) had complete resolution of trichiasis. 157 Repeat tarsotomy was required in 6 eyelids due to recurrence, and it was successful in all. The success rate after revision was 92.5%. 157 Ito and colleagues 158 describe another technique for the correction of pediatric eyelid entropion that involves resection of a length of pretarsal orbicularis muscle without skin resection. Severe cases also receive a lid-bracing suture. The authors believe that swelling of the orbicularis oculi muscle at the lid margin is the underlying mechanism of persistent ciliary entropion in children. Unimpressive results in 8 patients are illustrated. Siegel 153 offers a simple technique for the treatment of involutional entropion. A 4 x 20mm strip of cartilage harvested from the conchal bowl is placed within the lower lid just deep to the auricularis muscle. The graft creates a new, more rigid tarsal plate to replace the natural one, which seems to soften and shrink with age. Drawbacks of this operation include possible follicular destruction, vascular compromise, and a palpable graft. Millman, Katzen, and Putterman 159 describe their experience in 98 patients (152 lids) treated for cicatricial entropion with transverse blepharotomy and lid margin rotation. The overall success rate was 85%; recurrences were seen in 11 lids, 7 in patients with ocular pemphigoid and 4 with Stevens-Johnson syndrome. Seven eyelids were overcorrected, while 22 lids developed subsequent conjunctival granulomas that required excision. An additional 10 lids required electrolysis for aberrant lashes despite good lid margin position. When entropion is associated with laxity of the eyelid, a lid-tightening procedure should be included, 136,137 commonly with horizontal lid shortening and tarsal rotation. 129 If there is associated epiblepharon, this must be corrected by careful excision of the fold and plication of the capsulo- 28

30 palpebral fascia to the lower border of the tarsus, with or without lid tightening. 129 Allen 150 describes a modification of Quickert and Jones s 160 procedure for correction of lower lid entropion that combines lid shortening with repair of the lower lid retractor complex. Rougraff and coworkers 161 from Bascom Palmer analyzed the surgical results in a large series of patients with involutional lower eyelid entropion who were treated at their institution during a 12- year period. There were 152 eyelids with followup longer than 6 months. Group 1 (125) had combined repair with fornix suture placement and lateral tarsal strip. Group 2 (9) had repair with fornix sutures only. Group 3 (18) had repair with the lateral tarsal strip procedure only. After an average follow-up of 36 months, the recurrence rate in these surgical subsets was 1.6%, 33%, and 22%, respectively. The authors conclude that suture advancement of the lower eyelid retractors in conjunction with a lateral tarsal strip procedure is a simple, quick, physiologic, and effective approach in achieving long-lasting correction for involutional entropion. SURGERY ON THE MEDIAL CANTHUS Medial Lid and Punctal Lacerations Palpebral defects in an otherwise stable medial canthus are best treated as any full-thickness wound of the eyelid. Common options for repair involve a lower lid switch flap with lateral cheek advancement or an upper lid tarsoconjunctival flap 54,77 covered by a full-thickness skin graft or glabellar flap. 55 Tendon Avulsion or Malposition Zide and McCarthy 12 detail the anatomy of the medial canthus and stress the importance of the canthal tendon, which anchors the mobile central part of the levator complex in the medial upper lid. McCord 162 describes the medial canthal retinaculum as consisting of the deep head of the pretarsal orbicularis, the orbital septum, the medial end of Lockwood s ligament, the medial horn of the levator aponeurosis, the check ligaments of the medial rectus muscle, and Whitnall s ligament. Injury to the medial canthal tendon may cause lid ptosis. Spontaneous granulation. A reasonable outcome may be expected when the lesion in the medial canthus is allowed to heal on its own. 163,164 Harrington 165 noted excellent results in 75% of patients whose medial canthal defects were allowed to heal secondarily, but emphasizes the need for suture-fixation of the lid margins to the nasal periosteum, believing it to be important in preventing lateral retraction of the eyelids. Harrington also advocates tension-relieving incisions and advancement flaps to cover as much of the defect as possible. The best results with spontaneous granulation are seen in defects of the medial lower eyelid no longer than 5 6mm and directly over the inner canthal area. 163 With extension of the defect onto the side of the nose, there is an increasing tendency for the spontaneously healed canthus to lie higher than the normal one and for the lids to pull away from the globe. As the wounds extend into the parapalpebral tissues and away from the medial canthus, problems with spontaneous granulation also increase. V Y glabellar flap. Small or moderate sized defects of the inner canthus can be resurfaced with a V Y glabellar flap, as recommended by Hughes. 113 Larger defects may be corrected with a combined nasolabial V Y advancement flap and glabellar flap. 166 In a series of 23 patients who underwent this medial canthus repair after tumor resection, Yildirim and colleagues 166 report good functional and cosmetic results and no complications. The technique may be criticized for a tendency of the V Y advancement flap to pincushion, for crossing anatomical lines, and for placing scars at right angles to the lid margin. Musculocutaneous and muscle flaps. Jelks and coworkers 167 described medial canthus reconstruction in 10 patients with a medially based upper eyelid musculocutaneous flap. The flap is incised through the skin and the preseptal and orbital orbicularis oculi muscle down to the level of the septum orbitale, and elevated from lateral to medial in continuity with the medial fat pocket (Fig 36). Its blood supply is from supratrochlear, infratrochlear, and medial palpebral perforating vessels. The flap can be raised on a thin pedicle and can be rotated into several locations in the medial periorbital glabellar region. There was only one partial flap 29

31 Fig 36. A medially based musculocutaneous flap from the upper lid raised to repair defects of the medial canthus and periorbita. Left, the perforating vessel feeding the flap emerges from the medial fat pad. Right, potential arc of rotation of this versatile flap. (Reprinted with permission from Jelks GW, Glat PM, Jelks EB, Longaker MT: Medial canthal reconstruction using a medially based upper eyelid myocutaneous flap. Plast Reconstr Surg 110:1636, 2002.) loss in the series, and the authors believe this flap offers an excellent solution to the difficult problem of medial canthal reconstruction. Chiarelli and others 168 report their experience with a forehead flap to repair medial canthal defects involving both eyelids in 3 patients. The myofascial flaps were raised from the central forehead and were combined with septal chondromucosal grafts, grafts of oral mucosa, and skin grafts. The part of the forehead muscle taken for the flap is vascularized by the deep branch of the supraorbital artery and by the supratrochlear artery. The authors praise the flap for its thin, elastic, and resistant features and recommend it for reconstruction in this difficult area. Canthopexy. Canthopexy should be made a part of the repair of medial canthal defects to prevent telecanthus. The technique involves suturing the medial ends of the upper and lower lid tarsus to the nasal periosteum; 23 the point of fixation should be well below the anterior lacrimal crest to keep the lids coapted against the globe. Large tendon plications, however, are associated with a high rate of recurrence rate and occasional canalicular kinking. 137 When nasal periosteum has been removed, transnasal canthopexy affords the most stable fixation. Zide and McCarthy 12 feel that the tension required of a medial canthopexy is too much for the nasal periosteum to withstand and recommend a more liberal use of transnasal canthopexy. 169 They describe a tripartite fixation that has anterior and posterior horizontal components as well as a vertical component; this results in a vector of suspension directed posteriorly and superiorly to the anterior lacrimal crest. Freihofer 170 analyzed the results of 49 transnasal canthopexies in 28 patients and concluded that transnasal canthopexy is a difficult procedure and the outcome is not always favorable. To avoid excessive tension, he locates the inner canthus 5 7mm lateral to the anterior lacrimal crest and adds a lateral canthotomy or wide dissection of the periorbita for lateral release. A technically inadequate canthopexy will invariably yield a poor result: The most common errors in performance are incomplete removal of bone and intervening soft tissue, use of catgut instead of permanent suture, and exaggerated traction during the inner canthal fixation. Mustardé 23 believes that a canthal fixation taken too far anteriorly will also cause problems, and recommends placing the fixation sutures in the vicinity of the posterior lacrimal crest. Canthoplasty. Leibsohn and Hahn 171 report reconstruction of the medial canthal tendon using a flap of nasal periosteum as replacement. The flap is elevated as a horizontal rectangular strip, 6 10mm wide and up to 2cm long, that is hinged laterally or as close as possible to the stump of the medial canthal tendon. The flap is rotated into place, split to create the upper and lower crura of the tendon, if necessary, and sutured to the medial eyelid(s). Although this technique seems reasonable, the nasal periosteum is extremely thin and may be insufficiently strong for permanent reconstruction of the canthal tendon. 30

32 An interesting approach to medial canthoplasty was described by Howard, Nerad, and Kersten. 172 The authors reattached the medial canthal tendon to a titanium microplate under the lateral nasal sidewall. The plate was stabilized along the anterior lacrimal crest and extended onto the posterior lacrimal crest. On the basis of their experience with 6 patients who had malpositioned or avulsed medial canthal tendons, the authors feel this technique is safer, faster, and in many cases more effective than traditional methods of reconstruction. Obviously the procedure is only applicable when the ipsilateral nasal sidewall is anatomically intact. Medial tarsal strip. Jordan, Anderson, and Thiese 173 described the medial tarsal strip, a modification of the lateral tarsal strip procedure for lid tightening. The technique can be easily combined with other procedures such as flaps or grafts. Indications for medial tarsal strip are: (a) medial canthal malposition; (b) marked medial ectropion associated with a nonfunctioning canalicular system; and (c) cases in which loss of function of a patent canaliculus is acceptable or desirable, such as dry eye syndrome or exposure keratitis. In the isolated instance where canalicular sacrifice can be tolerated or should one wish to reduce the tear flow, this procedure could be useful and would avoid transnasal canthopexy. Epicanthal Fold An epicanthal fold that partially covers the medial canthus can have a traumatic origin, represent a developmental anomaly, or simply be an ethnic trait see discussion below under Blepharophimosis Syndrome. Fuente del Campo 174 illustrates various historical methods for the correction of epicanthal folds and introduces a transposition flap based on the fold tissues. The flap curves along the edge of the epicanthal fold (first incision), toward the lower palpebral margin ending 2mm below the punctum (second incision), and is transposed medially with its apex pointing toward the midline (third incision perpendicular to the first) (Fig 37). The medial canthal tendon is simultaneously shortened by a plication suture. Flowers 175 prefers a V-W-plasty procedure because it produces better scars. Fig 37. Fuente del Campo s flap technique for correction of epicanthal fold. (Reprinted with permission from Fuente del Campo A: Surgical treatment of the epicanthal fold. Plast Reconstr Surg 73:566, 1984.) LID RETRACTION The terms complex ectropion and lid retraction are often interchangeable in the literature. They refer to a condition characterized by constriction of both the inner and outer lamellae as well as constriction of the supporting structures of the lid. The eyelid itself is everted only if the outer lamella is contracted more than the other layers. Lid retraction is the indirect result of marked inflammation and edema during wound healing that lead to fusion of the lid structures with the orbital septum. It occurs frequently after complex facial trauma, full-thickness burns, and postoperative hematoma. The key to correction of the retracted lid deformity is a thorough dissection of the tissues to release all scar, followed by insertion of a rigid lid-supporting element. Whether it is necessary to bring in skin or lining to the repair is controversial. In theory there is no skin or conjunctival shortage, and all that is needed for correction is complete scar release and insertion of a strong middle lamella, such as nasal septal cartilage, to withstand any subsequent deforming forces. If the tissues have been stretched from the inferior pole of the scar contracture, one should consider adding a lid-tightening procedure such as a lateral tarsal strip advancement. In contrast to this popular opinion stands a report by Hurwitz, Archer, and Gruss 176 of 23 patients with severe lower eyelid retraction (>4mm scleral show) treated with free grafts of skin and sclera and 31

33 bipedicle orbicularis flaps. The operative sequence involved 1) infraciliary incision and lysis of adhesions; 2) homologous free scleral graft for the posterior lamella; 3) free retroauricular skin graft to the anterior lamella; and 4) bipedicle orbicularis flap mobilization and interposition between the free grafts. In a follow-up of 3 to 6 years, the authors noted lid height at the inferior limbus in 21 of 26 operated eyelids; the other 5 eyelids were within 2mm of the limbus. The authors emphasize complete release of the supporting tarsus from the inferior lid retractors as crucial to the success of the procedure. Their good results cannot be overlooked. Baylis, Nelson, and Goldberg 177 reviewed 30 consecutive patients with lower eyelid retraction after blepharoplasty. In addition to vertical skin shortage, scarring in the plane of the orbital septum was a common cause of lid retraction. Surgical correction varied with time since blepharoplasty, prominence of the globe, and degree of septal or skin involvement. Mild cases of less than 6 months duration were treated by release of the lower eyelid retractors, thorough dissection of the scar tissue, and lateral canthal suspension. (A simple canthopexy may actually lower an already retracted eyelid margin.) In slightly more severe cases, a spacer graft of cartilage was added between the tarsus and the lower eyelid retractors. Severe or long-standing cases had orbicularis dissection and superolateral suspension. Fixation of the orbicularis was often sufficient for correction, although most patients needed more than one operation to achieve acceptable symmetry. Graves Ophthalmopathy Graves disease consists of hyperthyroidism associated with goiter, pretibial dermopathy, and infiltrative ophthalmopathy. Ocular manifestations include eyelid retraction, often with a lag on downward gaze; exophthalmos secondary to anterior displacement of the globe; disorders of ocular motility; inflamed ocular surface; and rarely a compressive optic neuropathy. 178 The natural course of Graves ophthalmopathy is usually self-limiting but may not correspond directly with the patient s thyroid status. The early inflammatory infiltrate of the extraocular muscles, connective tissues, and lacrimal gland is later replaced by fibrosis. The orbital pads in both upper and lower eyelids are frequently involved in the inflammatory process. Diplopia and strabismus are common because of fibrosis of the extraocular muscles. Surgical intervention is not recommended during the inflammatory stage. Stability of the disease should be documented for at least 6 months before any operative correction is undertaken. The pathophysiology of eyelid retraction in patients with Graves disease is still not well delineated, but several factors are thought to play an important role. Excessive sympathetic stimulation of Müller s muscle can contribute to upper eyelid retraction. 179,180 The inflammation and fibrosis may result in contracture of the inferior rectus muscle and overaction of the synergistic superior rectus and levator muscles. 179,181,182 Proptosis certainly contributes to the appearance of eyelid retraction. Corticosteroids have been used to treat the ophthalmic manifestations of Graves disease. 183,184 Steroid administration in the inflammatory stages improves the eyelid symptoms, but the effect lessens as steroid doses are reduced. 185 Long-term use of corticosteroids is associated with a wide range of complications. 186 Surgical management follows two different pathways. Mild to moderate cases of eyelid retraction may be treated with eyelid procedures to mask the ocular proptosis. More severe symptoms frequently require orbital decompression to enlarge the orbital volume. Vertical Lid Lengthening In 1972 Putterman 179 described surgical treatment of patients with upper eyelid retraction by excision of Müller s muscle, incorporating partial tenotomy of the levator aponeurosis as needed. A sensory nerve block allows the surgeon to assess the degree of correction required. Excision of only the temporal two thirds of Müller s muscle reduces postoperative ptosis on the nasal side. 180 The authors note that eyelid retraction may develop in the contralateral lid following unilateral upper eyelid surgery (Haring s law). 181,187 Ceisler et al 186 reported their experience with Müller s myotomy and transposition of the levator aponeurosis for the correction of eyelid retraction in patients with Graves disease. In their experience with 72 eyelids of 37 patients, 58 eyelids (30 32

34 patients) showed excellent results, 13 eyelids (7 patients) had good results, and 1 eyelid had a poor result. Two patients required further surgery, one because of significant overcorrection and the other because of undercorrection. The most common complication was a high eyelid crease (33.3%). The authors stress the importance of lateral levator aponeurosis transposition to lengthen the eyelid vertically and obtain suitable eyelid contour. 186 In contrast to the upper lid, lower eyelid retraction requires a scleral interpositional graft for correction. 188 The grafts are typically made 4X wider than the measured scleral show. 180 This technique is reported to be very effective; in one series of 30 lids, the success rate was 90% after a single operation. 188 Feldman, Putterman, and Farber 180 review their 15-year experience with the surgical treatment of thyroid-related lower eyelid retraction. The authors conclude that residual lid retraction after scleral grafting was a common occurrence. They modified their procedure to include a lateral canthal suspension, and later incorporated both lateral tarsal strip and tarsorrhaphy. The authors note a significant decrease in persistent lower lid retraction postoperatively following these changes. Orbital Decompression The indications for orbital decompression in the treatment of thyroid ophthalmopathy include: a sight-threatening compressive optic neuropathy unresponsive to immunosuppressive therapy proptosis causing severe ocular surface disease cosmetic appearance unlikely to be improved by lid surgery alone before strabismus surgery, if it is thought that decompression will be needed at some point 169 Osteotomies are typically performed through either the medial wall of the orbit or the orbital floor to allow herniation of intraorbital contents into the paranasal sinuses. 189 Thaller and Kawamoto 190 propose a three-wall decompression through the lateral and medial orbital walls as well as the orbital floor. The lateral orbital wall is displaced in a swinging door fashion, which allows expansion of the intraorbital contents while preserving the position of the lateral orbital rim. The floor and medial wall of the orbit are carefully outfractured; the medial canthal region is left undisturbed. The periorbital tissues are incised and the herniated retrobulbar fat is excised under direct vision. Garrity et al 185 retrospectively reviewed 428 consecutive patients with severe Graves ophthalmopathy who were treated with transantral orbital decompression. The bone is removed from the medial wall of the orbit to the roof of the ethmoid and, depending on the location of the infraorbital nerve, the orbital floor is removed either lateral or medial to the nerve. Numerous crosshatching incisions are placed within the periorbita. Their review found that this technique reduced proptosis effectively and usually corrected optic neuropathy associated with Graves disease. 185 Shore, Carvajal, and Westfall 191 approach orbital decompression by excising the lateral orbital rim and using a titanium miniplate to reconstruct the lateral canthus. Their results in 18 patients (33 orbits) showed excellent eyelid and globe position without complications. UPPER EYELID PTOSIS Blepharoptosis may be congenital or acquired. This is an important distinction to make, as the etiology of the deformity determines its anatomy, physiology, and expected outcome after surgical correction. Conditions that mimic eyelid ptosis include retraction of the opposite lid secondary to Graves disease, enophthalmos, contralateral exophthalmos, and any mechanical pressure on the lids caused by heavy skin folds, eyelid edema, or tumors. 192 Congenital These patients have an anomalous levator muscle at birth. Histologically there is fibrosis or absence of striated muscle fibers consistent with a muscular dystrophy. 193 The levator is stiff, which translates into poor excursion clinically. Lagophthalmos in down gaze-is a sign of congenital ptosis. Affected children show a high incidence of coexistent strabismus, amblyopia, and anisometropia. 192 The surgical repair of congenital eyelid ptosis depends on the severity of the anatomic deformity, specifically the degree of ptosis and levator mal- 33

35 function. 194 Excision of the tarsus and Müller s muscle or small resection of the levator aponeurosis may be all that is necessary for patients with mild ptosis and good levator function. Patients with moderate ptosis and fair levator function may require more extensive levator resection for correction. Less clear is the recommended surgical technique for patients who have severe ptosis and poor levator function. 194 Beard, 195 Putterman, 196 and others 197 propose maximum levator resection at age 2, while Crawford 198 suggests grafts of fascia lata for frontalis muscle suspension at age 3½. Saunders and Grice 194 reason that early surgical repair of severe congenital ptosis before 1 year of age not only improves appearance but also averts future physiological and developmental problems associated with ptosis; definitive suspension with grafts is carried out when the child is older. Their procedure of choice is frontalis suspension with Supramid Extra sutures, which avoids a complex dissection yet produces the necessary improvement in function during this critical stage in a child s development. In their series of 12 infants, 10 achieved near-normal eyelid position and all had resolution of their chin-up posture. Two slings eventually failed and had to be repeated. Orbitoblepharophimosis Syndrome One form of congenital ptosis is the orbitoblepharophimosis syndrome. Clinical manifestations of the syndrome are bilateral upper blepharoptosis, epicanthal folds, and narrowing of the palpebral fissure. A common finding is an elongated medial canthal tendon. Associated anomalies such as skin shortage in the upper and lower lids, congenital ectropion, telecanthus, and flattening of the glabellar area may also be present. Congenital blepharophimosis is inherited as an autosomal dominant trait and is said to be more common in people of Asian origin than in Europeans. Surgical correction of blepharophimosis should involve repair of the epicanthal folds as well as correction of the eyelid ptosis. Nakajima and colleagues 199 repair all cases of congenital eyelid ptosis, regardless of functional status, by levator resection and medial canthoplasty in one operative stage. If correction is insufficient, a fascial suspension can be added later. A deep superior fornix is recreated and maintained with sutures tied over bolsters on the skin to prevent prolapse of the conjunctiva postoperatively. The medial canthal tendon is not cut but is plicated and affixed to the periosteum of the frontal process of the maxilla. After surgery, all patients had temporary lagophthalmos that took 4 6 months to subside, and some patients had 2 3mm of lagophthalmos during sleep for as long as 2 years postoperatively. Ophthalmic lubricants and taping during sleep effectively prevented any exposure keratopathy. Krastinova and Jasinski 200 describe a 16-year, 50- patient experience with orbitoblepharophimosis syndrome. They review the three forms of presentation, epidemiology, genetics, and operative correction of the malformation. In their words, surgical treatment involves 3 to 4 operations: orbital remodeling by burring and grafting (intraorbital and extraorbital), epicanthus correction, and ptosis operation. Skin grafting was used liberally for correction of insufficient upper lid skin. Results varied depending on the severity of the form and the quality of the tissues. Nowinski 201 reviews the various published techniques for correction of epicanthal folds in blepharophimosis and promotes the five-flap technique described by Anderson. 202 The procedure combines double Z-plasties with a Y-to-V flap (Fig 38). Fig 38. Anderson s five-flap technique for repair of epicanthal folds associated with the blepharophimosis syndrome. Traction has been applied medially to obliterate the fold. (Reprinted with permission from Anderson RL, Nowinski TS: The five-flap technique for blepharophimosis. Arch Ophthalmol 107:448, 1989.) Nowinski 201 recommends extensive defatting of the flaps to allow the soft tissues of the medial canthus to recede posteriorly. The ideal final position of the canthus in most patients is halfway between the pupil and the center of the nasal bridge. 34

36 Acquired Upper eyelid ptosis of traumatic, myogenic, neurogenic, or mechanical origin 203 is said to be acquired. Common causes of acquired ptosis include surgery or accidental injury, tumor, myopathy, chronic progressive ophthalmoplegia, third nerve palsy, Horner s syndrome, myasthenia gravis, and mechanical changes with anophthalmos. 192 A history of increasing ptosis toward the end of the day is not pathognomonic of myasthenia gravis but simply represents fatigue. It is estimated that 40 50% of cases of acquired ptosis are involutional (myopathic) in nature and 30% are posttraumatic. Conventional wisdom holds that the immediate reason for ptosis is dehiscence or disinsertion of the levator aponeurosis from the anterior lower surface of the tarsus. Martin and Tenzel 204 reviewed the records of their cases of acquired ptosis and found evidence to contradict this widely held belief. A retrospective analysis of the intraoperative findings in 98 patients who had surgery for involutional ptosis using only sharp dissection revealed no disinsertions and no dehiscences of the levator aponeurosis, which was seen to be markedly attenuated. The authors theorize that the formerly recommended technique of blunt dissection during levator resection surgery 204 may have been responsible for the reported frequency of dehiscence and disinsertion. Their data support the concept that most cases of acquired ptosis are secondary to a stretching of the aponeurosis above the tarsus. 204 A previous study by Collin 205 showed that 90% of patients with senile involutional ptosis associated with aging had aponeurotic weakness and only 10% had degeneration of the anterior portion of the levator muscle as the cause of the ptosis. Similarly, Carroll 206 found a 5% incidence of disinsertion or dehiscence of the aponeurosis in more than 450 consecutive eyelids with congenital or acquired ptosis requiring levator surgery. The severity of ptosis is graded according to upper eyelid position in primary gaze and the range of levator excursion (Table). 203,207,208 The distance between the upper and lower limbus measured across the pupil is 11mm. The upper limbus should rest about 2mm below the superior edge of the iris and 2mm above the superior edge of the pupil. 207 The functional status of the levator muscle is determined by measuring the excursion of the upper lid margin while going from a downward gaze to an upward position with the eyes fixed on a light held at a distance. During examination of levator excursion, the effect of the frontalis muscle must be neutralized by exerting pressure above the eyebrow. 207 TABLE Classification of Upper Eyelid Ptosis (Data from Souther SG, Corboy JM, Thompson JB: The Fasanella- Servat operation for ptosis of the upper eyelid. Plast Reconstr Surg 53:123, 1974.) Frueh and Musch 209 found in their study of 187 patients with ptosis that levator force (maximum force generated on upward gaze) predicted the correct diagnosis 95.2% of the time. In contrast, measurement of eyelid excursion predicted the correct diagnosis 78.2% of the time. A correct diagnosis was obtained 98% of the time when levator force was combined with a good physical examination. 209 Patients with involutional blepharoptosis due to pure aponeurotic disinsertion typically have ptosis with good levator excursion, an elevated or absent upper lid skin crease, and thinning of the upper lid tissues above the tarsal plate. 210 A complete visual field examination is mandatory when evaluating eyelid ptosis. 192,211 Preoperative evaluation should include a Schirmer test to assess the tear film. Adequate function of the trigeminal and facial nerves should be ascertained prior to surgery. Anterior Levator Resection Wobig 212 details the technique of vertical lid shortening by resection of the levator muscle through an anterior approach. This is the time-honored 35

37 method for the correction of eyelid ptosis 203 and can be performed through a conjunctival approach in cases of mild to moderate ptosis or externally when higher corrections are needed. Surgery on the Levator Aponeurosis Jones, Quickert, and Wobig 213 described correction by plication or reattachment of the levator aponeurosis using local anesthesia since the level of fixation for the levator is determined by having the patient move his eyes through various fields. Levator excursion of at least 8mm is required for a successful outcome, and generally overcorrection by 1mm produces the desired result. Wobig 213 notes that lidocaine effectively blocks orbicularis oculi resting tension so that the lid will be approximately 1mm higher than the opposite side, and this must be taken into account when setting the lid level intraoperatively. Carraway and Vincent 214 preserve the full length of the levator muscle and instead advocate levator advancement at a rate of 4mm of advancement for each 1mm of ptosis. The authors illustrate good results with this approach in over 20 patients, with increased muscle function in some cases. Anderson and Dixon s 215 technique consists of reinserting the aponeurosis into the midportion of the tarsal plate, preserving the tear-producing structures, Müller s muscle, Whitnall s ligament, and normal anatomic planes and structures of the eyelid. Tucking of the aponeurosis is to be avoided because it leaves no raw surfaces for healing. The procedure is indicated in cases of acquired ptosis and also for patients with congenital ptosis who have at least 5mm of levator function. Overcorrection by 1mm in acquired ptosis and 3mm in congenital ptosis is recommended. Jordan and Anderson 216 published an update of their aponeurotic approach in 228 patients (265 lids) with congenital ptosis. Advantages of the technique include dissection along normal anatomic planes, minimal disruption of normal structures, no resection of the muscular levator or Müller s muscle, and maintenance of an intact Whitnall s ligament. Postoperatively most patients were improved. The degree of correction achieved varied with the quality of preoperative lid function. Older 217 describes his experience with levator aponeurosis surgery in 113 ptotic upper eyelids. Satisfactory correction within 1mm of the desired result was achieved in 95% of lids. The range of eyelid lift was 1 5.5mm. Doxanas 218 recently described a simplified aponeurotic ptosis repair that minimizes surgical dissection and enhances the predictability of postoperative eyelid position. The procedure is applicable in cases of minimal or mild congenital ptosis with good levator function, for the repair of unilateral ptosis, and for reoperation after standard levator surgery. The author cautions that the technique is best suited for surgeons who have a thorough knowledge of the levator aponeurosis anatomy. 218 Jackson 219 describes a simple technique combining conjunctiva and skin for locating the levator muscle in difficult dissections. Anderson 215,216 and Carraway 214 use the preaponeurotic fat to identify the levator aponeurosis in surgical correction of eyelid ptosis. Liu 220 prospectively evaluated 169 ptotic lids whose levator function was >8mm and which were repaired by a single-suture aponeurotic tuck (Fig 39). Correction to within 1mm was achieved in 95% of patients; 12 patients required reoperation. Overcorrection was noted in 3 patients, undercorrection in 6, peaking in 5, 2 had immediate recurrences, and 3 had late recurrences, for an overall complication rate of 7%. Liu s technique is simple and versatile. Fig 39. Suture plication of the lid aponeurosis for correction of upper eyelid ptosis. (Reprinted with permission from Liu D: Ptosis repair by single suture aponeurotic tuck. Ophthalmology 100:251, 1993.) 36

38 Collin and O Donnell 221 recommend adjustable sutures to secure the eyelid in the proper position postoperatively. They also use this technique for repair of eyelid retraction secondary to thyroid disease. Borman and Öscan 57 describe a modification of Collin and O Donnell s adjustable-suture technique (Fig 40) for reattaching the avulsed levator muscle to the Mustardé flap used in the reconstruction. Their modification staggers two rows of sutures across the levator to allow further advancement if necessary and to add more strength to the muscletarsal plate abutment. Fig 40. Top, original levator anchoring technique as described by Collin and O Donnel. Bottom, modified adjustable suture technique for flap retraction. (Modified from Borman H, Õzcan G: Modified adjustable technique to anchor the levator muscle to the flap used in total upper eyelid reconstruction. Br J Plast Surg 51:566, 1998.) Fasanella-Servat Procedure Souther and colleagues 207 detail the technique and applicability of the Fasanella-Servat operation, a milestone in ptosis surgery. In its classic form, the Fasanella-Servat procedure involves resection of conjunctiva, tarsus, and Müller s muscle along the entire length of the everted upper lid (Fig 41). Putterman and Urist, 222 Gavaris, 223 Iliff, 224 and Lauring 225 attempted to circumvent some of the drawbacks of the original Fasanella-Servat procedure by introducing certain modifications. Putterman 226 analyzed his results with Müller s muscle resection for blepharoptosis over a 10-year Fig 41. The upper lid is everted in the Fasanella-Servat operation. (Reprinted with permission from Souther SG, Corboy JM, Thompson JB: The Fasanella-Servat operation for ptosis of the upper eyelid. Plast Reconstr Surg 53:123, 1974.) period and found 90% of lids in the acquired ptosis group and 100% of those in the congenital group were within 1.5mm of the contralateral normal lid; only 2 of 232 treated lids required additional surgery. Candidates for the procedure have upper lids that elevate to near-normal level following instillation of 10% or 2.5% phenylephrine hydrochloride 227 drops into the upper ocular fornix ie, patients with minimal congenital ptosis or variable degrees of acquired ptosis. Guyuron and Davies 228 report excellent results with the Putterman conjunctivo-müllerectomy in the treatment of 43 ptotic eyelids. Glatt, Putterman, and Fett 229 described using the Müller s muscle conjunctival resection in 6 patients with Horner s syndrome and an average 2.3mm ptosis. Even though denervation in Horner s syndrome renders Müller s muscle nonfunctional, conjunctivo-müllerectomy proved effective in correcting ptosis in these patients. Lesavoy et al 230 recently reported yet another modification of the Fasanella-Servat operation that involves horizontal lenticular tarsal plate resection well within the medial and lateral edges of the tarsus. The amount of vertical excision is equal to the degree of ptosis present and should not exceed 4mm. The technique is indicated for use in cases of minimal ptosis (<4mm). Good results were obtained in 6 patients and these have been maintained for 9y or more. The primary advantages of this procedure are lack of disruption of the levator and Müller s muscles, precise correction of the deformity, and theoretically less strain on the muscles 37

39 of elevation of the upper eyelid because of the reduced weight of the tarsus. Mustardé 231 describes a full-thickness, split-level lid resection that includes excision of skin and preseptal muscle anteriorly as well as small, lower segments of levator aponeurosis and Müller s muscle, conjunctiva, and most of the tarsus posteriorly. Atabay et al 232 recommend making the tarsoconjunctival incision 5mm away from the central lid margin, as opposed to 3mm as recommended by Mustardé. They feel that this helps minimize central peaking of the eyelid margin as well as the eyelash line deformity occasionally reported with this technique. Karesh 233 reports surgical correction of severe acquired ptosis in 6 eyelids through an external approach. The technique consists of a multilevel full-thickness resection of eyelid tissue combined with plication of the levator aponeurosis-müller s muscle complex. Fascial Sling Fascial sling procedures are used in patients with severe ptosis who have no levator function. The concept of a fascial sling was first suggested by Payr and Wright and was popularized by Crawford. 234 Since that time numerous modifications have been reported in the literature Pearl s 242,243 variation is designed for use in severe congenital blepharoptosis. His technique consists of direct tarsal fixation, partial lid resection, and a circular sling (Fig 42). 242,243 Holds, McLeish, and Anderson 244 describe the Whitnall sling procedure for severe, unilateral, problematic blepharoptosis. As described, Whitnall s ligament is sutured to the superior portion of the tarsal plate. The authors combine this with superior tarsectomy to enhance the long-term result. Advantages of this technique are said to include the following: can be used as a unilateral procedure preserves the muscular elevating structures of the eyelid is an anatomic procedure with some dynamic eyelid function produces an esthetically pleasing eyelid crease Fig 42. Frontalis fascial sling for correction of upper eyelid ptosis. See text for details. (Modified from Chen TH, Yang JY, Chen YR: Refined frontalis fascial sling with proper lid crease formation for blepharoptosis. Plast Reconstr Surg 99:34, 1997.) Disadvantages include asymmetry of eyelid motility with eyelid retraction in downward gaze; postoperative edema lasting 1 2mo; marked degree of induced lagophthalmos with potential for exposure keratopathy; and technical complexity of the procedure. 244 Frontalis suspension using an alloplastic sling (Supramid) was evaluated by Liu 245 in 81 consecutive patients. The author found it to give only temporary correction for about 1 year, and concluded that it had a limited role in blepharoptosis surgery. BLEPHAROCHALASIS The blepharochalasis syndrome is an uncommon disorder of young people characterized by repeated episodes of eyelid edema that eventually cause a stretching of the supporting structures of the eyelid. In time, this produces the typical clinical features of thin and excessive lid skin, blepharoptosis, pseudoepicanthal folds, prolapse of orbital fat and lacrimal gland, and often disinserted lateral canthal tendons. 246 The etiology of the syndrome is unknown, but there may be autosomal dominant 38