Atlas of Oculoplastic and Orbital Surgery

ATLAS OF
OCULOPLASTIC AND
ORBITAL SURGERY
JONATHAN J. DUTTON, M.D., Ph.D.
University of North Carolina
Chapel Hill, North Carolina, USA
THOMAS G. WALDROP, M.S.M.I.

Illustrator
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Library of Congress Cataloging-in-Publication Data

Dutton, Jonathan J.
Atlas of oculoplastic and orbital surgery / Jonathan J. Dutton ; Thomas G. Waldrop, illustrator. 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4511-4312-6
I. Title.
[DNLM: 1. EyelidssurgeryAtlases. 2. OrbitsurgeryAtlases. 3. Lacrimal Apparatussurgery
Atlases. 4. Ophthalmologic Surgical ProceduresmethodsAtlases. 5. Reconstructive Surgical ProceduresmethodsAtlases. WW 17]
617.7'71dc23
2012011414
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About the Author
About the Illustrator
JONATHAN J. DUTTON, M.D., Ph.D., is professor
THOMAS G. WALDROP, M.S.M.I., received his

Master of Science degree in medical illustration from the
Medical College of Georgia in 1978. He directed the ophthalmic photography and ultrasound section of the Retina
Institute in St. Louis before establishing his medical illustration service in Hillsborough, North Carolina, in 1980.
Since then, he has worked closely with Dr. Dutton on four
atlases and editions on ophthalmic surgery and anatomy.
Mr. Waldrop is an active professional member of the
Association of Medical Illustrators.
and vice chair in the Department of Ophthalmology at

the University of North Carolina at Chapel Hill. He completed his masters and doctorate degrees in zoology and
vertebrate biology, respectively, at Harvard University in
1970. He joined the faculty of Princeton University from
1970 to 1973 as Sinclair Professor of Vertebrate Paleontology and Evolutionary Biology. Between 1965 and 1973,
Dr. Dutton led 10 field expeditions to East Africa and
published widely on vertebrate morphology and mammalian evolution. After receiving his M.D. degree in 1978
and going on to residency training in ophthalmology at
Washington University Medical School, he completed
a fellowship in oculoplastic and orbital surgery at the
University of Iowa. Dr. Dutton joined the faculty at the
Duke University Eye Center from 1983 to 1999. He served
as CEO of the Atlantic Eye and Face Center in Cary North
Carolina from 1999 to 2002 and then joined the faculty at
the University of North Carolina in 2002. He serves on the
editorial board of several ophthalmology journals, and is
Editor-in-Chief of Ophthalmic Plastic and Reconstructive
Surgery. Dr. Dutton specializes in oculoplastic reconstructive and orbital surgery and periorbital and ocular oncology. He has published eight books on ophthalmic surgery,
anatomy, radiology, eyelid, and orbital disease, and has contributed more than 150 peer reviewed articles in scientific
journals.
iii
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Preface
his atlas is an updated version of a book originally published in 1992 as part of a four-volume set on ophthalmic
surgery. That version has been out of print for several years.
In the present version we have updated many procedures,
eliminated some that are no longer in general use, and added
12 new procedures that have gained popularity during the
past decade. As in the original version, this book presents a
visual guide to ophthalmic plastic and reconstructive surgery.
We present basic oculoplastic eyelid, lacrimal, and orbital
procedures in a manner that will provide a quick and readily comprehensible reference. There is no attempt at exhaustive compilation of procedures, many hundreds of which have
been described. Instead, for each group of disease processes
or anatomical conditions we have selected those operations
that have withstood the tests of time and numbers and that
most oculoplastic surgeons have found particularly useful.
We do not intend this book primarily for the trained
oculoplastic specialist who is familiar with a variety of surgical procedures. Rather, we direct it at the less experienced
surgeon in oculoplastic procedures, in particular residents
in training, as well as those who may perform these operations infrequently, such as the general ophthalmologist,
otolaryngologist, dermatologist, and some general plastic
surgeons.
The atlas is organized into three major sections: eyelid surgery, lacrimal system surgery, and orbital surgery.
Most of the eyelid procedures are grouped according to
the disease processes they correct, such as blepharoptosis
or ectropion. Lacrimal drainage operations are grouped
according to the anatomic location of the blockage; for
example punctal, canalicular, and nasolacrimal duct. Deep
orbital operations are arranged mainly by the route of
access into the most important surgical spaces, not by specific pathologic processes.
Each major section or part begins with a discussion of
relevant surgical anatomy, illustrated with sequentially layered figures through the relevant structures. It is difficult to
perform any surgery optimally without a solid understanding of local anatomic and physiologic relationships. These
anatomical chapters provide foundations for understanding the surgical descriptions that follow.
For each group of related procedures, there is a discussion of etiologic pathology and techniques of preoperative
evaluation that are indispensable for planning any surgical approach. The proper selection of a specific operation
for any given disease or malposition often means the difference between success and failure. Therefore, the text
includes key points that will help the reader plan the most
appropriate operation and minimize unnecessary complications. We conclude each section with a short list of
selected references for those interested in further readings.
Following the general discussion of the disease or condition, we detail our approach to the operative techniques in
stepwise fashion, with captioned text on the left-hand page
and matching illustrations on the right-hand page. In the
original version of this book, we introduced the concept
of inverting the figures. Again, here, we depart from the
standard approach of illustrating oculoplastic procedures
facing the patient in the upright position. Rather, we draw
illustrations from the view as seen by the operating surgeon, which in most cases is standing at the patients head.
The image is thereby seen upside-down, but best approximates the view seen by the surgeon. For some operations,
such as dacryocystorhinostomy or lateral orbitotomy, the
view is from the side, again approximating the surgeons
perspective. We believe that this eases the transition from
the printed page to the operating table.
In a few cases, certain eponyms are so intrinsic to the
literature that deleting them would be confusing. For the
most part, however, eponyms are nondescriptive and convey little useful information. Therefore, we have elected to
replace most of them with more anatomically meaningful
descriptive terms. For each operation, we also include a
brief list of the most appropriate indications and, in some
cases, contraindications. Following a description of the
technique, we indicate appropriate postoperative care. In
addition, we list the most common potential complications, along with a brief discussion of how to avoid and
correct them.
The number of individuals who have contributed innovative approaches to the field of oculoplastic and reconstructive surgery is legion, and useful modifications of
older procedures frequently appear in the literature. Few
operations described in this book are new, and in most
cases, we have merely compiled the cumulative experiences of our colleagues. We are indebted to their vision
and dedication.
Jonathan J. Dutton, M.D., Ph.D., and
Thomas G. Waldrop, M.S.M.I.
iv
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Contents
About the Author/About the Illustrator
Preface
iv
PART I
Eyelid Surgery
A. Anesthesia
iii
23. External Levator Aponeurosis Advancement

88
24. Supra-Whitnalls Ligament Levator
Muscle Resection
92
25. Harvesting Autogenous Fascia Lata
96
26. Frontalis Muscle Suspension with Autogenous
Fascia Lata
98
27. Frontalis Muscle Suspension with Silicone
Rod
102
1. Anesthesia in Ophthalmic Plastic Surgery
B. Surgical Anatomy of the Eyelids

2. Eyelid Anatomy
H. Ectropion
C. Hordeolum and Chalazion
25
3. Chalazion Incision and Drainage, Transcutaneous

Approach
26
4. Chalazion Incision and Drainage, Transconjunctival
Approach
28
D. Trichiasis and Distichiasis
30
5. Cryosurgery for Trichiasis

32
6. Radiosurgery for Trichiasis
34
7. Internal Eyelash Bulb Resection
36
E. Cosmetic Blepharoplasty
8.
9.
10.
11.
12.
13.
14.
Etiology and Associated Deformities

40
Upper Eyelid Blepharoplasty with Fat Excision
42
Asian Upper Eyelid Blepharoplasty
46
Rexation of Lacrimal Gland Prolapse
48
Reformation of the Upper Eyelid Crease
50
Lower Eyelid Blepharoplasty with Fat Excision
52
Lower Eyelid Blepharoplasty with Fat
Redraping
56
15. Lower Eyelid Blepharoplasty with Eyelid
Shortening
60
16. Lower Eyelid Blepharoplasty with Lateral
Canthopexy
64
17. Transconjunctival Excision of Lower Eyelid
Herniated Orbital Fat
68
F. Brow Ptosis
70
18. Direct Brow Elevation

72
19. Transblepharoplasty Endotine Brow Fixation
20. Endoscopic Forehead Elevation
76
G. Blepharoptosis
80
21. Posterior Tarsoconjunctival Resection

(Fasanella-Servat)
84
22. Posterior Mllers MuscleConjunctival
Resection
86
28. Lateral Tarsorrhaphy

106
29. Eyelid Shortening by Lateral Tarsal Strip
Fixation
108
30. Medial Spindle Tarsoconjunctival
Resection
110
31. Full-thickness Marginal Wedge Resection
32. Modied Lazy-T Procedure
114
33. Medial Canthal Ligament Plication
116
34. Temporal Fascia Lower Eyelid Suspension
35. Anterior Lamellar Eyelid Lengthening
with Skin Graft
120
I. Entropion
38
74
104
112
118
123
36. Full-thickness Eyelid Sutures

(Quickert-Rathbun)
126
37. Modied Full-thickness Eyelid Sutures
forEpiblepharon Repair
128
38. Lower Eyelid Crease Reformation for Epiblepharon
Correction
130
39. Lower Eyelid Retractor Reinsertion
132
40. Retractor Reinsertion with Horizontal
EyelidShortening
134
41. Retractor Reinsertion with Lateral Tarsal Strip
Fixation
136
42. Anterior Lamellar Shortening with Epitarsal
MuscleFixation
138
43. Marginal Eyelid Rotation by Anterior
HorizontalTarsalGroove Resection
140
44. Horizontal Blepharotomy with Marginal Eyelid
Rotation (Wies Procedure)
142
45. Posterior Lamellar Eyelid Lengthening with
Free Tarsoconjunctival, Scleral, or Cartilage
Graft
144
46. Posterior Eyelid Lengthening with Mucous
MembraneGraft
146
J. Correction of Eyelid Retraction
148
47. Levator Aponeurosis Recession with Mllers

Muscle Extirpation
150
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vi
Contents
48. Lower Eyelid Retractor Disinsertion with Scleral
Graft
154
49. SMAS Midface Elevation and Fixation
156
K. Repair of Supercal Non-marginal

Eyelid
158
50. Simple Direct Closure of an Elliptical Skin
Defect
160
51. Myocutaneous Advancement Flap
162
52. Myocutaneous Rotation Flap
164
53. Myocutaneous Transposition Flap
166
54. Rhombic Flap
168
55. Z-plasty Transposition Flap
170
L. Upper Eyelid Reconstruction
172
56. Direct Layered Closure of Marginal Eyelid

Defects
174
57. Lateral Semicircular Rotation Flap (Tenzel)
176
58. Horizontal Tarsoconjunctival Transposition
Flap
178
59. Free Tarsoconjunctival Graft
180
60. Lower Eyelid Single Bridged Advancement Flap
(Cutler-Beard)
182
61. Lower Eyelid Double Bridged Advancement
Flap
184
M. Lower Eyelid Reconstruction
186
62. Lateral Semicircular Rotation Flap with Periosteal

Fixation
188
63. Free Tarsoconjunctival Graft and Myocutaneous
Advancement Flap
190
64. Upper-to-lower Eyelid Tarsoconjunctival
Advancement Flap (Hughes Procedure)
192
N. Medial and Lateral Canthal

Reconstruction
196
65. Reduction of Epicanthal Folds
with Y to V Advancement Flap
198
66. Reduction of Epicanthal Fold
by Four-ap Technique
200
67. Lateral Augmentation Canthoplasty
202
68. Lateral Reduction Canthoplasty
204
69. Correction of Vertical Canthal Angle
Dystopia
206
70. Glabellar Rotation Flap
208
71. Median Forehead Transposition Flap
210
PART II
Lacrimal Drainage System

Surgery
213
A. Surgical Anatomy of the Lacrimal Drainage

System 215
72. Surgical Anatomy of the Lacrimal Drainage
System
216
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B. Surgery on the Lacrimal Puncta and

Canaliculi
220
73. Two-snip Punctoplasty
222
74. Repair of Canalicular Lacerations
224
75. Canalicular Reconstruction
228
C. Surgery on the Lacrimal Sac and

Duct
230
76. Nasolacrimal System Probing, with Infracturing
oftheInferior Turbinate
232
77. Nasolacrimal System Probing with Silicone
Intubation Stents
234
78. Nasolacrimal System Balloon Dacryoplasty
236
79. Dacryocystorhinostomy
238
80. Canaliculodacryocystorhinostomy
242
81. Conjunctivodacryocystorhinostomy
244
PART III
Orbital Surgery
247
A. Surgical Anatomy of the Orbit

82. Surgical Anatomy of the Orbit
B. Orbitotomy Procedures
250
252
270
83. Transcutaneous, Transseptal Anterior

Orbitotomy
272
84. Transcutaneous, Transperiosteal Anterior
Orbitotomy
274
85. Lateral Orbitotomy
276
C. Surgery on the Orbital Walls
281
86. Orbital Decompression, Inferior

and Medial Walls
284
87. Orbital Decompression, Transcaruncular Medial
Wall
290
88. Orbital Decompression, Transconjunctival
InferiorWall
292
89. Orbital Decompression, Lateral Wall
294
90. Repair of Orbital Floor Fracture
296
91. Miniplate Fixation for Orbital Rim Fracture
298
92. Subperiosteal Orbital Volume
Augmentation
300
D. Enucleation, Evisceration,
andExenteration 302
93. Enucleation with Primary Acrylic or Silicone
Implant
306
94. Enucleation with Biointegrated Porous Ocular
Implant
310
95. Dermis-fat Orbital Implant Graft
312
96. Repair of the Exposed Ocular Implant
314
97. Evisceration
316
98. Orbital Exenteration
318
Index
321
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I
Eyelid
Surgery
Dutton_Chap01.indd 1
HE EYELIDS ARE COMPLEX ANATOMIC STRUCTURES THAT PERFORM A VITAL
function of ocular protection. They provide a mechanical barrier against sunlight and foreign material. The eyelids also contribute to the physiologic maintenance of the corneal surface and precorneal tear lm. Adequate function of the
eyelids requires the integrity of numerous structural components, proper alignment
with the globe, and the coordination of several different neuromuscular groups.
Many congenital and acquired deformities can affect the eyelids. Some result from
normal aging phenomena such as canthal ligament laxity, involutional ptosis, prolapse
of orbital fat, or redundancy of eyelid skin. Others may follow traumatic injury or be
associated with periocular manifestations of systemic diseases, such as thyroid orbitopathy. When mild, as with minimal ptosis, or dermatochalasis, these deformities may
be of cosmetic concern only. When severe, however, they may signicantly interfere
with vision. In some cases, eyelid malpositions or deformities may cause corneal injury
and permanent loss of vision. It is important to remember that some eyelid abnormalities result from deeper orbital pathologic processes. Thus, subtle proptosis can mimic
eyelid retraction, and enophthalmos may initially be confused with ptosis.
Complete evaluation of the eyelid and the orbit is essential before consideration of
any oculoplastic operation. As with all ophthalmic procedures, a best-corrected visual
acuity must be recorded before proceeding further with any examination. A complete
medical and ophthalmic history is taken, and a current list of medications is noted.
There is some disagreement in the literature regarding the need to stop anticoagulation
therapy prior to oculoplastic surgery. These days as many as 60% of individuals may be
on such medications, most of them for nonmedical reasons. Most often, this may be
a low-dose aspirin for prophylactic purposes. In such cases, it is reasonable to ask the
patient to discontinue aspirin use 7 to 10 days prior to surgery. However, if the patient
is on anticoagulation for medical reasons, such as recently placed arterial stents, pulmonary embolism, recent stroke, or deep venous thrombosis, then the risks of bleeding
must be weighed against the risk of a thromboembolic event. For procedures with a
low risk of bleeding and negligible consequences such as ptosis or blepharoplasty, and
a higher risk of thromboembolism, it is usually best not to discontinue anticoagulation.
This approach has been documented extensively in the surgical literature. On the other
hand, for cases at higher risk of bleeding or those with a greater consequence from
bleeding, such as deep orbital surgery or procedures on vascular tumors, if the risk of
thromboembolism is low to moderate, it may be possible to stop anticoagulation with
or without bridge therapy, with the consultation of the patients cardiologist or primary
8/3/2012 6:46:00 PM
care physician. In cases at high risk for both bleeding and a thromboembolic event, it
may be better to postpone the surgery until the patient can more safely be taken off
these medications.
The eyelids are examined in the primary position and in all other positions of gaze.
The height, contour, tone, and orientation of the eyelid margins are noted. Levator
muscle function, associated dystonic movements, and synkinetic contractions with
ocular motility or facial movements are carefully documented. Unsuspected anterior
orbital pathologic processes may be revealed by palpation and eversion of the eyelids. A slit lamp examination is essential to determine either ocular surface or anterior
segment disease that may result in secondary eyelid dysfunction, or to establish the
extent of corneal injury from eyelid malpositions. A Schirmers test for baseline tear
production is important in estimating the potential effect of eyelid repair, especially in
elderly patients. Specialized tests must be employed for certain disease states, such as
the Jones tests in lacrimal drainage disorders and orbital radiology or echography for
suspected orbital extension of eyelid lesions.
For most cases where oculoplastic surgery may be indicated, preoperative photographs should be taken for documentation and are usually required for third-party
reimbursement. In cases of eyelid and brow ptosis, visual eld testing is important for
documentation and is usually done with the brows in normal position and elevated.
In cases of traumatic loss or surgical injury from excision of tumors, the size and
location of the defect are recorded, as is any involvement of associated structures, such
as the levator aponeurosis, canthal ligaments, or the lacrimal drainage system. The
visual status of the opposite eye and the condition of adjacent tissues, including laxity
or the presence of any pathologic process, must be noted because these may affect the
choice of operative technique.
In all cases of eyelid reconstruction, choosing the appropriate surgical procedure is
critical to successful treatment. Numerous etiologies may be responsible for any anatomic disorder, and each may require a different approach to therapy. In some cases,
medical management may be more appropriate than surgical intervention. Therefore,
in the sections below, we discuss the specic causes of each condition and attempt to
provide some rationale for determining the most suitable operation. Where appropriate for each disorder, there is further discussion of preoperative evaluation and specic
diagnostic tests.
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SECTION
Anesthesia
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1
T
Anesthesia in Ophthalmic Plastic Surgery
he general principles of surgical anesthesia apply in

ophthalmic plastic procedures as in any other surgery.
Presurgical evaluation, including a detailed medical history
and current medications list, is mandatory for determining
patient risk. Patients with hypertension, diabetes, and other
systemic illnesses should be under adequate control before any
elective operations. The patient's age, level of apprehension,
and ability to cooperate and the nature and potential length of
the operative procedure will influence the type of anesthesia
selected. For all local monitored and general anesthetic cases,
the anesthesiologist should participate fully in the preoperative evaluation and in the intraoperative care of the patient.
Successful surgery depends on not only surgical skill and
technique but also patient comfort and cooperation and
on minimizing intraoperative and postoperative bleeding.
This is especially important in oculoplastic surgery where
the majority of procedures are performed under local anesthesia with monitored anesthesia care. Premedication for
both local and general anesthesia will relax the patient
and allay inevitable anxiety. This is usually managed by
the anesthesiologist in all general and local standby cases
performed in a hospital or surgicenter setting. For office
procedures, a mild sedative such as 5 or 10 mg of valium
given by mouth 60 minutes before surgery may be used if
desired.
Topical anesthesia can minimize the discomfort associated with local injection of anesthetic agents. EMLA
(topical lidocaine 2.5% and prilocaine 2.5%) applied 30
to 60 minutes before the procedure or ice compresses for
10 minutes can reduce the pain of local needle injection.
General anesthesia is necessary for young children
and preferred for adults undergoing lengthy procedures
or deeper orbital surgery. It is also useful when surgery is
planned on multiple sites, as with harvesting oral mucosa or
large skin grafts. Although certain procedures such as enucleation are easily performed with local or regional anesthetic, the emotional trauma of losing an eye often makes
general anesthesia preferable in most cases. The choice of
any general anesthetic agent is usually left to the discretion of the anesthesiologist. This will be determined by the
patient's age, general medical condition, and prior anesthetic history. The anesthesiologist should be requested
to maintain systemic blood pressure within the normal
to low-normal range during surgery. For more extensive
dissections or for orbital procedures, blood pressures in
the hypotensive range may be beneficial, especially when
anticipating vascular lesions. However, many procedures
traditionally performed under general anesthetic can be
performed equally as well with local infiltration or regional
nerve blocks. These include dacryocystorhinostomy, ante-
rior orbitotomy, placement of a secondary ocular implant,

and most eyelid reconstructions.
A small amount of local anesthetic with epinephrine
injected into the operative site will facilitate hemostasis
and make the surgery considerably easier. This is recommended even on general cases. Local infiltrative or retrobulbar anesthetic with epinephrine is administered 5 to
10 minutes before surgery. With orbital procedures, such
as enucleation, this will allow a nearly bloodless dissection
and will reduce the risk of vagal-induced bradycardia during traction on the extraocular muscles. We avoid the use
of epinephrine on other orbital cases so that we can monitor pupillary reaction during the case.
Regional and local anesthetic agents work by blocking
sodium conduction and inhibiting membrane excitation
in peripheral nerves. With the exception of cocaine, these
agents cause vasodilatation and are therefore usually mixed
with epinephrine in a concentration of 1:100,000 or less for
local hemostasis. The surgeon must be aware of the potential systemic effects and toxic doses of local anesthetics,
especially in major reconstructive procedures where larger
amounts must be used. Toxicity is generally manifest by
cardiac dysfunction and cortical inhibitory neuron blockade with central nervous system excitation. The patient may
experience syncope and become agitated and uncooperative. Self-limited focal seizures may follow. At higher toxic
levels, depression of autonomic centers may lead to apnea
and hypotension requiring full cardiopulmonary support.
The maximum safe limit for initial injection of 2% lidocaine
is about 15 mL (4 mg/kg). In the presence of epinephrine,
this can be increased to 20 mL. If additional anesthetic
is required during the case, no more than 5 to 10 mL/h
should be administered. For 1% lidocaine, these values can
be doubled. Allergic reactions to local anesthetic agents are
rare and manifest as rashes, hives, edema, dyspnea, tachycardia, and hypotension. In most cases, these are managed
with corticosteroids and antihistamines.
Epinephrine is usually added to the local anesthetic
because of its vasoconstrictive properties. This not only
provides hemostasis but also helps to slow the absorption of
the infiltrative agent, thus prolonging its duration of action.
The typical dilution in most anesthetic agents is 1:100,000
to 1:200,000. This can be associated with potential systemic
complications including apprehension, tremor, tachycardia,
and extra systoles as possible sequelae. Elevation of blood
pressure may lead to excessive bleeding. The use of epinephrine should be limited or omitted in patients with significant hypertension or a known history of cardiac arrhythmia.
Dilution to 1:400,000 will reduce systemic complications
without significantly reducing its local hemostatic effect.
8/3/2012 6:46:01 PM
CHAPTER 1 Anesthesia in Ophthalmic Plastic Surgery

Local anesthesia is appropriate for most ophthalmic
plastic procedures and may be used in cooperative children as young as 6 years of age. Agents are usually of the
amino amide class with a rapid onset of action and duration of action of 1 to 4 hours. We prefer to use lidocaine 2%
with 1:100,000 epinephrine mixed 50:50 with bupivacaine
0.75%. This gives anesthesia for 4 to 8 hours with minimal
epinephrine side effects. Adequate topical anesthetic to the
corneal surface should be used throughout local surgery
with topical proparacaine or tetracaine.
The major site of local anesthesia used in oculoplastic
eyelid surgery is the pretarsal subcutaneous block. It provides excellent anesthesia to the anterior lamella, including
the skin, orbicularis muscle, and orbital septum, and also
the anterior tarsal surface. The posterior tarsal surface and
conjunctiva usually remain sensitive. It is important to use
as little anesthetic agent as possible to avoid tissue distortion. In general, 0.5 to 1.0 mL is sufficient for most unilateral
eyelid procedures such as correction of ptosis, entropion
repair, or blepharoplasty. Massage of the area immediately
following injection will help disperse the bolus and prevent
hematoma. The use of hyaluronidase in the local anesthetic
will further disperse the bolus and restore the eyelid to
near-normal anatomy prior to incision.
When anesthesia is needed for surgery on the palpebral conjunctiva or posterior tarsal surface, a retrotarsal
block is indicated. In this procedure, the local anesthetic
is injected subconjunctivally along the proximal tarsal border or subconjunctivally in the fornix. This block does not
anesthetize the skin or orbicularis muscle so that for fullthickness eyelid procedures the retrotarsal block must be
combined with subcutaneous infiltration. With injection
into Mller's muscle, bleeding is more common and digital
pressure over the injection site should be maintained for
several minutes.
Orbital nerve blocks, such as frontal, supratrochlear,
or infraorbital, provide excellent regional anesthesia
without distortion of tissues but do not allow for local
epinephrine-induced hemostasis. When placed into the
anterior orbit, they also carry the risk of orbital hemorrhage
and paralysis of orbital muscles, such as the levator muscle,
whose full function may be needed during the operation. If

desired, orbital nerve blocks should be given at their foraminal exit points around the bony orbital rims rather than
deeper in the orbit.
Inhalation anesthesia with nitrous oxide or other agents
is useful for short procedures in children and in adults
where infiltrative or full general anesthesia is not desirable.
It may also be used prior to local anesthetic infiltration to
avoid the use of narcotics and sedatives in elderly patients
or in those with cardiovascular diseases.
SUGGESTED FURTHER READING
Bramhall J. Regional anesthesia for aesthetic surgery. Semin Cutan Med
Surg. 2002;21:326.
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831844.
Harmatz A. Local anesthetics: uses and toxicities. Surg Clin N Am.
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Kaweski S. Topical anesthetic creams. Plast Reconstr Surg. 2008;121:
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Quaba O, Huntley JS, Bahia H, McKeown DW. A users guide for reducing the pain of local anesthetic administration. Emerg Med J. 2005;
22:188189.
Ramos-Zabala A, Perez-Mencia MT, Fernandez-Garcia R, et al. Anesthesia
techniques for outpatient laser resurfacing. Lasers Surg Med. 2004;
34:269272.
Sarfakioglu N, Sarfakioglu E. Evaluating the effects of ice application
on the pain felt during botulinum toxin type-a injections: a prospective randomized, single-blind controlled trial. Ann Plast Surg.
2004;53:543546.
Shapiro FE. Anesthesia for outpatient cosmetic surgery. Curr Opin
Anaesthesiol. 2008;21:704710.
Suresh S, Voronov P. Head and neck blocks in children: an anatomical and
procedural review. Paediatr Anaesth 2006;16:910918.
Thorne AC. Local anesthetics. In: Aston SJ, Beasley RW, Thorne CHM,
eds. Grabb and Smith's Plastic Surgery. Philadelphia, PA: LippincottRaven; 1997:99103.
8/3/2012 6:46:01 PM
SECTION
Surgical Anatomy of the

Eyelids
7/16/2012 9:19:00 AM
2
S
Eyelid Anatomy
urgery on the eyelids and periorbital tissues requires a

thorough knowledge of normal anatomic structural and
functional relationships. Numerous anatomic systems are
tightly juxtaposed within a very small space, and even under
ideal circumstances normal anatomy may be difficult to interpret. Successful surgery demands correction of pathologic
states while preserving or reconstructing normal structures
whenever possible.
The interpalpebral fissure measures 9 to 12 mm in
vertical height and 28 to 30 mm in horizontal extent. In
primary position of gaze, the normal upper eyelid margin
lies at the superior corneal limbus in children and 1.5 to
2 mm below it in the adult. The marginal contour reaches
its highest point just nasal to the midpupil. The lower eyelid margin normally rests at the inferior corneal limbus.
These relationships must be kept in mind during repair or
reconstruction of eyelid malpositions.
The upper eyelid crease is a horizontal fold in the skin
caused by attachments of superficial levator aponeurotic
fibers to orbicularis intermuscular septa. Normally the
crease lies 8 to 10 mm above the eyelid margin. In nonAsian eyelids, this crease should be reformed during ptosis or blepharoplasty surgery to maintain normal cosmetic
appearance and to prevent overhang of eyelid skin. In the
Asian eyelid, this crease is either lower in position or absent,
because of the more distal insertion of the orbital septum
and the inferior extension of extraconal orbital fat. A less
well-defined crease is present in the medial two-thirds
of the lower eyelid. These creases are important in eyelid
function, as they maintain a union of the anterior and posterior eyelid lamellae. This prevents overhang of skin and
mechanical entropion or secondary epiblepharon. During
any procedure on the eyelids in which the skinmuscle
lamella is elevated from underlying tissues, reformation of
this crease is important to avoid these complications.
The orbicularis oculi is a complex, striated muscle
sheet lying just beneath the eyelid skin. It is innervated by
the temporal and zygomatic branches of the facial nerve,
with some variable contribution from the buccal branch.
The muscle is divided anatomically into an orbital portion
overlying the bony orbital rims and a palpebral portion
within the mobile portion of the eyelid. The latter is further somewhat arbitrarily subdivided into a preseptal portion overlying the orbital septum and a pretarsal portion
overlying the tarsus. The pretarsal portion ends medially
and laterally in slips that pass posterior to the main insertions of the preseptal fibers. These slips form components
of the posterior crura of the canthal ligaments and tighten
the eyelids against the globe. The medial slip is especially
well developed and forms a distinct structure known as
Horner's muscle. Reconstruction in the canthal areas must

take these relationships into consideration. Normal tone in
the orbicularis muscle is essential, not only for proper eyelid closure and apposition to the cornea but also for functioning of the lacrimal pump mechanism. This is especially
true for the lower eyelid, where gravitational effects acting upon even minimal eyelid laxity or orbicularis muscle
weakening may result in symptomatic ectropion.
The postorbicular fascial plane is an avascular, loose
areolar tissue layer between the orbicularis muscle and
the orbital septumlevator aponeurosis fascial complex.
It anatomically separates the eyelid into an anterior skin
muscle lamella and a posterior tarsoconjunctival lamella.
It is an important surgical reference plane during eyelid surgery, and it allows nearly bloodless dissection and
identification of the underlying orbital septum. This plane
extends to the eyelid margin where it is represented as the
gray line. Occasionally, the subbrow fat pad may extend
into the upper eyelid within this plane where it overlies the
orbital septum. In such cases, it may be misidentified as
the preaponeurotic fat pockets that are situated posterior
to the septum. When this happens, the septum might be
thought to be the aponeurosis, which could have disastrous
consequences in some surgical procedures.
The orbital septum is a thin, connective tissue membrane that separates the eyelid proper from the orbit.
It originates around the bony orbital rim where it arises
from a dense fibrous adhesion ring, the arcus marginalis.
The latter is the point of confluence of the facial periosteum, orbital periorbita, the galea aponeurotica from the
forehead and scalp, and the orbital septum. Superiorly, the
septum passes into the upper eyelid, where it inserts onto
the levator aponeurosis 3 to 5 mm above the upper tarsal
border in Caucasians, and lower in Asians. In the lower
eyelid, the septum usually inserts directly onto the inferior
edge of the tarsus, where it fuses with the capsulopalpebral
fascia, although it may insert onto the latter prior to joining the tarsal plate. These relationships are important to
note because advancement of the aponeurosis or capsulopalpebral fascia without first separating the septum could
cause a tethering of the lid to the orbital rim with resultant
lagophthalmos. At the canthal angles, the septum divides
into two layers. The anterior layer inserts onto the fibrous
canthal ligament, and the posterior layer passes back in
company with the deep heads of the orbicularis muscle to
insert onto the posterior lacrimal crest medially and the
orbital tubercle laterally.
The preaponeurotic fat pockets in the upper eyelid and
the precapsulopalpebral fat pockets in the lower eyelid
are anterior extensions of extraconal orbital fat. They are
7/16/2012 9:19:00 AM
SECTION B Surgical Anatomy of the Eyelids
surgically important landmarks because they help identify

a plane immediately anterior to the major eyelid retractors.
In the upper eyelid, these fat pockets lie just in front of the
levator aponeurosis, thus creating a relationship that is
essential to remember during eyelid surgery under general
anesthesia, or in cases of eyelid trauma where other normal
anatomic relationships may be distorted. With weakening
and redundancy of the orbital septum, these fat pockets
bulge forward, producing the puff y and baggy eyelids seen
commonly in the elderly and as a familial trait in some
younger individuals.
In the upper eyelid, the levator palpebrae superioris
muscle arises from the lesser sphenoid wing and passes
forward in close approximation to the superior rectus
muscle. Just behind the superior orbital rim, the levator muscle widens, and a variably thickened condensation is seen in the muscle sheath. This structure runs
horizontally across the superior orbit both anterior and
posterior to the levator muscle. It attaches medially to
the fascia around the trochlea and to the surrounding
orbital bone. Laterally it inserts onto the capsule of the
lacrimal gland and to the periosteum of the frontal bone.
This structure forms the superior transverse orbital ligament of Whitnall and provides support for the eyelid and
levator aponeurosis and for the anterior portion of the
extensive superior orbital fascial system. Except in some
older levator resection procedures, this ligament should
never be cut.
At Whitnall's ligament, the levator muscle passes into
its fibrous aponeurosis, which continues downward some
14 to 20 mm to the tarsus. Near the upper tarsal border,
the aponeurosis sends slips forward to insert onto the
intermuscular septa of the pretarsal orbicularis muscle.
As mentioned earlier, on retraction of the lid, these slips
pull on the muscle and skin to form the eyelid crease. The
aponeurosis inserts into the tarsus along the lower twothirds of its anterior surface, but most significantly along
the lower one-third. Distally, the aponeurosis broadens
into the medial and lateral horns, which insert behind
the canthal ligaments. These are usually cut during levator
muscle resection surgery and with large advancements of
the aponeurosis, and they must not be confused with the
more superior attachments of Whitnall's ligament.
In the lower eyelid, the capsulopalpebral fascia is a
fibrous, sheet-like extension from Lockwood's inferior
orbital suspensory ligament and is the analogue of the levator aponeurosis. Lockwood's ligament is a condensation of
the coapted sheaths around the inferior rectus and inferior
oblique muscles and their pulley systems and traverses the
inferior orbit. The capsulopalpebral fascia passes upward
to insert onto the lower border of the tarsus along with
the inferior orbital septum. Fine, fibrous slips pass from
this fascial sheet to the orbicularis intermuscular septa,
thus forming the lower eyelid crease. Medially and laterally broad extensions contribute to the posterior crura of
the canthal ligaments, as do slips from the superior septum
and the horns of the aponeurosis in the upper eyelid.
Immediately posterior to the levator aponeurosis in the

upper eyelid and the capsulopalpebral fascia in the lower
eyelid is the sympathetic smooth muscle of Mller. This
is an accessory retractor of the eyelid and is responsible
for the minimal upper eyelid ptosis and lower lid elevation
seen in patients with Horner's syndrome. In the upper eyelid, Mller's muscle is a thin, highly vascular sheet arising
from Whitnall's ligament and the distal-most fibers of the
levator muscle. It extends to the upper border of the tarsal
plate. A fine membrane extends downward from Mller's
muscle anterior to the tarsus and may be considered as
its tendon. In the lower eyelid, Mller's muscle is less well
developed and may be difficult to identify intraoperatively.
The tarsal plates consist of dense, fibrous tissue that
gives structural integrity to the eyelids. A replacement
for this structure is important in reconstructive procedures, especially in the lower eyelid. The vertical height of
the plate is 8 to 10 mm in the upper eyelid and 3 to 4 mm
in the lower. Medially and laterally the tarsus passes into
fibrous strands that, with the superficial and deep heads
of the orbicularis muscle, form the canthal ligaments. The
lateral canthal ligament is especially flimsy and with age
frequently becomes redundant, thus causing laxity of the
lower eyelid. Reestablishment of lateral canthal support is
essential in reconstruction of the lower eyelid and in correction of involutional laxity to successfully counter the
effects of gravity.
The conjunctiva is a mucous membrane that covers the
posterior surface of the eyelids. The palpebral portions lie
immediately posterior to the tarsal plates and the sympathetic muscles of Mller and continue into the fornices,
where they join the bulbar conjunctiva. At the superior
fornix is a suspensory ligament, which consists of fascial
strands and smooth muscle cells arising from the conjoined sheaths of the levator and superior rectus muscles.
The inferior fornix suspensory ligament arises from Lockwood's ligament. These suspensory structures must be
reconstructed during certain procedures to prevent conjunctival prolapse.
Vascular supply to the eyelids is extensive. The posterior
eyelid lamellae receive blood primarily via the lacrimal and
nasal branches of the ophthalmic artery, with anastomotic
connections from the anterior ciliary arteries through the
conjunctiva. In the upper eyelid, two arterial arcades are
present: the marginal arcade along the lid margin and the
peripheral arcade along the upper border of the tarsus. In
the lower eyelid, usually only a marginal arcade is present,
and a peripheral arcade may be seen as a variant. In each
eyelid, the arcades are fed by the medial and lateral palpebral arteries. Whenever possible, at least one of these
feeding vessels should be preserved during eyelid reconstructive procedures, although vascular compromise is
rarely seen even when both feeding vessels are sacrificed.
The anterior eyelid lamellae also receive blood from the
superficial carotid system through the transverse facial,
superficial temporal, and angular arteries, which anastomose with the deep orbital system near the medial and
7/16/2012 9:19:00 AM
CHAPTER 2 Eyelid Anatomy

lateral origins of the arcades. The venous system from the
eyelids is more diffuse and drains into both the anterior
facial vessels and the deep orbital system via the superior
ophthalmic vein.
The sensory nerve supply from the eyelids passes to
the gasserian ganglion via the ophthalmic and maxillary
divisions of the trigeminal nerve. Sensory information
from the central upper eyelid is carried in the supraorbital nerve and from the medial upper eyelid in the supratrochlear and infratrochlear nerves. All three nerves
pass backward to join the ophthalmic division. Terminal branches of the lacrimal nerve receive sensory input
from the lateral portion of the upper lid. Two additional
branches, the zygomaticotemporal and zygomaticofacial
nerves, carry sensory information from the temple and
lateral canthal regions, respectively. These nerves penetrate the lateral orbital wall through small foramina to
join the zygomatic nerve within the orbit, and the latter passes backward to unite with the infraorbital nerve.
Sensory innervation from the lower eyelid stems mainly
from the maxillary division of the trigeminal nerve via
the infraorbital nerve, with some contributions from the
infratrochlear nerve medially.
The motor supply to the orbicularis muscle comes from
the facial nerve via its temporal and zygomatic branches
and frequently also contains anastomotic connections
from the buccal branch. These anastomotic connections
form an arborizing pattern laterally, where they may be
injured during lateral canthal and eyelid reconstructive
procedures. The levator muscle receives motor innervation
from the superior division of the oculomotor nerve, and

Mller's muscle receives diffuse sympathetic branches primarily via the internal carotid system along various orbital
nerves and arteries.
Lymphatic vessels are present in the eyelids and conjunctiva. Drainage is inferior and lateral into the deep and
superficial cervical node systems. The lateral two-thirds of
the upper eyelid and the lateral one-third of the lower eyelid drain laterally into the superficial parotid preauricular
nodes. The medial one-third of the upper eyelid and medial
two-thirds of the lower eyelid drain inferiorly to the submandibular nodes. However, recent studies suggest a more
diffuse drainage pattern where almost all regions around
the eye may drain into the preauricular nodes. Extensive
excision of subcutaneous eyelid tissues or deep incisions in
the inferolateral eyelid area may result in persistent lymphedema due to disruption of these vessels.
The lacrimal drainage system establishes a complex relationship with the medial canthal ligament, thus complicating surgery in this region. The puncta are situated on the
eyelid margins 6 to 8 mm lateral to the medial canthal angle.
They pass into the canaliculi, which run immediately in
front of the anterior fibrous crura of the canthal ligament,
and are surrounded by a band of short, muscular fibers
known as the muscles of Riolan. Anatomically the latter are
part of the pretarsal orbicularis muscle. The lacrimal sac lies
in a bony fossa separated from the nose by the thin lacrimal
bone. Slips of the orbicularis muscle insert onto and around
the sac and, together with the muscles of Riolan and Horner's muscle, contribute to the lacrimal pump mechanism.
7/16/2012 9:19:00 AM
10

FIG. 2.1. External anatomy of eyelids and periorbital structures. 1, Superior sulcus
(eyelid crease). 2, Superior marginal cilia. 3, Lateral canthal angle. 4, Lacrimal puncta.
5, Malar fold (zygomatic furrow). 6, Inferior eyelid crease. 7, Plica semilunaris. 8, Medial
canthal angle. 9, Caruncle. 10, Nasojugal fold.
FIG. 2.2. Supercial facial and orbicularis oculi muscles. 1, Frontalis muscle.
2, Procerus muscle. 3, Corrugator supercilii muscle. 49: Orbicularis muscle. 4, Superior
orbital portion. 5, Superior preseptal portion. 6, Superior pretarsal portion. 7, Inferior
pretarsal portion. 8, Inferior preseptal portion. 9, Inferior orbital portion. 10, Medial
canthal ligament.
FIG. 2.3. Details of medial canthal insertions of the orbicularis oculi muscle
in the lower eyelid. 1, Muscle of Riolan. 2, Horner's muscle (deep head of pretarsal
portion). 3, Lacrimal sac. 4, Superior head of pretarsal portion. 5, Supercial head of
preseptal portion. 6, Supercial head of orbital portion.
7/16/2012 9:19:00 AM
11
FIG. 2.1
2
3
8
4
9
5
10
6
FIG. 2.2
FIG. 2.3
1
2
3
4
1
2
7
8
5
6
9
10
7/16/2012 9:19:00 AM
12

FIG. 2.4. Orbital septum and preaponeurotic fat pads. The orbicularis muscle is
removed, and the orbital septum is opened to reveal the preaponeurotic fat.
1, Cut edge of the superior orbital septum. 2, Lacrimal gland. 3, Superior tarsal plate.
4, Inferior tarsal plate. 5, Cut edge of the inferior orbital septum. 6, Superior central fat
pad. 7, Superior medial fat pad. 8, Levator aponeurosis. 9, Capsulopalpebral fascia.
10, Inferior medial fat pad. 11, Inferior central fat pad. 12, Inferior lateral fat pad.
FIG. 2.5. Major retractors of the upper and lower eyelids. 1, Superior tarsal plate.
2, Lateral horn of levator aponeurosis. 3, Inferior tarsal plate. 4, Lockwood's suspensory
ligament. 5, Whitnall's suspensory ligament. 6, Levator aponeurosis. 7, Medial horn of
levator aponeurosis. 8, Capsulopalpebral fascia.
7/16/2012 9:19:10 AM
13
FIG. 2.4
7
2
3
4
9
10
11
12
FIG. 2.5
5
1
3
8
4
7/16/2012 9:19:10 AM
14

FIG. 2.6. Arterial supply to the eyelids. 1, Lacrimal artery. 2, Superior peripheral
arcade. 3, Superior lateral palpebral artery. 4, Superior marginal arcade. 5, Inferior
lateral palpebral artery. 6, Inferior palpebral branches. 7, Zygomaticofacial artery.
8,Transverse facial artery. 9, Supraorbital artery. 10, Supratrochlear artery. 11, Dorsal
nasal artery. 12, Superior medial palpebral artery. 13, Inferior medial palpebral artery.
14, Inferior marginal arcade. 15, Angular artery. 16, Facial artery. 17, Infraorbital artery.
FIG. 2.7. Venous supply from the eyelids. 1, Supraorbital vein. 2, Supercial temporal vein. 3, Transverse facial vein. 4, Frontal vein. 5, Supratrochlear vein. 6, Nasofrontal
vein. 7, Angular vein. 8, Anterior facial vein.
7/16/2012 9:19:16 AM
15
FIG. 2.6
9
1
10
2
11
3
12
4
5
6
7
13
14
15
16
17
FIG. 2.7
1
2
4
5
6
7
3
8
7/16/2012 9:19:16 AM
16

FIG. 2.8. Sensory nerves from the eyelids via trigeminal nerve branches.
1, Lacrimal nerve. 2, Zygomaticotemporal nerve. 3, Zygomaticofacial nerve.
4, Supraorbital nerve. 5, Supratrochlear nerve. 6, Infratrochlear nerve. 7, Infraorbital
nerve.
FIG. 2.9. Motor innervation to the eyelid protractors. 1, Temporal branch of the
facial nerve (N. VII). 2, Zygomatic branch of the facial nerve. 3, Buccal branch of the
facial nerve. 4, Frontalis muscle. 5, Orbicularis muscle.
7/16/2012 9:19:22 AM
17
FIG. 2.8
4
5
3
7
FIG. 2.9
7/16/2012 9:19:22 AM
18

FIG. 2.10. Lymphatic drainage from the eyelids. 1, Supercial and deep parotid
(preauricular) nodes. 2, Submandibular nodes. 3, Supercial and deep cervical nodes.
FIG. 2.11. Horizontal cross section through the upper eyelid and orbit at the
level of the canthal ligaments. 1, Preseptal portion of orbicularis muscle. 2, Anterior
crus of medial canthal ligament. 3, Posterior crus of medial canthal ligament.
4, Anterior lacrimal crest. 5, Lacrimal sac. 6, Posterior lacrimal crest. 7, Horner's muscle.
8, Medial check ligament. 9, Superior tarsal plate. 10, Superior pretarsal orbicularis
muscle. 11, Lateral horizontal raphe. 12, Lateral orbital septum. 13, Lateral canthal ligament. 14, Lateral check ligament. 15, Orbital portion of orbicularis muscle.
16, Lacrimal gland (lower pole). 17, Temporalis muscle.
7/16/2012 9:19:29 AM
19
FIG. 2.10
FIG. 2.11
2
3
4
5
6
7
10
11
12
13
14
15
16
17
7/16/2012 9:19:29 AM
20

FIG. 2.12. Sagittal cross section through central eyelids and anterior orbit at
the level of the ocular lens. 1, Whitnall's suspensory ligament. 2, Levator muscle.
3, Superior rectus muscle. 4, Suspensory ligament of the superior fornix. 5, Superior
conjunctival fornix. 6, Inferior conjunctival fornix. 7, Inferior rectus muscle. 8, Inferior
oblique muscle. 9, Lockwood's suspensory ligament. 10, Frontalis muscle. 11, Orbital
portion of orbicularis muscle. 12, Superior orbital septum. 13, Superior preseptal
orbicularis muscle. 14, Superior tarsal plate. 15, Superior pretarsal orbicularis muscle.
16, Inferior tarsal plate. 17, Inferior pretarsal orbicularis muscle. 18, Inferior preseptal
orbicularis muscle. 19, Inferior orbital septum. 20, Inferior orbital orbicularis muscle.
7/16/2012 9:19:35 AM
21
FIG. 2.12
10
1
11
2
3
12
13
4
5
14
15
6
16
7
17
18
19
20
7/16/2012 9:19:35 AM
22

FIG. 2.13. Layered sagittal cross section through the eyelids showing the orbital
septum and insertions of the levator aponeurosis. 1, Preaponeurotic fat pad.
2, Mller's muscle. 3, Inferior sympathetic muscle of Mller. 4, Precapsulopalpebral
orbital fat pad. 5, Arcus marginalis. 6, Superior orbital septum. 7, Levator aponeurosis.
8, Superior pretarsal orbicularis muscle. 9, Inferior pretarsal orbicularis muscle.
10, Inferior orbital septum.
FIG. 2.14. Layered sagittal cross section through the eyelids showing tarsus and
Mller's muscle. 1, Whitnall's ligament. 2, Cut edge of the levator aponeurosis.
3, Mller's sympathetic muscle. 4, Superior peripheral arterial arcade. 5, Superior
tarsal plate. 6, Inferior tarsal plate. 7, Inferior peripheral arterial arcade. 8, Inferior
sympathetic muscle of Mller. 9, Cut edge of the capsulopalpebral fascia.
FIG. 2.15. Layered sagittal cross section through the eyelids showing the bulbar
and palpebral conjunctiva. 1, Superior rectus muscle. 2, Superior fornix suspensory
ligament. 3, Bulbar conjunctiva. 4, Palpebral conjunctiva. 5, Superior tarsal plate.
6, Inferior tarsal plate. 7, Inferior fornix suspensory ligament. 8, Inferior rectus muscle.
FIG. 2.13
5
1
6
7
2
8
9
3
10
4
7/16/2012 9:19:42 AM
23
FIG. 2.14
2
3
4
5
6
7
8
9
FIG. 2.15
1
2
3
4
7
8
7/16/2012 9:19:46 AM
24

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7/16/2012 9:19:51 AM
SECTION
Hordeolum and
Chalazion
A
hordeolum is an acute infectious abscess of an eyelid

gland characterized by localized swelling, erythema, and
tenderness. The external hordeolum, or stye, is a superficial
infection of a Zeis or Moll gland in the anterior eyelid lamella.
A stye usually forms on the marginal eyelid skin in the region
of the lash follicles. Medical management consists of warm
compresses and topical antibiotics, and spontaneous resolution is common. Surgical drainage is indicated only when the
lesion fails to respond to conservative treatment and when the
lesion points on the surface.
An internal hordeolum is an acute, usually staphylococcal, infection of a meibomian gland within the tarsal plate.
These may point toward the conjunctiva or the skin, and
purulent material can frequently be expressed from the
inspissated meibomian ductule on the lid margin. Treatment consists of warm compresses and topical antibiotics
and may require systemic antibiotics for control.
A chalazion is a noninfectious sterile accumulation of
lipid material that is almost always secondary to obstruction of a meibomian gland ductule. It may cause significant
inflammation and pressure necrosis of the tarsus in addition to thickening from granuloma formation. A chalazion
rarely resolves spontaneously. Medical therapy includes
injection of corticosteroids, 0.1 or 0.2 mL, of triamcinolone acetonide, 40 mg/mL, directly into the lesion. Treatment may have to be repeated after several weeks. Surgery
may be necessary for curettage of the thick caseous contents or for excision of any persistent granulomatous mass.
Recurrent chalazia in the same location require histologic
examination to rule out sebaceous cell carcinoma.
For drainage of external hordeola, a local infiltrative
anesthetic is injected around the base of the lesion rather
than directly into it. For internal hordeola or chalazia in
the tarsus, infiltrative anesthesia should be given both
subcutaneously and subconjunctivally along the proximal

border of the tarsal plate. A regional block may also be
given at the appropriate branches of the trigeminal nerve.
For the transcutaneous approach, the incision is horizontal
and is thereby parallel to skin tension lines to avoid scar
contraction. When posterior drainage on the conjunctival
surface is necessary, a vertical incision is used to minimize
injury to adjacent meibomian glands.
Ahmad S, Baig MA, Khan MA, et al. Intralesional corticosteroid injection
vs surgical treatment of chalazia in pigmented patients. J Coll Physicians Surg Pak. 2006;16:4244.
Ben Simon GJ, Rosen N, Rosner M, Spierer A. Intralesional triamcinolone
acetonide injection versus incision and curettage for primary chalazia:
a prospective, randomized study. Am J Ophthalmol. 2011;151:
714718.
Carrim ZI, Shields L. A simplified technique for incision and curettage of
chalazia. Orbit. 2008;27:401402.
Dhaliwal U, Bhatia A. A rationale for therapeutic decision-making in chalazia. Orbit. 2005;24:227230.
Dua HDD, Nilawar DV. Nonsurgical treatment of chalazia. Am J Ophthalmol. 1982;94:424 (letter).
Duarte AF, Moreira E, Nogueira A, et al. Chalazion surgery: advantages
of a subconjunctival approach. J Cosmet Laser Ther. 2009;11:154156.
Lederman C, Miller M. Hordeola and chalazia. Pediatr Rev. 1999;20:
283284.
Mansour AM. Injections for chalazia? Ophthalmology. 2006;113:353354.
Ozdal PC, Codre F, Callejo S, et al. Accuracy of the clinical diagnosis of
chalazion. Eye. 2004;18:135138.
Pizzarello LD, Jakobiec FA, Hofeldt JD, et al. Intralesional corticosteroid
therapy of chalazia. Am J Ophthalmol. 1978;85:818821.
Sandramouli S, Gonglore BC. Triamcinolone for chalazia. Ophthalmology. 2006;113:889.
Starr MB. Infections and hypersensitivities of the eyelids. In: Smith BC,
Delia Rocca RC, Nesi FA, Lisman RD, eds. Ophthalmic Surgery. Vol 1.
St. Louis, MO: Mosby-Year Book; 1987.
Unal M. Chalazion treatment. Orbit. 2008;27:397398.
25
7/12/2012 9:43:37 AM
Chalazion Incision and Drainage,

Transcutaneous Approach
INDICATIONS: Chronic chalazion granuloma with the major portion pointing anterior to the tarsus and acute internal
hordeola pointing toward the skin and not responding to medical therapy.
FIG. 3.1. Place a chalazion clamp over the eyelid margin

with the solid backing plate on the conjunctival surface.
Center the oval, open ring plate over the pointing lesion on the
skin surface, and tighten the clamp. Cut the skin with a scalpel
blade, making a horizontal incision at least 3 mm from the
eyelid margin to avoid injury to the lash follicles. Deepen the
incision until the cyst contents extrude into the wound.
FIG. 3.2. Using a chalazion curette, remove the contents
of the lesion completely. Scrape the walls of the entire inner
surface. Carefully explore the interior for loculated pockets.
Open these and curette the cavities to the level of normal tarsus.
POSTOPERATIVE CARE: Apply antibiotic ointment to

the suture line twice daily for 1 week or until the sutures
are dissolved.
POTENTIAL COMPLICATIONS:
Hypertrophic scar formationThis is rarely seen, mainly
in patients with a known history of forming keloids. Steroid injection into the scar or massage with topical steroids or Mederma may help reduce the scar. It may also
be excised after it is matured.
Loss of ciliaThis may occur if the dissection is carried
too far toward the lid margin. Take care not to injure the
FIG. 3.3. With chronic chalazia, excise the entire granulomatous capsule with scissors. Avoid excessive excision within
2 mm of lid margin to prevent lid notching and injury to the
cilia.
FIG. 3.4. Gently hyfrecate the base of the cavity with
bipolar cautery to achieve hemostasis. Remove the chalazion
clamp and close the skin wound with 6-0 fast-absorbing plain
gut sutures. If the lesion was very large, a small amount of
redundant skin may be excised before closure.
lash bulbs, which lie about 2 mm from the mucocutaneous eyelid border.
Eyelid notchingOccasionally, the full-thickness tarsus is
necrotic. If the excision bed is large and is carried closer
than 2 mm from the eyelid margin, a buckling or notching may result. If cosmetically objectionable, this is
corrected with a secondary eyelid wedge resection and
primary repair.
Recurrence of chalazion or hordeolumRecurrence
may follow incomplete excision of the abscess cavity lining or failure to curette all loculated chambers.
26
7/12/2012 9:43:37 AM
CHAPTER 3 Chalazion Incision and Drainage, Transcutaneous Approach
FIG. 3.1
FIG. 3.3
FIG. 3.2
FIG. 3.4
27
7/12/2012 9:43:37 AM
Chalazion Incision and Drainage,

Transconjunctival Approach
INDICATIONS: Acute internal hordeolum or chronic chalazion pointing on the conjunctival surface.
FIG. 4.1. Tighten a chalazion clamp over the eyelid margin

with the open plate centered over the pointing lesion on
the conjunctival surface. Evert the eyelid to expose the lesion.
FIG. 4.2. Make a vertical incision through the conjunctiva
and the posterior tarsal abscess wall. If possible, the incision
should not extend closer than 2 to 3 mm to the eyelid margin.
FIG. 4.4. Remove the cyst contents completely with a chalazion curette. Explore for loculated pockets toward the eyelid
margin, being careful not to injure eyelash follicles. Excise the
residual brous cyst capsule with scissors. Lightly hyfrecate
the cavity walls, if necessary, to promote hemostasis. Remove
the clamp and leave the wound open for continued drainage.
FIG. 4.3. Grasp one edge of the wound and cut a small,
triangular ap of the tarsus and conjunctiva from one side
of the posterior cyst wall to allow for drainage.
POSTOPERATIVE CARE: If mild bleeding continues after

the clamp is removed, place a firm dressing over the eyelids
for 6 to 12 hours. Apply warm compresses and antibiotic
ointment on the eye twice daily for 5 to 7 days.
Loss of ciliaThis may occur when incisions, cautery, or
excessive curettage is used within 2 to 3 mm of the eyelid margin.
Marginal eyelid notchNotching can result from excessive excision of the stabilizing tarsus too close to the
lid margin. It is important to leave at least 2 to 3 mm

of intact tarsus along the margin if possible, especially
when full-thickness tarsal necrosis is present around
the lesion.
Chronic obstruction of meibomian glandsThis may
follow the conjunctival approach when large, horizontal
incisions cut across many ductules. Except for the small,
triangular flap excision suggested for drainage, keep all
transconjunctival incisions vertical.
28
7/12/2012 9:46:11 AM
CHAPTER 4 Chalazion Incision and Drainage, Transconjunctival Approach
FIG. 4.1
FIG. 4.3
FIG. 4.2
FIG. 4.4
29
7/12/2012 9:46:11 AM
SECTION
Trichiasis and Distichiasis

T
richiasis is a disorder in which eyelid cilia are misdirected toward the globe, thus resulting in corneal and
conjunctival abrasion and chronic ocular surface pain.
Trichiasis may be primary or secondary. In primary trichiasis, the lash follicles are distorted and misaligned in an
otherwise normally positioned eyelid margin. It may result
from chronic inflammatory disorders such as severe blepharitis or recurrent chalazia. Primary trichiasis may also follow as a result of mechanical or chemical eyelid trauma or
previous eyelid surgery. In secondary trichiasis, the lash
follicles are normally aligned in the lid, but the eyelid margin is rotated inward and the lashes touch the cornea. This
condition may be caused by any severe entropion associated with horizontal eyelid laxity, retractor disinsertion,
or posterior lamellar contraction. Posterior lamellar contraction may be seen with conjunctival cicatricial inflammatory diseases, such as cicatricial ocular pemphigoid or
Stevens-Johnson syndrome, in trachoma, or with chemical
burns. In congenital or acquired epiblepharon, the anterior
skinmuscle lamella rides up over the lower eyelid tarsus
and mechanically rotates the lashes inward against the
globe, especially in downward gaze.
Distichiasis is a congenital or acquired development of
one or more extra rows of cilia located within the tarsus
and situated behind the normal row of lashes. Even though
growth is usually undistorted, because of their abnormal
position, these cilia frequently result in corneal touch. In
both primary trichiasis and distichiasis, the aberrant cilia
must be removed for comfort and to prevent further corneal damage.
Medical management of trichiasis consists of liberal
ocular lubrication and frequent mechanical epilation of
the offending cilia. The results are usually unsatisfactory
and surgical intervention eventually will be necessary in
most cases. However, many surgical approaches yield less
than ideal results, usually because of recurrence and less
commonly because of undesirable functional or cosmetic
sequelae.
When associated with eyelid malpositions such as
entropion or eyelid margin deformity, the management
of secondary trichiasis must be directed toward marginal
reconstruction. This is discussed later under the appropriate sections. The treatment of trichitic or distichitic cilia in
an otherwise normal eyelid can be achieved by a number of
procedures with varying success rates.
The technique of cryodestruction is useful in the management of large areas of trichiasis and when carefully performed is associated with minimal risk to normal eyelid
tissues. Its success depends upon adequate degree of freezing at the site of the lash follicle and requires the use of a
thermocouple probe. A rapid rate of freeze induces intracellular crystallization, which is necessary for cell destruction. Slow thaw is associated with recrystallization, which
further enhances intracellular membrane disruption. The
use of epinephrine in the local anesthetic reduces heat
transfer through adjacent tissues and improves the effectiveness of treatment. In addition, the rate of thermal conductivity is significantly enhanced with repeat freezing,
and a double freezethaw cycle yields greater destructive
results. Caution should be used in applying cryotherapy to
dark-skinned individuals since this can result is significant
depigmentation.
Electrohyfrecation and radiosurgery are more suited to
eradication of one or a few cilia. However, because of the
very small area of destruction and the uncertainty of localizing the needle tip at individual follicles, results are less
predictable and recurrences more frequent than with cryosurgery. In this procedure, injury to normal tissues is also
more common, especially when large numbers of lashes
are treated simultaneously.
When the entire eyelid margin is involved, surgical
excision may be more appropriate, especially if cryodestruction has failed. Excision may be accomplished by an
internal resection of the lash follicles beneath a small myocutaneous flap. Eyelid splitting procedures, either with or
without mucous membrane grafting, are more difficult,
may require harvesting of oral mucosa, and usually lead to
poorer functional and cosmetic results.
Alemayehu W, Kello AB. Trichiasis surgery: a patient-based approach.
Community Eye Health. 2010;23:5859.
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Baar E, Ozdemir H, Ozkan S, et al. Treatment of trichiasis with argon
laser. Eur J Ophthalmol. 2000;10:273275.
Chi MJ, Park MS, Nam DH, et al. Eyelid splitting with follicular extirpation using a monopolar cautery for the treatment of trichiasis and
distichiasis. Graefes Arch Clin Exp Ophthalmol. 2007;245:637640.
Choo PN. Distichiasis, trichiasis, and entropion: advances in management. Int Ophthalmol Clin. 2002;42:7587.
Dutton JJ, Tawfik HA, DeBacker CM, Lipham WJ. Direct internal eyelash bulb extirpation for trichiasis. Ophthal Plast Reconstr Surg.
2000;16:142145.
Gower EW, Merbs SL, Munoz BE, et al. Rates and risk factors for unfavorable outcomes 6 weeks after trichiasis surgery. Invest Ophthalmol Vis
Sci. 2011;52:27042711.
Kersten RC, Leiner FP, Kulwin DR. Tarsotomy for the treatment of cicatricial entropion with trichiasis. Arch Ophthalmol. 1992;110:714717.
30
7/12/2012 9:48:34 AM
SECTION D Trichiasis and Distichiasis

Kezirian GM. Treatment of localized trichiasis with radiosurgery. Ophthal
Plast Reconstr Surg. 1993;9:260266.
McCracken MS, Kikkawa DO, Vasani SN. Treatment of trichiasis and
distichiasis by eyelash trephination. Ophthal Plast Reconstr Surg.
2006;22:349351.
Moosavi AH, Mollan SP, Berry-Brincat A, et al. Simple surgery for severe
trichiasis. Ophthal Plast Reconstr Surg. 2007;23:296297.
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810-nm diode laser: an efficacy study. Ophthal Plast Reconstr Surg.
2006;22:445447.
Rosner M, Bourla N, Rosen N. Eyelid splitting and extirpation of hair follicles using a radiosurgical technique for treatment of trichiasis. Ophthalmic Surg Lasers Imaging. 2004;35:116122.
31
Sodhi PK, Verma L. Surgery for trichiasis. Ophthalmology. 2004;111:

21472148.
Vaughn GL, Dortzbach RK, Sires BS, Lemke BN. Eyelid splitting with
excision or microhyfrecation for distichiasis. Arch Ophthalmol.
1997;115:282284.
Wojno TH. Lid splitting with lash resection for cicatricial entropion and
trichiasis. Ophthal Plast Reconstr Surg. 1992;8:287289.
Wu AY, Thakker MM, Wladis EJ, Weinberg DA. Eyelash resection procedure for severe, recurrent, or segmental cicatricial entropion. Ophthal
Yeung YM, Hon CY, Ho CK. A simple surgical treatment for upper lid
trichiasis. Ophthalmic Surg Lasers 1997;28:7476.
7/12/2012 9:48:34 AM
Cryosurgery for Trichiasis
INDICATIONS: Misdirected eyelid cilia of any number.

CONTRAINDICATIONS: Additional caution should be used with dark-skinned individuals because this technique may
cause depigmentation. Patients with active cicatricial inflammatory diseases should be on adequate systemic immunosuppression for several months prior to any cryodestructive procedure to minimize risk of exacerbation.
FIG. 5.1. Position a scleral shell over the globe for protection. Inject local anesthetic with 1:100,000 epinephrine 3 to
4 mm from the lid margin and subconjunctivally along
the proximal tarsal border. Take care to avoid injury to the
marginal vascular arcade. Allow 10 minutes for maximum
vasoconstriction.
FIG. 5.3. Place the cryoprobe tip on the conjunctival surface 2 to 3 mm from the eyelid margin and adjacent to the
aberrant cilia near the thermocouple needle. Apply a freeze
cycle to 20C. A white area of frost should form on the lid.
Allow the lid to thaw slowly and completely, followed by a
second freeze cycle to 20C.
FIG. 5.2. Insert a 23-gauge microthermocouple needle

probe into the postorbicular fascial plane 3 mm from
and parallel to the eyelid margin. The probe tip must
be positioned adjacent to the eyelash bulbs for accurate
temperature recording.
FIG. 5.4. Five to seven days after treatment, mechanically

remove the cilia with epilation forceps. There should be no
resistance. If treatment fails to eradicate all offending lashes,
repeat the procedure after 2 to 3 months.
POSTOPERATIVE CARE: Apply a topical steroid and

antibiotic ointment to the eyelid margin three to four
times daily for 5 days. A mild analgesic may be needed for
the first 1 to 2 days.
If excessive tissue breakdown is noted early, hyperbaric

oxygen may be considered.
DepigmentationThis is more common in darkly pigmented skin, and an alternative treatment modality
should be considered in such individuals.
Treatment failurePartial recurrence is common and
may be seen more frequently with inadequate freeze
temperature or misplacement of the thermocouple
needle probe. Treatment may be repeated after 2 to
3 months. If a large area offailure is involved, internal surgical excision of lash bulbs would be more
appropriate.
Eyelid edemaThis may be significant for 12 to 72 hours
after treatment and is proportional to the size of the
area treated. It typically resolves without sequelae.
Eyelid necrosisThe risk of necrosis is greater with temperatures below 30C. Epidermal necrosis is more
common with cryoprobe application to the skin surface.
32
7/12/2012 9:48:34 AM
CHAPTER 5 Cryosurgery for Trichiasis
FIG. 5.1
FIG. 5.3
FIG. 5.2
FIG. 5.4
33
7/12/2012 9:48:34 AM
Radiosurgery for Trichiasis
INDICATIONS: One to a few trichitic or distichitic cilia.
FIG. 6.1. Inltrate local anesthetic subcutaneously along

the lid margin adjacent to the area to be treated. Pull the
eyelid margin away from the globe or use a scleral protector.
Insert an insulated radiosurgery wire needle into the lash
follicle to the bulb, parallel to the cilium shaft.
FIG. 6.2. Apply the radio frequency (RF) pulse for 5 to

10 seconds until small bubbles appear at the lid margin
surface. If more immediate destruction or contraction of tissue
is seen, reduce the power setting. Manually epilate the cilium
with epilation forceps. There should be no resistance and the lash
bulb should be attached to the cilium to indicate adequate ablation. If the lash does not pull out easily, repeat the treatment.
POSTOPERATIVE CARE: Apply a steroid and antibiotic

ointment three to four times daily for 4 to 5 days. Mild
analgesics may be needed for the first 1 to 2 days.
Treatment failureThis usually follows poor placement

of the needle tip so that the lash bulb remains untreated.
This is especially true with distichiasis because the lash
follicles may be curved and not located directly below
the external cilium. Treatment failure also results from
applying too low a power setting. Radiosurgery or cryosurgery may be performed again after 2 to 3 months.
Lid margin distortionThis may result from excessive
tissue destruction and thermal contraction of the tarsus.
Apply only the minimal RF power necessary to cause
very mild bubbling. Avoid simultaneous treatment over
large areas of the eyelid.
34
7/12/2012 9:51:10 AM
CHAPTER 6 Radiosurgery for Trichiasis

FIG. 6.1
35
FIG. 6.2
7/12/2012 9:51:10 AM
Internal Eyelash Bulb Resection
INDICATIONS: Trichiasis with more than one-quarter lid margin involvement; failure of other treatment modalities.
FIG. 7.1. Mark an incision line in an existing eyelid crease.

Inltrate local anesthetic into the postorbicular fascial plane
along the marked line. Cut through the skin with a scalpel
blade and open the orbicularis muscle with Westcott scissors.
used to destroy the lash bulbs. Take care not to cut through the
skin. If distichitic cilia are noted arising from within the tarsus,
follow their shafts with small, vertical cuts into the tarsus until the
bulb is found. These are then excised or destroyed with cautery.
FIG. 7.2. Carry the dissection in the postorbicular fascial

plane along the anterior face of the tarsus toward the eyelid
margin. In the upper eyelid, take care not to injure the levator
aponeurosis or the marginal vascular arcade. About 2 mm from
the lid margin, identify the lash bulbs as small, rounded, dark
objects lying in a row within a small horizontal gap between
the orbicularis muscle and the muscle of Riolan.
FIG. 7.4. Mechanically epilate the cilia from along the

treated area. There should be no resistance, and the cilia
should come out lacking their bulbs. Any residual bulbs may be
destroyed individually with additional light cautery.
FIG. 7.3. Using ne micro-Westcott scissors, excise the cilia

bulbs and a strip of orbicularis muscle from along the entire
area of trichiasis. Alternatively, low-level bipolar cautery can be
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours while awake. Place antibiotic ointment on the suture line three to four times daily for 5 to 7
days or until the sutures are dissolved.
Treatment failureThis is caused by inadequate excision of all offending lash bulbs in the affected area. If
FIG. 7.5. Reform the eyelid crease by xing the orbicularis

muscle to epitarsus or to the orbital septum with three or
four 7-0 chromic sutures.
FIG. 7.6. Close the skin with 6-0 fast-absorbing plain gut
sutures.
a few cilia remain, treat these with spot cryosurgery or
radiosurgery after 4 to 6 weeks. With distichiasis, cilia
typically originate within the tarsal plate and are more
difficult to remove by this technique.
Eyelid margin scarringThis is a result of excessive
removal of the marginal orbicularis muscle and buttonholing of the skin. Limit the dissection to the lash bulbs
and a thin strip of muscle.
36
7/12/2012 9:53:31 AM
CHAPTER 7 Internal Eyelash Bulb Resection
FIG. 7.1
FIG. 7.4
FIG. 7.2
FIG. 7.5
FIG. 7.3
FIG. 7.6
37
7/12/2012 9:53:31 AM
SECTION
Cosmetic Blepharoplasty
B
lepharoplasty is a procedure for the removal of lax eyelid

skin and/or reduction of prolapsed eyelid fat. It can be
performed for functional purposes to improve visual field, or
it can be done for purely aesthetic concerns. Cosmetic surgery performed by the ophthalmologist is usually confined
to the upper and lower eyelids and brows. Many patients
desiring aesthetic reconstruction, however, may also benefit from surgery on adjacent facial structures such as the
forehead, nose, temple, and cheeks. Preoperative examination must take note of these associated abnormalities, and
in some cases, a more inclusive facial surgery might be more
appropriate.
During evaluation of the patient for cosmetic surgery, it
is essential to discuss the patients expectations, the results
that realistically can be achieved, and any potential complications. The patient must understand that although excess
eyelid skin and herniating orbital fat can be removed,
small lateral eyelid furrows, sagging malar cheek pads,
and dark circles beneath the lower lids typically will not be
improved with standard blepharoplasty procedures alone.
Such abnormalities should be pointed out before surgery in
order to avoid disappointment.
Preoperative evaluation should record in detail the
presence of associated eyelid deformities, so modifications in the surgical approach can be planned in advance.
The amount of excess eyelid skin is estimated while the
patient is in the upright position, because it appears considerably less when the patient is supine. Location and
degree of protruding fat pockets are recorded, also while
the patient is upright. Hypertrophy of the pretarsal orbicularis muscle appears as a horizontal thickening of the
lower eyelid immediately beneath the lid margin. It is
more prominent when the patient is smiling and is frequently confused with prolapse of orbital fat. The presence of lateral upper eyelid hooding will require some
modification with regard to the extent and shape of the
incision line. The same is true for significant medial upper
eyelid pouching. Ptosis of the upper eyelid is measured
and if necessary is repaired at the time of blepharoplasty.
Shortening of the levator aponeurosis will affect the
amount of skin excised, so the ptosis correction precedes
removal of excess skin.
Prolapse of the lacrimal gland is common and must not
be confused with protrusion of orbital fat. There is no anterior fat pocket in the temporal upper eyelid. The lacrimal
gland is firmer to palpation than orbital fat and can easily
be displaced beneath the orbital rim. At surgery, it is pinker
in color than fat. When present, a prolapsed lacrimal gland
is repositioned to avoid postoperative fullness in the lateral

eyelid.
The presence of any inferior scleral show should be noted
and care taken not to exacerbate this by overly aggressive
vertical removal of lower eyelid skin. In some cases, elevation of the lid margin may be needed for cosmetic improvement. Any blunting of the lateral canthal angle resulting
from laxity of the lateral canthal ligament should also be
recorded and may be corrected by lateral tarsal strip fixation at the time of surgery. Greater degrees of generalized
eyelid laxity and even frank ectropion may require further
eyelid shortening. During preoperative evaluation, it is
particularly important to recognize the presence of brow
ptosis. Failure to correct significant brow droop will result
in little improvement from blepharoplasty alone. Brow
ptosis correction must be performed either through direct or
through endoscopic lift, or with a brow pexy, before excision
of upper eyelid skin. The existence, position, and symmetry of the eyelid creases must be measured and appropriate crease reformation performed if necessary. All of these
factors, when present, will alter the surgical approach somewhat and may significantly affect the outcome.
The ordering of steps in blepharoplasty is essential for
a successful result. Marking of excess eyelid skin is done
before administration of local anesthetic, since the latter
might distend and distort the tissues, thus making accurate
marking more difficult. If significant upper eyelid fat is to
be removed, or if the levator aponeurosis is to be shortened,
the upper incision line is not cut until the orbital work has
been completed. At this point, the upper skinmuscle flap
is draped over the inferior wound edge and excess flap is
resected.
In most blepharoplasty procedures designed for reduction of excess eyelid skin, excision of a skin flap that
includes orbicularis muscle is preferred because redundancy of muscle almost always accompanies redundancy of
overlying skin. The exceptions occur when lymphedematous and thickened subcutaneous tissues produce baggy
lids and festoons anterior to the underlying muscle. In such
cases, skin and subcutaneous tissue may be removed with
preservation of most of the muscle layer. Removal of skin
with preservation of muscle may result in less postoperative edema, but the long-term results are the same as with
skin and muscle resection.
Fixation of the upper eyelid crease will significantly
enhance the cosmetic effect, unless an Asian lid is to be
maintained. In general, the crease is placed 10 to 12 mm
above the lid margin and fixed to the levator aponeurosis.
38
7/12/2012 9:55:20 AM
SECTION E Cosmetic Blepharoplasty

Upper Eyelid Blepharoplasty with Fat Excision
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Surgery. Vol I. New York: Pergamon Press Ltd; 1982.
Lower Eyelid Blepharoplasty with Fat Excision

Dortzbach RK. Lower eyelid blepharoplasty by anterior approach. Prevention of complications. Ophthalmology. 1983;90:223229.
Guy C. Standard technique of lower blepharoplasty. In: Aston SJ, ed. Third
International Symposium of Plastic and Reconstructive Surgery of the
Eye and Adnexa. Baltimore, MD: Williams & Wilkins; 1982.
Kikkawa DO, Kim JW. Lower-eyelid blepharoplasty. Int Ophthalmol Clin.
1997;37:163178.
McCord CD Jr. Lower blepharoplasty and primary cheeklift. In: Chen
PD, Khan JA, McCord CD Jr, eds. Color Atlas of Cosmetic Oculofacial
Surgery. Philadelphia, PA: Butterworth Heinemann; 2004:109140.
Morax S, Touitou V. Complications of blepharoplasty. Orbit. 2006;25:
303318.
Putterman AM. Treatment of lower eyelid dermatochalasis, herniated
orbital fat, and hypertrophied orbicularis: a skin flap approach. In:
Putterman AM, ed. Cosmetic Oculoplastic Surgery. Philadelphia, PA:
WB Saunders; 1999.
Small RG. Extended lower eyelid blepharoplasty. Ophthal Surg. 1981;
99:14021405.
Wilkins RB, Hunter GJ. Blepharoplasty: cosmetic and functional. In:
McCord CD, ed. Oculoplastic Surgery. New York: Raven Press; 1981.
Lower Eyelid Blepharoplasty with Fat Repositioning

Couch SM, Buchanan AG, Holds JB. Orbicularis muscle position during
lower blepharoplasty with fat repositioning. Arch Facial Plast Surg.
2011;13:387391.
Goldberg RA. Transconjunctival orbital fat repositioning: transposition
of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg.
2000;105:743748.
Goldberg RA, Edelstein C, Shorr N. Fat repositioning in lower blepharoplasty to maintain infraorbital rim contour. Facial Plast Surg.
1999;15:225229.
Momosawa A, Kurita M, Ozaki M, et al. A transconjunctival orbital fat
repositioning for tear trough deformity in young Asians. Aesthet Surg
J. 2008;28:265271.
Nassif PS. Lower blepharoplasty: transconjunctival fat repositioning.
Otolaryngol Clin North Am. 2007;40:381390.
Stark GB, Iblher N, Penna V. Arcus marginalis release in blepharoplasty I:
technical facilitation. Aesthet Plast Surg. 2008;32:785789.
Lower Eyelid Blepharoplasty Combined with Canthopexy

Beard C. Lower lid blepharoplasty. Ophthalmology 1978;85:712715.
Edgarton MT. Causes and prevention of lower lid ectropion following
blepharoplasty. Plast Reconstr Surg. 1972;49:367.
Pacella SJ, Nahai FR, Nahai F. Transconjunctival blepharoplasty for upper
and lower eyelids. Plast Reconstr Surg. 2010;125:384392.
Putterman AM. Tarsal strip procedure combined with lower blepharoplasty. In: Putterman AM, ed. Cosmetic Oculoplastic Surgery.
Philadelphia, PA: WB Saunders; 1999.
Stasior OG. Cosmetic blepharoplasty: a search for perfection. Ophthalmology. 1978;85:705708.
Tenzel RR. Cosmetic blepharoplasty. Int Ophthalmol Clin. 1978;18:8799.
Transconjunctival Excision of Herniated Lower Eyelid Orbital Fat

Hidalgo DA. An integrated approach to lower blepharoplasty. Plast
Reconstr Surg. 2011;127:386395.
Mahe E. Lower lid blepharoplastythe transconjunctival approach:
extended indications. Aesthetic Plast Surg. 1998;22:18.
Patel BC, Anderson RL. Transconjunctival blepharoplasty. Plast Reconstr
Surg. 1996;97:15141515.
Pechter EA. Transconjunctival lower blepharoplasty through interrupted
incisions. Plast Reconstr Surg. 2009;124:166e167e.
Putterman AM. Baggy eyelids have a single anatomic basis. Plast Reconstr
Surg. 2006;117:2504.
Putterman AM. Transconjunctival approach to resection of lower eyelid
herniated orbital fat. In: Putterman AM, ed. Cosmetic Oculoplastic
Surgery. Philadelphia, PA: WB Saunders; 1999:203210.
7/12/2012 9:55:20 AM
Etiology and Associated Deformities
FIG. 8.1. Dermatochalasis of the upper eyelid without fat

prolapse results in marked overhang of redundant skin,
frequently obscuring the eyelid margin and sometimes
producing a pseudoptosis. In the lower eyelid, dermatochalasis produces at folds of excess skin draping over the malar
eminence.
FIG. 8.2. When associated with prolapse of extraconal
orbital fat, dermatochalasis results in fullness of the eyelids,
which becomes more pronounced in the upright position
and with pressure on the globe.
FIG. 8.3. When true eyelid ptosis complicates dermatochalasis, the upper eyelid margin to the pupillary reex
distance (MRD1) is reduced to <2 mm and does not correct
with mechanical elevation of the redundant skin.
FIG. 8.4. Brow ptosis can markedly accentuate the
apparent degree of upper eyelid dermatochalasis, resulting
in broad folding of upper eyelid skin. It is frequently more
pronounced temporally.
FIG. 8.5. Temporal hooding of eyelid skin may hang over the
lateral palpebral ssure and canthal angle. It requires more
extensive lateral skin resection over the orbital rim.
FIG. 8.6. Medial pouching results from bulging of the
medial fat pocket, with or without associated redundant
skin. When extensive, an M-plasty modication of the medial
excision bed may be required.
FIG. 8.7. Prolapse of the lacrimal gland results in lateral
fullness of the upper eyelid, which supercially resembles
bulging fat. On palpation, the gland is rm with rounded
contour and can easily be displaced upward beneath the
orbital rim.
FIG. 8.8. Lower eyelid laxity is frequently associated with
dermatochalasis and results from stretching of the lateral
canthal ligament or the tarsus. It may cause inferior scleral
show, ectropion, and epiphora.
40
7/12/2012 9:55:20 AM
CHAPTER 8 Etiology and Associated Deformities

FIG. 8.1
FIG. 8.5
FIG. 8.2
FIG. 8.6
FIG. 8.3
FIG. 8.7
FIG. 8.4
FIG. 8.8
41
7/12/2012 9:55:20 AM
Upper Eyelid Blepharoplasty

with Fat Excision
INDICATIONS: Redundant upper eyelid skin with herniation of orbital fat pockets.
FIG. 9.1. Mark an incision line along the eyelid crease if

present, or at the planned new crease position 10 to 12 mm
above the central eyelid margin. Extend the line medially and
downward to 5 mm above the lid margin. Laterally, the line
should end at the canthal angle about 6 mm above the lid margin. From this point, extend the line upward toward the lateral
brow 3 to 8 mm beyond the lateral commissure, depending
upon the degree of temporal hooding.
FIG. 9.2. With the patient's eyes gently closed, mark the
upper incision line by grasping the excess skin centrally
with a smooth forceps. Adjust the amount of pinched skin
until the excess skin is all incorporated in the forceps fold. Mark
this point. Repeat the procedure at three or four points along
the lid nasally and again temporally.
FIG. 9.3. Connect the dots with a smooth, continuous line
from the medial to the lateral canthus. If a large, vertical
skin excision is to be made and the medial upper and lower
lines meet at 60 degrees or more, an M-plasty or V-plasty is
marked to prevent webbing and to equalize the upper and
lower incision lines. Rarely a similar procedure may be needed
laterally.
FIG. 9.4. Administer 0.5 to 1.0 mL of local anesthetic with
epinephrine subcutaneously beneath the marked area.
Massage to dissipate the bolus and prevent hematoma, and
allow 5 to 10 minutes for hemostasis.
FIG. 9.5. Place the lid on tension horizontally and cut the
skin with a rounded scalpel blade along the upper and
lower marked lines.
FIG. 9.6. With scissors, cut through the orbicularis muscle
laterally to enter the areolar space between muscle and
underlying periosteum. Pull the eyelid margin downward to
atten the orbital septum. Dissect in the plane between the
muscle and the septum in a medial direction by dividing the
ne fascial attachments. Cauterize bleeding along the muscle
edge with bipolar cautery. If a skin-only blepharoplasty is to be
performed, proceed to Fig. 9.13 below. In some cases, where
the orbital septum is lax but there is no signicant fat herniation, the septum can be tightened with gentle bipolar cautery
over its surface until it contracts sufficiently.
FIG. 9.7. Apply gentle pressure on the globe through the
closed eyelid. The excess medial and central fat pockets will
be seen bulging forward from behind the overlying orbital septum. Tent up the septum with forceps to pull it away from the
underlying fat, and open it with scissors along the entire eyelid.
Cut the thin fat capsules and any imsy fascial attachments to
the underlying levator aponeurosis. Medially, the fat capsules
may be thicker and the interlobular septa more extensive.
FIG. 9.8. Hold the herniated medial fat lobules with forceps
and clamp a small, curved hemostat across its base near the
orbital rim. Do not exert excessive traction on the fat.
42
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CHAPTER 9 Upper Eyelid Blepharoplasty with Fat Excision
FIG. 9.1
FIG. 9.5
FIG. 9.2
FIG. 9.6
FIG. 9.3
FIG. 9.7
FIG. 9.4
FIG. 9.8
43
7/12/2012 9:58:53 AM
44

FIG. 9.9. Cut the fat pedicle along the upper edge of the hemostat with scissors.
FIG. 9.10. Cauterize the fat stump completely with a bipolar electrode forceps.
FIG. 9.11. Grasp the base of the cauterized fat pedicle with a forceps below the
hemostat to prevent retraction and release the clamp. Observe the stump for
adequate hemostasis, and cauterize any residual bleeding points before releasing the
forceps. Alternatively, the fat pedicle can be cauterized and cut without the use of a
hemostat.
FIG. 9.12. Repeat this procedure on the central fat pocket by cauterizing, cutting, and inspecting the pedicle.
FIG. 9.13. Close the skin wound with a running suture of 6-0 fast-absorbing plain
gut. Fix the skin edges to form a deep eyelid crease by passing each second or third
pass of the suture through a bite of the levator aponeurosis. Gently pull the lower skin
ap upward during closure, but take care not to evert the lid margin. Alternatively,
separate crease sutures of 7-0 chromic gut may be placed before closure of the skin
edges.
FIG. 9.14. When a large medial pouch is present and an M-plasty is required,
close the central V-shaped ap by pulling it slightly laterally to eliminate the
medial web. Pass an interrupted suture from the upper to the lower wound edge and
subcuticularly through the ap tip. Close the remaining M-plasty with interrupted
sutures.
FIG. 9.15. When a large, vertical skin excision is made and the upper wound margin is signicantly longer than the lower wound margin, a V-plasty Burow's-type
triangle is removed from the upper skin margin nasally to equalize the upper and
lower wound lengths and to prevent pouching. Make a cut superonasally in the
skin 4 to 6 mm from the medial wound corner. Undermine the skin, pull the triangle
laterally, and excise the area of overlap.
FIG. 9.16. Close the skin with interrupted sutures of 6-0 fast-absorbing plain gut.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the
suture line three to four times daily for 7 days or until the
sutures are dissolved.
HematomaThis may result from inadequate hemostasis
of the orbicularis muscle or the transected fat pedicle. If
severe, open the wound to drain clots and cauterize any
residual bleeding points.
Visual lossThis rare event is usually caused by deep
orbital bleeding from traction on the fat pedicle during excision. It can result in central retinal artery occlusion and requires immediate opening of the wound
for decompression. If necessary, a lateral canthotomy
should be performed, and medical treatment for arterial
occlusion should be instituted.
LagophthalmosThis is caused by excessive removal of

skin and usually resolves with time. Improvement may
be hastened with vigorous massage. Topical lubricants
are used until resolution occurs. If severe and persistent,
the condition may require skin grafting for correction.
Residual redundant skinThis is most commonly caused
by inadequate removal of skin or failure to recognize
and correct associated brow ptosis. It can be repaired
postoperatively by secondary brow elevation or by
repeat blepharoplasty.
Asymmetric or irregular eyelid creasesThis results
from poor placement of crease fixation sutures at the
time of closure. It can be repaired by a secondary crease
reformation procedure that includes levator aponeurosis fixation.
7/12/2012 9:58:57 AM
CHAPTER 9 Upper Eyelid Blepharoplasty with Fat Excision
FIG. 9.9
FIG. 9.13
FIG. 9.10
FIG. 9.14
FIG. 9.11
FIG. 9.15
FIG. 9.12
FIG. 9.16
45
7/12/2012 9:58:57 AM
10
Asian Upper Eyelid Blepharoplasty
INDICATIONS: Redundant upper eyelid skin obscuring superior visual field, or creation of a secondary upper eyelid fold
in a patient with Asian eyelid crease anatomy.
FIG. 10.1. Mark an incision line 4 to 5 mm above the upper

eyelid margin.
FIG. 10.2. Inject 0.5 mL of local anesthetic just beneath the
marked incision line.
FIG. 10.3. Incise through skin and orbicularis muscle along
the line with a scalpel blade. Control any bleeding points
with bipolar cautery.
FIG. 10.4. Elevate the skin and dissect upward between
the skin and orbicularis muscle in the subcutaneous plane
to the level of the superior edge of the tarsus.
LagophthalmosThis is caused by excessive removal of
skin and usually resolves with time. Improvement may
be hastened with vigorous massage. Topical lubricants
are used until resolution occurs. If severe and persistent,
the condition may require skin grafting for correction.
FIG. 10.5. Cut through the orbicularis muscle and dissect

upward between the orbicularis muscle and the underling
orbital septum. If some fat is to be removed, open the septum
with scissors. If not, proceed to Fig. 10.7.
FIG. 10.6. If removing fat, gently hold up small amounts of
fat, cauterize across its base, and excise with scissors.
FIG. 10.7. Remove a small 1- to 2-mm strip of orbicularis
muscle from along the lower border of the incision.
FIG. 10.8. Close the skin and muscle with a running suture
of 6-0 fast-absorbing gut.
Residual redundant skinThis is most commonly caused
by inadequate removal of skin or failure to recognize
and correct associated brow ptosis. It can be repaired
postoperatively by secondary brow elevation or by
repeat blepharoplasty.
Asymmetric or irregular eyelid creasesThis results
from poor placement of crease fixation sutures at the
time of closure. It can be repaired by a secondary crease
reformation procedure that includes levator aponeurosis fixation.
46
7/12/2012 10:01:34 AM
CHAPTER 10 Asian Upper Eyelid Blepharoplasty

FIG. 10.1
FIG. 10.5
FIG. 10.2
FIG. 10.6
FIG. 10.3
FIG. 10.7
FIG. 10.4
47
FIG. 10.8
7/12/2012 10:01:34 AM
11
Rexation of Lacrimal Gland Prolapse
INDICATIONS: Downward displacement of the lacrimal gland with lateral upper eyelid fullness.
FIG. 11.1. Mark an incision line in the upper eyelid crease

from the central eyelid to the lateral canthus. If this procedure is to be combined with blepharoplasty, mark the upper
incision line as described previously, on page 42. Inltrate 0.5 to
1.0 mL of local anesthetic subcutaneously.
FIG. 11.5. Identify the soft, yellow medial and central

preaponeurotic fat pockets. Distinguish the rounded, tan,
coarsely lobulated prolapsed lacrimal gland in the temporal
one-third of the eyelid. Sometimes the gland may be covered
with a thin layer of fat.
FIG. 11.2. Pull the skin taut horizontally to prevent wrinkling

and cut along the marked line with a rounded scalpel blade.
FIG. 11.6. Place one or two 6-0 prolene xation sutures

through the lacrimal gland capsule at its inferior pole, and
reposition the gland into its bony fossa beneath the superior orbital rim.
FIG. 11.3. Tent up the orbicularis muscle with forceps to

pull it away from the levator aponeurosis, and open it with
scissors. Identify the underlying orbital septum.
FIG. 11.4. With forceps, grasp the orbital septum centrally
and pull it away from the underlying fat. Cut the septum
with scissors and open it along the length of the wound. Place
a Desmarres retractor into the upper edge of the wound to
expose the orbital fat.
POSTOPERATIVE CARE: Apply iced compresses to the

eyelid intermittently for 24 hours. Place antibiotic ointment on the suture line three to four times daily for 5 to 7
days or until the sutures are dissolved.
FIG. 11.7. Pass the xation sutures through the periosteum

just inside the superior orbital rim. Tie the sutures to anchor
the gland into position.
FIG. 11.8. Proceed with a blepharoplasty if that is to be
done at this time; otherwise, close the skin with a running
suture of 6-0 fast-absorbing plain gut.
rotation of the gland can cause one edge of it to bulge
into the eyelid. This may not be apparent until the
patient is upright after surgery. It can be prevented by
slightly rocking the gland back and forth after placement of a suture and, if necessary, placing a second
suture.
Persistent eyelid fullnessIf the lacrimal gland is large,

a single fixation suture may not be sufficient, and
48
7/12/2012 10:10:31 AM
CHAPTER 11 Refixation of Lacrimal Gland Prolapse

FIG. 11.1
FIG. 11.5
FIG. 11.2
FIG. 11.6
FIG. 11.3
FIG. 11.7
FIG. 11.4
49
FIG. 11.8
7/12/2012 10:10:31 AM
12
INDICATIONS: Asymmetric, or absent upper eyelid crease, either primary or as a complication of eyelid surgery.
FIG. 12.1. Mark the incision line 10 to 12 mm above the

central eyelid margin. Extend the line nasally to 5 mm above
the superior punctum and temporally to 6 mm above the
lateral canthal angle. Inltrate 0.5 to 1.0 mL of local anesthetic
subcutaneously.
FIG. 12.2. Hold the lid taut horizontally to prevent buckling and cut the skin with a rounded scalpel blade along the
marked line.
FIG. 12.3. Tent up the skin edges with forceps to pull the
orbicularis away from the levator aponeurosis. Cut the
muscle centrally with scissors to enter the postorbicular fascial
plane. Open the orbicularis muscle across the eyelid with scissors. Do not cut the orbital septum.
suture line three to four times daily for 5 to 7 days.
FIG. 12.4. Grasp the orbicularis muscle along the lower

skin edge with forceps, and while holding the scissors
oblique to the skin edge, excise a 3-mm strip of muscle from
along the lower wound skin margin.
FIG. 12.5. Close the skin edges with a running suture of 6-0
fast-absorbing plain gut. If necessary, excise any redundant
skin before closure. Pass every second or third bite of the suture
through the levator aponeurosis to supratarsally x the new lid
crease. Alternatively, 3-4 interrupted sutures of 7-0 chromic can
be placed from the orbicularis muscle inferiorly to the orbital
septum, and then close the skin separately.
FIG. 12.6. At closure, the skin edges should be slightly
everted and a deep crease should be formed.
orbital septum so that a smooth crease results. If the
crease appears irregular at the end of the case, the skin
suture should be removed and replaced.
Irregular creaseCare must be taken to maintain a uniform line of closure and attachment of muscle to the
50
7/12/2012 10:12:54 AM
CHAPTER 12 Reformation of the Upper Eyelid Crease
FIG. 12.1
FIG. 12.4
FIG. 12.2
FIG. 12.5
FIG. 12.3
FIG. 12.6
51
7/12/2012 10:12:54 AM
13
Lower Eyelid Blepharoplasty

withFatExcision
INDICATIONS: Redundant lower eyelid skin with herniation of extraconal orbital fat pockets.
FIG. 13.1. Mark the incision line 2 to 3 mm below the lid margin, beginning 1 mm temporal to the inferior punctum and
extending to 2 mm beyond the lateral canthal angle. Continue
the line laterally and downward in a preexisting laugh crease for a
distance of 10 to 15 mm, depending upon the amount of skin to be
excised. Inltrate 0.5 to 1.0 mL of local anesthetic subcutaneously.
FIG. 13.2. Pull the lid taut to prevent horizontal buckling and
cut the skin along the marked line with a rounded scalpel blade.
fascial connections between them. With scissors, sharply dissect the ap from the underlying tarsal plate and orbital septum.
FIG. 13.5. Tent up the orbital septum with forceps to pull
it away from the underlying fat pockets. Make a small cut
through it centrally with scissors. Open the septum to either
side along the width of the eyelid.
FIG. 13.6. Identify the lateral, central, and medial fat
pockets. Cut the delicate, brous fat capsules overlying the
individual pockets and gently apply pressure on the globe to
further prolapse the fat lobules.
FIG. 13.3. Pull up the skin at the lateral end of the wound
with forceps and cut through the orbicularis muscle to enter
the fascial plane between muscle and periosteum of the
orbital rim. Cut through the muscle along the incision line and
continue dissecting medially in the postorbicular fascial plane.
Cauterize bleeding points with a bipolar electrode forceps.
FIG. 13.7. Hold the herniated lateral pocket with forceps

and clamp a small, curved hemostat across the base of the
fat pedicle.
FIG. 13.4. Gently pull the eyelid margin upward and the
skinmuscle ap downward with forceps to visualize the
FIG. 13.8. Cut the fat along the upper edge of the hemostat and
cauterize the pedicle stump with bipolar electrode forceps.
52
7/12/2012 10:15:29 AM
CHAPTER 13 Lower Eyelid Blepharoplasty withFatExcision

FIG. 13.1
FIG. 13.5
FIG. 13.2
FIG. 13.6
FIG. 13.3
FIG. 13.7
FIG. 13.4
53
FIG. 13.8
7/12/2012 10:15:29 AM
54

FIG. 13.9. Grasp the fat pedicle with forceps below the hemostat. Release
the clamp and cauterize any residual bleeding points before releasing the forceps.
Alternatively, the fat can be cauterized and cut without the use of a hemostat.
FIG. 13.10. Repeat this procedure to excise the central and medial fat pockets
and any additional lateral fat that prolapses with further pressure on the globe.
Avoid injury to the inferior oblique muscle, which passes between the medial and
central fat pockets.
FIG. 13.11. Drape the skinmuscle ap upward, over the lower eyelid incision
line, and ask the patient to look upward to estimate the amount of vertical skin
to be resected. Do not remove more skin than necessary. Rarely will more than 4 to 5
mm of vertical skin have to be excised. Cut the excess skinmuscle ap with scissors.
FIG. 13.12. Pull the ap temporally and slightly upward on slight tension to
overlap the lateral skin incision. Mark and cut off the redundant lateral triangular
ap. Cauterize any bleeding points along the cut muscle surfaces.
FIG. 13.13. Place one or two deep supporting sutures of 6-0 Vicryl through the
orbicularis muscle of the temporal ap edge and into the deep subcutaneous
fascia of the upper skin incision over the lateral orbital rim.
FIG. 13.14. Close the skin with a running suture of 6-0 fast-absorbing plain gut
along the subciliary incision and with interrupted sutures along the temporal
portion of the wound.
FIG. 13.15. If a lymphedematous festoon is present and cannot be reduced
with horizontal skinmuscle ap tightening, a secondary procedure may be
performed 2 weeks later. Mark the base of the festoon with a convex line and cut
the skin and subcutaneous tissues with a scalpel blade. Dissect the skin ap from the
underlying orbicularis muscle.
FIG. 13.16. Close the orbicularis muscle with interrupted 6-0 Vicryl sutures and
the skin edges with stitches of 6-0 fast-absorbing plain gut sutures.
POSTOPERATIVE CARE: Apply ice packs intermittently

for 24 hours. Place antibiotic ointment on the suture line
three to four times daily for 7 days or until the sutures are
dissolved.
Lower eyelid retractionThis results from mild overresection of vertical skin, inadvertent shortening of the
orbital septum during skin closure, or internal lid scarring. It may respond to upward massage but frequently
will require lysis of the septum or scar bands, or an eyelid tightening procedure.
EctropionCaused by excessive vertical resection of skin.

When mild, this may respond to vigorous massage, but
when severe it will require skin grafting for correction.
Rounded lateral canthal angleResults from a lateral
incision line that is directed too inferiorly, causing
downward traction on the lateral eyelid. It can be prevented by placing deep fixation sutures to vertically support the lateral eyelid. Postoperatively, the condition is
corrected with a lateral canthoplasty.
Orbital hemorrhage and visual lossSee the discussion
for Upper Eyelid Blepharoplasty (p. 46).
7/12/2012 10:15:33 AM
CHAPTER 13 Lower Eyelid Blepharoplasty withFatExcision
FIG. 13.9
FIG. 13.13
FIG. 13.10
FIG. 13.14
FIG. 13.11
FIG. 13.15
FIG. 13.12
FIG. 13.16
55
7/12/2012 10:15:33 AM
14
Lower Eyelid Blepharoplasty

with Fat Redraping
INDICATIONS: Redundant lower eyelid skin with or without herniation of orbital fat pockets, associated with deepening
of the tear trough and descent of the malar fat pad.
FIG. 14.1. Mark the incision line 2 to 3 mm below the lid

margin, beginning 1 mm temporal to the inferior punctum
and extending to 2 mm beyond the lateral canthal angle.
Continue the line laterally and downward in a preexisting laugh
crease for a distance of 10 to 15 mm, depending upon the
amount of skin to be excised. Inltrate 0.5 to 1.0 mL of local
anesthetic subcutaneously.
FIG. 14.2. Pull the lid taut to prevent horizontal buckling
and cut the skin along the marked line with a rounded
scalpel blade.
FIG. 14.3. Pull up the skin at the lateral end of the wound
with forceps and cut through the orbicularis muscle to
enter the fascial plane between muscle and periosteum
of the orbital rim. Continue cutting medially into this plane
to open the muscle along the entire skin incision. Cauterize
bleeding points with a bipolar electrode forceps.
fascial connections between them. With scissors, sharply

dissect the ap from the underlying tarsal plate and orbital
septum. Continue to the inferior orbital rim and cut through
the orbicularis retaining ligaments along the anterior rim
from medial to lateral to enter the retro Supercial musculoaponeurotic system (SMAS) space along the upper cheek for a
distance of about 1 cm below the orbital rim and beneath the
tear trough.
FIG. 14.5. Tent up the orbital septum with forceps to pull
it away from the underlying fat pockets. Make a small cut
through it centrally with scissors. Open the septum to either
side along the width of the eyelid.
FIG. 14.6. Carefully prolapse the lower eyelid fat pockets
by gently dissecting any brous adhesions between the
interlobular capsules, and between these and the orbital
septum. Pass 2 or 3 5-0 prolene sutures through the fat
capsules along the inferior fat pockets.
FIG. 14.4. Gently pull the eyelid margin upward and the
skinmuscle ap downward with forceps to visualize the
56
7/12/2012 10:17:38 AM
CHAPTER 14 Lower Eyelid Blepharoplasty with Fat Redraping
FIG. 14.1
FIG. 14.4
FIG. 14.2
FIG. 14.5
FIG. 14.3
FIG. 14.6
57
7/12/2012 10:17:38 AM
58

FIG. 14.7. Drape the fat pocket over the orbital rim and pass the Vicryl suture
through the periosteum along the anterior maxillary bone 5 to 6 mm below the
orbital rim. Alternatively, the sutures can be passed through the skin and tied on the
surface.
FIG. 14.8. Drape the skinmuscle ap upward, over the lower eyelid incision line,
and ask the patient to look upward to estimate the amount of vertical skin to be
resected. Do not remove more skin than is necessary. Rarely will more than 4 to 5 mm
of vertical skin have to be excised. Cut the excess skinmuscle ap with scissors.
FIG. 14.9. Pull the ap temporally and slightly upward on slight tension to overlap
the lateral skin incision. Mark and cut off the redundant lateral triangular ap.
orbicularis muscle of the temporal ap edge and into the deep subcutaneous
fascia of the upper skin incision over the orbital rim.
FIG. 14.11. Close the skin with a running suture of 6-0 fast-absorbing plain gut
along the subciliary incision and with interrupted sutures along the temporal
portion of the wound.
POSTOPERATIVE CARE: Apply ice packs intermittently

for 24 hours. Place antibiotic ointment on the suture line
three to four times daily for 7 days. Remove any permanent sutures after 5 to 7 days.
Potential complications are similar to those for Lower Eyelid Blepharoplasty with fat excision, page 58. Prevention
and management are as discussed previously.
7/12/2012 10:17:41 AM
CHAPTER 14 Lower Eyelid Blepharoplasty with Fat Redraping

FIG. 14.7
FIG. 14.10
FIG. 14.8
FIG. 14.11
59
FIG. 14.9
7/12/2012 10:17:41 AM
15
Lower Eyelid Blepharoplasty with

Eyelid Shortening
INDICATIONS: Redundant lower eyelid skin, with or without herniation of orbital fat pockets, combined with horizontal
eyelid laxity.
FIG. 15.1. Mark the lower eyelid incision line, cut the skin,
and elevate a skinmuscle ap as described in Figs. 13.113.4
(page 55).
FIG. 15.2. Open the orbital septum and excise the lateral,
central, and medial fat pockets as described in Figs. 13.5
13.10 (pages 5556).
FIG. 15.3. With two toothed forceps, grasp the eyelid and
pull it away from the globe. With a pointed scalpel blade,
pierce through the eyelid from the conjunctival side just below
the tarsal plate at the lateral third of the lid. Pull the blade
upward toward the lid margin to complete the vertical cut.
FIG. 15.4. Cut through the capsulopalpebral fascia and
conjunctiva with scissors, beginning at the lower edge
of the vertical incision and extending diagonally in an
inferomedial direction. The greater the horizontal width of lid
to be resected, the more this diagonal cut is angled medially.
FIG. 15.5. Grasp the eyelid margins with toothed forceps on

each side of the initial vertical cut. Pull the lateral margin toward
the nose and the medial margin toward the temple so the medial
margin overlaps the lateral one. When slight tension is encountered,
mark the amount of medial eyelid margin to be resected.
FIG. 15.6. With a scalpel blade, make a vertical cut through
the tarsus and the conjunctiva at the overlap mark.
FIG. 15.7. With scissors, complete the pentagonal excision
by cutting diagonally through the lower lid retractors from
the bottom of the vertical cut to the lowermost corner of the
previously cut lateral incision. Cauterize all bleeding points.
FIG. 15.8. Place a 6-0 silk vertical mattress suture through
the tarsus at the lid margin but do not tie it. Take care
to align the suture so that the eyelid margin approximates
without a step-off.
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7/12/2012 10:19:38 AM
CHAPTER 15 Lower Eyelid Blepharoplasty with Eyelid Shortening
FIG. 15.1
FIG. 15.5
FIG. 15.2
FIG. 15.6
FIG. 15.3
FIG. 15.7
FIG. 15.4
FIG. 15.8
61
7/12/2012 10:19:38 AM
62

FIG. 15.9. Place a second interrupted 6-0 silk suture through the outer lid margin
at the lash line and leave it untied.
FIG. 15.10. With gentle upward traction on the marginal sutures to atten and
align the wound, pass three interrupted 6-0 Vicryl sutures horizontally through
the partial thickness of the tarsus to reapproximate the cut edges. The sutures
should not extend onto the conjunctival surface. Tie the Vicryl sutures to rmly
oppose the tarsal plate.
FIG. 15.11. Tie the silk marginal sutures and adjust the tension so that the wound
edges are slightly everted. Leave the ends of these marginal sutures 2 cm long. Place
several additional Vicryl sutures as needed to close the retractors below the tarsus.
FIG. 15.12. Drape the skinmuscle ap over the lid and ask the patient to look
upward. Mark the amount of overlap along the lid margin. Be certain there is no vertical tension on the ap. Cut the excess skin and muscle from along the upper border
of the ap.
FIG. 15.13. Pull the ap laterally and mark the amount of overlap of the temporal wound edge. Cut the excess skin and muscle with scissors.
orbicularis muscle laterally and then through the deep fascial tissues at the lateral orbital rim for vertical support.
FIG. 15.15. Close the subciliary skin incision with a running stitch of 6-0 fastabsorbing plain gut. Place several interrupted sutures across the lateral part of the
skin ap incision.
FIG. 15.16. Tie the long ends of the marginal silk sutures to the skin with one or
two interrupted stitches below the eyelid margin to keep them from abrading
the cornea.
suture line three to four times daily for 7 to 10 days. Leave
the eyelid margin sutures in place for 10 to 14 days.
Notching of the eyelid marginThis may be caused by

poor apposition of the eyelid margins, gaping of the
wound, or step-off. Critical alignment is essential, and
the marginal sutures should be tightened enough to
cause slight eversion of the skin edges.
Complications are the same as for Lower Eyelid Blepharoplasty with Fat Excision (page 58). In addition:
7/12/2012 10:19:42 AM
CHAPTER 15 Lower Eyelid Blepharoplasty with Eyelid Shortening
FIG. 15.9
FIG. 15.13
FIG. 15.10
FIG. 15.14
FIG. 15.11
FIG. 15.15
FIG. 15.12
FIG. 15.16
63
7/12/2012 10:19:42 AM
16
Lower Eyelid Blepharoplasty with

Lateral Canthopexy
INDICATIONS: Redundant lower eyelid skin, with or without herniation of orbital fat pockets, combined with eyelid
laxity due to lateral canthal ligament redundancy.
FIG. 16.1. Mark the lower eyelid incision line, cut the skin,
and elevate a skinmuscle ap as described in
Figs.13.113.4 (page 55).
FIG. 16.2. Open the orbital septum and excise or redrape
the fat pockets as described in the previous procedures on
lower eyelid blepharoplasty (pages 5563).
FIG. 16.3. Pull the eyelid medially to straighten the lateral canthal ligament. Make a horizontal cut through the
lateral canthal angle to perform a lateral canthotomy to the
orbital rim. Transect the inferior crus of the ligament. Grasp
the edge of the lower eyelid and pull gently to conrm that all
attachments are free.
FIG. 16.4. Split the eyelid along the gray line laterally
with ne scissors to separate the anterior skinmuscle
lamella from the posterior tarsusconjunctiva lamella for a
distance of 5 to 10 mm, depending upon the amount of lid
shortening required. Continue this separation down to the
inferior border of the tarsus.
FIG. 16.5. With a scissors, cut the lower eyelid retractor
from the inferior border of the tarsus beneath the split
portion of the lid.
FIG. 16.6. Remove a thin strip of marginal epithelium from
the split portion of the lid using a scissors.
64
7/12/2012 10:22:57 AM
CHAPTER 16 Lower Eyelid Blepharoplasty with Lateral Canthopexy
FIG. 16.1
FIG. 16.4
FIG. 16.2
FIG. 16.5
FIG. 16.3
FIG. 16.6
65
7/12/2012 10:22:57 AM
66

FIG. 16.7. Lay the anterior face of the tarsal strip over the at face of a forceps
handle for stability, and gently scrape the conjunctival epithelium from its posterior surface with a scalpel blade. Cut off the redundant remnant of the lateral
canthal ligament, leaving a bare strip of tarsus measuring approximately 3 to 4 mm
wide and 4 mm long.
FIG. 16.8. Pass a 4-0 Vicryl or Mersilene suture on a small half-curved needle
through the tarsal strip from outside to inside and then through periosteum just
inside the lateral orbital rim. To be certain that a rm periosteal bite is achieved,
pull up on the suture and observe the head move slightly. Tie the suture rmly.
FIG. 16.9. Pull the skinmuscle ap laterally and mark the amount of overlap at
the temporal wound edge. Cut the triangular wedge with scissors.
FIG. 16.10. Reform the canthal angle with an interrupted suture of 6-0 fastabsorbing plain gut through the upper and lower lid margins. Close the orbicularis
muscle and skin with multiple interrupted sutures of 6-0 plain gut.
Potential complications are the same as for Lower Eyelid
Blepharoplasty (page 58).
In addition:
Rounded lateral canthal angleThis results from failure
to reform the canthus by suturing the lateral upper and
lower eyelids together at the lateral canthal angle.
Canthal angle dystopiaThe lateral lower lid margin can
stand away from the globe if the periosteal anchoring
suture is not placed inside the lateral rim. This is corrected
by repositioning the suture or later by repeating a lateral
tarsal strip procedure.
7/12/2012 10:23:01 AM
CHAPTER 16 Lower Eyelid Blepharoplasty with Lateral Canthopexy
FIG. 16.7
FIG. 16.9
FIG. 16.8
FIG. 16.10
67
7/12/2012 10:23:01 AM
17
Transconjunctival Excision of Lower

Eyelid Herniated Orbital Fat
INDICATIONS: Lower eyelid herniated orbital fat without dermatochalasis; fat herniation in thyroid orbitopathy;
patients with known history of keloid formation.
FIG. 17.1. Inltrate the lower eyelid subcutaneously

with 0.5 to 1.0 mL of local anesthetic. Evert the eyelid and
inltrate subconjunctivally along the proximal tarsal border.
FIG. 17.2. Pass a 4-0 silk traction suture horizontally
through the tarsus at the eyelid margin. Stay within the
tarsus to avoid injury to the lashes.
FIG. 17.3. Doubly evert the eyelid over a Desmarres
retractor to expose the internal palpebral surface. With
toothed forceps, tent up the conjunctiva, Mllers muscle, and
the capsulopalpebral fascia 3 to 4 mm below the lower edge of
the tarsus temporally. With scissors, cut a buttonhole through
them.
FIG. 17.4. Open the conjunctiva, Mllers muscle, and the
capsulopalpebral fascia along the horizontal length of the
eyelid but do not extend medial to the inferior lacrimal
punctum.
FIG. 17.5. With forceps pull the capsulopalpebral fascia
upward and away from the everted eyelid, and dissect
it from the orbital septum to the orbital rim. If the initial incision was placed too close to the tarsus, the orbital
septum may be reected toward the globe along with the
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment on the inferior
palpebral conjunctiva three to four times daily for 7 days.
Sunken, hollow appearanceThis is usually the result of
excessive resection of orbital fat so that a concave contour is present above the orbital rim. Do not apply more
than gentle pressure on the globe during resection, and
do not put excessive traction on the fat pedicles. In some
cases redrapping of the fat beneath the tear trough will
provide a more aesthetically pleasing lid-cheek contour.
capsulopalpebral fascia. In this case, open the septum with scissors to reveal the orbital fat.
FIG. 17.6. Reverse the Desmarres retractor by placing the
blade inside the wound to expose the fat pockets. Cut open
the ne interlobular fascial capsules and apply gentle pressure
to the globe to further prolapse the fat. Hold the lateral fat
pocket with forceps and apply a curved hemostat across its
base.
FIG. 17.7. With scissors cut the fat along the upper edge of
the clamp and cauterize the pedicle with bipolar electrode
forceps. Hold the pedicle below the hemostat, release the clamp,
and inspect the cut surface for residual bleeding. Alternatively,
the fat can be cauterized and cut without a hemostat. Excise the
central and medial fat pockets in similar fashion. Alternatively,
some of the fat may be redrapped to ll in a deep tear trough as
in Figs. 14.614.7, pages 6162).
FIG. 17.8. Reverse the Desmarres retractor to evert the lid
margin and expose the wound. Reattach the cut edges of the
capsulopalpebral fascia and Mllers muscle with a running
stitch of 6-0 plain gut. The lid may be splinted with strips of
tape below the tarsus and extended to the temple and nasal
bridge.
AsymmetryThis is caused by unequal resection of fat
on the two sides. Save the fat from each side and carefully compare the volume taken from each fat pocket
before closure. The exception is in cases where initial
asymmetry of fat herniation is noted and marked preoperatively.
Lower eyelid retraction and scleral showThis is seen
rarely but may result from inadvertent shortening of the
orbital septum during closure. Care should be taken to
cut open and to close only the capsulopalpebral fascia.
If the septum was opened to reach the fat pockets, it
should be left without closure.
68
7/12/2012 10:25:02 AM
CHAPTER 17 Transconjunctival Excision of Lower Eyelid Herniated Orbital Fat
FIG. 17.1
FIG. 17.5
FIG. 17.2
FIG. 17.6
FIG. 17.3
FIG. 17.7
FIG. 17.4
FIG. 17.8
69
7/12/2012 10:25:03 AM
SECTION
Brow Ptosis
B
row ptosis results from sagging of forehead skin and loss

of fascial support to the eyebrows. It is a common finding
in the aging face and frequently accompanies laxity of other
periorbital structures such as eyelid skin, facial retaining ligaments, and canthal ligaments. Recognition of significant brow
ptosis is essential to the success of other cosmetic procedures
involving the upper eyelid. A downward displacement of the
eyebrows can accentuate the degree of redundancy in upper
eyelid skin. A simple blepharoplasty designed to reduce this
excess skin will pull the brow further downward and shorten
the brow-to-eyelid margin cleft, thereby producing a cosmetically displeasing result. Brow ptosis may result in a pseudoblepharoptosis, which cannot be adequately repaired with
standard aponeurotic advancement.
Several procedures are available for the correction of
brow ptosis. The choice depends upon a number of factors:
(1) the sex of the patient and therefore the desired brow
contour; (2) the relative position of the brows; (3) the density of brow cilia; (4) the presence of associated deformities
such as lateral rhytids and prominent transverse glabellar folds; (5) the height of the scalp hairline or presence of
male pattern baldness. Each procedure has its advantages
and disadvantages, and selection of the most appropriate
operation must be individualized for each patient. In general, the direct brow lift and the endoscopic forehead lift
are the most useful procedures.
The direct brow lift allows some shaping of the final
brow contour. In particular, it facilitates segmental brow
elevation if needed temporally or medially by customizing
the shape of the excised skin flap. The direct approach is
better for the correction of asymmetric defects in brow
position and especially for unilateral brow ptosis associated
with seventh nerve palsy. In general, however, it results in
a somewhat feminine arched contour. Complications are
minimal and healing is rapid.
A significant disadvantage of the direct brow lift procedure is a scar at the upper border of the brow. With careful orientation of the incision, meticulous layered closure,
and eversion of the wound edges using vertical mattress
sutures, the resultant scar can be camouflaged very satisfactorily in most individuals. Scarring is more visible
in patients with thin eyebrows. The operation does little
to eliminate deep forehead and glabellar creases and lateral rhytids. Although the incision can be carried laterally beyond the brow or medially across the nasal bridge,
these procedures leave far more conspicuous scars, and the
lateral incision risks injury to the temporal branch of the
facial nerve.
The temporal forehead lift may be useful in patients with

lateral brow droop and prominent lateral canthal rhytids.
This application, however, is limited and does not correct
ptosis in the medial one-half of the brow. Another disadvantage is the resultant elevation of the temporal hairline,
which some patients may find objectionable.
When deep midforehead frown lines and glabellar folds
are present, a forehead lifting procedure is better. The midforehead lift places the incision line within a prominent
horizontal forehead crease. Although the scar is impossible
to completely camouflage, when deep furrows are already
present, the resulting scar can be relatively inconspicuous.
The procedure has the advantage of allowing flattening of
glabellar folds along with elevation of the brows. Precise
contouring of the brows, however, is not possible.
The endoscopic forehead lift provides elevation of the
forehead, brows, and temples with camouflage of the incision scars above the hairline. The procedure has the added
advantage of allowing interruption of the procerus and
corrugator muscles, which are responsible for horizontal
glabellar furrows. One disadvantage is the elevation of the
hairline and the inability to precisely sculpture the brow
contour. In addition, it cannot be performed on balding
male patients.
Newer procedures include brow fixation either with dissolvable polymer tines implanted into the frontal bone, or
with sutures fixed to periosteum. While these procedures
work well to fixate the brow against gravity descent, they
do not elevate the brows more than about 1 cm at most.
The timing of brow elevation, whatever the procedure,
is critical. It must be done before blepharoplasty so accurate estimation of redundant eyelid skin to be resected can
be determined. Both procedures can be performed at the
same surgical sitting.
Direct brow and transblepharoplasty endotine fixation
is usually performed under local infiltrative anesthesia. The
endoscopic forehead lift can be performed under general
or local anesthesia. In the latter case, a supraorbital and
supratrochlear nerve block with infiltration along the incision lines is adequate.
Browpexy
Cohen BD, Reifel AJ, Spinelli HM. Browpexy through the upper lid: a new
technique of lifting the brow with a standard blepharoplasty incision.
Aesthet Surg J. 2011;31:163169.
Massry GG. The external borwpexy. Ophthal Plast Reconstr Surg. 2012;
28:9095.
70
7/12/2012 10:29:38 AM
SECTION F Brow Ptosis

Direct Brow Lift
Bamer HO. Frown disfigurement and ptosis of eyebrows. Plast Reconstr
Surg. 1957;19:337340.
Booth AJ, Murray A, Tyres AG. The direct brrw lift: efficacy,
complications, and patient satisfaction. Br J Ophthalmol. 2004;88:
688691.
Brennan HG. Correction of the ptotic brow. Otolaryngol Clin North Am.
1980;13:26573.
Connell B. Brow ptosislocal resections. In: Aston SJ, ed. Third International Symposium of Plastic and Reconstructive Surgery of the Eye and
Adnexa. Baltimore, MD: Williams & Wilkins; 1982.
Johnson CM Jr, Anderson JR, Katz RB. The brow-lift. Arch Otolaryngol.
1978;105:124126.
Tyers AG. Brow lift via the direct and trans-blepharoplasty approaches.
Orbit. 2006;25:261265.
Webster RC, Fanous N, Smith RC. Blepharoplasty: when to combine it
with brow, temple, or coronal lift. J Otolaryngol. 1979;8:339343.
Trans-blepharoplasty Endotine Brow Fixation

Berkowitz RL, Apfelberg DB. Preliminary evaluation of a fast-absorbing
multipoint fixation device. Aesthet Surg J. 2008;28:584589.
Chowdhury S, Malhotra R, Smith R, Arnstein P. Patient and surgeon
experience with the endotine forehead device for brow and forehead
lift. Ophthal Plast Reconstr Surg. 2007;23:358362.
71
Hnig JF, Frank MH, Knutti D, de La Fuente A. Video endoscopic-assisted

brow lift: comparison of the eyebrow position after Endotine tissue
fixation versus suture fixation. J Craniofac Surg. 2008;19:11401147.
Langsdon PR, Williams GB, Rajan R, Metzinger SE. Transblepharoplasty
brow suspension with a biodegradable fixation device. Aesthet Surg J.
2010;30:802809.
Stevens WG, Apfelberg DB, Stoker DA, Schantz, SA. The endotine: a new
biodegradable fixation device for endoscopic forehead lifts. Aesthet
Surg J. 2003;23:103107.
Endoscopic Forehead and Brow Elevation

Angelos PC, Stallworth CL, Wang TD. Forehead lifting: state of the art.
Codner MA, Kikkawa DO, Korn BS, Pacella SJ. Blepharoplasty and brow
lift. Plast Reconstr Surg. 2010;126:1e17e.
Dailey RA, Saunly SM. Current treatments for brow ptosis. Curr Opin
Ophthalmol. 2003;14:260266.
Georgescu D, Anderson RL, McCann JD. Brow ptosis correction: a comparison of five techniques. Facial Plast Surg. 2010;26:186192.
Patel BC. Endoscopic brow lifts uber alles. Orbit. 2006;25:267301.
Romo T III, Yalamanchili H. Endoscopic forehead lifting. Dermatol Clin.
2005;23:457467.
Watson SW, Niamtu J III, Cunningham LL Jr. The endoscopic brow and midface lift. Atlas Oral Maxillofac Surg Clin North Am. 2003;11:145155.
7/12/2012 10:29:39 AM
18
Direct Brow Elevation
INDICATIONS: Involutional or paralytic brow ptosis.
FIG. 18.1 With the patient upright, elevate the brow to the
desired position, and then allow the brow to relax. Measure
the distance (x) between the central upper brow margin in the
ptotic position and elevated position. Repeat the measurement
medially and laterally. This represents the width of skin to be
removed from above the brow.
FIG. 18.2. Mark a fusiform incision pattern with the inferior
line just at the uppermost row of brow hairs, and the superior line an appropriate distance above the brow as determined in Figure 18.1 The medial and lateral extent of the
incision should not continue beyond the eyebrow. The exact
shape of the area to be excised and its location, for example,
lateral part of the brow only, are determined by the pattern of
the ptosis. For reference, mark a small line where the supraorbital neurovascular bundle exits from the supraorbital notch.
Inject local anesthetic subcutaneously along the incision lines.
FIG. 18.4. Complete the superior incision by cutting a

beveled edge parallel to that of the inferior incision.
FIG. 18.5 Dissect a skin ap by cutting the fascial
attachments in the subcutaneous plane. The dissection can
be deeper medially and laterally, but remain above the frontalis
muscle in the region over the supraorbital nerve. Cautiously
cauterize bleeding points, and lay a cottonoid sponge with
epinephrine in the wound.
FIG. 18.6. Close the subdermal layer with sutures of 5-0
Vicryl. Except in cases of facial nerve paralysis, do not x this layer
to the periosteum because it will limit dynamic brow movement.
FIG. 18.7. Close the skin with vertical mattress sutures of
5-0 prolene, and evert the wound margin approximately
1 mm to prevent a depressed scar when healed.
FIG. 18.3. With a rounded scalpel blade, make a beveled cut

through the skin along the inferior incision line. Orient the blade
to cut parallel to the direction of hair follicles, which may vary along
the length of the brow but in general are oriented downward as they
exit from the skin. As the blade passes over the area of the supraorbital neurovascular bundle, make the cut more supercial.
FIG. 18.8. Apply antibiotic ointment to the suture

line and wrap the brow and forehead in a 2-inch-wide
circumferential compression bandage.
POSTOPERATIVE CARE: Leave the compression bandage

in position for 24 hours. After removal, apply antibiotic
ointment to the suture line three to four times daily for 7 to
10 days. Remove the skin sutures after 10 days.
Poor brow contourSome degree of arching is inevitable

with this operation because of the inability to elevate the
medial and lateral corners as much as centrally. Some
males may find this objectionable. With greater degrees
of elevation, the two brow incisions can be joined across
the midline to prevent this deformity, although doing so
will result in a more obvious glabellar scar.
Adynamic browThis is a result of suturing the wound to
the periosteum. Only the subcutaneous tissue, dermis,
and epidermis should be reapproximated. The exceptions are the paralytic brow with poor frontalis tone and
cases of mild blepharospasm, where periosteal fixation
is helpful.
Supraorbital anesthesiaThis complication is caused by
injury to the supraorbital nerve branches, which interdigitate among the superficial frontalis muscle fibers as
they extend over the orbital rim from the supraorbital
notch or foramen. Care must be taken to keep the incisions shallow in this region.
Visible scarFailure to cut the incision line parallel to the hair
shafts may result in truncation of the lash follicles and loss of
several rows of cilia adjacent to the incision line. The resulting scar will then lie several millimeters from the new superior brow margin, thus making camouflage more difficult. A
wide scar is the result of excessive tension on the skin caused
by inadequately placed dermal and subdermal sutures. Failure to evert the skin edges may result in a depressed scar.
AsymmetryBrow ptosis is frequently asymmetric and
must be corrected for when planning the incisions.
Careful preoperative measurements taken while the
patient is in the upright position with a relaxed brow
will minimize this complication.
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CHAPTER 18 Direct Brow Elevation
FIG. 18.1
FIG. 18.5
FIG. 18.2
FIG. 18.6
FIG. 18.3
FIG. 18.7
FIG. 18.4
FIG. 18.8
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7/12/2012 10:29:39 AM
19
Transblepharoplasty Endotine Brow

Fixation
INDICATIONS: Mild to moderate brow ptosis, especially lateral brow droop, exaggerated by gravity.

from above the superior punctum to the lateral canthus.
Pull the skin taut to prevent buckling and cut along the marked
line with a scalpel blade.
FIG. 19.2. Tent up the orbicularis muscle with forceps
to pull it away from the levator aponeurosis and orbital
septum, and open it with scissors. Identify the underlying
orbital septum.
FIG. 19.3. Follow the orbital septum superiorly by dissecting just beneath the orbicularis muscle to the superior
orbital rim.
FIG. 19.4. Cut through the superior orbicularis muscle
retaining ligaments to fully expose the orbital rim. Take care
not to injure the supraorbital nerves.
FIG. 19.5. Make a horizontal cut through periosteum along
the rim from just lateral to the supraorbital notch to the
lateral canthal angle. With a Freer elevator, lift the periosteum
from the underlying frontal bone from the orbital rim upward
POSTOPERATIVE CARE: Place a 2-inch gauze head roll

around the head over the brows to maintain pressure on
the Endotines for 48 hours. Apply iced compresses to
the eyelids intermittently for 24 hours. After the roll is
removed place antibiotic ointment on the suture line three
to four times daily for 7 days.
HematomaBleeding is sometimes encountered from
beneath the periosteal flap, especially if the dissection
is carried too far laterally onto the superficial temporal
fascia and over temporalis muscle. It usually subsides by
placing a cottonoid pack with epinephrine into the subperiosteal space for a few minutes.
Scalp and forehead anesthesiaNumbness occurs with
injury to the neurovascular bundle during dissection
for a distance of about 4 cm. Make a 1-cm vertical cut through

the edge of periosteum at the medial and lateral extents of the
dissection to allow better elevation of the brow.
FIG. 19.6. Using the drill bit that comes with the
TransBleph Endotine kit, drill a hole into the frontal bone
at the junction of the middle and lateral thirds of the brow,
and about 1 cm above the orbital rim. Push the Endotine
into the drilled hole so that the at wings lie at against the
forehead and the tines are directed upward.
FIG. 19.7. Drape the cut edge of the periosteum superiorly
over the tines to aid in xation, and push the orbicularis
muscle onto the tines for xation. If desired, a xation suture
can be used to anchor periosteum to the Endotine.
FIG. 19.8. If there is still some redundant skin on the
upper eyelid, a skin or skin muscle blepharoplasty can be
performed at this time (see Upper Eyelid Blepharoplasty,
pp. 4245). Otherwise, close the upper eyelid skin incision
with a running suture of 6-0 fast-absorbing plain gut. Be careful
not to disturb the brow xation.
along the superior orbital rim. It can be avoided by
being careful not to extend the dissection to the supraorbital notch. Sensation is usually reestablished within
6 to 8 months.
Pain at the Endotine sitePain or tenderness sometimes results around the Endotine fixation site if there
is inflammation or pressure at the lateral deep branch
of the supraorbital nerve. This usually resolves with
time, but in severe cases, the Endotine may have to be
removed.
Palpable EndotineIn patients with thin skin, the Endotine can sometimes be palpable just above the lateral
brow even with the shorter 3.0-mm tines. Patients
should be warned of this possibility. This resolves after 6
to 8 months when the tine dissolves.
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CHAPTER 19 Transblepharoplasty Endotine Brow Fixation
FIG. 19.1
FIG. 19.5
FIG. 19.2
FIG. 19.6
FIG. 19.3
FIG. 19.7
FIG. 19.4
FIG. 19.8
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7/12/2012 10:33:15 AM
20
Endoscopic Forehead Elevation
INDICATIONS: Brow and forehead ptosis, especially with medial brow droop associated with horizontal glabellar folds
and forehead creases.
CONTRAINDICATIONS: Balding males or patients with a receding hairline.
FIG. 20.1. Mark a central incision about 1 cm in length

and positioned 1 cm above the hairline in the midsagittal
plane. Mark two similar paracentral incisions parallel to, and
about 4.5 cm lateral to, the midline mark. Mark a 3-cm incision line laterally, below the lateral temporal fusion line and
oriented perpendicular to the lateral eyebrow. Incise the three
central lines with a scalpel blade through the galea and periosteum. Incise the lateral temporal lines to the level of the supercial temporal fascia. The latter is identied as a loose tissue
that moves easily over the deep fascia lying on the temporalis
muscle.
FIG. 20.2. Through the central incision, incise periosteum.
Pass a periosteal dissector beneath periosteum and separate
it from the underlying frontal bone around each of the three
central incisions.
FIG. 20.3. Continue to elevate periosteum posteriorly
for about 8 to 10 cm, laterally to the superior temporal fusionlines, and forward to about 1 cm above the
supraorbital rim. Through the lateral temporal incisions,
elevate the supercial temporal fascia from the deep fascia
through a small incision. Medially, break through the temporal fusion line to join the subperiosteal space over the frontal
bone.
FIG. 20.4. Pass an endoscope and a periosteal dissector

into two of the scalp incisions. Cut through periosteum
horizontally with the sharp edge of the dissector about
1 cm above the orbital rim and continue the dissection in
the supraperiosteal plane forward under direct visualization.
Carefully visualize the supraorbital neurovascular bundle.
FIG. 20.5. Release the superior orbicularis retaining the
ligament along the superior orbital rim with a dissector.
Expose the corrugator and procerus muscles near the midline,
and with a grasping forceps, cut or disinsert these muscles to
release the glabellar xation.
FIG. 20.6. Drill a hole at the anterior edge in each of the
paracentral incisions with the Endoscopic Brow Endotine
drill bit. Snap the Endotine into the hole with the tines
oriented posteriorly. Alternatively, use another xation device
of your choice.
FIG. 20.7. Lift the scalp and forehead up with a large
double-pronged skin hook and pull it backward. Engage the
scalp onto the tines for xation.
FIG. 20.8. Close the three central incisions with surgical
staples.
76
7/12/2012 10:39:10 AM
CHAPTER 20 Endoscopic Forehead Elevation
FIG. 20.1
FIG. 20.5
FIG. 20.2
FIG. 20.6
FIG. 20.3
FIG. 20.7
FIG. 20.4
FIG. 20.8
77
7/12/2012 10:39:10 AM
78
SECTION F Brow Ptosis

FIG. 20.9. In the lateral incisions, further open the supercial temporal fascia
(STF) with scissors or scalpel. Take care not to injure the supercial temporal artery.
FIG. 20.10. Using a small Metzenbaum scissors or an elevator, dissect between
the supercial and deep temporal fascias inferiorly and gently separate them.
FIG. 20.11. Continue the dissection to the temporalis fossa and lateral brow.
FIG. 20.12. Pass a 4-0 double-armed Mersilene suture through the under surface
of the STF with multiple locking throws. Pull the lateral temporal skin ap upward
to elevate the lateral brow, and pass the two needles of the suture through the deep
temporal fascia and tie the two ends to each other.
FIG. 20.13. Overlap the posterior temporal skin ap and mark the excess to be
removed. Excise the excess skin with a scalpel blade.
FIG. 20.14. Cauterize the skin edges as needed.
FIG. 20.15. Close the temporal incisions with surgical sutures.
POSTOPERATIVE CARE: Apply antibiotic ointment liberally along the staple lines and place a firm head dressing
for 48 hours. Place topical antibiotic ointment on the incisions three to four times daily for 7 to 10 days. The staples
are removed after 10 days.
HematomaThis results mainly from the cut muscles.
Meticulous hemostasis is mandatory before closure.
Small hematomas will resolve without treatment. Larger
ones can be aspirated once they liquefy. Rarely, open
drainage will be required.
Scalp anesthesiaNumbness occurs with injury to the
supraorbital nerve during dissection along the superior
orbital rim. Sensation is usually reestablished within 6
to 8 months.
AlopeciaThis can be seen along the incision lines when

excessive cautery is applied. Secondary resection of the
bare area can be performed after stretching loosens the
skin.
Palpable EndotineIn patients with thin skin, the Endotine can sometimes be palpable on the scalp even with
the shorter 3.0-mm tines. Patients should be warned of
this possibility. This resolves after 6 to 8 months when
the tine dissolves.
Frontalis muscle weakness or paralysisThis results
from injury the the seventh nerve while elevating the
STF over the temple and lateral brow. Extreme care
must be taken and the dissection done under direct
endoscopic observation.
7/12/2012 10:39:14 AM
CHAPTER 20 Endoscopic Forehead Elevation

FIG. 20.9
FIG. 20.13
FIG. 20.10
FIG. 20.14
FIG. 20.11
FIG. 20.15
79
FIG. 20.12
7/12/2012 10:39:14 AM
SECTION
Blepharoptosis
P
tosis of the upper eyelid is a common malposition in both

children and adults. Its consequences vary from a mild
cosmetic blemish to severe visual disability and functional
blindness. The etiologies of upper eyelid ptosis are numerous
and are often associated with other anatomic or physiologic
conditions.
Any approach to the treatment of ptosis must be based
on an accurate assessment of its cause. Without such
knowledge, even the most enthusiastic and perfectly executed surgical operation could be unsuccessful. The first
step in understanding the diverse causes of ptosis is developing an unambiguous classification system that reflects
mechanistic principles. Unfortunately, some older classifications have in part been burdened by unnatural groupings based on fortuitous associations rather than on true
etiologic factors. Some groupings, such as congenital,
acquired, or traumatic ptosis, convey little useful information, and similar etiologies are seen in all three groups.
The following mechanistic classification allows a more
natural grouping of disorders responsible for ptosis and
provides a more appropriate basis for its management.
Clearly, in many cases of ptosis, good medical judgment
will demand more complete clinical evaluation or modification in surgical correction.
Neurogenic Ptosis. This group includes ptosis
resulting from dysfunction of the oculomotor nerve. The
pathologic process may be anywhere from its central nuclei
to the peripheral branches of its superior division within
the orbit. Etiologies include vascular lesions, ischemic
infarction, demyelinating diseases, toxic effects, infectious
processes, tumors, and trauma. Similar processes may
affect the sympathetic innervation to Mllers muscle, thus
resulting in Horners syndrome. Also included here are the
synkinetic ptoses such as the Marcus Gunn jaw wink syndrome and misdirected third nerve fibers.
In all cases of neurogenic ptosis, except the synkinetic
group and Horners syndrome, there is an innervational
deficiency in levator muscle function. This can vary from
mild to profound. There may be associated neurologic findings, either on examination or by history, that suggest a more
serious condition. Surgical correction of the ptosis should
in all cases be deferred until its cause has been thoroughly
investigated and the condition has stabilized. Therapy must
be individualized and may be achieved with any appropriate ptosis operation. Levator muscle function will remain
defective despite reestablishment of adequate eyelid height.
Myogenic Ptosis. In myogenic ptosis, the defect is
in the striated levator muscle. Similar disorders affecting
G
Mllers sympathetic muscle are not known. By far, the
most common cause is a congenital developmental dystrophy, accounting for half of all cases of ptosis. Rarely a
similar dystrophic development of the levator muscle is
associated with a genetic dysmorphic syndrome such as
blepharophimosis syndrome. Some cases of adult ptosis appear to be the result of an acquired myopathy that
combines poor levator muscle function, fatty infiltration,
and fibrous replacement of muscle fibers. A similar, lateacquired myopathy occurs as a hereditary disorder. Congenital fibrosis of extraocular muscles is usually associated
with myogenic ptosis. Other rare causes include chronic
progressive external ophthalmoplegia (CPEO), myotonic
dystrophy, and oculopharyngeal muscular dystrophy.
Myasthenia gravis may properly be included among
both the neurogenic and myogenic classifications, although
it is most frequently associated with the latter. Toxic myogenic ptosis is reportedly a result of prolonged use of corticosteroids and mascara. Traumatic injury to the levator
muscle may produce a myopathic dysfunction that generally resolves spontaneously.
Determination of a myogenic cause for ptosis may alert
the surgeon to potentially life-threatening conditions,
such as CPEO. Conditions such as myasthenia gravis also
demand very different consideration, and surgery is generally delayed until stable medical therapy is certain.
Surgical correction of myogenic ptosis is indicated when
the condition is stable. The choice of procedure depends
upon the degree of residual levator muscle function and
the nature of associated dysfunctions. Surgical intervention
in some patients, for example, where Bells phenomenon
may be severely defective, requires a far more conservative
approach or modification of technique.
Aponeurotic Ptosis. Defects in the mechanical linkage between the levator muscle and tarsal plate are grouped
as the aponeurotic ptoses. Involutional redundancy of the
aponeurosis is the most common cause of adult-acquired
ptosis and frequently accompanies senile degeneration of
other periorbital tissues. Thinning and dehiscence of the
aponeurosis are also seen as aging phenomena, as is frank
disinsertion, although the last is much less common. Separation of the aponeurosis from the tarsus is seen frequently
with trauma, both congenital and adult, and following
repeated bouts of eyelid edema.
In aponeurotic ptosis, the levator muscle is usually
completely normal, and function is excellent. Correction
is directed at shortening the aponeurosis or reattaching it
to the tarsal plate. Similar surgery can also yield gratifying
80
7/12/2012 10:42:52 AM
SECTION G Blepharoptosis
results in some cases of neurogenic and myogenic ptosis
where function is good, in spite of the fact that the pathologic process does not reside with the aponeurosis itself.
Mechanical Ptosis. In mechanical ptosis, there is
a physical obstruction impeding eyelid elevation in the
presence of an otherwise normal levator muscle and oculomotor nerve. Eyelid mass lesions, such as abscesses and
tumors, and skin or conjunctival scarring can restrict lid
movement. Dermatochalasis and brow droop may put
excessive weight on the lid, resulting in a secondary ptosis. Orbital lesions frequently present with ptosis when the
levator and superior rectus muscles are involved. The correction of mechanical ptosis is directed first at the cause.
Any residual ptosis may then be corrected with other surgical techniques designed to elevate the lid.
Pseudoptosis. This is a poorly defined group of unrelated disorders resulting in ptosis and caused by defects
in posterior eyelid support, changes in ocular position, or
counter effects of the protractor muscles. Loss of orbital
volume seen with microphthalmos, phthisis bulbi, enucleation, and traumatic fat atrophy result in sagging of support
to the levator muscle and Whitnalls ligament, with associated ptosis. Correction may require orbital soft tissue volume augmentation or repositioning rather than standard
ptosis repair. Hypotropia and ptosis are frequently related
because of both anatomic and physiologic mechanisms.
Correction of the strabismus frequently also corrects the
ptosis. Blepharospasm, either primary or secondary to ocular surface irritation or iritis, can increase protractor force
against the levator muscle, resulting in a pseudoptosis.
Eyelid retraction from thyroid orbitopathy or sympathomimetic drugs can cause a pseudoptosis of the contralateral
eyelid because of reduced central output and Herings law of
equal innervation. In all these conditions, treatment clearly
is not directed at the levator muscle or its aponeurosis without first attending to the primary pathologic process.
PATIENT EVALUATION
Evaluation of the ptotic patient should include an attempt
to determine the precise etiology. Once other treatable diseases have been ruled out, attention is directed at repair of
the ptosis. The most important criterion in selecting a successful surgical procedure is levator muscle function. This
must be measured with extreme care because in the poor
function range, even a difference of 1 or 2 mm may result
in the choice of an inappropriate operation.
Levator muscle function is measured as maximum eyelid
margin excursion from extreme downward gaze to extreme
upward gaze positions. The frontalis muscle must be immobilized with the examiners finger at the brow to eliminate
its contribution to lid elevation. This is especially important
in children. By convention, more than 12 mm of function is
considered excellent, 8 to 11 mm is good, 5 to 7 mm is fair, 3
to 4 mm is poor, and 0 to 2 mm is considered absent.
Minimal degrees of ptosis up to 3 mm with good levator muscle function may be corrected with any number of
81
procedures. The tarsoconjunctival resection procedure is

simple to perform and provide good results. However, it
sacrifices the upper portion of the tarsus and accessory lacrimal glands, and in most cases, it fails to correct the source
of the pathologic process, namely the redundant levator
aponeurosis. The posterior Mllers muscleconjunctival
resection preserves the tarsus and accessory glands and
specifically does not address any defects in the aponeurosis. Nevertheless, it provides good lid elevation and predictable results. During the preoperative evaluation, 10%
phenylephrine drops are instilled in the eye. After 10 minutes, the lid position is noted. If the position is normal, an
8-mm resection is planned. If it is slightly less than normal,
9 mm is resected. If it is slightly more than normal, a 7-mm
resection is anticipated. If the test does not elevate the lid
to within 1 to 2 mm of normal lid position, an alternative
procedure should be selected.
There are a number of other ptosis operations, many
of which require a greater knowledge of eyelid anatomy.
Most, such as the external tarsoaponeurectomy, the
A-frame Mllers muscle aponeurectomy, and the splitlevel tarsectomytarsoaponeurectomy, offer little advantage over the simpler aponeurotic advancement procedure.
In most cases with fair to good levator muscle function,
ptosis can be corrected easily with aponeurotic advancement or repair. Although most appropriate for acquired
aponeurotic ptosis, this procedure also works well in
cases of congenital, other myopathic, and neurogenic ptoses. This operation allows accurate adjustment of eyelid
height and contour, especially when performed under local
anesthesia.
Some fair-function ptosis cases may respond to maximum aponeurosis advancement up to Whitnalls ligament.
However, most will require a levator muscle resection procedure. This may be performed through a transcutaneous
or transconjunctival route, although the former is easier
for the beginning eyelid surgeon.
In levator muscle resection surgery, an estimate of the
amount of muscle to be removed should be made preoperatively. The quantitative data below derive from the collective experience of many surgeons and have provided
predictable results. With very poor levator muscle function, the estimate is less accurate. The following approximate resections are recommended:
Ptosis
12 mm
3 mm
3 mm
4+ mm
4+ mm
Levator Muscle
Function
good (8+ mm)
good (8+ mm)
fair (57 mm)
fair (57 mm)
poor (34 mm)
Levator Muscle
Resection
1013 mm
1417 mm
1822 mm
2326 mm
27+ mm
Additional intraoperative adjustment is made according to

the Berke method, which is based on the degree of expected
postoperative fall or elevation in the lid position. With this
7/12/2012 10:42:52 AM
82
method, the lid margin is placed at the superior corneal

limbus when levator muscle function is poor to fair, and a
postoperative fall of several millimeters is expected. With
fair to good function, the lid is placed 2 to 3 mm below the
limbus and no postoperative fall is expected. Such intraoperative adjustment is a useful addition to the quantitative
estimation made preoperatively. However, when epinephrine is present in the local, there will be some Mllers muscle stimulation so that a postoperative fall of 1 to 2 mm is
typical.
The levator muscle resection procedure described below
is a modification designed to achieve muscle shortening,
with preservation of Whitnalls ligament as a suspensory
structure for the superior orbital fascial system. The procedure also preserves Mllers muscle, which in many congenital cases may be the major source of intrinsic eyelid
retraction.
In patients with no levator muscle function, the only
operation that will achieve adequate eyelid elevation is
frontalis suspension. In this procedure, the eyelid is fixed to
the frontalis muscle at the brow. Functionally, the frontalis
muscle is used as a supplemental eyelid retractor. A variety
of suspensory materials have been advocated. Autogenous
fascia lata has proven to give good results with minimal
complications but requires secondary surgery on the leg
for harvesting of the fascia. A silicone rod has become very
popular and has the advantage of not scarring into position, so that it can be adjusted indefinitely.
Whenever possible, all ptosis surgery should be performed under local anesthesia to allow more precise
adjustment of eyelid height and contour. In cooperative
children, local anesthesia can be used successfully as early
as 6 years of age.
Blepharoptosis, Transcutaneous Approach
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Beard C. Ptosis. 3rd ed. St. Louis, MO: Mosby-Year Book; 1981.
Berke RN. Results of resection of the levator muscle through a skin incision in congenital ptosis. Arch Ophthalmol. 1959;61:177201.
Callahan M, Beard C. Beards Ptosis. 4th ed. Birmingham, UK: Aesculapius; 1990.
Dutton JJ. A Color Atlas of Ptosis: A Practical Guide to Evaluation and
Management. Singapore: P. G. Publishing Co.; 1988.
Frueh BR. The mechanistic classification of ptosis. Ophthalmology.
1980;87:10191021.
Jones LT, Quicker MH, Wobig JL. The cure of ptosis by aponeurotic repair.
Arch Ophthalmol. 1975;93:629634.
Lucarelli MJ, Lemke BN. Small incision external levator repair: technique
and early results. Am J Ophthalmol. 1999;127:637644.
Mauriello JA, Wagner RS, Caputo AR, et al. Treatment of congenital ptosis by maximum levator resection. Ophthalmology. 1985;93:466469.
McCord CD Jr. The evaluation and management of the patient with ptosis.
Clin Plast Surg. 1988;15:169184.
Mustarde JC. Correction of ptosis by split level lid resection. Clin Plast
Surg. 1978;5:533535.
Older JJ. Levator aponeurosis surgery for the correction of acquired ptosis. Analysis of 113 procedures. Ophthalmology. 1983;90:10561059.
Waqar S, McMurray C, Madge SN. Transcutaneous blepharoptosis surgeryadvancement of levator aponeurosis. Open Ophthalmol J.
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Blepharoptosis, Transconjunctival Approach

Ben Simon GJ, Lee S, Schwarcz RM, et al. External levator advancement
vs Mllers muscle-conjunctival resection for correction of upper eyelid involutional ptosis. Am J Ophthalmol. 2005;140:426432.
Ben Simon GJ, Lee S, Schwarcz RM, et al. Mllers muscle-conjunctival
resection for correction of upper eyelid ptosis: relationship between
phenylephrine testing and the amount of tissue resected with final
eyelid position. Arch Facial Plast Surg. 2007;9:413417.
Carroll RP. Preventable problems following the Fasanella Servat procedure. Ophthal Surg. 1980;11:4451.
Dortzbach RK. Superior tarsal muscle resection to correct blepharoptosis. Ophthalmology. 1979;86:18831891.
Fasanella RM, Servat J. Levator resection for minimal ptosis: another
simple operation. Arch Ophthalmol. 1961;65:493496.
Glatt HJ, Putterman AM, Fett DR. Muellers muscle-conjunctival resection procedure in the treatment of ptosis in Horners syndrome. Ophthal Surg. 1990;21:9396.
Ichinose A, Leibovitch I. Transconjunctival levator aponeurosis advancement without resection of Mllers muscle in aponeurotic ptosis
repair. Open Ophthalmol J. 2010;14:8590.
Illif CE. Ptosis surgery. In: Duane TD, ed. Clinical Ophthalmology. Vol 5.
New York: Harper and Row; 1976.
Marcet MM, Setabutr P, Lemke BN, et al. Surgical microanatomy of the
Mller muscle-conjunctival resection ptosis procedure. Ophthal Plast
Reconstr Surg. 2010;26:360364.
Mercandetti M, Putterman AM, Cohen ME, et al. Internal levator
advancement by Mllers muscle-conjunctival resection: technique
and review. Arch Facial Plast Surg. 2001;3:104110.
Putterman AM, Urist MJ. Mueller muscle-conjunctiva resection. Arch
Ophthalmol. 1975;93:619623.
Putterman AM, Urist MJ. Muellers muscle-conjunctiva resection ptosis
procedure. Ophthal Surg. 1978;9:2732.
Putterman AM. Mllers muscle-conjunctival resection ptosis procedure.
Aust N Z J Ophthalmol. 1985;13:179183.
Shields M, Putterman A. Blepharoptosis correction. Curr Opin Otolaryngol Head Neck Surg. 2003;11:261266.
Waller RR. Evaluation and management of the ptosis patient. In: McCord
CD, ed. Oculoplastic Surgery. New York: Raven Press; 1981.
Weinstein GS, Buerger GF Jr. Modification of the Muellers muscleconjunctival resection operation for blepharoptosis. Am J Ophthalmol.
1982;93:647651.
Wiggs EO. The Fasanella-Servat operation. Ophthal Surg. 1978;9:4857.
Levator Resection and Supra-Whitnalls Levator Muscle Resection

Beard C. Ptosis. 3rd ed. St. Louis, MO: Mosby-Year Book; 1981.
Berke RN. Results of resection of the levator muscle through a skin incision in congenital ptosis. Arch Ophthalmol. 1959;61:177.
Callahan M, Beard C. Beards Ptosis. 4th ed. Birmingham, UK: Aesculapius; 1990:269270.
Crawford JS. Congenital blepharoptosis. In: Smith BC, Delia Rocca RC,
Nesi FA, Lisman RD, eds. Ophthalmic Plastic and Reconstructive Surgery. Vol 1. St. Louis, MO: Mosby-Year Book; 1987.
Dutton JJ. A Color Atlas of PtosisA Practical Guide to Evaluation and
Management. Singapore: P. G Publishing Co.; 1988:95119.
Mauriello JA, Wagner RS, Caputo AR, et al. Treatment of congenital ptosis by maximum levator resection. Ophthalmology. 1986;93:466469.
Frontalis Suspension
Chow K, Deva N, Ng SG. Prolene frontalis suspension in paediatric ptosis.
Eye. 2011;25:735739.
Osborn SF, Sloan B. Modified eyelid crease approach frontalis suspension
without brow incision. Ophthal Plast Reconstr Surg. 2011;27:e11e13.
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Sokol JA, Thornton IL, Lee HB, Nunery WR. Modified frontalis suspension techniques with review of large series. Ophthal Plast Reconstr
Surg. 2011;27:211215.
Takahashi Y, Leibovitch I, Kakizaki H. Frontalis suspension surgery in
upper eyelid blepharoptosis. Open Ophthalmol J. 2010;14:9197.
Harvesting Autogenous Fascia Lata

Callahan M, Beard C. Beards ptosis. 4th ed. Birmingham, UK: Aesculapius; 1990:151155.
Crawford JS. Repair of ptosis using frontalis muscle and fascia lata. Trans
Am Acad Ophthalmol Otolaryngol. 1959;60:672678.
Wright WW. The use of living sutures in the treatment of ptosis. Arch
Ophthalmol. 1922;51:99.
Frontalis Muscle Suspension with Autogenous Fascia Lata

Callahan M, Beard C. Beards Ptosis. 4th ed. Birmingham, UK: Aesculapius; 1990:155160.
Crawford JS. Repair of ptosis using frontalis muscle and fascia lata. Trans
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Crawford JS. Repair of ptosis using frontalis muscle and fascia lata: a
20-year review. Ophthalmic Surg. 1977;8:3140.
Dutton JJ. A Color Atlas of Ptosis: A Practical Guide to Evaluation and
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Fox SA. Complications of frontalis sling surgery. Am Ophthalmol.
1967;63:758762.
Frontalis Muscle Suspension with Silicone Rod

Ahn J, Kim NJ, Choung HK, et al. Frontalis sling operation using silicone
rod for the correction of ptosis in chronic progressive external ophthalmoplegia. Br J Ophthalmol. 2008;92:16851688.
83
Bernardini FP, de Conciliis C, Devoto MH. Frontalis suspension sling

using a silicone rod in patients affected by myogenic blepharoptosis.
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Friedhofer H, Nigro MV, Filho AC, Ferreira MC. Correction of blepharophimosis with silicone implant suspensor. Plast Reconstr Surg.
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lata in pediatric frontalis suspension. J Pediatr Ophthalmol Strabismus. 2006;43:212218.
Lamont M, Tyres AG. Silicone sling allows adjustable ptosis correction in
children and in adults at risk of corneal exposure. Orbit. 2010;29:102105.
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21
Posterior Tarsoconjunctival Resection

(Fasanella-Servat)
INDICATIONS: Minimal ptosis of up to 2 mm with good to excellent levator muscle function.

CONTRAINDICATIONS: Moderate to severe ptosis of more than 3 mm; fair to poor levator muscle function; associated
deformities, such as dermatochalasis, requiring concomitant repair.
FIG. 21.1. Inltrate 0.5 mL of local anesthetic

subcutaneously along the eyelid crease and another 0.5 mL
subconjunctivally along the superior tarsal border. Allow
10 minutes for hemostasis.
FIG. 21.2. Place a traction suture of 4-0 silk through the
tarsus and across the eyelid margin. Evert the lid over a
Desmarres retractor, using the suture for xation. The tip of the
retractor blade should lie at the supratarsal fold.
FIG. 21.3. Place two curved hemostat clamps across the
upper tarsus 3 to 4 mm from its superior border. Close
the clamps by sliding the tightening jaws over the Desmarres
retractor so that the tarsus and conjunctiva are included in the
bite. Align the clamps so that the curved tips lie closer centrally
to the superior edge of the tarsus than elsewhere.
from the supratarsal conjunctiva to the tarsal conjunctiva

behind the clamps. Include all eyelid layers except the skin and
orbicularis muscle. Tie the sutures and leave the ends long.
FIG. 21.5. Remove the clamps and cut along the crush
marks with scissors. With ne forceps, tease the conjunctiva
away from the underlying tissues to reveal the tarsus, Mller's
muscle, and conjunctiva.
FIG. 21.6. Pass a 6-0 chromic suture from the skin surface to
emerge within the lateral end of the tarsal wound.
FIG. 21.7. Reapproximate the cut tarsal surface to Mller's
muscle with a running stitch, using the 6-0 chromic suture.
Keep the suture loops beneath the conjunctiva. At the nasal
end of the wound, pass the suture through to the skin surface.
FIG. 21.4. Remove the Desmarres retractor. Pull the skin

and muscle away from the clamped tissue with forceps to
ensure that these layers are not included in the bite. Pass three
temporary double-armed 4-0 silk sutures through the eyelid
FIG. 21.8. Cut out the three temporary silk sutures and the
marginal traction suture. Return the lid to its normal position. Take small bites through the skin with each end of
the chromic suture and tie the ends to themselves.
globe four times daily for 7 days or until the chromic
sutures dissolve.
no treatment. If significant, cut the chromic sutures

after 3 days and massage the lid downward to gape the
wound.
Corneal abrasionThis results from the chromic sutures
placed across the conjunctival edges. Ophthalmic ointment must be used liberally until the sutures dissolve.
Contour defectsThis is caused by uneven placement of
the clamps, failure to leave the central tarsus longer than
the sides, or resection of too wide a segment of the tarsus. If peaking occurs, the central portion of the chromic suture can be cut and the lid massaged downward,
beginning 3 to 4 days after surgery.
UndercorrectionThis is more common when patients
are not carefully evaluated and more than 2.5 mm of
ptosis is present. The procedure should be limited to
cases of minimal, good-function ptosis.
OvercorrectionThis may occur if more than 3 to 4 mm
of tarsus is resected. If minimal, overcorrection requires
84
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CHAPTER 21 Posterior Tarsoconjunctival Resection (Fasanella-Servat)
FIG. 21.1
FIG. 21.5
FIG. 21.2
FIG. 21.6
FIG. 21.3
FIG. 21.7
FIG. 21.4
FIG. 21.8
85
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22
Posterior Mller's MuscleConjunctival

Resection
INDICATIONS: Mild to moderate ptosis of up to 3 mm with good to excellent levator muscle function, especially Horners
neurogenic ptosis, and where the phenylephrine test shows correction with Mllers muscle stimulation.
CONTRAINDICATIONS: Ptosis >3 mm with fair to poor function, or where the phenylephrine test fails to correct the lid
position.
FIG. 22.1. Administer a frontal nerve block, using 1 mL

of anesthetic solution without epinephrine to avoid
stimulation and distortion of Mller's muscle. Place a 4-0 silk
traction suture through the tarsus and across the lid margin,
and evert the lid over a Desmarres retractor to expose the
supratarsal palpebral conjunctiva.
FIG. 22.2. Pass a 6-0 silk marking suture horizontally
through the conjunctiva and Mller's muscle 8 mm above
the superior tarsal border (or 7 to 9 mm, depending upon
the results of the phenylephrine test). Take one bite centrally
and two additional bites 6 mm to either side.
FIG. 22.3. With toothed forceps, grasp the conjunctiva and the
part of Mller's muscle that is adherent to its undersurface.
Pull it from side to side and up and down to separate its loose
areolar connections from the levator aponeurosis. Repeat this
procedure at several positions across the lid.
FIG. 22.4. Place a toothed Mller's muscleconjunctival
resection clamp with one blade adjacent to the superior
tarsal border and the other at the 6-0 silk marking suture.
The clamped tissue should include 8 mm of conjunctiva
and Mller's muscle. Tighten the clamp while removing the
Desmarres retractor.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place antibiotic ointment beneath
the upper lid four times daily for 7 days.
UndercorrectionThis results from failure to resect
enough tissue or from poor patient selection. If 10%
FIG. 22.5. Pull the clamp and enclosed tissues upward and
the overlying skin downward to conrm that the skin and
levator aponeurosis are not included in the bite. The skin
should pull away easily. If there is resistance, remove the clamp
and replace it.
FIG. 22.6. Hold the clamp straight out and pass a
double-armed 6-0 plain gut suture through the clamped
tissues nasally, 1.5 mm behind the clamp blades. Run
one end of this suture to the temporal side of the clamp as a
mattress stitch, taking 2-mm bites.
FIG. 22.7. With a scalpel, cut the conjunctiva and Mller's
muscle between the clamp and the running mattress
suture. Remove the previously placed 6-0 silk conjunctival
marking suture.
FIG. 22.8. Replace the Desmarres retractor and run the
nasal end of the 6-0 plain suture in continuous fashion
across the wound, apposing the edges of Mller's muscle
and conjunctiva to the superior tarsal border. Bring the two
arms of the suture through the lid temporally and into a 4-mm
horizontal skin incision at the temporal edge of the supratarsal
eyelid crease. Tie the ends to bury the knot below the skin.
Remove the traction suture.
phenylephrine fails to elevate the lid to within 1 mm
of the desired level, an alternative procedure should be
selected.
Punctate corneal stainingThis may be caused by the
tarsal sutures. It is treated with liberal topical lubrication and typically resolves within 1 week after the
sutures dissolve.
86
7/12/2012 10:48:17 AM
CHAPTER 22 Posterior Mller's MuscleConjunctival Resection
FIG. 22.1
FIG. 22.5
FIG. 22.2
FIG. 22.6
FIG. 22.3
FIG. 22.7
FIG. 22.4
FIG. 22.8
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23
External Levator Aponeurosis

Advancement
INDICATIONS: Mild to severe aponeurotic ptosis with good to excellent levator function. Also, mild to moderate neurogenic and myogenic ptosis with good function.
CONTRAINDICATIONS: Ptosis from any cause in which levator function is poor or absent.
FIG. 23.1. Mark the incision line within the existing eyelid
crease or at a level symmetric with the opposite eyelid.
In bilateral surgery, place the incision lines 8 to 10 mm above
the lid margin.
FIG. 23.5. Cauterize the muscle edges with bipolar

electrodes.
FIG. 23.2. Inltrate 1 mL of local anesthetic along the

incision line. Wait 15 minutes for hemostasis.
FIG. 23.6. Identify the orbital septum, which inserts onto

the aponeurosis 3 to 5 mm above the tarsus. The yellow fat
pockets are visible through it. Hold the orbital septum with
forceps, and cut a buttonhole centrally with scissors.
FIG. 23.3. Hold the lid taut to prevent buckling and cut
the skin with a rounded scalpel blade. The circumferential
bers of the orbicularis muscle should be visible within
the wound.
FIG. 23.7. Open the septum all the way across the wound.
Carefully separate all attachments between the septum and
aponeurosis at the extreme medial and lateral sides of the incision to prevent postoperative lagophthalmos.
FIG. 23.4. Tent up the skin edges with forceps and cut
through the orbicularis muscle with scissors to enter the
postorbicular fascial plane. Open the muscle nasally and
temporally to expose the underlying orbital septum and
aponeurosis.
FIG. 23.8. With cotton-tipped applicators, brush the

preaponeurotic fat pockets upward to reveal the levator
aponeurosis. Divide the ne fascial attachments between the
fat capsules and aponeurosis with scissors, if necessary.
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CHAPTER 23 External Levator Aponeurosis Advancement
FIG. 23.1
FIG. 23.5
FIG. 23.2
FIG. 23.6
FIG. 23.3
FIG. 23.7
FIG. 23.4
FIG. 23.8
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7/12/2012 10:56:22 AM
90
FIG. 23.9. Note the status of the aponeurosis. It may be attached to the tarsus but
redundant, or it may be dehisced or disinserted. In the latter case, Mller's muscle
will be visible inferior to the edge of the aponeurosis, and the ne peripheral vascular
arcade will be seen running horizontally just above the tarsal border.
FIG. 23.10. Excise a strip of orbicularis muscle from the inferior skin edge to
reveal the tarsal surface.
FIG. 23.11. Pass a 6-0 prolene suture through partial thickness of the tarsus
3mm from its upper border and above the central pupil and then through the
lower edge of the aponeurosis.
FIG. 23.12. Tie the suture in a temporary knot and ask the patient to look forward with eyes open. If necessary, replace the suture upward or downward in the
aponeurosis until the eyelid margin lies 1.5 to 2.0 mm above the desired level. Some
fall in eyelid height usually will be seen within 5 to 10 minutes of suture placement.
FIG. 23.13. Place additional sutures through the tarsus and aponeurosis medially and laterally to produce a normal marginal contour. Adjust the sutures as
needed.
FIG. 23.14. If necessary, resect a strip of the skin and orbicularis muscle from
along the superior wound edge to prevent excessive overhang. Close the skin with
a running suture of 6-0 fast-absorbing plain gut or interrupted stitches of 7-0 chromic.
If the skin-muscle lamella is not xed to the tarsus and folds down over the lashes
easily, reform the eyelid crease. Except when an Asian lid is to be maintained, pass the
suture through the aponeurosis with every second or third loop to reform the eyelid crease. Alternatively, reform the crease by placing 4 to 5 interrupted 6-0 chromic
sutures to x the orbicularis muscle to the aponeurosis prior to closing the skin.
suture line four times daily for 7 days.
UndercorrectionThis results from inadequate advancement of the aponeurosis or from failure to allow for the
expected 1- to-2 mm postoperative fall in the eyelid
height. Within the first week, it may be corrected in the
office by pulling the wound open and placing the sutures
higher on the aponeurosis.
OvercorrectionThis is uncommon but is seen with
excessive advancement of the aponeurosis. If mild, it
may be corrected with vigorous downward massage
after 2 weeks. If overcorrection is more than 2 mm, it
can be repaired at 1 week in the office by pulling open
the wound and replacing the tarsal sutures lower on the
aponeurosis.
Asymmetry of the eyelid creaseThis is caused by failure
to adequately reform the eyelid crease or by misplace-
ment of the incision line. If the crease is too high, it will

usually fall spontaneously over several months. If it is
too low, reform the crease by opening the wound and
refixing the skin edges. If there is an excessive overhang
of the skin obscuring the crease, resect a strip of skin
and muscle prior to closure.
LagophthalmosSome degree of lagophthalmos is
expected postoperatively. It almost always resolves
within a few days. Significant and persistent lagophthalmos may result from inadvertent shortening of the
orbital septum by failure to separate it from the aponeurosis or by including it in the skin sutures. This may
require opening of the wound with lysis of the septal
attachments.
Poor eyelid contourThis is caused by uneven advancement of the aponeurosis and it is prevented by careful attention to the contour intraoperatively. Uneven
contour can be corrected within 1 week by pulling the
wound open with segmental advancement or recession
of the aponeurosis.
7/12/2012 10:56:30 AM
CHAPTER 23 External Levator Aponeurosis Advancement
FIG. 23.9
FIG. 23.12
FIG. 23.10
FIG. 23.13
FIG. 23.11
FIG. 23.14
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7/12/2012 10:56:30 AM
24
Supra-Whitnalls Ligament Levator

Muscle Resection
INDICATIONS: Myogenic or neurogenic ptosis with fair to poor levator muscle function of 4 to 6 mm.
CONTRAINDICATIONS: Ptosis with good to excellent levator muscle function or very poor to absent function.
FIG. 24.1. Mark the incision line within the existing eyelid
crease or symmetric with the opposite lid. For bilateral
ptosis, place the line 8 to 10 mm above the lid margin. Inject
local anesthetic with epinephrine along the marked line for
hemostasis.
FIG. 24.2. Cut the skin with a rounded scalpel blade while
holding the lid taut to prevent buckling.
FIG. 24.3. Tent up the skin edges to pull the orbicularis
away from the levator. With scissors, cut the muscle centrally
to enter the postorbicular fascial plane.
FIG. 24.4. Open the orbicularis muscle across the entire
wound. Cauterize the muscle edges with bipolar electrodes.
FIG. 24.5. Identify the orbital septum, which inserts onto
the aponeurosis 3 to 5 mm above the tarsus, and the
yellowish orbital fat behind it. Hold the septum up with

forceps and cut a central opening with scissors.
FIG. 24.6. Cut open the septum across the lid, being careful
to completely separate the septum from the aponeurosis at
the medial and lateral extremes.
FIG. 24.7. With cotton-tipped applicators, brush the
preaponeurotic fat pockets upward to the level of Whitnalls
ligament. Measure the distance from the superior border of the
tarsus to Whitnalls ligament (X mm). Subtract this number from
the total planned resection (Y mm) to give the amount of levator
muscle to be excised above Whitnalls ligament (Y X mm = Z mm).
FIG. 24.8. Identify the levator muscle above Whitnalls
ligament. Using the scissors and blunt dissection, carefully
separate the levator muscle from the underlying superior
rectus muscle and conjunctiva.
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7/12/2012 11:00:34 AM
CHAPTER 24 Supra-Whitnalls Ligament Levator Muscle Resection
FIG. 24.1
FIG. 24.5
FIG. 24.2
FIG. 24.6
FIG. 24.3
FIG. 24.7
FIG. 24.4
FIG. 24.8
93
7/12/2012 11:00:34 AM
94
FIG. 24.9. Slide one jaw of a Berke ptosis clamp beneath the levator muscle just
above the level of Whitnalls ligament. Tighten the clamp.
FIG. 24.10. With scissors, cut the levator muscle between the clamp and
Whitnalls ligament.
FIG. 24.11. Evert the levator muscle by pulling the clamp upward. Divide the
fascial connections between the levator and the underlying superior rectus muscle
and conjunctiva superiorly for 10 to 15 mm, depending upon the amount of planned
resection.
FIG. 24.12. Pass three double-armed 6-0 prolene sutures through partial thickness of the tarsus, near its superior border.
FIG. 24.13. Advance the levator muscle over Whitnalls ligament and over the
intact aponeurosis and Mllers muscle to the tarsus. Pass the central prolene
suture through the levator muscle Z mm above the cut edge as determined in
Fig. 24.7.
FIG. 24.14. Remove the Berke ptosis clamp. Note the position of the upper eyelid.
The lid margin should rest at or within 1 mm of the superior corneal limbus. If it does
not, reposition the prolene suture.
FIG. 24.15. Pass the nasal and temporal prolene sutures through the levator
muscle and adjust their positions to achieve an adequate eyelid contour. Excise
any excess levator muscle distal to the sutures with Westcott scissors.
FIG. 24.16. Use scissors to remove a strip of skin and orbicularis muscle from
along the upper edge of the wound if necessary to prevent overhang. This is
frequently needed with larger resections for congenital ptosis. Close the skin with a
running suture of 6-0 fast-absorbing plain gut. Reform the eyelid crease if necessary by
incorporating the bite through the levator muscle on every second or third loop.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place ophthalmic ointment on the
globe at the end of the operation and every 2 hours for 24
hours. Thereafter, apply ointment four times daily and at
bedtime for 1 week. Substitute artificial tears during the
day, but continue applying ointment at bedtime for at least
4 weeks. Adults may have to continue bedtime application
indefinitely.
UndercorrectionThis is a common occurrence, especially in poor function cases. After several months,
additional resection can be performed, using the
same criteria as used initially. A tarsectomy procedure
performed transcutaneously works well for smaller
amounts of undercorrection.
OvercorrectionThis is seen rarely in primary repair of
congenital ptosis but is more commonly seen in repeat
operations and adults. Massage and time may resolve
small overcorrections of 1 to 2 mm. For larger or persis-
tent overcorrections, levator muscle recession or a horizontal tarsotomy with gaping of the wound may be useful.
Prolapse of conjunctivaThis results from loss of forniceal fascial suspension during dissection. If it is recognized intraoperatively, refix the fornix with several
double-armed 4-0 chromic sutures passed from the
conjunctiva through the levator muscle. Postoperatively,
prolapse is corrected with full-thickness eyelid sutures
passed from conjunctiva to skin. With chronic edema
and hypertrophy, a portion of the thickened conjunctiva
may have to be excised.
Poor eyelid creaseThis is caused by failure to reform
the crease during closure or from an overhang of excess
skin. It is repaired with a secondary crease reformation
procedure, or blepharoplasty.
Poor eyelid contourThis follows inadequate adjustment
of sutures intraoperatively. This is best repaired within 1
week after surgery with further advancement or recession of the levator muscle. Later, segmental tarsotomy
or tarsectomy will correct small defects.
7/12/2012 11:00:38 AM
CHAPTER 24 Supra-Whitnalls Ligament Levator Muscle Resection
FIG. 24.9
FIG. 24.13
FIG. 24.10
FIG. 24.14
FIG. 24.11
FIG. 24.15
FIG. 24.12
FIG. 24.16
95
7/12/2012 11:00:38 AM
25
Harvesting Autogenous Fascia Lata
INDICATIONS: For use in frontalis fixation procedures and eyelid reconstructions.

CONTRAINDICATIONS: The fascia lata is thin and poorly developed in children under 3 years old.
FIG. 25.1. Straighten the leg with the toes turned medially.
Mark the approximate direction of bers in the iliotibial tract
with a line sited between the lateral femoral condyle and a
point 1 to 2 cm behind the anterior superior iliac crest. With
two short cross-marks, dene a 2-cm segment of this line 6 cm
above the lateral condyle of the femur. Inject 0.5 mL of local
anesthetic with 1:100,000 epinephrine subcutaneously beneath
this short segment.
FIG. 25.2. Cut through the skin with a scalpel blade along
the 2-cm segment previously marked and dissect through
subcutaneous fat to the level of the fascia lata. There may be
a thin membrane beneath the fat, which obscures the fascia.
FIG. 25.3. Bluntly dissect upward between the fascia lata
and the overlying fat with a long-handled Metzenbaum
scissors. Extend the dissection for a distance of 15 cm along the
externally marked leg line by pushing the closed scissors into the
wound, opening the scissors, and withdrawing it without closing
again. This separates the fascia and prevents later bleeding.
collagen bundles in the fascia. These will usually approximate

the direction of the external leg line.
FIG. 25.5. Using blunt dissection with long-handled
Metzenbaum scissors, separate the fascia from the
underlying vastus lateralis muscle for a distance of 15 cm
along the marked leg line.
FIG. 25.6. Pass the fascial tongue into the cutting port of
a Crawford or other fascial stripper and secure it with a
straight hemostat. Advance the fascial stripper 15 cm into
the wound, parallel to the collagen bundles, while holding the
fascia taut with the hemostat. Release the cutting blade lock,
cut the strip, and withdraw it from the wound. If there is a
small amount of bleeding, apply pressure for 5 minutes.
FIG. 25.7. Trim away any adherent fat or areolar tissue and
carefully cut the fascia into 2-mm wide strips. Take care to
make these cuts parallel to the collagen bundles. Wrap the
strips in a saline-moistened sponge and set them aside.
FIG. 25.4. Cut a tongue in the fascia 1 cm wide and 2 cm

long, with its attached base toward the patient's head.
Carefully align the longitudinal cuts with the direction of
FIG. 25.8. Close the leg wound with deep, interrupted

4-0 chromic sutures and vertical mattress sutures of 5-0 silk
or Vicryl. Do not close the defect in the fascia.
POSTOPERATIVE CARE: Apply a firm, nonencircling

pressure dressing for 48 hours. Thereafter, place a light
dressing daily until the sutures are removed. Place antibiotic ointment on the suture line four times daily for 7 days.
Remove the skin sutures after 7 days.
Leg painDiscomfort along the site of fascia removal is

frequent with ambulation. This typically resolves within
1 to 2 weeks.
Poor scar formationThe skin over the lateral thigh is
thick, and especially in children, scar formation may on
rare occasions be exuberant. Carefully close the underlying fat and dermal layers separately, and use vertical
mattress sutures on the skin to evert and slightly pucker
the wound to avoid later depression.
InfectionThis is uncommon; however, because of its
location, the wound is more difficult to keep clean. Systemic antibiotics may be used postoperatively, although
they are not routinely necessary.
96
7/12/2012 11:04:20 AM
CHAPTER 25 Harvesting Autogenous Fascia Lata
FIG. 25.1
FIG. 25.5
FIG. 25.2
FIG. 25.6
FIG. 25.3
FIG. 25.7
FIG. 25.4
FIG. 25.8
97
7/12/2012 11:04:20 AM
26
Frontalis Muscle Suspension with

Autogenous Fascia Lata
INDICATIONS: Severe ptosis with very poor to absent levator muscle function of 3 mm or less.
CONTRAINDICATIONS: Ptosis with 6 mm of function. Caution is required in patients with impaired Bells phenomenon.
FIG. 26.1. Place three short guide marks 2 mm above the

lash line, one above the pupil and one each above the
junctional thirds of the lid margin. Elevate the lid to the
desired height and site lines perpendicular to the lid margin
above the lateral and medial guide marks. Mark a line 3 mm
in length at the points where the perpendicular line intersects
the upper border of the brow. Place another 3 mm line midway
between these two brow marks and 1 cm above them.
FIG. 26.4. Thread a strip of prepared autogenous or

preserved fascia into the eyelet of the Wright needle, and
pull it through to the brow incision.
FIG. 26.2. Make stab incisions at the three brow marks

through the skin and frontalis muscle. Place a lid plate
beneath the upper eyelid, and make stab incisions to the
level of the tarsus at the three previously placed marginal
guide marks. Bleeding is controlled with pressure for several
minutes.
FIG. 26.6. Reinsert the Wright needle into the lateral brow
incision and pass it toward the central eyelid incision.
Thread the fascia into the eyelet.
FIG. 26.3. Place a lid plate beneath the eyelid to the orbital
rim, and pass a Wright fascia needle from the lateral brow
stab incision toward the lateral lid incision. As the needle
passes over the brow ridge, direct it slightly backward to
remain deep to the orbicularis muscle. Continue advancing the
needle at a level just anterior to the levator aponeurosis and
the tarsus.
FIG. 26.5. Pass the Wright needle from the central to the
lateral eyelid incision. Thread the free end of the fascia
into the needle eyelet, and pull the strip into the central lid
incision.
FIG. 26.7. Pull the fascia to the lateral brow incision to

complete a triangle, with its short arm along the lateral
eyelid margin and its apex at the lateral brow.
FIG. 26.8. Thread a second strip of fascia between the
medial brow and eyelid incisions in similar fashion to form
a second triangle, with its short arm along the medial eyelid
margin and its apex at the medial brow. The two triangles
meet at the central lid incision.
98
7/12/2012 11:12:05 AM
CHAPTER 26 Frontalis Muscle Suspension with Autogenous Fascia Lata
FIG. 26.1
FIG. 26.5
FIG. 26.2
FIG. 26.6
FIG. 26.3
FIG. 26.7
FIG. 26.4
FIG. 26.8
99
7/12/2012 11:12:05 AM
100 SECTION G Blepharoptosis

FIG. 26.9. Tie the ends of the fascial strips with a square knot and adjust the
tension to produce a normal eyelid contour. Place the height about 1 to 2 mm
higher than the nal desired level or at the superior corneal limbus. Secure the knot at
each brow incision with a 6-0 prolene suture to prevent slippage.
FIG. 26.10. Pass the Wright needle from the central brow incision to the lateral
brow incision and pull through one end of the fascial strip. Repeat this procedure
to pull one end of the medial strip to the central brow.
FIG. 26.11. Tie the strips together at the central brow incision with a square
knot. Adjust the tension on each strip to maintain the eyelid margin contour.
FIG. 26.12. Secure the knot with a 6-0 prolene suture to prevent slippage.
FIG. 26.13. Push the fascial knots to the base of the wounds. Trim all the fascia
ends to 1 cm in length and push these ends into pockets beneath the frontalis muscle
with smooth dressing forceps.
FIG. 26.14. Close all three brow incisions with a 6-0 fast-absorbing plain gut. The
eyelid incisions need not be closed.
POSTOPERATIVE CARE: Apply iced compresses intermittently for 24 hours. Place ophthalmic ointment on the
globe immediately, four times daily, and at bedtime for 7
days. Continue the bedtime ointment application for several weeks with children and several months with adults.
UndercorrectionThis is caused by failure to position the
lid at the superior limbus when the knot is tied. Pushing
the knot into the wound results in lowering of the lid
by 1 to 1.5 mm. If recognized within the first week, the
fascia can be retrieved at the brow wounds and relied.
After fibrosis, a new sling will be needed.
OvercorrectionThis is exceptionally rare in children but
is more common in adults. The sling may loosen with
vigorous massage. After fibrosis has developed along
the sling, cutting the fascial strip will allow some recession of the lid. Fibrosis along the strip prevents complete
return of ptosis.
LagophthalmosThis is a very common sequel to frontalis suspension. The condition is temporized with
artificial tears and ophthalmic ointments until the cornea adapts to chronic exposure. If keratitis is severe
and persistent, especially in adults, the sling may have
to be lowered.
EctropionThis results from placing the sling too close to
the lid margin, especially when the eyes are deep set or
the brow ridges are prominent. If mild, it may resolve
with time. Small amounts of ectropion can be corrected
with minimal lid shortening at the lateral canthus. If
ectropion is more severe, the sling must be reversed.
EntropionThis is caused by failure to excise overhang
of excess skin or from placing the sling too close to the
upper tarsal border. If necessary, an eyelid crease formation procedure can be performed with excision of a strip
of skin and orbicularis muscle from the upper skin edge
prior to closure. Occasionally, the sling may have to be
replaced.
Poor lift contourThis results from inadequate adjustment at the time of surgery. If noted intraoperatively,
slide the lid margin over the sling, using forceps to
adjust the contour.
7/12/2012 11:12:10 AM
CHAPTER 26 Frontalis Muscle Suspension with Autogenous Fascia Lata 101
FIG. 26.9
FIG. 26.12
FIG. 26.10
FIG. 26.13
FIG. 26.11
FIG. 26.14
7/12/2012 11:12:10 AM
27
Frontalis Muscle Suspension

with Silicone Rod
INDICATIONS: Severe ptosis with very poor to absent levator muscle function of 3 mm or less.
CONTRAINDICATIONS: Ptosis with 6 mm of function. Caution is required in patients with impaired Bells phenomenon
or those at risk for corneal exposure.
FIG. 27.1. Mark an incision line at the upper eyelid crease.

Mark two small 5-mm lines at the upper medial and lateral
brow and one centrally about 5 to 8 mm above these. Inltrate
the eyelid with 0.5 to 1.0 mL local anesthetic. Also, inltrate
along the superior orbital rim and beneath the eyebrow. Hold
the lid taut to prevent buckling and incise the skin with a scalpel blade. Make stab incisions at the brow marks.
FIG. 27.2. Cut through the orbicularis muscle with a scissors
and open it to the full extent of the wound. Continue the dissection inferiorly to expose the anterior surface of the tarsus. Separate
the orbicularis from the tarsus for a distance of about 6 to 8 mm.
FIG. 27.3. Place a 1-mm-diameter silicone rod with the
wire introducers removed horizontally across the tarsus.
Suture the rod to the tarsus with three interrupted sutures
of 6-0 prolene. The medial and lateral sutures should be
approximately over the medial and lateral corneal limbus. Be
careful not to penetrate to the conjunctival surface.
FIG. 27.4. Place a lid plate beneath the lid and pass a Wright
fascia needle from the medial and lateral brow incisions,
over the orbital rim, and then behind the orbital septum
toward the tarsus. Thread the ends of the silicone rod through
POSTOPERATIVE CARE: Apply iced compresses continuously for 2 hours and intermittently for 24 hours. Place
ophthalmic ointment on the globe immediately, four times
daily, and at bedtime for 7 days. Continue the bedtime
ointment application for several weeks with children and
several months with adults. For young children, the bedtime application should be continued indefinitely.
UndercorrectionThis is caused by failure to position the lid
at the superior limbus when the silicone band is synched.
Pushing the knot into the wound results in lowering of the
lid by 1 to 1.5 mm. With silicone, the sling can be adjusted
at any time postoperatively, even many years later.
OvercorrectionThis is rare in children but is more common in adults. If there is corneal compromise, the central brow incision can be opened and the sling loosened.
the needle eyelet and pull them through to the brow incisions.
Then pass the Wright needle from the central brow incision
to each of the medial and lateral incisions and pull the rod
through so that both emerge from the central incision.
FIG. 27.5. Pass the silicone rod ends through a silicone band
in opposite directions. A Watsky sleeve spreader will facilitate
this operation.
FIG. 27.6. Before tightening the rod, close the upper eyelid incision with a running suture of 6-0 fast-absorbing gut. Tighten
the silicone sling by pulling the ends through the sleeve until the
eyelid margin is at or just below the superior corneal limbus. Synch
the band with an interrupted suture of 6-0 prolene.
FIG. 27.7. Close the medial and lateral brow incisions with
one or two interrupted sutures. Cut the free ends of the
silicone rod to a length of about 1 cm. With a narrow smooth
dressing forceps, grasp each end of the rod and push it into the
wound beneath the frontalis muscle. Make sure it lies at and
is not bucked to prevent extrusion.
FIG. 27.8. Close the central brow incision with one or two
interrupted sutures of 6-0 fast-absorbing plain gut.
LagophthalmosThis is a very common sequel to frontalis
suspension. The condition is temporized with artificial
tears and ophthalmic ointments until the cornea adapts
to chronic exposure. If keratitis is significant and persistent, especially in adults, the sling may have to be lowered.
EctropionThis results from suturing the sling too close
to the lid margin, especially when the eyes are deep set
or the brow ridges are prominent. If mild, it may resolve
with time. If ectropion is more severe, the sling must be
revised.
EntropionThis is caused by failure to excise overhang
of excess skin or from placing the sling too close to the
upper tarsal border. If necessary, an eyelid crease formation procedure can be performed with excision of a strip
of skin and orbicularis muscle from the upper skin edge
prior to closure. Occasionally, the sling may have to be
repositioned on the tarsus.
102
7/12/2012 11:20:14 AM
CHAPTER 27 Frontalis Muscle Suspension with Silicone Rod 103
FIG. 27.1
FIG. 27.5
FIG. 27.2
FIG. 27.6
FIG. 27.3
FIG. 27.7
FIG. 27.4
FIG. 27.8
7/12/2012 11:20:14 AM
SECTION
Ectropion
I
n ectropion, the eyelid margin is turned outward, away

from the globe. This leads to inadequate corneal protection, discomfort, and ultimately epithelial and stromal injury.
Tear drainage dysfunction results from poor apposition of
the puncta to the globe. The causes are varied, and correction
must be directed at the source of the pathologic process.
The most common etiology is involutional eyelid redundancy. The laxity may be diffuse, involving the entire lid
margin. More commonly, however, laxity is confined to
the lateral one-half of the lid, where it results from stretching of the lateral canthal ligament and loss of horizontal
eyelid support. Less frequently, the thicker medial canthal
ligament may be redundant, resulting in punctal eversion.
Laxity of the orbicularis muscle and overlying skin further
contribute to loss of eyelid tone, thus exacerbating the
ectropion. Involutional ectropion is confined to the lower
eyelid. Because gravity tends to hold the upper lid in position against the globe, ectropion resulting from laxity is not
seen here. A variant of laxity-induced ectropion that does
affect the upper eyelid is the floppy eyelid syndrome, which
is seen occasionally in obese males and less commonly in
females. With this form of ectropion, the tarsus is redundant, causing eversion during sleep.
During examination, patients with involutional ectropion
show some degree of eyelid redundancy on the pinch test.
The latter is performed by pulling the lower lid away from
the globe. A forward displacement of more than 8 mm is
abnormal. Upon release, the lid does not snap back to its former position but drifts slowly, sometimes requiring a blink
before complete return to apposition with the globe. These
signs confirm abnormal laxity. In the presence of medial
canthal ligament redundancy, pulling the eyelid margin laterally causes displacement of the inferior punctum toward
the nasal corneal limbus. Similarly, when lateral canthal
ligament laxity is prominent, pulling the lid medially causes
movement of the lateral canthal angle toward the temporal
limbus. With significant medial lid eversion, stenosis and
occlusion of the inferior punctum is frequently seen, with
tear pooling and overflow. Corneal exposure is common and
may be associated with superficial punctate keratopathy.
Keratinization of the conjunctiva and inflammatory infiltration result in lid thickening and further ectropion.
Repair of involutional ectropion is directed at tightening
of the lax components of eyelid structure. Frequently, this
requires the simultaneous correction of several abnormal elements such as the lateral canthal ligament and the orbicularis
muscle. The most useful lid shortening procedures include
the lateral tarsal strip fixation for canthal ligament reconstruction and the simple wedge resection with or without
H
orbicularis tightening. These may be used on the upper as
well as the lower eyelid. Lid shortening alone may not always
correct punctal eversion, in which case, it can be combined
with a medial spindle tarsoconjunctival resection. When
long-standing ectropion has resulted in secondary deformities, such as punctal occlusion or cicatricial eyelid retraction,
other procedures may have to be added. These include punctoplasty or canaliculoplasty, recession of the eyelid retractors, or release of the cicatrized subcutaneous tissues.
In paralytic ectropion resulting from seventh nerve
dysfunction, the canthal ligaments are frequently normal.
However, loss of orbicularis muscle tone results in outward
displacement of the lower lid under the influence of gravity and the downward traction of a droopy cheek. Paralytic
ectropion is often associated with brow ptosis and secondary dermatochalasis, pseudoptosis of the upper eyelid, and
drooping of the lateral canthal angle. With long-standing
downward tension on the atonic eyelid, progressive stretching occurs so that laxity becomes an additional component.
The goals in the management of paralytic ectropion are
protection of the cornea, ocular comfort, and improved
cosmesis. When ectropion is mild, a simple tarsorrhaphy
shortens the horizontal interpalpebral fissure, provides
minimal vertical support for the lateral lower lid, and reapposes the lid margins to the globe. With greater degrees of
ectropion, especially when significant facial droop is also
present, a tarsorrhaphy alone does not usually withstand
the continued downward tension, and results are temporary at best. Lid shortening achieves good functional and
cosmetic results but must be combined with subcutaneous
cheek suspension to relieve downward traction. When tensional forces are marked, more substantial lid support is
required. This is achieved with a fascial sling or temporalis
muscle transfer procedure.
In cicatricial ectropion, the anterior skin or skinmuscle lamella is shortened, resulting in outward forces on the
lid margin. It is seen in both the upper and lower eyelid
and may be associated with dermatologic disorders, such
as rosacea and ichthyosis, traumatic scarring, burns, infection, radiation, or sequelae to eyelid surgery. Secondary
complications that involve the puncta, conjunctiva, and
cornea may be seen as with other forms of ectropion.
Correction is directed at replacing the deficient tissue with
local flaps or free skin grafts.
Mechanical ectropion results from mass lesions that
interpose between the eyelid and the globe. The lesions
may be conjunctival or subconjunctival infiltrates, lid or
epibulbar tumors, or abscesses. Treatment involves medical or surgical elimination of the causative lesion.
104
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SECTION H Ectropion 105

Medial Spindle Tarsoconjunctival Resection
Ectropion
Mulhern MG, Sheikh I, Subrayan V, et al. The E-Z(easy) clampa new

instrument to facilitate medial ectropion repair. Orbit. 2005;24:109111.
Nowinski TS, Anderson RL. The medial spindle procedure for involutional medial ectropion. Arch Ophthalmol. 1985;103:17501753.
ODonnell FEJ. Medial ectropion associated with lower lacrimal obstruction and combined management. Ophthal Surg. 1986;17:573576.
Bedran EG, Pereira MV, Bernardes TF. Ectropion. Semin Ophthalmol.

2010;25:5965.
Chung JE, Yen MT. Midface lifting as an adjunct procedure in ectropion
repair. Ann Plast Surg. 2007;59:635640.
Damasceno RW, Heindl LM, Hofmann-Rummelt C, et al. Pathogenesis
of involutional ectropion and entropion: the involvement of matrix
metalloproteinases in elastic fiber degradation. Orbit. 2011;30:
132139.
Damasceno RW, Osaki MH, Dantas PE, Belfort R Jr. Involutional entropion and ectropion of the lower eyelid: prevalence and associated
risk factors in the elderly population. Ophthal Plast Reconstr Surg.
2011;27:317320.
Fezza JP. Nonsurgical treatment of cicatricial ectropion with hyaluronic
acid filler. Plast Reconstr Surg. 2008;121:10091014.
Goldberg RA. Use of a suture anchor for correction of ectropion in facial
paralysis. Plast Reconstr Surg. 2006;117:675676.
Heimmel MR, Enzer YR, Hofmann RJ. Entropion-ectropion: the influence
of axial globe projection on lower eyelid malposition. Ophthal Plast
Kahana A, Lucarelli MJ. Adjunctive transcanthotomy lateral suborbicularis fat lift and orbitomalar ligament resuspension in lower eyelid
ectropion repair. Ophthal Plast Reconstr Surg. 2009;25:16.
Nainiwal S, Kumar H, Kumar A. Laser conjunctivoplasty: a new technique
for correction of mild medial ectropion. Orbit. 2003;22:199201.
Osborne SF, Eidsness RB, Carroll SC, Rosser PM. The use of fibrin tissue
glue in the repair of cicatricial ectropion of the lower eyelid. Ophthal
Papalkar D, Francis IC, Wilcsek G. Correction of ectropion in facial paralysis. Plast Reconstr Surg. 2006;117:677.
Lateral Tarsorrhaphy
Cole G. Lateral canthoplasty in ophthalmic plastic surgery. In: Hughes
WL, ed. Manual on Oculoplastic Surgery. San Francisco, CA: The
American Academy of Ophthalmology; 1961.
de Silva DJ, Ramkissoon YD, Ismail AR, Beaconsfield M. Surgical technique: modified lateral tarsorrhaphy. Ophthal Plast Reconstr Surg.
2011;27:216218.
Garber PF. Lateral canthoplasty. In: Smith B, Bosniak S, eds. Advances in
Ophthalmic Plastic and Reconstructive Surgery. Vol 2. Elmsford, NY:
Pergamon Press; 1983.
Soll DB. Entropion and ectropion. In: Soll DB, ed. Management of Complications in Ophthalmic Plastic Surgery. Birmingham, UK: Aesculapius; 1976.
Eyelid Shortening by Lateral Tarsal Strip Fixation

Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol.
1979;97:21922196.
Becker FF. Lateral tarsal strip procedure for the correction of paralytic
ectropion. Laryngoscope. 1982;92:382384.
Georgescu D, Anderson RL, McCann JD. Lateral canthal resuspension
sine canthotomy. Ophthal Plast Reconstr Surg. 2011;27:371375.
Jordan DR, Anderson RL. The lateral tarsal strip revisited. The enhanced
tarsal strip. Arch Ophthalmol. 1989;107:604606.
Vagefi MR, Anderson RL. The lateral tarsal strip mini-tarsorrhaphy procedure. Arch Facial Plast Surg. 2009;11:136139.
Wesley RE, Collins JW. McCord procedure for ectropion repair. Arch
Ophthalmol. 1983;109:319322.
Full-Thickness Marginal Wedge Resection

Fox SA. A modified Kuhnt-Szymanowski procedure. Am J Ophthalmol.
1966;62:533536.
Leone Jr CR.. Repair of senile ectropion. In: Ashton SJ, ed. Third International Symposium of Plastic Surgery of the Eye and Adnexa. Baltimore,
MD: Williams & Wilkins; 1982.
The Modied Lazy T Procedure

Bosniak SL. Ectropion. In: Smith BC, Delia Rocca RC, Nesi FA, Lisman RD, eds. Ophthalmic Plastic and Reconstructive Surgery. Vol 1.
St. Louis: Mosby-Year Book; 1987.
Ferguson AW, Chadha V, Kearns PP. The not-so-lazy-T: a modification of
medial ectropion repair. Surgeon. 2006;4:8789.
Smith B. The lazy-T correction of ectropion of the lower punctum. Arch
Ophthalmol. 1976;94:11491150.
Medial Canthal Ligament Plication

Fante RG, Elner VM. Transcaruncular approach to medial canthal tendon plication for lower eyelid laxity. Ophthal Plast Reconstr Surg. 2001;17:1627.
Fong KC, Mavrikakis I, Sagili S, Malhotra R. Correction of involutional
lower eyelid medial ectropion with transconjunctival approach
retractor plication and lateral tarsal strip. Acta Ophthalmol Scand.
2006;84:246249.
Jelks GW, Smith B, Bosniak S. The evaluation and management of the eye
in facial palsy. Clin Plast Surg. 1979;6:397419.
Olver JM, Sathia PJ, Wright M. Lower eyelid medial canthal tendon laxity
grading: an interobserver study of normal subjects. Ophthalmology.
2001;108:23212325.
Sodhi PK, Verma L, Pandey RM, Ratan SK. Appraisal of a modified medial
canthal plication for treating laxity of the medial lower eyelid. J Craniomaxillofac Surg. 2005;33:205209.
Fascial Suspension Procedure

de la Torre J, Simpson RL, Tenenhaus M, Bourhill I. Using lower eyelid fascial slings for recalcitrant burn ectropion. Ann Plast Surg.
2001;46:621624.
Vistnes LM, Iverson RE, Laub DR. The anophthalmic orbit, surgical correction of lower eyelid ptosis. Plast Reconstr Surg. 1973;52:346.
Weinstein GS, Anderson RL, Tse DT, et al. The use of a periosteal strip for
eyelid reconstruction. Arch Ophthalmol. 1985;103:357359.
Wiggs EO, Guibor P, Hecht SD, et al. Surgical treatment of the denervated
or sagging lower lid. Ophthalmology. 1982;89:428432.
Anterior Lamellar Lengthening with Skin Graft

Bosniak S. Ectropion. In: Smith B, Delia Rocca RC, Nesi F, Lisman RD,
eds. Ophthalmic Plastic and Reconstructive Surgery. Vol 1. St. Louis,
MO: Mosby-Year Book; 1987.
Osborne SF, Eidsness RB, Carroll SC, Rosser PM. The use of fibrin tissue
glue in the repair of cicatricial ectropion of the lower eyelid. Ophthal
Stasior OG. Cicatricial ectropion. In: Ashton SJ, ed. Third Intl Symposium
of Plastic and Reconstructive Surgery of the Eye and Adnexa. Baltimore, MD: Williams & Williams; 1982.
7/12/2012 11:22:34 AM
28
Lateral Tarsorrhaphy
INDICATIONS: Mild to moderate ectropion; mild congenital or acquired eyelid retraction.
FIG. 28.1. Grasp the lower eyelid margin with forceps and
cut along the gray line with a scalpel blade from the lateral
canthal angle medially for a distance of about 10 mm. The
exact distance depends on the amount of intermarginal adhesion needed.
FIG. 28.2. With micro-Westcott scissors, sharply dissect in
the postorbicular fascial plane to a depth of 3 to 4 mm to
separate the anterior skinmuscle lamella from the anterior tarsus.
FIG. 28.3. Cut a strip of epithelium from the marginal border of the tarsus along the area of the split eyelid. Leave the
lashes along the skinmuscle ap intact so the tarsorrhaphy
can be taken down later without distortion of the lid margin.
FIG. 28.4. Grasp the upper eyelid margin and split the
lid along the gray line for a distance equal to that in the
opposing lower lid. Sharply dissect in the postorbicular fascial

plane to a depth of 3 to 4 mm.
FIG. 28.5. Cut a strip of marginal epithelium from the
separated upper tarsus to form a free edge opposite that in
the lower eyelid.
FIG. 28.6. Pass a 6-0 Vicryl suture into the exposed anterior
surface of the lower eyelid tarsus to emerge through the free
margin at the medial extent of the split lid. Place the suture
into the free margin of the opposing upper lid tarsus and out
through its anterior surface. Add two or three additional sutures.
FIG. 28.7. Tie the sutures to oppose the tarsal surfaces.
FIG. 28.8. Allow the lash-bearing skin margins to close over
the approximated tarsal plates. It is not necessary to place
sutures across them.
POSTOPERATIVE CARE: Place antibiotic ointment in

the lateral canthal angle and on the lid margins four times
daily for 7 days.
106
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CHAPTER 28 Lateral Tarsorrhaphy 107
FIG. 28.1
FIG. 28.5
FIG. 28.2
FIG. 28.6
FIG. 28.3
FIG. 28.7
FIG. 28.4
FIG. 28.8
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29
Eyelid Shortening by Lateral

Tarsal Strip Fixation
INDICATIONS: Mild to moderate horizontal laxity of the lower or upper eyelid, especially when resulting from stretching of the lateral canthal ligament.
CONTRAINDICATIONS: Eyelid laxity resulting from medial canthal ligament redundancy; all but the mildest forms of
cicatricial ectropion.
FIG. 29.1. Pull the eyelid medially to prevent buckling, and

with scissors, cut a lateral canthotomy to the orbital rim.
Transect the inferior crus of the lateral canthal ligament. Grasp
the lateral lid with forceps and pull it medially to conrm
interruption of all attachments.
FIG. 29.2. Split the eyelid with ne, pointed scissors along
the gray line for a distance of 5 to 10 mm, depending on the
amount of lid shortening required. Continue the dissection
to separate the anterior skinmuscle lamella from the posterior
tarsoconjunctival lamella.
FIG. 29.3. Cut the retractors and conjunctiva from along
the inferior border of the tarsus beneath the split section.
Cauterize the palpebral vessels, which are usually injured at this
stage.
FIG. 29.4. With ne scissors, remove a strip of marginal
epithelium from the free portion of the tarsus.

the sutures three to four times daily for 7 days.
Persistent laxityUndercorrection of laxity occurs with
failure to adequately shorten the lid. With the patient in
the supine position, the laxity is less obvious. It is best
to slightly overtighten the lid intraoperatively because
some stretching occurs within the first 1 to 2 weeks.
OvercorrectionResults from cutting the tarsal strip too
short before placing the fixation sutures. Mild overcorrection is of no consequence since the lid will stretch over
several weeks. If the strip is too short to be sutured to the
orbital rim, a small periosteal flap is elevated from the
rim, and its free end is sutured to the strip for fixation.
Lateral canthal angle dystopiaElevation of the canthal
angle occurs when the suture is placed too high onto
FIG. 29.5. Lay the anterior surface of the ap over the

at face of a forceps handle and scrape the conjunctival
epithelium from the posterior surface of the tarsus with
a scalpel blade. Cut off the remnant of the lateral canthal
ligament from the bare tarsus to form a strip 3 to 4 mm wide
and 4 mm long.
FIG. 29.6. Pass a 4-0 Mersilene or Vicryl suture on a small,
half-circle needle through the tarsal strip from outside
to inside and then through the periosteum just inside the
lateral orbital rim. Tie the sutures rmly.
FIG. 29.7. With forceps, pull the skinmuscle ap laterally
and excise the excess triangle with its marginal cilia.
FIG. 29.8. Reform the canthal angle with an interrupted
suture of 6-0 fast-absorbing gut. Close the orbicularis
muscle and skin with interrupted stitches of 6-0 fast-absorbing
plain gut.
the lateral orbital rim. This may not be noticed until the
patient sits upright postoperatively. A slight elevation is
tolerable, but excessive elevation does not resolve spontaneously and should be repositioned.
Trichiasis at the lateral canthusThis results from failure to remove the excess lash-bearing marginal skin at
the newly reformed canthal angle. The offending lashes
are removed later by excision or hyfrecation in a separate procedure.
Redundancy of lateral eyelid skinThis is seen with
significant shortening of the lid in the presence of
dermatochalasis. If noted intraoperatively, a subciliary incision is continued from the lateral anterior
lamellar flap and if necessary, the lateral skin incision
is continued slightly downward. A blepharoplasty
type of flap is completed with excision of excess skin
temporally.
108
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CHAPTER 29 Eyelid Shortening by Lateral Tarsal Strip Fixation 109
FIG. 29.1
FIG. 29.5
FIG. 29.2
FIG. 29.6
FIG. 29.3
FIG. 29.7
FIG. 29.4
FIG. 29.8
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30
Medial Spindle Tarsoconjunctival

Resection
INDICATIONS: Ectropion of the medial one-third to one-half of the eyelid with punctal eversion.
FIG. 30.1. Place a no. 00 or 0 Bowman probe in the inferior

canaliculus to mark its position, and evert the lower eyelid
with forceps.
FIG. 30.2. With a scalpel blade cut a spindle-shaped
segment 8 to 10 mm long and 4 to 6 mm high from the
conjunctiva and tarsus. Locate the excision 4 mm below the
inferior punctum, positioned so two-thirds of the spindle lie
lateral to the papilla.
FIG. 30.3. Remove the Bowman probe. Pass a double-armed
4-0 chromic suture through the inferior wound edge from
inside the wound to the conjunctival surface.

the conjunctival fornix and skin suture twice daily until
the suture dissolves.
FIG. 30.4. Continue passing the same sutures through

the superior wound edge from the conjunctival surface
to the subtarsal space to form a double vertical mattress
stitch.
FIG. 30.5. Pass both needles anteriorly through the
center of the spindle-shaped defect to emerge on the skin
surface.
FIG. 30.6. Tie the suture on the skin surface with enough
tension to pull the wound edges together and to invert the
lid margin and punctum.
sutures too close to the canaliculus and is avoided

by careful attention to the position of the Bowman
probe.
Canalicular injuryThis results from placement of the
spindle excision too high on the lid or passing the
110
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CHAPTER 30 Medial Spindle Tarsoconjunctival Resection 111
FIG. 30.1
FIG. 30.4
FIG. 30.2
FIG. 30.5
FIG. 30.3
FIG. 30.6
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31
Full-thickness Marginal Wedge Resection
INDICATIONS: Ectropion from diffuse horizontal eyelid laxity; floppy eyelid syndrome.
FIG. 31.1. Mark an incision line 2 to 3 mm below the

lid margin from just lateral to the inferior punctum to
the lateral canthus. Extend the line laterally and slightly
downward for 1 cm as for a blepharoplasty incision.
FIG. 31.2. Pull the lid laterally to prevent buckling, and
cut the skin along the marked incision line with a rounded
scalpel blade.
FIG. 31.3. With scissors cut through the orbicularis muscle
and dissect a skinmuscle ap by dividing the ne fascial
attachments between the orbicularis and underlying
orbital septum.
FIG. 31.4. At the junction of the central and lateral thirds
of the eyelid, make an angled cut through the tarsus and
the conjunctiva from the lid margin to the fornix in an
inferomedial direction.
FIG. 31.5. With toothed forceps, grasp the free tarsal
edges and overlap them with moderate tension. Mark the
V-shaped area of excess lid, with the point of the V in the
conjunctival fornix.
suture line and in the fornix four times daily for 7 days.
Remove the silk marginal suture after 7 days.
Corneal abrasionThis may result from placing the lid
excision centrally and the tarsal sutures through the
FIG. 31.6. Excise the outlined triangular area with scissors.

Place two or three 6-0 Vicryl sutures across the tarsus, keeping
them beneath the conjunctival surface to prevent corneal
abrasion. Place a 6-0 silk vertical mattress alignment suture
through the tarsus at the lid margin and another through the
lash line. Tie these with enough tension to slightly evert the
wound at the lid margin. Leave the marginal suture ends long.
If necessary, place several additional Vicryl sutures to close the
eyelid retractors below the tarsus.
FIG. 31.7. Drape the skinmuscle ap over the lid and
pull it laterally with moderate tension. Mark the excess that
overlaps the lateral incision line, and cut along this mark with
scissors. It may be necessary to trim 2 to 3 mm of skin from
along the lid margin.
FIG. 31.8. Place one or two deep 6-0 chromic sutures at
the lateral wound to anchor the orbicularis. Close the skin
along the lid margin and at the lateral wound with interrupted
sutures. Tie the long, marginal silk suture ends into one or two
skin stitches to keep them away from the cornea.
conjunctiva. It may also result from not carefully tying

the marginal sutures away from the lid margin.
Eyelid margin notchThis results from poor tarsal closure and failure to evert the margin with mattress
sutures. It may also follow as a result of wound dehiscence. The condition is repaired with wound revision
after several months.
112
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CHAPTER 31 Full-thickness Marginal Wedge Resection 113
FIG. 31.1
FIG. 31.5
FIG. 31.2
FIG. 31.6
FIG. 31.3
FIG. 31.7
FIG. 31.4
FIG. 31.8
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32
Modied Lazy-T Procedure
INDICATIONS: Diffuse horizontal eyelid laxity with moderate punctal eversion.
FIG. 32.1. Hold the lid margin with two forceps, and with
scissors make a full-thickness vertical cut through the lid
4mm lateral to the inferior punctum. Cauterize the marginal
artery.
FIG. 32.2. With forceps, grasp the two free tarsal edges and
overlap them with moderate tension. On the lateral side of
the wound, mark the amount of excess lid to be resected.
FIG. 32.3. Cut along the mark with scissors to excise a
V-shaped segment of full-thickness eyelid.
FIG. 32.4. Evert the medial portion of the eyelid with
forceps. Place a no. 00 or 0 Bowman probe into the canaliculus
to mark its location. Cut a horizontal V-shaped segment of
conjunctiva and capsulopalpebral fascia 4 mm below the
canaliculus. The excised wedge should measure about 5 mm
vertically by 8 mm horizontally and should have its broad base
laterally, at the previously cut vertical eyelid defect.
POSTOPERATIVE CARE: Apply antibiotic ointment to the

sutures and conjunctival fornix four times daily for 10 days.
FIG. 32.5. Close the horizontal incision with several

6-0plain or chromic gut sutures to shorten the posterior
lamella. Bury the knots to prevent corneal abrasion.
FIG. 32.6. Pass a 6-0 silk vertical mattress suture across
the tarsal defect at the eyelid margin for alignment.
Reapproximate the cut tarsal surfaces with several 6-0 Vicryl
sutures, keeping them beneath the conjunctiva.
FIG. 32.7. Place a second marginal 6-0 silk suture through
the lash line. Tie the marginal sutures with enough tension to
evert the wound edges slightly, and leave the suture ends long.
Tie together the remaining tarsal sutures.
FIG. 32.8. Close the orbicularis muscle with interrupted
6-0chromic gut sutures and the skin with 6-0 fastabsorbing plain gut. Tie the long ends of the marginal sutures
into these skin stitches to keep them off the cornea.
Eyelid margin notchThis results from poor marginal

wound closure and failure to evert the wound edges. It
may be repaired secondarily by resecting a small wedge
with primary layered closure.
Canalicular injuryThis is caused by placement of the

infrapunctal incision or sutures too close to the canaliculus. Remain 4 mm below the position of the probe.
114
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CHAPTER 32 Modified Lazy-T Procedure 115

FIG. 32.1
FIG. 32.5
FIG. 32.2
FIG. 32.6
FIG. 32.3
FIG. 32.7
FIG. 32.4
FIG. 32.8
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33
Medial Canthal Ligament Plication
INDICATIONS: Laxity of the medial canthal ligament with medial ectropion or punctal eversion. This may be combined
with any other procedure for ectropion repair.
FIG. 33.1. Place a no. 00 or 0 Bowman probe into the

inferior canaliculus to indicate its location. Mark a skin
incision line 2 mm below the cilia, beginning 3 mm lateral to
the punctum. Carry the line around the medial canthal angle
to 2 mm above the canthal ligament.
FIG. 33.2. Cut the skin along the marked line with a scalpel
blade.
FIG. 33.3. With forceps, tent up the orbicularis and carefully
cut through it. With blunt dissection, expose the inferior crus
of the canthal ligament and trace it to its insertion onto the
frontal process of the maxillary bone.

the suture line four times daily for 5 days.
FIG. 33.4. Place a double-armed 5-0 prolene suture

vertically through the medial canthal ligament near its
insertion. Take care not to enter the lacrimal sac. Pass each
arm of the suture longitudinally through the inferior crus to
emerge near its origin on the tarsus. Note the position of the
Bowman probe to avoid injuring the canaliculus.
FIG. 33.5. Tie the suture to tuck the ligament and pull the
punctum medially to a normal position 5 to 6 mm from the
canthal angle.
FIG. 33.6. Close the skin with a running stitch of 6-0
fast-absorbing plain gut. Perform other lid shortening
procedures as needed.
Canalicular occlusionPlacement of the plication suture
around or through the canaliculus will occlude its lumen
and result in possible epiphora.
116
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CHAPTER 33 Medial Canthal Ligament Plication 117
FIG. 33.1
FIG. 33.4
FIG. 33.2
FIG. 33.5
FIG. 32.3
FIG. 33.6
7/12/2012 11:37:34 AM
34
Temporal Fascia Lower Eyelid Suspension
INDICATIONS: Paralytic ectropion or recurrent lower eyelid laxity where vertical support is needed.
FIG. 34.1. Mark an incision line 2 mm below the lid margin

from just lateral to the inferior punctum to just above the
lateral canthal angle. Extend the line laterally and slightly
inferiorly in a skin crease for a distance of 1 cm, as for lower
eyelid blepharoplasty. Hold the eyelid taut to prevent buckling
and cut the skin with a rounded scalpel blade along the
marked line.
FIG. 34.2. With forceps, tent up the skin edges at the lateral
end of the wound and cut through the orbicularis muscle.
Spread the divided muscle to enter the postorbicular areolar
plane. Open the muscle along the lid margin and dissect a
skinmuscle ap from the underlying orbital septum.
portion of the strip over the anterior edge of the orbital rim
with a Freer elevator. Rotate the fascial strip medially into the
lower eyelid defect.
FIG. 34.6. Make an incision 5 to 6 mm long, inferior and
medial to the medial canthal ligament. Expose the ligament
and surrounding periosteum with blunt dissection. Pass a
Wright needle from the medial canthal incision beneath the
orbicularis muscle and laterally to the lower lid incision. Thread
the fascial strip into the needle eyelet and pull it through to the
medial canthal ligament.
FIG. 34.3. If necessary, perform a lid shortening procedure

at this point. Dissect laterally in the postorbicular fascial
plane toward the ear. Continue the dissection 4 to 5 cm from
the lateral orbital rim to expose the deep temporalis fascia
covering the temporalis muscle.
FIG. 34.7. Put enough tension on the fascia to pull the lid
margin against the globe and to position it 2 mm above the
inferior corneal limbus. Mark the point where the fascial strip
contacts the insertion of the medial canthal ligament. Trim off
the excess. Pass a double-armed 5-0 prolene suture through the
insertion of the medial canthal ligament and then through the
fascial strip.
FIG. 34.4. Make two parallel cuts in the fascia 5 to 6 mm

apart and 1 mm above the lateral canthus. Take care to
avoid injuring the underlying temporalis muscle. Extend these
cuts toward the upper margin of the ear for a distance of 4 cm.
Continue the cuts anteriorly through the periosteum covering
the lateral orbital rim. Cut the distal end of the fascial strip
(toward the ear) with long, curved scissors.
FIG. 34.8. Fix the fascia to the tarsus just below the lid
margin with 4 to 5 interrupted 6-0 prolene sutures. Close
the medial canthal incision with interrupted 6-0 fast-absorbing
plain gut. Drape the skinmuscle ap over the lid and close
the orbicularis muscle laterally with several buried 6-0 chromic
or Vicryl sutures. Close the skin with a running suture of 6-0
fast-absorbing plain gut.
FIG. 34.5. Divide any ne attachments between the fascia

and underlying temporalis muscle. Raise the periosteal
POSTOPERATIVE CARE: Place a firm dressing for 24

hours. Apply cold compresses intermittently for 24 hours
after the dressing is removed. Place antibiotic ointment on
the suture lines four times daily for 7 days.
Lateral canthal angle dystopiaThis is caused by poor
positioning of the fascial strip on the lateral orbital wall.
The point of origin of the strip should be 1 mm above
the lateral canthal angle.
Lateral canthal angle ectropionThis is seen when the

fascial strip origin is at the external surface of the lateral
orbital rim. The periosteal extension of the strip should
be dissected around the rim so that it originates from
the inner surface.
EctropionThis results from failure to suture the fascial
strip to the tarsus or placement of the strip too low in
the eyelid. The strip should be placed in contact with the
full width of the tarsus.
118
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CHAPTER 34 Temporal Fascia Lower Eyelid Suspension 119
FIG. 34.1
FIG. 34.5
FIG. 34.2
FIG. 34.6
FIG. 34.3
FIG. 34.7
FIG. 34.4
FIG. 34.8
7/12/2012 11:39:34 AM
35
Anterior Lamellar Eyelid Lengthening

with Skin Graft
INDICATIONS: Moderate to severe cicatricial ectropion due to anterior lamellar shortening.
FIG. 35.1. Mark the line of incision 3 mm below the eyelid

margin or along the upper edge of the contracted area
ofskin if nonmarginal. Extend the line at least 6 to 8 mm on
either side of the contracted area. Place a traction suture of
4-0silk through the marginal tarsus.
FIG. 35.2. Cut along the marked incision line with a
scalpel blade. Sharply dissect the skin from the underlying
orbicularis muscle for a distance of 5 to 6 mm beyond all
areas of contraction. Divide any prominent scar bands. When
free, the eyelid margin should overlap the corneal limbus
without tension by 1 to 2 mm. Obtain meticulous hemostasis
with pressure or epinephrine-soaked gauze. Avoid excessive
cautery.
FIG. 35.5. If a larger graft is needed, an alternative donor

site is retroauricular skin. Center the graft at the posterior
base of the ear so that half extends onto the retroauricular skin
and half onto the nonhair-bearing supramastoid skin. Mark
the graft the appropriate shape and 1.5 times the width of the
recipient defect. Cut the skin with a scalpel blade and dissect
the skin from subcutaneous tissue with scissors. Close the
donor site with a running stitch of 4-0 Vicryl.
FIG. 35.6. Remove all subcutaneous tissue from the skin
graft with sharp dissection. If needed, trim the graft to t the
defect, keeping it 1.5 times the required width.
FIG. 35.3. Mark an incision line in the supratarsal

eyelid crease of the ipsilateral or contralateral upper
eyelid. Outline an elliptical segment, as for upper eyelid
blepharoplasty. The width of the graft should be 1.5 times the
width of the recipient bed defect.
FIG. 35.7. Suture the graft into the recipient bed using
interrupted 7-0 Vicryl stitches. Fibrin tissue glue can be used
to help x the graft in position. If the graft is larger than 2cm in
diameter, cut one or more stab incisions in its central portion
for drainage. Place a 4-0 silk Frost suture through the eyelid
margin and tape it to the brow to keep the eyelid closed and
the graft at.
FIG. 35.4. Cut the donor skin along the marked line with a
scalpel blade. Undermine the graft with scissors and dissect
it from the orbicularis muscle. It may be necessary to excise
part of the muscle to allow closure of the wound. Closethe
donor site with a running suture of 6-0 fast-absorbing
plaingut.
FIG. 35.8. Pass a 5-0 nylon vertical mattress suture

through the skin beyond the graft edges centrally, and put
additional mattress sutures on either side. Place a Telfa pad
soaked in antibiotic solution over the graft, and position a
rolled sterile sponge or dental roll over the pad. Tie the mattress sutures snugly to keep the graft immobile.

the suture line, and place a firm dressing over the eyelids.
Change the dressing after 4 days. Remove the dressing and
Frost sutures after 10 days.
Lagophthalmos of the donor upper eyelidThis may

be seen if too large a graft is harvested from an upper
eyelid without sufficient redundant skin. Carefully
measure the excess skin available prior to cutting the
graft.
Graft failureThis is unusual but can occur if the donor
site is poorly vascularized, if hematoma results from
inadequate hemostasis, or if the graft is not properly
stented for 10 days so that it lies in intimate contact with
its vascular bed.
Persistent or recurrent ectropionThis usually results
from failure to completely undermine the skin beyond
the area of cicatricial shortening or from not allowing for
graft shrinkage. The graft should be 1.5 times the width
of the shortest vertical dimension of the recipient defect.
120
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CHAPTER 35 Anterior Lamellar Eyelid Lengthening with Skin Graft 121
FIG. 35.1
FIG. 35.5
FIG. 35.2
FIG. 35.6
FIG. 35.3
FIG. 35.7
FIG. 35.4
FIG. 35.8
7/16/2012 9:16:59 AM
7/16/2012 9:17:05 AM
SECTION
Entropion
E
ntropion is a turning inward of the eyelid margin. Like

ectropion, the causes are numerous, but unlike the latter,
the results may be far more devastating to the eye. Whatever
the specific etiology, in the presence of entropion, both the
mucocutaneous border of the eyelid and the lashes are
directed toward the globe, resulting in conjunctival irritation
and corneal abrasion. In some cases, as with cicatricial ocular pemphigoid, distortion of eyelid tissues may include a true
trichiasis in addition to entropion. However, in most cases of
entropion, the lashes are in a normal position relative to the
lid margin, and the resulting corneal touch is secondary to the
lid malposition.
The clinical spectrum of entropion ranges from mild,
intermittent backward tilting of the marginal tarsus
associated with only occasional corneal touch to severe
180-degree inversion of the eyelid, with the lashes and skin
in full contact with the cornea. The resulting ocular surface
irritation is associated with conjunctival injection, reflex
lacrimation and epiphora, and ocular discomfort from corneal epithelial disruption. A secondary blepharospasm is
frequently present, which exacerbates the condition.
Entropion may be classified into congenital, involutional, cicatricial, and mechanical types, each with its
own different pathophysiology. The anatomic basis for the
deformity must be understood if effective correction is to
be achieved. Although relief of symptoms is accomplished
with a number of simple procedures, some of which are
useful in selected situations, permanent correction is only
attained by careful restoration of normal anatomical and
physiologic relationships.
Congenital entropion in the upper eyelid is unusual but
may be associated with a deformity of the tarsal plate, as in
the tarsal kink syndrome. It also occurs with incomplete
development of the tarsus, which includes absence of the lid
crease and overriding of the orbicularis muscle. Correction
usually requires a marginal rotation procedure and reformation of the eyelid crease. True congenital entropion in
the lower eyelid is exceptionally rare, and in most cases,
a secondary entropion results from epiblepharon. In this
case, the tarsus is in a normal position relative to the primary position of gaze. Absence of the lower eyelid crease
results in upward override of skin and orbicularis muscle
and mild entropion during downgaze. The condition usually resolves spontaneously during the second or third year
of life. Repair may be necessary when there is significant
corneal irritation and is directed at refixation of the preseptal orbicularis muscle by formation of the eyelid crease.
This may be achieved with full-thickness eyelid sutures
because the temporary effect of this type of procedure

generally lasts until the condition corrects itself. When this
disorder persists into later childhood or adulthood, a more
permanent procedure is indicated with resection of a small
segment of skin and muscle with direct crease reformation.
An acquired form of epiblepharon may be seen in patients
following eyelid surgery in which a subciliary skinmuscle
flap has been elevated to the eyelid margin and normal
fascial attachments between anterior and posterior lamellae have been disrupted. It may also occur spontaneously,
associated with involutional changes. Repair consists of
reformation of the lower eyelid crease, generally through a
direct skin incision approach.
The most common kind of acquired entropion is of the
involutional type. This results from several anatomic alterations in the aging eyelid and orbit. The clinical findings
and symptoms depend on the balance of specific causative
elements. Laxity of the eyelid is probably the most important factor in tarsal malposition. Most frequently, laxity results from stretching of the lateral canthal ligament,
which is the weakest segment of lower eyelid support, but
it may also involve generalized laxity of the entire tarsal
plate and medial canthal ligament. The laxity commonly
also involves skin and muscle of the anterior lamella. When
other involutional changes are absent, the only symptoms
of eyelid laxity may be epiphora caused by loss of orbicularis muscle tone and corneal exposure, or ectropion
attributable to ocular surfaceeyelid length disparity.
When eyelid laxity is associated with redundancy of the
lower lid retractors, tarsal instability and mild entropion
may result. Loss of retractor fixation in the presence of normal eyelid tone, however, does not typically produce entropion. Involutional orbital fat atrophy and enophthalmos
further contribute to eyelid flaccidity and inward rotation
of the tarsal plate margin. Loss of fine fascial attachments
between the orbicularis muscle and underlying orbital
septum allows upward overriding of preseptal fibers onto
the tarsus and pretarsal orbicularis. When associated
with significant horizontal eyelid redundancy and laxity
of the retractors, this shift in the rotational vector around
the canthal ligaments produces significant entropion. It
is more marked in patients with a relatively narrow tarsal plate. With persistent secondary blepharospasm from
corneal irritation and subsequent preseptal muscle hypertrophy, this process may eventually dominate the picture,
resulting in what has been referred to as chronic spastic
entropion. However, this is a secondary condition, not a
primary one. An acute form of spastic entropion results
123
7/12/2012 12:19:14 PM
124 SECTION I Entropion

from secondary blepharospasm following eye surgery
or ocular surface irritation in the presence of otherwise
asymptomatic, predisposing, involutional eyelid changes.
The surgical correction of involutional entropion is
directed at repair of the primary anatomic defects. If eyelid
laxity is the only significant finding, repair may be achieved
with simple horizontal lid shortening. When horizontal lid
laxity is minimal but retractor redundancy or frank disinsertion is the major factor, tightening or reattachment of
the retractors alone will correct the entropion. In most
cases, however, laxity will also require fixation of the preseptal orbicularis muscle to the capsulopalpebral fascia in
order to prevent override. When both horizontal eyelid
and vertical retractor laxity are significant, as is commonly
the case, horizontal lid shortening by lateral canthal ligament tucking, full-thickness pentagonal wedge resection,
or lateral tarsal strip fixation will be necessary in addition
to retractor repair.
A less satisfactory procedure is the placement of fullthickness Quickert-Rathbun type sutures to create fixation
of the preseptal orbicularis and tightening of the retractors.
The advantage of the operation is that it can be performed
at the bedside of patients who are unable to undergo more
definitive surgery. However, its results tend to be temporary because it does not correct the major defect of eyelid
laxity, nor does it permanently reattach the retractors to
the tarsal plate.
Cicatricial entropion occurs when deformation forces
are applied to the tarsus in such a way that it is bent inward
toward the globe. Such forces are seen in cicatricial diseases of the conjunctiva, such as ocular pemphigoid or
Stevens-Johnson syndrome. More permanent distortion
of the tarsal shape may be associated with chemical burns,
traumatic injuries, or infectious processes such as trachoma. A congenital kinking of the tarsal plate produces
a similar picture. The symptoms associated with cicatricial
entropion are similar to those of involutional entropion,
with the frequent addition of severe dry eyes caused by a
loss of accessory lacrimal glands, mechanical corneal abrasion from conjunctival scarring, and chronic exposure
when lagophthalmos is significant.
Correction of cicatricial entropion is aimed at restoration of the deficient posterior lamella, either the conjunctiva alone or the conjunctiva plus the tarsus. Four basic
approaches have been used in a variety of described procedures, depending upon the anatomic defect. Simple shortening of the anterior skin and muscle lamella may be useful
in very mild cases that are not associated with appreciable
tarsal deformity. This can be achieved by resection of skin
and muscle with epitarsal fixation, or less permanently
with full-thickness Quickert-Rathbun type of sutures.
When tarsus is buckled inward or conjunctival shortening is the principle cause, lengthening of the posterior
lamella with mucous membrane or tarsal grafting is necessary. Eyelid margin entropion, when mild, may be repaired
by a marginal lid-splitting procedure, with or without an
interposing graft. When the entropion is more severe, one

of the marginal rotation operations is more appropriate.
Mechanical entropion is seen with mass lesions of the
eyelid that secondarily invert the lid margin. These may be
inflammatory or neoplastic. Management must be directed
at the source of the pathologic process, with any residual
eyelid malposition repaired as necessary.
Evaluation of the patient with entropion attempts to
determine the status of the various components of eyelid
anatomy that may be associated with marginal instability. This must include components of the horizontal eyelid
support sling, in which group are the medial and lateral
canthal ligaments, as well as the tarsal plate and tone of
the orbicularis muscle. If the central eyelid margin can be
pulled away from the globe more than 7 to 8 mm without
undue tension, horizontal laxity is present. In such cases,
the lid will not snap back into apposition with the globe as
it does when tone is normal. Rather, the lax eyelid slowly
drifts back into position. On pulling the lid margin laterally, an increase of more than 3 to 4 mm in the distance
between the medial canthal angle and punctum indicates
significant stretching of the medial canthal ligament. On
forced lid closure, the lid becomes entropic, and with loss
of retractor fixation, the inferior border of the unstable tarsus will rotate outward where it is easily palpable through
the skin. Gentle palpation just beneath the tarsus during
vertical gaze shifts may demonstrate the disinserted edge
of the lower lid retractors. In such cases, the conjunctival
fornix, which is usually white because of the underlying
retractor sheet, may appear pink because of the presence
of orbicularis muscle immediately behind the conjunctiva.
When the retractors are merely redundant without true
disinsertion, these findings are absent. The presence of a
deep supratarsal sulcus and exophthalmometry of <12 to
14 mm suggests enophthalmos is a contributing factor.
Entropion
Benger RS, Musch DC. A comparative study of eyelid parameters in involutional entropion. Ophthal Plast Reconstr Surg. 1989;5:281287.
Bernardino CR. Alternative etiology and surgical correction of acquired
lower-eyelid entropion. Ann Plast Surg. 2007;59:229.
Bernardino R, Chang EL, Rubin PA. Entropion. Ophthalmology. 2011;
118:226227.
Dryden RM, Leibsohn J, Wobig J. Senile entropion, pathogenesis and
treatment. Arch Ophthalmol. 1978;96:18831885.
Kakizaki H, Zako M, Kinoshita S, Iwaki M. Posterior layer advancement
of the lower eyelid retractor in involutional entropion repair. Ophthal
Kocaoglu FA, Katircioglu YA, Tok OY, et al. The histopathology of involutional ectropion and entropion. Can J Ophthalmol. 2009;44:677679.
Olver JM, Barnes JA. Effective small-incision surgery for involutional
lower eyelid entropion. Ophthalmology. 2000;107:19821988.
Shore JW. Changes in lower eyelid resting position, movement, and treatment, and tone with age. Am J Ophthalmol. 1985;99:415423.
Marginal Rotation
Bleyen I, Dolman PJ. The Wies procedure for management of trichiasis or
cicatricial entropion of either upper or lower eyelids. Br J Ophthalmol.
2009;93:16121615.
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SECTION I Entropion 125

Dutton JJ, Tawfik HA, DeBacker CM, Lipham WJ. Anterior tarsal
V-wedge resection for cicatricial entropion. Ophthal Plast Reconstr
Surg. 2000;16:126130.
Hoh HB, Harrad RA. Factors affecting the success rate of the Quickert and Wies procedures for lower lid entropion. Orbit. 1998;17:
169172.
Yagci A, Palamar M. Long-term results of tarsal marginal rotation and
extended lamellae advancement for end stage trachoma. Ophthal
Mucous Membrane and Hard Palate Graft

Bartley GB, Kay PP. Posterior lamellar eyelid reconstruction with a hard
palate mucosal graft. Am J Ophthalmol. 1989;107:609612.
Dryden RM, Soll DB. The use of scleral transplantation in cicatricial
entropion and eyelid retraction. Trans Sect Ophthalmol Am Acad
Ophthalmol Otolaryngol. 1977;83:669678.
Goldberg RA, Joshi AR, McCann JD, Shorr N. Management of severe
cicatricial entropion using shared mucosal grafts. Arch Ophthalmol.
1999;117:12551259.
Koreen IV, Taich A, Elner VM. Anterior lamellar recession with buccal
mucous membrane grafting for cicatricial entropion. Ophthal Plast
Matsuo K, Hirose T. The use of conchal cartilage graft in involutional
entropion. Plast Reconstr Surg. 1990;86:968970.
Swamy BN, Benger R, Taylor S. Cicatricial entropion repair with hard

palate mucous membrane graft: surgical technique and outcomes.
Clin Exp Ophthalmol. 2008;36:348352.
Thommy CP. Scleral homograft inlay for correction of cicatricial entropion
and trichiasis. Br J Ophthalmol. 1981;65:198201.
Quickert-Rathbun Sutures
Miyamoto T, Eguchi H, Katome T, et al. Efficacy of the Quickert procedure for involutional entropion. The first case series in Asia. J Med
Invest. 2012;59:136142.
Pereira MG, Rodrigues MA, Rodrigues SA. Eyelid entropion. Semin
Ophthalmol. 2010;25:5258.
Quist LH. Tarsal strip combined with modified Quickert-Rathbun sutures
for involutional entropion. Can J Ophthalmol. 2002;37:238244.
Retractor Reinsertion
Caldato R, Lauande-Pimentel R, Sabrosa NA, et al. Role of reinsertion of
the lower eyelid retractor on involutional entropion. Br J Ophthalmol.
2000;84:606608.
Erb MH, Uzcategui N, Dresner SC. Efficacy and complications of the
transconjunctival entropion repair for lower eyelid involutional entropion. Ophthalmology. 2006;113:23512356.
Then SY, Salam A, Kakizaki H, Malhotra R. A lateral approach to
lower eyelid entropion repair. Ophthalmic Surg Lasers Imaging.
2011;42:519522.
7/12/2012 12:19:14 PM
36
Full-thickness Eyelid Sutures

(Quickert-Rathbun)
INDICATIONS: Mild to moderate involutional entropion; acute spastic entropion following ocular surgery; mild
cicatricial entropion when more definitive procedures cannot be performed.
FIG. 36.1. Grasp the lower eyelid with a toothed forceps

and gently pull it away from the globe. Place one arm of a
double-armed 4-0 chromic suture on a large, curved needle
into the inferior conjunctival fornix just lateral to the
central eyelid.
FIG. 36.2. Push the needle straight through the
conjunctiva, capsulopalpebral fascia, and orbital
septum until the needle point is just visible beneath
the skin.

the conjunctival fornix and on the skin sutures four times
daily until the sutures fall out.
OvercorrectionThis is caused by excessive tightening of
the sutures, especially when there is significant eyelid
FIG. 36.3. Pull the skin downward slightly and move the
needle point upward beneath the skin to a position 3 mm
below the eyelid margin. Push the needle through the skin.
FIG. 36.4. Pass the second arm of the mattress suture in
a similar fashion 3 to 4 mm from the rst arm. Place two
additional mattress sutures 8 mm medial and lateral to the
rst. Tie all three sutures rmly without bolsters, and adjust the
tension to produce a slight ectropion. Place ve to six throws in
the knot to prevent loosening.
laxity. The situation is usually temporary, and correction
may be hastened with massage to soften the scar bands.
RecurrenceThis is common and results from the inability of the operation to reattach the retractors to the tarsus. The procedure fixes the retractors to the orbicularis
muscle and serves mainly to prevent preseptal muscle
override.
126
7/12/2012 12:19:14 PM
CHAPTER 36 Full-thickness Eyelid Sutures (Quickert-Rathbun) 127

FIG. 36.1
FIG. 36.3
FIG. 36.2
FIG. 36.4
7/12/2012 12:19:14 PM
37
Modied Full-thickness Eyelid Sutures

forEpiblepharon Repair
INDICATIONS: Congenital or acquired epiblepharon with corneal irritation.
FIG. 37.1. Mark the intended position of the lower eyelid

crease, beginning below the punctum, 3 mm beneath the
eyelid margin. Extend the mark laterally to the junction of the
middle and lateral thirds of the lid and slightly downward to
5mm from the margin.
FIG. 37.2. Grasp the central eyelid margin with toothed
forceps and pull the lid gently away from the globe. Pass
one arm of a double-armed 4-0 chromic suture through the
full-thickness of the eyelid centrally from just below the inferior

tarsal border to exit at the premarked crease line.
FIG. 37.3. Pass the second arm of the suture 3 mm from the
rst, and tie the stitch rmly without a bolster.
FIG. 37.4. Place two additional mattress sutures along the
marked line in the medial two-thirds of the eyelid.

the conjunctival fornix and on the skin sutures four times
daily until the sutures fall out.
128
7/12/2012 12:21:03 PM
CHAPTER 37 Modified Full-thickness Eyelid Sutures forEpiblepharon Repair 129
FIG. 37.1
FIG. 37.3
FIG. 37.2
FIG. 37.4
7/12/2012 12:21:03 PM
38
Lower Eyelid Crease Reformation for

Epiblepharon Correction
INDICATIONS: Congenital and acquired epiblepharon with corneal irritation, especially in older children and adults.
FIG. 38.1. Mark the position of the intended lower eyelid

crease, beginning 3 mm below the inferior punctum. Extend
the line laterally and slightly downward to the junction of the
middle and lateral thirds of the eyelid. Here the line should be
5mm below the lid margin.
FIG. 38.2. Hold the skin taut to prevent buckling and cut
the skin with a scalpel blade along the marked line.
FIG. 38.3. Tent up the skin edges with toothed forceps and
cut through the pretarsal orbicularis muscle with scissors.
Dissect downward in the postorbicular fascial plane with
scissors for a distance of 5 mm to reveal the orbital septum
andeyelid retractors.
FIG. 38.4. Using forceps, gently pull the marginal

skinmuscle ap downward to slightly evert the lash line
into a normal position. Pull the inferior skinmuscle ap
upward, over the marginal ap. Mark the excess skin and
muscle strip on the inferior ap. This should usually not exceed
2 to 4 mm.
FIG. 38.5. With scissors, cut the excess skin and muscle from
the lower ap.
FIG. 38.6. Close the skin edges with interrupted
6-0fast-absorbing plain gut sutures. Each suture should pass
through the eyelid retractors at the inferior border of the tarsus
to x the muscle.

the suture line four times daily until the sutures dissolve.
130
7/12/2012 12:28:01 PM
CHAPTER 38 Lower Eyelid Crease Reformation for Epiblepharon Correction 131
FIG. 38.1
FIG. 38.4
FIG. 38.2
FIG. 38.5
FIG. 38.3
FIG. 38.6
7/12/2012 12:28:02 PM
39
Lower Eyelid Retractor Reinsertion
INDICATIONS: Involutional entropion with vertical redundancy or disinsertion of the lower eyelid retractors.
FIG. 39.1. Mark the proposed incision line 2 to 3 mm below

the lower eyelid margin from the inferior punctum to the
lateral canthal angle and then slightly downward in a laugh
line for a distance of 10 mm.
FIG. 39.2. Hold the skin taut to prevent buckling and with a
scalpel blade cut it along the marked line.
the tarsus if it is inserted but redundant. Pass the suture into

the inferior border of the tarsal plate. Tie the suture. Adjust the
position of the suture on the capsulopalpebral fascia until the
eyelid margin retracts 3 to 4 mm on downward gaze. Suture the
remaining edge of the fascia to the tarsus with four additional
6-0 prolene sutures. Do not shorten the orbital septum.
through the orbicularis muscle temporally with scissors.
Open the muscle along the entire length of the skin incision.
FIG. 39.6. Drape the skin and muscle ap upward and with
gentle tension pull the ap laterally. Mark the excess skin
along the lid margin and at the lateral wound edge. Cut the
excess skin and muscle along the mark. Rarely is it necessary to
remove more than 2 to 4 mm of vertical skin.
FIG. 39.4. With scissors dissect downward in the postorbicular fascial plane to the inferior orbital rim to expose
the orbital septum. Open the septum across the length of
theeyelid. If the retractors are disinserted, the edge of the
capsulopalpebral fascia may be seen some distance below
the inferior tarsal border, thus revealing Mllers muscle and
conjunctiva.
FIG. 39.7. Internally reform the lower eyelid crease by

placing several 7-0 chromic sutures through the orbicularis
muscle 5 to 6 mm below the edge of the inferior wound and
through the capsulopalpebral fascia just below the tarsal
plate.
FIG. 39.5. Place a 6-0 prolene suture through the edge of the
capsulopalpebral fascia if disinserted or 4 to 6 mm below

eyelid intermittently for 24 hours. Apply antibiotic ointment to the suture line four times daily for 7 days.
Recurrence of entropionThis results from failure to
adequately tighten the retractors when redundant. It is
also seen when horizontal eyelid laxity is present and
not simultaneously repaired.
FIG. 39.8. Close the skin edges with a running stitch of

6-0fast absorbing plain gut below the eyelid margin and
with several interrupted stitches beyond the lateral canthus.
EctropionThis is caused by placement of fixation sutures
too high on the anterior tarsal face. If the ectropion is
minimal, it may be corrected with massage or a lateral
tarsal striptightening procedure.
Eyelid retractionThis may result from excessive tucking
of the capsulopalpebral fascia.
132
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CHAPTER 39 Lower Eyelid Retractor Reinsertion 133
FIG. 39.1
FIG. 39.5
FIG. 39.2
FIG. 39.6
FIG. 39.3
FIG. 39.7
FIG. 39.4
FIG. 39.8
7/12/2012 12:25:38 PM
40
Retractor Reinsertion with Horizontal

EyelidShortening
INDICATIONS: Involutional entropion from retractor disinsertion combined with horizontal eyelid laxity.
FIG. 40.1. Proceed as for Lower Eyelid Retractor

Reinsertion, Fig. 39.1 through 39.5 (pp. 168 to 169). Mark a
vertical line at the junction of the central and lateral thirds of
the lid to the lower tarsal border and then angled medially to
the inferior fornix.
FIG. 40.2. Grasp the eyelid margin with a toothed forceps.
Cut along the marked line with scissors, from the lid margin to
the base of the tarsus. The cut should be angled slightly laterally
at its inferior-most point. Extend the cut inferiorly and medially
to the lower conjunctival fornix. Hold the cut edges of the eyelid
margin with forceps and overlap them under slight tension. Mark
the amount of excess lid from the medial ap.
FIG. 40.3. With scissors make an angled vertical cut
through the tarsus at the mark, directing the cut inferiorly

eyelid intermittently for 24 hours. Place antibiotic ointment to the suture line four times daily for 7 days.
Corneal abrasionThis results from placement of marginal
sutures too close to the posterior eyelid surface or failure
to tie the suture ends onto the skin surface. If noted intra-
and slightly medially so that the resulting wedge resection is 2 to 3 mm wider at the tarsal base than at the eyelid
margin. Complete the pentagonal resection by extending this
cut to the inferior fornix. Repair the marginal eyelid defect
as described for Direct Layered Closure of Marginal Defects,
Fig.56.2 through 56.5 (pp. 214 to 215).
FIG. 40.4. Drape the skin and muscle ap upward and
with gentle tension pull it laterally over the wound edges.
Mark the excess ap and excise it with scissors. Rarely is it
necessary to remove more than 2 to 4 mm vertically. Place
four to ve interrupted 7-0 chromic sutures through the
preseptal orbicularis muscle 5 to 6 mm below the skin edge
and through the capsulopalpebral fascia. Close the skin edges
with a running stitch of 6-0 fast-absorbing plain gut along the
lid margin and with interrupted sutures laterally.
operatively, remove and replace the marginal sutures.
Postoperatively, a soft contact lens may be applied until
sutures are removed. Occasionally, the posterior marginal sutures may have to be removed early.
Wound dehiscenceThis may be caused by resection of
too much eyelid with repair under excessive tension. It
is corrected by freshening the wound margins if necessary and resuturing the defect.
134
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CHAPTER 40 Retractor Reinsertion with Horizontal EyelidShortening 135
FIG. 40.1
FIG. 40.3
FIG. 40.2
FIG. 40.4
7/12/2012 12:23:46 PM
41
Retractor Reinsertion with Lateral Tarsal

Strip Fixation
INDICATIONS: Involutional entropion with laxity of the lateral canthal ligament.
FIG. 41.1. Proceed as for Lower Eyelid Retractor Reinsertion,

Fig. 39.1 through 39.5 (pp. 168 to 169). With forceps pull the
eyelid medially to straighten the lateral canthal ligament, and
with scissors cut a lateral canthotomy to the lateral orbital rim.
Turn the scissors downward and cut through the inferior crus
to free all lateral attachments of the eyelid.
FIG. 41.2. Pull the lid laterally and mark the amount to
be shortened. Split the lid along the gray line to this mark
and remove the strip of anterior skin and muscle. Detach the
retractors from this portion of the lid by cutting along the
inferior tarsal border. Cut a strip of marginal epithelium from
the tarsus, and scrape the conjunctival epithelium from the
posterior surface with a scalpel blade. Trim any excess canthal
ligament and tarsus to leave only a 3- to 4-mm strip of bare
tarsus.

eyelid intermittently for 24 hours. Place antibiotic ointment on the suture line four times daily for 7 days.
Elevation of lateral canthal angleThis results from
placement of the periosteal sutures too high on the lateral orbital rim. The sutures should be positioned at, or
only very slightly higher than, the original insertion of
the inferior crus.
FIG. 41.3. Place two single-armed sutures of 4-0 Mersilene

or Vicryl through the tarsal strip and into the periosteum
of the inside surface of the lateral orbital rim. Use of a small,
stout, half-curved needle facilitates this maneuver. Tie the
sutures.
FIG. 41.4. Drape the skin and muscle ap over the wound
edges without vertical tension. Mark and trim the excess
with scissors. Place four to ve interrupted 7-0 chromic sutures
through the preseptal orbicularis muscle 5 to 6 mm below the
skin edge and through the capsulopalpebral fascia about 5 to
6 mm below the lid margin. Close the orbicularis muscle with
interrupted 6-0 chromic sutures and the skin edges below the
eyelid margin with a running suture of 6-0 fast-absorbing plain
gut. Reform a sharp, lateral canthal angle with an interrupted
stitch.
Lateral canthal angle ectropionThis is caused by placement of the periosteal suture on the outer surface of
the lateral orbital rim. The tarsal strip must be sutured
against the inner rim wall.
Recurrent eyelid laxityThis may be seen as a late complication if the tarsal strip is not firmly secured to the periosteum.
Rounded canthal angleThis results from failure to
reform the canthal angle with a suture through the
upper and lower eyelid margins. It may be corrected
secondarily with a simple lateral canthoplasty.
136
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CHAPTER 41 Retractor Reinsertion with Lateral Tarsal Strip Fixation 137
FIG. 41.1
FIG. 41.3
FIG. 41.2
FIG. 41.4
7/12/2012 12:43:46 PM
42
Anterior Lamellar Shortening with

Epitarsal MuscleFixation
INDICATIONS: Mild cicatricial entropion without significant tarsal deformity.
FIG. 42.1. Mark the line of incision along the upper eyelid
4to 5 mm from the margin centrally and 3 to 4 mm from
the margin laterally and medially.
FIG. 42.2. Pull the eyelid laterally to prevent buckling, and
with a scalpel blade cut the skin along the marked incision
line.
postorbicular fascial plane. Extend the incision along the
entire eyelid skin wound.
FIG. 42.5. Pass a 6-0 prolene or Vicryl suture through the

orbicularis muscle on the marginal wound edge. Pull the
skinmuscle ap superiorly about 4 mm until the eyelid
margin is slightly rotated outward and pass the suture through
the supercial tarsus.
FIG. 42.6. Place additional sutures along the wound edge
insimilar fashion and tie them so the entire eyelid margin
isslightly overcorrected and ectropic.
FIG. 42.7. If necessary, excise a small strip of skin and
muscle from the superior edge of the wound.
FIG. 42.4. With scissors, dissect in the postorbicular fascial

plane from the superior border of the tarsus to 2 mm from
the eyelid margin. Take care to avoid injuring the eyelash
bulbs.

6-0fast-absorbing plain gut, and reform the new eyelid
crease by taking deep bites into the levator aponeurosis or
the epitarsus with every second or third pass of the suture.

eyelid intermittently for 24 hours. Place antibiotic ointment on the suture line four times daily for 7 days and on
the globe until the ectropion resolves.
OvercorrectionThis is caused by excessive shortening of

the skin and muscle lamella and usually resolves with
time. Correction may be hastened with massage after 10
days.
Irregular eyelid creaseThis may result from placement
of the epitarsal fixation sutures at uneven distances from
the lid margin. Have the patient look up during placement to confirm the appropriate position. Slight irregularities may correct spontaneously after several weeks,
but more significant deformities may require secondary
crease reformation.
Undercorrection of entropionThis results from insufficient shortening of the anterior lamella or failure to
suture the orbicularis muscle to the tarsus. It also results
from using this procedure in the presence of significant
tarsal deformity. Following closure, the eyelid should be
slightly ectropic.
138
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CHAPTER 42 Anterior Lamellar Shortening with Epitarsal MuscleFixation 139
FIG. 42.1
FIG. 42.5
FIG. 42.2
FIG. 42.6
FIG. 42.3
FIG. 42.7
FIG. 42.4
FIG. 42.8
7/12/2012 12:51:05 PM
43
Marginal Eyelid Rotation by Anterior

HorizontalTarsalGroove Resection
INDICATIONS: Mild to moderate cicatricial marginal entropion with tarsal deformity.
FIG. 43.1. Mark an incision line 5 to 6 mm from the eyelid

margin. Place the lid on lateral tension to prevent buckling and
cut through the skin with a scalpel blade.
FIG. 43.2. With scissors dissect in the postorbicular fascial
plane to 2 mm from the lid margin to expose the anterior
tarsal surface. Take care to avoid injuring the eyelash bulbs.
FIG. 43.3. Place a lid plate beneath the eyelid. Cut a horizontal
V-shaped groove 4 mm from the lid margin along the entire
width of the tarsus and through only 85% to 90% of the tarsal
thickness. The groove should be at least 3 mm wide at the anterior tarsal surface. Alternatively, this can be cut with a radiofrequency cutting instrument using a diamond-shaped cutting wire.

eyelid intermittently for 24 hours. Place antibiotic ointment on the suture line four times daily for 7 days.
UndercorrectionThis may result from insufficient
resection of the tarsus. The groove must be at least 3
mm wide at the anterior tarsal surface, and on closure,
the eyelid should be somewhat overcorrected.
FIG. 43.4. Close the tarsal groove with interrupted

6-0prolene sutures passed only through the superior lips
ofthe groove. The eyelid margin should be turned slightly
outward when tying the sutures. If necessary, reattach the levator
aponeurosis to the tarsus with interrupted 6-0 prolene stitches.
FIG. 43.5. Pull the marginal skin and muscle ap superiorly
and with slight tension to rotate the lashes outward. Suture
the orbicularis muscle to the superior border of the tarsus with
interrupted 6-0 prolene or Vicryl stitches.
FIG. 43.6. Close the skin with a running suture of 6-0 fastabsorbing plain gut. If necessary, remove a strip of any excess
skin and muscle prior to closure.
Corneal injuryThis can result from making the incision
through full-thickness tarsus while cutting the groove or
from placing sutures through full-thickness tarsus and
conjunctiva. It can be avoided by using a lid plate while
cutting the groove and by passing the sutures through
partial-thickness tarsus only.
140
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CHAPTER 43 Marginal Eyelid Rotation by Anterior HorizontalTarsalGroove Resection 141
FIG. 43.1
FIG. 43.4
FIG. 43.2
FIG. 43.5
FIG. 43.3
FIG. 43.6
7/12/2012 12:54:46 PM
44
Horizontal Blepharotomy with Marginal

Eyelid Rotation (Wies Procedure)
INDICATIONS: Moderate to severe upper or lower eyelid cicatricial entropion from the tarsal deformity.
FIG. 44.1. Mark a horizontal incision line across the upper

or lower eyelid 4 mm from the lid margin.
FIG. 44.2. Place a lid plate behind the lid, and with a scalpel
blade cut through the full-thickness of the eyelid in the
central portion of the mark. Be sure the cut is at the same
distance from the lid margin on both the skin and conjunctival
surfaces.
FIG. 44.4. Pass a double-armed 5-0 chromic mattress

suture through the skin edge on the marginal bridge ap
and through the posterior one-half thickness of the tarsal
plate in the upper wound edge.
FIG. 44.5. Place two or more additional mattress sutures
insimilar fashion, medial and lateral to the central suture.
Tie the sutures tight enough to slightly evert the eyelid margin.
FIG. 44.3. With scissors extend the cut laterally and medially
across the full width of the tarsal plate. Do not extend
beyond the tarsus to avoid injury to the palpebral arteries.

6-0fast-absorbing plain gut. The eyelid margin should be
slightly overcorrected.

eyelid intermittently for 24 hours. Place antibiotic ointment on the suture line and on the globe four times daily
for 7 days.
HemorrhageThis may result from injury to the palpebral

artery when extending the blepharotomy toward the
canthal angles. Injury to both palpebral arteries could
compromise vascular supply and, in rare instances, may
cause necrosis of the marginal bridge.
Corneal abrasionThis can be caused by the chromic
sutures being passed onto the conjunctival surface. It
is important to place the suture subconjunctivally, with
the knot toward the skin surface.
OvercorrectionSeen in the immediate postoperative
period, this condition is usually temporary. If persistent,
it may be corrected with massage or Ziegler-type light
cautery to contract the conjunctival surface.
142
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CHAPTER 44 Horizontal Blepharotomy with Marginal Eyelid Rotation (Wies Procedure) 143
FIG. 44.1
FIG. 44.4
FIG. 44.2
FIG. 44.5
FIG. 44.3
FIG. 44.6
7/12/2012 12:56:46 PM
45
Posterior Lamellar Eyelid Lengthening

with Free Tarsoconjunctival, Scleral, or
Cartilage Graft
INDICATIONS: Severe cicatricial entropion with conjunctival contraction and tarsal deformity.
FIG. 45.1. If using a tarsoconjunctival graft, pass a 4-0 silk

traction suture through the donor upper eyelid marginal
tarsus and evert the eyelid over a Desmarres retractor.
FIG. 45.2. With a scalpel blade make a horizontal scratch
incision through the conjunctiva and the tarsus along the
width of the tarsal plate, 4 mm from the lid margin. Do not
injure the levator aponeurosis, which lies immediately anterior
to the tarsus.
FIG. 45.3. At the medial and lateral ends of this incision,
extend a 4- to 5-mm vertical cut with micro-Westcott
scissors through the tarsus and the conjunctiva.
FIG. 45.4. Carefully dissect the tarsoconjunctival ap from
the levator aponeurosis. Make a horizontal cut across the
base of the ap to free a rectangular block of the tarsus and
associated conjunctiva. It is not necessary to repair the donor
defect and doing so may result in eyelid retraction or peaking
of the central lid.
FIG. 45.5. Place a traction suture through the marginal
tarsus of the recipient eyelid and evert it over a Desmarres
retractor. With a scalpel blade, make a horizontal scratch incision through the conjunctiva and the tarsus 2 to 3 mm from
the lid margin.
POSTOPERATIVE CARE: Place antibiotic ointment on

the globes of both the donor and recipient eyes. Tape a
firm dressing over the closed recipient eyelid for 24 hours.
Continue applying antibiotic ointment to the conjunctival
surface of the operated eyelid for 10 days. The sutures are
allowed to dissolve spontaneously.
FIG. 45.6. With micro-Westcott scissors, separate the

anterior tarsal surface from the overlying orbicularis
muscle (lower lid) or levator aponeurosis (upper lid) for
several millimeters.
FIG. 45.7. Place the graft with the mucosal side down on
the conjunctival surface of the recipient eyelid, below the
dissection bed. It may be necessary to trim the corners to t
the defect. Suture the graft to the proximal tarsal edge with
a running 6-0 Vicryl stitch, keeping the suture beneath the
conjunctiva. If a scleral graft is used, suture it into position in
similar fashion, but use a graft that is at least two times the
width of the recipient defect to allow for shrinkage.
FIG. 45.8. Rotate the graft up and into the dissection bed,
and place a double-armed 6-0 Vicryl mattress suture
from the graft tarsal surface centrally, emerging at the cut
surface beneath the conjunctiva. Pass the sutures into the
cut edge of the marginal recipient tarsus and then out onto
theskin surface just below the lash line. Place an additional
mattress suture on either side of the central one. Tie these
Vicryl stitches on the skin surface to position the graft and to
slightly evert the eyelid margin.
Granulation overgrowth of the donor siteThis occurs

rarely but may be extensive. It can be corrected by direct
excision or with light bipolar or laser cautery.
Donor eyelid retractionThis may result from closure of
the donor graft site, with tension on the levator aponeurosis and Mllers muscle. This is corrected secondarily
with a recession procedure.
Corneal abrasionThis results from exposure of the Vicryl sutures on the conjunctival surface. Care should be
taken to bury these within the tarsus only.
144
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CHAPTER 45 Posterior Lamellar Eyelid Lengthening with Free Tarsoconjunctival, Scleral, or Cartilage Graft 145
FIG. 45.1
FIG. 45.5
FIG. 45.2
FIG. 45.6
FIG. 45.3
FIG. 45.7
FIG. 45.4
FIG. 45.8
7/12/2012 12:58:10 PM
46
Posterior Eyelid Lengthening with Mucous

MembraneGraft
INDICATIONS: Moderate cicatricial entropion with conjunctival scarring and epidermalization, without tarsal deformity.
FIG. 46.1. Grasp the eyelid margin with two forceps and
split the lid at the gray line along its entire length with a
scalpel blade.
FIG. 46.2. With micro-Westcott scissors, separate the
anterior skinmuscle lamella from the posterior tarsus
conjunctiva lamella. Continue the dissection for a distance of
5 to 6 mm.
FIG. 46.3. Fix the skinmuscle ap to the anterior tarsal
surface with three double-armed 6-0 Vicryl sutures so it is
recessed 2 mm behind the lid margin.
FIG. 46.4. Pass a 4-0 silk traction suture through the
marginal tarsus and evert the eyelid over a Desmarres
retractor. Remove the scarred and epidermalized conjunctiva
from the entire tarsal surface with a diamond dermabrasion
tip on a rotary drill. Alternatively, conjunctiva may be dissected
with micro-Westcott scissors.
1:200,000 dilution of epinephrine to balloon up the mucosa

and create a rm surface.
FIG. 46.6. Using a mucotome, cut a 0.5-mm-thick mucous
membrane graft of sufficient dimension to cover the
recipient site. Place the graft mucosal side up, on a wooden
tongue-depressor to keep it at. The mucosal surface can
always be identied because the edges roll toward the nonepithelial surface.
FIG. 46.7. Trim the graft to the appropriate size, shape it,
and place it onto the raw tarsal surface of the recipient bed.
Make certain the epithelial side is up. Suture the graft to the
conjunctival edges with a running stitch of 7-0 chromic catgut.
Roll the free edge of the graft over the bare tarsal margin and
suture it to the recessed skinmuscle ap.
FIG. 46.8. Splint the graft by placing a temporary suture
tarsorrhaphy with two intermarginal mattress sutures of
4-0 silk tied over bolsters.
FIG. 46.5. Evert the lower lip with two towel clips. Using a
long 27-gauge needle, inject 4 to 6 mL of solution containing
POSTOPERATIVE CARE: Place antibiotic ointment along

the marginal graft edge and recessed skin surface and cover
the ointment with a piece of Telfa pad. Tape a light dressing over the eyelid for 48 hours. Apply antibiotic ointment
to the lid margins four times daily for 10 days. Administer a cephalosporin oral antibiotic for 7 days. Remove the
intermarginal sutures after 1 week.
avoided by baring the entire tarsal surface and placing

the suture line at the superior edge of tarsus.
Graft failureThis unusual complication may result
from graft movement before adequate vascularization
or from folds preventing firm contact with the vascular tarsal bed. Careful trimming and adequate splinting
minimizes failure.
Corneal abrasionThis results from the graft fixating suture being placed low on the tarsus. This can be
146
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CHAPTER 46 Posterior Eyelid Lengthening with Mucous MembraneGraft 147
FIG. 46.1
FIG. 46.5
FIG. 46.2
FIG. 46.6
FIG. 46.3
FIG. 46.7
FIG. 46.4
FIG. 46.8
7/12/2012 1:11:57 PM
SECTION
Correction of Eyelid
Retraction
I
n eyelid retraction, the vertical palpebral fissure is generally wider than normal because of an elevation of the upper
lid or a depression of the lower lid. However, a normal palpebral fissure does not always correlate with normal eyelid
positions; for example, in Graves disease, retraction of the
lower lid may be associated with ptosis of the upper lid,
which results in a normal interpalpebral width. In evaluation of eyelid retraction, it is best to measure marginal eyelid
position with respect to the central pupillary reflex or the
corneal limbus.
The causes of this condition are numerous. Primary
retraction may be the first sign of an orbital tumor, with
or without proptosis or extraocular muscle involvement.
Trauma or orbital surgery may result in fibrosis of the levator muscle or orbital septum with consequent retraction.
A pseudoretraction may be seen with marked proptosis or
associated with ptosis of the contralateral eyelid attributable to Herings phenomenon. Certainly, the most common etiology of eyelid retraction is Graves orbitopathy.
The ophthalmic manifestations of Graves disease
include chronic inflammation with ocular surface irritation, eyelid retraction, orbital congestion and proptosis,
extraocular muscle restriction, corneal exposure, and
occasionally compressive optic neuropathy. These consequences of the disease are not strictly correlated with
abnormal thyroid function, and many patients experience
progressive ocular complications long after restoration of
the euthyroid state. Early anatomic changes are related
to osmotic edema caused by deposition of abnormal
amounts of hyaluronic acid, inflammatory cellular infiltration, and adipogenesis. This results in increased orbital
fat volume and thickened extraocular muscles. This
inflammatory component is largely reversible with resolution of the disease. When chronic and long-standing,
however, inflammation and congestion lead to ischemic
fibrosis and permanent anatomic deformity. These complications will remain after abatement of the inflammatory
manifestations.
The management and rehabilitation of Graves orbitopathy must be individualized according to the patients specific symptomatology and to the evolutionary stage of the
disease. During the inflammatory phase, which may last for
1 to a few years, symptomatic therapy is indicated for the
eyelid retraction. This includes ocular lubrication, nocturnal patching, or a temporary lateral tarsorrhaphy for comfort. It is essential that any surgical intervention be delayed
until the disease burns itself out and the anatomic alterations have stabilized for at least 6 to 12 months. Although
reactivation may be seen even years after apparent stability,

it is less likely after 1 year.
Surgical correction of fibrotic changes should be carefully staged for maximum benefit. If orbital decompression is necessary for relief of compressive neuropathy or
for cosmesis, it must be performed as the initial procedure because displacement of the globes will alter both
ocular alignment and the eyelid positions. A period of
4 to 6 months is allowed for the globes to settle to their
final positions. Strabismus surgery to correct any residual
diplopia is the second stage of rehabilitation. This should
precede eyelid retraction repair because excessive vertical rectus muscle surgery may change eyelid positions.
Recession of upper and lower eyelids, with or without
blepharoplasty, is the final step and may be performed any
time after strabismus repair.
Retraction of the upper eyelid results primarily from overaction and hypertrophy of the sympathetic Mllers muscle,
from fibrosis of the levator muscle, and from contraction of
the suspensory ligaments of the superior conjunctival fornix. Correction should be aimed at all of these structures.
Extirpation of Mllers muscle alone corrects the eyelid
retraction in about 30% of cases. In the remainder, recession
of the levator aponeurosis and release of the suspensory ligaments of the fornix may also be required to achieve a normal
eyelid position. Scleral or cartilage spacers are not necessary.
Once the aponeurosis is disinserted to the level of Whitnalls
ligament, the operation proceeds as for ptosis repair.
Lower eyelid retraction in Graves disease is caused by
fibrotic shortening of the inferior rectus muscle and its
capsulopalpebral attachments. Correction requires recession of the eyelid retractors, which include both the capsulopalpebral fascia and the lower lid equivalent of Mllers
muscle. Because of gravitational effects on the lower eyelid,
a scleral or other type of spacer for support is required for
recessions over 2 to 3 mm.
Eyelid Recession
Ben Simon GJ, Mansury AM, Schwarcz RM, et al. Transconjunctival
Mller muscle recession with levator disinsertion for correction of
eyelid retraction associated with thyroid-related orbitopathy. Am J
Ophthalmol. 2005;140:9499.
Elner VM, Hassan AS, Frueh BR. Graded full-thickness anterior blepharotomy for upper eyelid retraction. Trans Am Ophthalmol Soc.
2003;101:6773.
Goldstein I. Recession of the levator muscle for lagophthalmos in exophthalmos goiter. Arch Ophthalmol. (n.s.) 1934;1:389.
Grove AS Jr. Levator lengthening by marginal myotomy. Arch Ophthalmol.
1980;98:1433.
148
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SECTION J Correction of Eyelid Retraction 149

Hassan AS, Frueh BR, Elner VM. Mllerectomy for upper eyelid retraction and lagophthalmos due to facial nerve palsy. Arch Ophthalmol.
2005;123:12211225.
Hintschich C, Haritoglou C. Full thickness eyelid transsection (blepharotomy) for upper eyelid lengthening in lid retraction associated with
Graves disease. Br J Ophthalmol. 2005;89:413416.
Looi AL, Sharma B, Dolman PJ. A modified posterior approach for upper
eyelid retraction. Ophthal Plast Reconstr Surg. 2006;22:434437.
McNab AA, Galbraith JE, Friebel J, Caesar R. Pre-Whitnall levator recession with hang-back sutures in Graves orbitopathy. Ophthal Plast
Patipa M. The evaluation and management of lower eyelid retraction following cosmetic surgery. Plast Reconstr Surg. 2000;106:438453.
Patipa M. Transblepharoplasty lower eyelid and midface rejuvenation.
II. Functional applications of midface elevation. Plast Reconstr Surg.
2004;113:14691474.
Putterman AM. Surgical treatment of dysthyroid eyelid retraction and
orbital fat herniation. Otolaryngol Clin North Am. 1980;13:39.
Mid-Face SMAS/SOOF Lift

Ben Simon GJ, Lee S, Schwarcz RM, et al. Subperiosteal midface lift with
or without a hard palate mucosal graft for correction of lower eyelid
retraction. Ophthalmology. 2006;113:18691873.
Horlock N, Sanders R, Harrison DH. The SOOF lift: its role in correcting
midfacial and lower facial asymmetry in patients with partial facial
palsy. Plast Reconstr Surg. 2002;109:839849.
Kahana A, Lucarelli MJ. Adjunctive transcanthotomy lateral suborbicularis fat lift and orbitomalar ligament resuspension in lower eyelid
ectropion repair. Ophthal Plast Reconstr Surg. 2009;25:16.
Marshak H, Morrow DM, Dresner SC. Small incision preperiosteal midface lift for correction of lower eyelid retraction. Ophthal Plast Reconstr Surg. 2010;26:176181.
Turk JB, Goldman A. SOOF lift and lateral retinacular canthoplasty.
Retractor Disinsertion with Graft

Dryden RM, Soll DB. The use of scleral transplantation in cicatricial
entropion and eyelid retraction. Trans Am Acad Ophthalmol Otol.
1977;83:669678.
Oestreicher JH, Pang NK, Liao W. Treatment of lower eyelid retraction by retractor release and posterior lamellar grafting: an analysis
of 659eyelids in 400 patients. Ophthal Plast Reconstr Surg. 2008;24:
207212.
Patel MP, Shapiro MD, Spinelli HM. Combined hard palate spacer
graft, midface suspension, and lateral canthoplasty for lower eyelid retraction: a tripartite approach. Plast Reconstr Surg. 2005;115:
21052114.
Schwarz GS, Spinelli HM. Correction of upper eyelid retraction using
deep temporal fascia spacer grafts. Plast Reconstr Surg. 2008;122:
765774.
Smith B, Obear M. Tarsal grafting to elevate the lower lid margin.
Am J Ophthalmol. 1965;59:1088.
7/12/2012 1:16:10 PM
47
Levator Aponeurosis Recession with

Mllers Muscle Extirpation
INDICATIONS: Eyelid retraction attributable to Graves orbitopathy. For other causes, extirpation of Mllers muscle
may be omitted.
FIG. 47.1. Mark a line of incision in the preexisting or

proposed upper eyelid crease 8 to 10 mm above the eyelid
margin. Incise the skin along the marked line with a scalpel
blade.
FIG. 47.2. Tent up the skin edges with forceps. Cut through
the orbicularis muscle with scissors to enter the postorbicular
fascial plane. Open the remaining muscle layer nasally and
temporally.
FIG. 47.3. Grasp the orbital septum centrally and cut
through it with scissors. Open the septum along the entire
length of the wound to reveal the preaponeurotic fat pockets.
FIG. 47.4. Apply gentle pressure on the globe to prolapse
the fat, and clamp the central fat pocket across its base
with a hemostat. Cut the fat just above the clamp and
cauterize the stump completely. Clamp and excise the medial
fat pocket in similar fashion. Take care not to excise the
lacrimal gland, which lies along the superolateral orbital rim,
and which in Graves patients, is frequently prolapsed. The fat
may be cauterized and cut without the use of a clamp.
FIG. 47.5. Cut a strip of orbicularis muscle and aponeurosis

from the anterior surface of the tarsus along the inferior
edge of the wound. Identify the insertion of Mllers muscle at
the upper edge of the tarsus with the meandering peripheral
arterial arcade on its surface.
FIG. 47.6. Place a Desmarres retractor to widely open
the incision. Inject a small amount of local anesthetic with
epinephrine between the aponeurosis and Mllers muscle,
to separate these planes.
FIG. 47.7. Sharply dissect the levator aponeurosis from
Mllers muscle with scissors. Disinsert the medial and lateral
horns where the aponeurosis joins the canthal ligaments. Carry
the dissection up to the level of Whitnalls ligament.
FIG. 47.8. Lift Mllers muscle off of the cornea and inject
a small amount of local anesthetic between the muscle and
conjunctiva to help separate these two layers.
150
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CHAPTER 47 Levator Aponeurosis Recession with Mllers Muscle Extirpation 151
FIG. 47.1
FIG. 47.5
FIG. 47.2
FIG. 47.6
FIG. 47.3
FIG. 47.7
FIG. 47.4
FIG. 47.8
7/12/2012 1:16:10 PM
152 SECTION J Correction of Eyelid Retraction

FIG. 47.9. With forceps, grasp Mllers muscle just above the superior tarsal
border and carefully cut through it with scissors to the level of conjunctiva.
FIG. 47.10. With a cotton-tipped applicator, place downward traction on the
conjunctiva and upward tension on Mllers muscle to dene the musculofascial
connections between them. Sharply dissect the muscle off of the conjunctiva up to
Whitnalls ligament.
FIG. 47.11. Cut Mllers muscle from just below the base of Whitnalls ligament,
across the entire lid. Cauterize the stump. Alternatively, Mllers muscle can be left
attached to the aponeurosis and the two recessed as a unit.
FIG. 47.12. Ask the patient to look upward to estimate the amount of induced
ptosis of the upper eyelid. Advance the aponeurosis downward to the tarsus or to
the supratarsal conjunctiva as needed to correct the ptosis.
FIG. 47.13. Fix the aponeurosis to the tarsus or directly to the conjunctiva with
6-0 chromic sutures. Adjust the sutures until the height and contour of the lid are
appropriate, about 1 mm higher than the normal opposite eyelid or than the
desired level.
FIG. 47.14. Advance the skinmuscle ap downward. It may be necessary to
excise a strip of skin and orbicularis muscle from the upper wound edge. If there is
signicant periorbital fullness, excise some of the subcutaneous subbrow fat and
edematous tissue to thin the skin. Close the skin with a running suture of 6-0 fastabsorbing plain gut.

eyelids intermittently for 24 hours. Place antibiotic ointment on the suture line three to four times daily for 7 days.
OvercorrectionPostoperative ptosis results from excessive recession of the aponeurosis or failure to allow for
postoperative drop in the eyelid height with the return
of orbicularis tone. It can be corrected during the first
postoperative week by pulling open the wound and
advancing the levator aponeurosis.
UndercorrectionThis may be caused by insufficient

recession of the levator aponeurosis or failure to completely separate the horns (especially the lateral) from
the tarsus and the conjunctiva. If undercorrection is
mild, it may be corrected with vigorous downward massage. If it is more than 2 to 3 mm, however, it will require
further aponeurotic recession.
Poor eyelid contourThis is caused by failure to properly
adjust the contour intraoperatively. It may be corrected
within 1 week by pulling open the wound and replacing
the aponeurotic sutures as needed.
7/12/2012 1:16:16 PM
CHAPTER 47 Levator Aponeurosis Recession with Mllers Muscle Extirpation 153
FIG. 47.9
FIG. 47.12
FIG. 47.10
FIG. 47.13
FIG. 47.11
FIG. 47.14
7/12/2012 1:16:16 PM
48
Lower Eyelid Retractor Disinsertion with

Scleral Graft
INDICATIONS: Lower eyelid retraction attributable to Graves orbitopathy or other causes.
FIG. 48.1. Place a 4-0 silk traction suture through the tarsus
at the lower eyelid margin. Evert the lid over a Desmarres
retractor to expose the palpebral conjunctiva.
the retractors to the inferior border of the tarsus. This should

be approximately 2.5 to 3 times the amount of preoperative
inferior scleral show.
FIG. 48.2. Grasp the conjunctiva and underlying

capsulopalpebral fascia with forceps 1 to 2 mm below the
inferior border of the tarsus and cut through them with
scissors. Place one blade of the scissors behind the retractors and
cut them from the inferior tarsal edge along the entire horizontal
width of the eyelid. Carefully cut the horns, which are brous
extensions from the fascial sheet to the canthal ligaments.
FIG. 48.5. Cut a biconvex section of donor sclera from an

eviscerated scleral shell. The section should be large enough
to t the measured width and length of the lower eyelid
posterior lamellar defect. Alternatively, porcine dermis or other
graft material may be used.
FIG. 48.3. With forceps apply forward traction on the

posterior eyelid lamella to put the retractors on tension.
Sharply divide the ne, brous attachments between the eyelid
retractors and the orbital septum and the orbicularis muscle.
FIG. 48.6. Suture the graft to the upper edge of the

retractors with a running stitch of 6-0 Vicryl. Use a separate 6-0 Vicryl suture to attach the graft to the lower border
of the tarsus. It is not necessary to cover a scleral graft with
conjunctiva, but healing is faster if conjunctiva is dissected
off the retractors and advanced upward to the tarsus.
FIG. 48.4. Allow the retractors to withdraw downward

and position the eyelid margin 2 mm above the inferior
corneal limbus. Measure the distance from the upper edge of
FIG. 48.7. Tape the marginal traction suture to the forehead

using multiple overlapping strips of tape to put the lower
eyelid on slight tension and to atten the graft.
POSTOPERATIVE CARE: Apply a firm dressing to keep

the graft flat for 5 days. Remove the dressing after 5 days
and apply antibiotic ointment three to four times daily for
another 2 weeks or until the graft is epithelialized.
should rest 2 mm above the limbus without tension. The

graft must measure at least 1.5 to 2 times the amount of
correction needed. Undercorrection may also result from
kinking of the graft if a firm dressing is not applied.
OvercorrectionThis is very unusual but can result from
placement of an excessively large graft or from hypotropia of the involved eye not appreciated preoperatively.
Some improvement is seen with graft shrinkage over
several months. Thereafter, tucking of the retractors is
necessary for correction.
UndercorrectionThis results from incomplete detachment
of the eyelid retractors from the lateral or medial ends of
the tarsus or from failure to separate the retractors from
the orbicularis muscle. Following dissection, the eyelid
154
7/12/2012 1:18:35 PM
CHAPTER 48 Lower Eyelid Retractor Disinsertion with Scleral Graft 155

FIG. 48.1
FIG. 48.5
FIG. 48.2
FIG. 48.6
FIG. 48.3
FIG. 48.7
FIG. 48.4
7/12/2012 1:18:35 PM
49
SMAS Midface Elevation and Fixation
INDICATIONS: Lower eyelid retraction with or without ectropion and mild vertical shortage of skin.
FIG. 49.1. Mark an incision line 2 to 3 mm below the

lid margin from just lateral to the inferior punctum to
the lateral canthus. Extend the line laterally and slightly
downward for 1 cm as for a blepharoplasty incision.
FIG. 49.2. Pull the lid laterally to prevent buckling, and
cut the skin along the marked incision line with a rounded
scalpel blade.
FIG. 49.4. Pass a double-armed 4-0 Mersilene suture

through the SMAS with multiple interlocking throws over
ashort distance to spread the area of contact.
FIG. 49.5. Pass the needles of the Mersilene suture through
the periosteum at the inferolateral orbital rim in a
horizontal mattress pattern, and tie the ends together
to elevate the SMAS and cheek.
FIG. 49.3. With scissors, cut through the orbicularis muscle

and dissect a skinmuscle ap by dividing the ne fascial
attachments between the orbicularis muscle and underlying
orbital septum. Cut through the inferior orbicularis muscle
retaining ligament along the inferior orbital rim and continue
the dissection beneath the SMAS (containing the orbicularis
muscle) for a distance of about 1.5 to 2 cm.
FIG. 49.6. Redrape the skinmuscle ap. If there is

some redundancy, resect a small triangle laterally as for a
blepharoplasty but be conservative since the patient is already
short of skin. Close the incision line with several deep sutures
of 6-0 Vicryl and the skin with interrupted and running sutures
of 6-0 fast-absorbing plain gut.
suture line three to four times daily for 7 days.
Residual lower eyelid ectropionThis can result from

excessive lateral canthal ligament laxity that was not
recognized preoperatively or not repaired. If there is
significant lower eyelid laxity, the inferior crus of the
canthal ligament should be tucked with a 6-0 prolene
suture prior to closing the wound as for Medial Canthal
Ligament Plication, Fig. 33.1 to33.6, pp. 150151.
Lateral canthal angle dystopiaThis may result from
placing the periosteal sutures too high on the lateral
orbital rim, thus distorting the lateral canthal angle
upward. It is avoided by carefully checking the canthal
position before closing the wound.
156
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CHAPTER 49 SMAS Midface Elevation and Fixation 157

FIG. 49.1
FIG. 49.4
FIG. 49.2
FIG. 49.5
FIG. 49.3
FIG. 49.6
7/12/2012 1:22:17 PM
SECTION
Repair of Superficial
Non-marginalEyelid Defects
E
yelid defects may result from surgical or traumatic

injuries. They can be repaired by a variety of techniques
depending on the anatomic structures involved. Because of
the unique anatomy and physiology of the eyelids, repair of
seemingly trivial defects often requires far more complex
procedures than would be necessary for a similar defect
elsewhere on the body.
In the repair of eyelid defects, separate attention must
be paid to the anterior and posterior lamellae, canthal
ligament support, retractor function, the lacrimal drainage system, and the mucocutaneous margin. Meticulous
repair of these structures is essential. The elimination of
all vertical tension is necessary to prevent malpositions
that can interfere with eyelid closure. Whenever possible,
direct closure of superficial, non-marginal eyelid defects is
a basic technique that yields very good cosmetic results.
However, excessive tension must be avoided by generous
undermining of the wound edges. If at all possible, all incisions should be oriented parallel to lines of tension and the
eyelid margins. The exception is in the lower eyelid, where
downward traction would result in scleral show or frank
ectropion. Here, conversion of the wound to a near vertical orientation with resultant horizontal tension will avoid
these complications.
When direct closure is not possible due to excessive
loss of tissue, local flaps can provide suitable replacement. The design of such flaps depends largely on the size
and shape of the defect, its location, and the availability of adjacent skin of appropriate thickness and texture.
A simple skin flap may be used for very superficial
wounds that do not involve the underlying orbicularis
muscle. In most cases, however, a skin and muscle flap
may be necessary. In the design and creation of such
flaps, the principles of tension load and vascular access
must be honored. The length of a flap with random vascular supply should not be greater than 2.5 to 3 times its
width. The flap must be undermined sufficiently to allow
transfer without tension across its base.
In the simple advancement flap, parallel incisions are
made from the wound edges into the donor site. For larger
flaps, where the skin will not stretch as easily, the use of
Burows triangles at the base will facilitate advancement
without tension on the flap tip. Where longer flaps are
required to close a defect, double advancement flaps from
either side may be utilized.
Rotational flaps are useful in certain situations in which
it is desirable to move adjacent skin sideways into the eyelid defect without tension. The small secondary donor
defect is repaired with a graft or by direct closure. With

this technique, the tension created across the donor site
can be shifted away from the eyelid margin and therefore
does not result in ectropion. When appropriate skin is not
available adjacent to the primary defect, a transpositional
flap (transposed over normal tissue) from a more distant
site may be used. Because of the greater stress on the flap
base as it is rotated, often through 90 degrees, care must
be taken to ensure preservation of vascular flow by deep
undermining and gentle manipulation.
The rhombic, or Limberg, flap is a rotational flap of
unique design that eliminates all tension along the flap
edges. Significant tension is generated across only one
known guideline, which can be oriented appropriately by
careful preoperative planning to avoid vertical traction on
the eyelid margin.
Skin grafting is an extremely useful procedure on the
eyelids and can obviate the need for extensive flap formation, especially where it is not possible to avoid tension.
Because of extensive vascular flow to the eyelids, grafts to
this area rarely fail. On the lower eyelids, full-thickness
skin grafts work well if some allowance is made for shrinkage. The graft should be 20% to 25% larger than the defect.
Ideal donor sites are contralateral upper eyelid, retroauricular, and supraclavicular skin. In the upper eyelid, because
of mobility requirements, split-thickness grafts are more
appropriate. The basic technique of skin grafting was discussed in Chapter 35.
One additional technique for repairing eyelid defects,
especially when excising contracted scars, is the Z-plasty.
In this simple procedure, the central long arm of the Z is
placed parallel to the contracted line of tension, and the
myocutaneous tissue flaps enclosed by the cross arms are
transposed. This maneuver can increase the length of the
long arm by up to one-third, thus relieving the tension.
Multiple Z-plasties can be placed end to end for a greater
increase in length. A modification of the Z-plasty is the
O-to-Z plasty in which a circular defect is converted to a
Z-plasty by creation of curved incisions on opposite sides
of the wound that are brought together as two advancement flaps.
When the eyelid margin is involved in the wound, special techniques of repair are applied. Release of horizontal
tension, meticulous reapproximation and eversion of the
lid margin to prevent notching, and carefully layered closure with fine sutures are mandatory, if a functional result
is to be achieved. These techniques are discussed in detail
in later sections.
158
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SECTION K Repair of Superficial Non-marginal Eyelid Defects 159

Repair of Eyelid Defects
Hudson DA. Achieving an optimal cosmetic result with excision of lesions
on the face. Ann Plast Surg. 2012;68:320325.
Madge SN, Malhotra R, Thaller VT, et al. A systematic approach to the
oculoplastic reconstruction of the eyelid medial canthal region after
cancer excision. Int Ophthalmol Clin. 2009;49:173194.
McCord CD Jr, Lisman RD. Upper eyelid reconstruction. In: Smith BC,
Delia Rocca RC, Nesi FA, Lisman RD, eds. Ophthalmic Plastic and
Reconstructive Surgery. St. Louis, MO: Mosby-Year Book; 1987.
Mutaf M, Gnal E, Temel M. A new technique for closure of the infraorbital defects. Ann Plast Surg. 2011;67:600605.
Schessler MJ, McClellan WT. Lower eyelid reconstruction following
Mohs surgery. W V Med J. 2009;105:1923.
Warren SM, Zide BM. Reconstruction of temporal and suprabrow defects.
Ann Plast Surg. 2010;64:298301.
Advancement Flaps
Anderson RL, Edwards JJ. Reconstruction by myocutaneous flaps. Arch
Ophthalmol. 1979;97:23582362.
Limberg AA. Designs of local flaps. In: Gibson T, ed. Modern Trends in
Plastic Surgery. 2nd ed. London, UK: Butterworth; 1966.
Motomura H, Taniguchi LL, Karada NM, et al. A combined flap reconstruction for full-thickness defects of the medial canthal region. J Plast
Reconstr Aesthet Surg. 2006;59:747751.
Rotational Flaps
Bertelmann E, Rieck P, Guthoff R. Medial canthal reconstruction by a
modified glabellar flap. Ophthalmologica. 2006;220:368371.
Emsen IM, Benlier E. The use of the super thinned inferior pedicled glabellar flap in reconstruction of small to large medial canthal defect.
JCraniofac Surg. 2008;19:500504.
Lister GD, Gibson T. Closure of rhomboid skin defects: the flaps of
Limberg and Dufourmental. R J Plast Surg. 1972;25:300314.
Maloof AJ, Leatherbarrow B. The glabellar flap dissected. Eye. 2000;
14:597605.
Ng SG, Inkster CF, Leatherbarrow B. The rhomboid flap in medial canthal
reconstruction. Br J Ophthalmol. 2001;85:556559.
Perry JD, Taban M. Superiorly based bilobed flap for inferior medial canthal and nasojugal fold defect reconstruction. Ophthal Plast Reconstr
Surg. 2009;25:276279.
Putterman AM. Semi-circular skin flap and reconstruction of eyelid,

nonmarginal skin defects. Am J Ophthalmol. 1977;84:708710.
Shotton FT. Optimal closure of medial canthal surgical defects with
rhomboid flaps: rules of thumb for flap and rhomboid defect orientations. Ophthalmic Surg. 1983;14:4652.
Tezel E, Snmez A, Numanolu A. Medial pedicled orbicularis oculi flap.
Ann Plast Surg. 2002;49:599603.
Turgut G, Ozcan A, Yeilolu N, Ba L. A new glabellar flap modification
for the reconstruction of medial canthal and nasal dorsal defects: flap
in flap technique. J Craniofac Surg. 2009;20:198200.
Wessels WL, Graewe FR, van Deventer PV. Reconstruction of the lower
eye lid with a rotation-advancement tarsoconjunctival cheek flap.
Transposition Flaps
Campbell LB, Ramsey ML. Transposition island pedicle flaps in the
reconstruction of nasal and perinasal defects. J Am Acad Dermatol.
2008;58:434436.
Custer PL. Trans-nasal flap for medial canthal reconstruction. Ophthalmic Surg. 1994;25:601603.
Jelks GW, Zide RT. Medial canthal reconstruction using a medially
based upper eyelid myocutaneous flap. Plast Reconstr Surg. 2002;110:
16361643.
Seo YJ, Hwang C, Choi S, Oh SH. Midface reconstruction with various flaps based on the angular artery. J Oral Maxillofac Surg.
2009;67:12261233.
Zinkernagel MS, Catalano E, Ammann-Rauch D. Free tarsal graft combined with skin transposition flap for full-thickness lower eyelid
reconstruction. Ophthal Plast Reconstr Surg. 2007;23:228231.
Z-Pasty and V-Y Flaps

Borgess AF, Gibson T. The original Z-plasty. Br J Plast Surg. 1973;26:237246.
Caldern W, Rinaldi B, Ortega J, et al. The V-Y advancement for lower eyelid
defect in preventing ectropion. Plast Reconstr Surg. 2006;118:557558.
English FP, Smith B. Restoration of the canthal region by Z-plasty. Aust N
Z J Ophthalmol. 1989;17:321322.
Kakudo N, Ogawa Y, Kusumoto K. Success of the orbicularis oculi myocutaneous vertical V-Y advancement flap for upper eyelid reconstruction. Plast Reconstr Surg. 2009;123:107e.
Marchac D, de Lange A, Binebine H. A horizontal V-Y advancement lower
eyelid flap. Plast Reconstr Surg. 2009;124:11331141.
7/12/2012 1:20:43 PM
50
Simple Direct Closure of an

Elliptical Skin Defect
INDICATIONS: Primary repair of small, nonmarginal skin or skin and muscle eyelid defects for which the edges can be
closed without excessive tension.
FIG. 50.1. Mark the lesion to be excised with a biconvex

line, allowing 1 to 1.5 mm of uninvolved skin on all
margins for benign lesions and 2 to 4 mm for malignant
ones. Orient the long axis of the ellipse parallel to the eyelid
margin in the upper lid and perpendicular to it in the lower
lid. In the canthal regions, orient the excision along the lines
of tension.
making certain that the lesion is not transected. For malignant

tumors, histologic conrmation of clear margins should be
obtained.
FIG. 50.2. With a scalpel blade, cut through the skin and
orbicularis muscle, remaining perpendicular to the skin
surface. Dissect beneath the ap in the subcutaneous plane,
FIG. 50.4. Close the orbicularis muscle layer with inverted,

interrupted 6-0 Vicryl and the skin edges with 6-0 silk or
prolene vertical mattress sutures.
FIG. 50.3. With scissors, undermine in the postorbicular

fascial plane around all sides of the resection bed for a
distance equal to one to two times its width.
160
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CHAPTER 50 Simple Direct Closure of an Elliptical Skin Defect 161
FIG. 50.1
FIG. 50.3
FIG. 50.2
FIG. 50.4
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51
Myocutaneous Advancement Flap
INDICATIONS: Primary repair of eyelid defects that cannot be closed directly and for which adjacent tissue can be
advanced into the defect with little or no tension.
FIG. 51.1. Outline the ap so the segment to be advanced is

at least two times the length of the defect. At the base of the
ap, mark a Burows triangle on each side to take up tension.
FIG. 51.3. With scissors, continue the dissection for adistance

of at least 5 mm beyond the base of the ap or until the ap
can be advanced into the defect without tension.
FIG. 51.2. Cut through the skin and orbicularis muscle with
a scalpel blade. Dissect the ap free from its underlying bed.
Cut the Burows triangles with scissors, making certain the
corners are sharp and free of subcutaneous tissue.
FIG. 51.4. Close the muscle layer with interrupted 6-0 Vicryl
stitches. Place several vertical mattress sutures across the
Burows triangles and close the skin with interrupted 6-0 Vicryl
or prolene sutures.
162
7/12/2012 1:27:48 PM
CHAPTER 51 Myocutaneous Advancement Flap 163
FIG. 51.1
FIG. 51.3
FIG. 51.2
FIG. 51.4
7/12/2012 1:27:48 PM
52
Myocutaneous Rotation Flap
INDICATIONS: Primary repair of eyelid defects for which adjacent tissue can be rotated sideways directly into the defect
or for which it is necessary to transfer the tension of direct closure away from the eyelid margin.
FIG. 52.1. Mark the rotational ap design adjacent to the

eyelid defect as a curvilinear line. The long axis should be
oriented parallel to the upper eyelid margin or perpendicular
to the lower eyelid margin.
FIG. 52.3. Rotate the ap into the eyelid defect to be

repaired. Suture the ap with deep, interrupted 6-0 Vicryl
stitches across the muscle, and close the skin with sutures of
6-0 Vicryl or prolene sutures.
FIG. 52.2. Cut along the marked line with a scalpel blade.
Gently dissect beneath the orbicularis muscle to elevate a
skinmuscle ap, taking care to preserve the vascular supply.
Undermine the ap from its bed and continue the dissection
beneath the edges of the donor site.
FIG. 52.4. Excise a triangular dog-ear ap from the donor

defect if necessary. Close the donor site with deep interrupted
6-0 Vicryl stitches and close the skin with sutures of 6-0 Vicryl
or prolene stitches.
164
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CHAPTER 52 Myocutaneous Rotation Flap 165
FIG. 52.1
FIG. 52.3
FIG. 52.2
FIG. 52.4
7/12/2012 1:31:16 PM
53
Myocutaneous Transposition Flap
INDICATIONS: Primary repair of eyelid defects where tissue is not available immediately adjacent to the eyelid but must
be transposed from a somewhat more distant site over an otherwise normal area.
FIG. 53.1. Mark the ap to be transposed as a tongue of skin

with or without orbicularis muscle. The base of the marked
ap should join one edge of the recipient defect and should be
temporal if possible. If the donor site is from the upper eyelid,
place the inferior edge of the ap in the existing lid crease.
FIG. 53.2. Incise the skin along the mark with a scalpel
blade, and cut through the underlying orbicularis muscle
with scissors. With forceps elevate the tip of the ap, and
gently separate the muscle from the underlying orbital septum.
FIG. 53.3. Undermine the wound edge above the ap and

around the ap base for a distance of 1 to 2 cm.
FIG. 53.4. Transpose the ap into the recipient bed. There
should be no tension across the rotated base. Close the incision
lines with subcutaneous interrupted 6-0 Vicryl stitches and
close the skin with sutures of 6-0 Vicryl or prolene.
166
7/12/2012 2:13:19 PM
CHAPTER 53 Myocutaneous Transposition Flap 167
FIG. 53.1
FIG. 53.3
FIG. 53.2
FIG. 53.4
7/12/2012 2:13:19 PM
54
Rhombic Flap
INDICATIONS: Primary repair of quadrangular eyelid defects with adjacent tissue when tension must be avoided at the
flap edges.
FIG. 54.1. Convert the recipient defect to a rhombic shape

with two opposite angles of approximately 60 degrees and
two of 120degrees. This technique also works well with four
angles of 90 degrees.
FIG. 54.2. Mark a line from the center of one angle equal
in length to the sides of the defect and bisecting the angle.
Make a second line oriented 45 to 60 degrees to the rst and
parallel to one leg of the rhombic shape. Maximum tension will
be across these two V-shaped lines, so the orientation of these
lines should be designed to prevent vertical tension on the lid
margin. Cut along the lines with a scalpel.
FIG. 54.3. Carefully elevate a skinmuscle ap. Undermine

widely until the ap can easily be rotated into the defect.
FIG. 54.4. Rotate the ap into the recipient defect. Close
the triangular donor defect rst, using deep 6-0 Vicryl sutures
to take up the tension. Place several vertical mattress sutures
of 6-0 prolene across this portion of the skin wound. Repair
the remaining wound with interrupted deep of 6-0 Vicryl and
supercial skin stitches of 6-0 Vicryl or prolene.
168
7/12/2012 2:11:29 PM
CHAPTER 54 Rhombic Flap 169
FIG. 54.1
FIG. 54.3
FIG. 54.2
FIG. 54.4
7/12/2012 2:11:29 PM
55
Z-plasty Transposition Flap
INDICATIONS: Repair of eyelid defects for which lengthening of the resection bed is indicated, reduction of tension is
needed, and redirection of stress lines is desired. Also can be used to reposition structures, such as the canthal angle.
FIG. 55.1. Mark the central arm of the Z along the scar
or line of contraction and outline the elliptical area to be
excised. Complete the Z by marking the cross arms at 45 to
60degrees to the central arm. A larger angle allows greater
lengthening of the bed but is more difficult to close.
FIG. 55.2. Excise the scar along the central elliptical line
(or simply cut along the line) with a scalpel blade, and cut
along the cross arms. With scissors dissect beneath the two
triangular skinmuscle aps. Hold the aps with skin hooks to
avoid injury to the triangular tips.
POSTOPERATIVE CARE: For all superficial, nonmarginal

repairs, place a light dressing for 24 hours. Avoid excessive
pressure that would compromise vascular supply to the
flaps. Apply antibiotic ointment three to four times daily
for 7days. Remove any nonabsorbable skin sutures after 7
days. The patient should be instructed not to use tobacco
products for 2 weeks after surgery.
Flap ischemiaThe flap may appear dark or blue at the
time of surgery because of compromised blood flow,
which usually results from tension at the flap base. A
dusky color frequently resolves without sequelae. If
ischemia is more severe, remove the sutures and return
the flap to its original bed.
Flap necrosisThis may result from tension or from
a flap that is too narrow for its length. It is important
FIG. 55.3. Resect any subcutaneous or muscular cicatricial

tissue from the dissection bed to relieve contraction. With
scissors, widely undermine around the base of the aps and
transpose them.
FIG. 55.4. Suture the muscle layer with 6-0 Vicryl stitches,
and the skin with interrupted sutures of 6-0 Vicryl or
prolene.
to widely undermine around the flap base so it can be

rotated without kinking. If caught early, a necrotic flap
may sometimes be salvaged with the use of hyperbaric
oxygen. If lost, however, it may have to be excised and
replaced with a skin graft.
Cicatricial ectropionThis is seen with orientations of
the flap that produce vertical tension on the lower eyelid. It is corrected secondarily with vigorous massage if
minimal or with a skin graft if severe.
Persistent flap thickeningThis occurs more frequently
with flaps near the eyelid margin and results from disruption of lymphatics or from advancement of thicker
tissue into the defect. Edema usually resolves over several months. A flap that is too thick can be elevated and
thinned after several months.
170
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CHAPTER 55 Z-plasty Transposition Flap 171
FIG. 55.1
FIG. 55.3
FIG. 55.2
FIG. 55.4
7/12/2012 1:57:52 PM
SECTION
Upper Eyelid Reconstruction

F
ull-thickness defects of the upper eyelid may result from

mechanical or thermal trauma, from the surgical excision
of eyelid tumors, or from congenital colobomas. In the reconstruction of such defects, it is essential not only to reestablish
the anatomic integrity of the lid but also to restore its physiologic function. The surgeon must pay special attention to the
individual layers of the eyelid to ensure appropriate mobility
and protection of the globe.
Small full-thickness marginal defects of 25% to 30% may
be closed by direct layered closure, depending on the laxity of the eyelid. In older individuals, when sufficient eyelid laxity permits, defects of 40% or more may be repaired
by this technique. The functional and cosmetic results are
superior to any other procedure, and when it is performed
properly, direct layered closure leaves an intact lid margin
with a full lash line.
In more complicated reconstructive procedures, the
anterior lamella of the upper lid must be covered with thin
skin, which is loose enough to allow complete eyelid closure, yet thin and flexible enough to fold easily when the
lid is opened. A circumferential muscle layer is necessary
for closure to prevent lagophthalmos and corneal exposure. Vertical retraction, either with the levator muscle or a
suitable substitute, is necessary to elevate the lid above the
visual axis. Internal support by replacement of the tarsus or
other firm tissue provides marginal stability and intimate
corneal contact in all positions of gaze. Reconstruction of
the canthal ligaments is less important here than in the
lower eyelid because the effects of gravity enhance eyelid
position rather than oppose it. A mucous membrane lining
on the posterior eyelid surface is critical to prevent corneal
abrasion. Meticulous detail is paid to reconstruction of the
eyelid margin to exclude keratinized epithelium and prevent notching and trichiasis.
Many procedures are available for the partial or complete
reconstruction of the upper eyelid. The choice depends
upon numerous factors, and frequently a combination of
techniques is necessary for adequate repair. In traumatic
injuries, especially following thermal or chemical burns,
tissue vascularity may be compromised. In such situations,
free grafts may not take as readily; therefore, the use of a
vascularized flap may be more appropriate. The same is
true for heavily irradiated tissues. The development of local
flaps for eyelid reconstruction requires some degree of tissue laxity, which may not readily be available in younger
individuals or in those with cicatrizing skin diseases.
No hard and fast rules for the reconstruction of specific
defects can be given. The surgical approach is dictated by
the size and location of the defect; involvement of deep

eyelid structures, such as the levator aponeurosis or canthal ligaments; the availability of adjacent or distant tissue
for repair; and the skills of the surgeon. Careful evaluation
of the defect and essential functional components of the
eyelid must precede any attempt at repair. Basic techniques
are illustrated below, but the appropriate application of
these procedures, in combination when necessary, will
determine the final functional and cosmetic result.
When possible, replacement of eyelid tissue should be
obtained from adjacent portions of the same or opposite
ipsilateral eyelid. Several techniques allow such transfer of
normal eyelid tissue, including the skin, orbicularis muscle,
tarsus, and conjunctiva. When these options are not possible, adjacent flaps from the temple, cheek, or forehead
may have to be used. These provide both skin and muscle, although functionally they are less suitable for eyelids.
When local flaps cannot be developed easily, free skin
grafts are a good alternative.
Internal stability with tarsal replacement can be
achieved by using eye bank scleral grafts, autogenous auricular or nasal cartilage grafts, or preserved fascia or cartilage. Mucous membrane is usually readily available from
the oral cavity except in situations in which oral mucosa
is diseased, such as in cicatricial mucous membrane pemphigoid. In some cases, vaginal mucosa may also be used.
Free tarsoconjunctival grafts from the contralateral upper
eyelid provide a superior source of tissue, containing both
normal tarsus and conjunctiva. Canthal ligaments can be
reconstructed with fascial flaps or grafts or with periosteum from the lateral orbital rims.
Direct Layered Closure of Marginal Defects
Grover AK, Chaudhuri Z, Malik S, et al. Congenital eyelid colobomas in
51 patients. J Pediatr Ophthalmol Strabismus. 2009;46:151159.
Tenzel RR. Lid reconstruction. In: Smith BC, Delia Rocca RC, Nesi FA,
Lisman RD, eds. Ophthalmic Plastic and Reconstructive Surgery. Vol
1. St. Louis, MO: Mosby-Year Book; 1987.
Lateral Semicircular Rotational Flap

Anderson RI, Edwards JJ. Reconstruction by myocutaneous eyelid flaps.
Tenzel RR, Stewart WB. Eyelid reconstruction by semicircular flap technique. Trans Am Soc Ophthalmol Otol. 1978;85:11641169.
Horizontal Tarsoconjunctival Transposition Flap

Bergin DJ, McCord CD. Reconstruction of the upper eyelid: major defects.
In: Hornblass A, ed. Oculoplastic, Orbital and Reconstructive Surgery.
Baltimore, MD: Williams & Wilkins; 1988.
Leone CR Jr. Tarsal-conjunctival advancement flaps for upper eyelid
reconstruction. Arch Ophthalmol. 1983;101:945948.
172
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SECTION L Upper Eyelid Reconstruction 173

Free Tarsoconjunctival Graft

Lisman RD, Smith BC. Eyelid surgery for thyroid ophthalmopathy. In: Smith
BC, Delia Rocca RC, Nesi FA, Lisman RD, eds. Ophthalmic Plastic and
Reconstructive Surgery. Vol 1. St. Louis, MO: Mosby-Year Book; 1987.
Obear M, Smith BC. Tarsal grafting to elevate the lower lid margin. Am
JOphthalmol. 1965;59:10881090.
Shaw GY, Khan J. The management of ectropion using the tarsoconjunctival composite graft. Arch Otolaryngol Head Neck Surg. 1996;122:5155.
Lower Eyelid Bridged Advancement Flap (Cutler-Beard Procedure)

Baylis HI, Perman KI, Fett DR, Sutcliffe RT. Autogenous auricular cartilage grafting for lower eyelid retraction. Ophthal Plast Reconstr Surg.
1985;1:2327.
Baylis HI, Rosen N, Neuhaus RW. Obtaining auricular cartilage for reconstructive surgery. Am J Ophthalmol. 1981;93:709712.
Cutler N, Beard C. A method for partial and total upper lid reconstruction. Am J Ophthalmol. 1955;39:17.
Fischer T, Noever G, Langer M, Kammer E. Experience in upper eyelid reconstruction with the Cutler-Beard technique. Ann Plast Surg.
2001;47:338342.
Holloman EL, Carter KD. Modification of the Cutler-Beard procedure

using donor Achilles tendon for upper eyelid reconstruction. Ophthal
Hsuan J, Selva D. Early division of a modified Cutler-Beard flap with a free
tarsal graft. Eye 2004;18:714717.
Kadoi C, Hayasaka S, Kato T, Nagaki Y, et al. The Cutler-Beard bridge flap
technique with use of donor sclera for upper eyelid reconstruction.
Ophthalmologica. 2000;214:140142.
Sa HS, Woo KI, Kim YD. Reverse modified Hughes procedure for
upper eyelid reconstruction. Ophthal Plast Reconstr Surg. 2010;26:
155160.
Smith B, Obear MF. Bridge flap technique for reconstruction of large
upper lid defects. Plast Reconstr Surg. 1966;38:4548.
Wesley RE, McCord CD. Transplantation of eyebank sclera in the Cutler-Beard method of upper eyelid reconstruction. Ophthalmology.
1980;87:10221028.
Double Bridged Flap Upper Eyelid Reconstruction

Dutton JJ, Fowler AM. Double-bridged flap procedure for non-marginal,
full-thickness, upper eyelid reconstruction. Ophthal Plast Reconstr
Surg. 2007;23:459462
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56
Direct Layered Closure of

Marginal Eyelid Defects
INDICATIONS: Reconstruction of small to medium eyelid defects involving the full-thickness lid margin where the
wound can be approximated without excessive tension.
FIG. 56.1. Create or reshape the upper eyelid defect to

form a pentagon, with vertical sides perpendicular to the
lid margin, extending the full length of the tarsus and
connecting arms meeting near the superior conjunctival
fornix.
FIG. 56.2. Pass a vertical mattress suture of 6-0 silk through
the tarsal plates across the defect at the lid margin. Place
the deep bite of the suture at the same depth from the margin
on both sides of the wound and the supercial bite through
the edge of the wound only.
FIG. 56.3. Pull the wound edges together gently. If the
wound does not close without excessive tension, pull the lid
medially to put the lateral canthal ligament on stretch, and
with scissors perform a lateral canthotomy to the orbital
rim. Divide the superior crus of the canthal ligament to allow
closure of the defect.

the sutures three to four times daily for 7 days. Remove
the Frost suture after 3 to 4 days and the skin sutures after
1 week. The marginal sutures are left in place for 7 to 10
days.
FIG. 56.4. Close the vertical edges of the tarsal plates

withthree interrupted 6-0 Vicryl sutures passed through
two-thirds thickness to avoid abrading the cornea.
FIG. 56.5. Place a second 6-0 silk vertical mattress suture
across the lid margin through the lash line and tie the
marginal sutures to slightly evert the wound edge. Leave
themarginal sutures long.
FIG. 56.6. Close the orbicularis muscle layer with 6-0 Vicryl
sutures and the skin with interrupted 6-0 silk stitches.
Incorporate the long marginal suture ends to keep them away
from the cornea.
FIG. 56.7. If there is upward traction on the repaired lid, or
in cases of traumatic laceration, pass a reverse-Frost traction
suture through the lid margin and over a silicone bolster,
and tape it to the cheek below to put the lid on stretch.
notching also results from not extending the pentagonal
defect to the upper border of the tarsal plate so the tarsus buckles on closure.
PtosisIt is usual for the lid to be tight and somewhat
ptotic following larger direct closures of the defect. This
typically resolves as the lid stretches over several weeks
to months.
Eyelid notchingThe primary cause is nonpentagonal, pie-shaped sides to the defect to be closed. Eyelid
174
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CHAPTER 56 Direct Layered Closure of Marginal Eyelid Defects 175

FIG. 56.1
FIG. 56.5
FIG. 56.2
FIG. 56.6
FIG. 56.3
FIG. 56.7
FIG. 56.4
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57
Lateral Semicircular Rotation Flap

(Tenzel)
INDICATIONS: Reconstruction of 30% to 50% upper eyelid defects that cannot be closed directly.
FIG. 57.1. Prepare the upper eyelid defect by excising the

lesion or freshening the wound edges to form a pentagonal
shape. Make the vertical cuts from the lid margin to the upper
border of the tarsus. Extend these to converge at a point close
to the superior fornix.
FIG. 57.2. Mark a semicircular line beginning at the lateral
canthal angle and arching downward and laterally to follow
the curve of the opened upper eyelid margin. Continue the
curve upward to end at a point 2 to 3 cm lateral to the canthal
angle, below the lateral extent of the eyebrow.
FIG. 57.5. The ap may be left bare of mucosa if less than

one-third of the lid is involved. If more than one-third of
the lid is to be reconstructed, evert the ap and mobilize
the conjunctiva to cover the orbicularis muscle. If this is not
possible, a mucous membrane graft can be placed over the
bare portion of the ap.
FIG. 57.6. Advance the lid and ap medially into the defect
and repair the eyelid margin as described for Direct Layere
Closure, 56.2 through 56.6 (pp. 214215).
FIG. 57.3. Pull the lids medially to straighten the lateral

canthal ligament, and cut the ligament along the marked
line from the canthal angle to the orbital rim. With a scalpel
blade, cut through the skin along the remainder of the marked
line. Open the orbicularis muscle with scissors. Dissect beneath
the skinmuscle ap and upward along the lateral rim.
FIG. 57.7. Anchor the orbicularis muscle of the lateral

portion of the ap to periosteum at the lateral orbital
rim and to the inferior crus of the canthal ligament with
interrupted 5-0 Vicryl sutures to reconstruct the canthal
angle support. If a dog-ear is present at the lateral extent of
the ap incision, remove a small triangle of skin and muscle
from the lateral side of the wound corner.
FIG. 57.4. Elevate the ap to expose the lateral canthal

ligament. With scissors, cut through the superior crus to
mobilize the lateral eyelid.
FIG. 57.8. Close the ap wound with deep interrupted 6-0

Vicryl sutures and close the skin with stitches of 6-0 Vicryl
or prolene.
POSTOPERATIVE CARE: Place a firm dressing over the

wound for 24 hours. Apply antibiotic ointment to the
suture lines three to four times daily for 7 days. Remove
the skin stitches after 5 to 7 days, except for the mattress
eyelid margin sutures, which are left in place for 7 to 10
days.
PtosisSome degree of ptosis is expected with this procedure but usually resolves within several weeks or
months. Added care should be taken to mobilize enough
flap to close the defect without excessive tension on the
upper eyelid.
Wound dehiscenceThis results from too much tension
on the marginal wound. Deep 5-0 Vicryl sutures are
used to anchor the orbicularis muscle of the temporal
flap to the periosteum of the lateral orbital rim to relieve
tension on the wound.
Rounded lateral eyelid contourThis may be caused by
failure to refix the lid to the lateral ligament.
Poor eyelid margin contourThe lateral canthal incision
line should follow the downward curve of the opened
eyelid margin. Angulation of the margin results from
extending the lateral cut horizontally instead of in a
downward curve.
176
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CHAPTER 57 Lateral Semicircular Rotation Flap (Tenzel) 177
FIG. 57.1
FIG. 57.5
FIG. 57.2
FIG. 57.6
FIG. 57.3
FIG. 57.7
FIG. 57.4
FIG. 57.8
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58
Horizontal Tarsoconjunctival
Transposition Flap
INDICATIONS: Reconstruction of 40% to 50% of upper eyelid defects when there is insufficient laxity of adjacent tissue to
mobilize myocutaneous flaps.
FIG. 58.1. Place a 4-0 silk suture through the marginal

eyelid tarsus adjacent to the defect. Evert the remaining lid
over a Desmarres retractor to expose the tarsal surface.
Be certain not to pass the suture onto the conjunctival surface.

Place a mattress suture across the lid margin to align the tarsal
surfaces as for Direct Layered Closure, Fig. 56.2 (p. 215).
FIG. 58.2. Make a horizontal cut through the conjunctiva

and the tarsus 3 to 4 mm from and parallel to the eyelid
margin. Continue the cut along the lid for a distance equal to
the horizontal width of the defect when the wound is closed
under mild tension.
FIG. 58.6. Suture the other free edge of the tarsal ap to

the opposite side of the eyelid defect or to the remnant of
the lateral canthal ligament with 6-0 Vicryl sutures.
FIG. 58.3. At the end of the horizontal incision, extend the

cut vertically to the superior border of the tarsus. With ne
scissors, separate the tarsoconjunctival ap from the underlying
levator aponeurosis.
FIG. 58.4. Cut Mllers muscle from the upper border of
the tarsus. Continue the dissection between the conjunctiva
and Mllers muscle to the superior fornix. Extend the vertical
cut in the conjunctiva to the fornix to complete the ap.
FIG. 58.5. Transpose the tarsoconjunctival ap horizontally into the defect and suture the tarsal edge to the
remaining eyelid with interrupted 6-0 Vicryl stitches.
POSTOPERATIVE CARE: Remove the Frost suture after

5 days. Apply antibiotic ointment to the skin edges until
the skin sutures dissolve. Remove any nonabsorbable skin
stitches after 7 to 10 days.
FIG. 58.7. Advance the cut edge of the levator aponeurosis

downward and suture it to the upper border of the tarsuswith
1-2 interrupted 6-0 prolene stitches. If it cannot beadvanced
without retracting the eyelid, allow the aponeurosis to retract
and suture it to the conjunctiva above the tarsus with interrupted
6-0 plain stitches. If performed under local anesthetic, ask the
patient to look up to conrm appropriate height of the lid margin.
FIG. 58.8. Repair the anterior lamella with a sliding or
rotational myocutaneous ap or with a skin graft. Recess
the skin edge 1 mm behind the distal edge of the tarsal ap
and suture it with a running 7-0 chromic stitch. Tie the long
marginal mattress suture ends to the skin with an interrupted
stitch. Place a Frost suture to hold the eyelid closed and apply
a rm dressing to hold the lid at.
the lid margin. At least 3 to 4 mm of marginal tarsus
should be left to support the lid.
Eyelid retractionCare must be taken to reconstruct the
lateral canthal ligament to prevent upward retraction of
the lid. The levator aponeurosis must not be advanced
to the tarsal flap under tension.
Marginal entropionInstability of the donor portion of

the eyelid may result from cutting the flap too close to
178
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CHAPTER 58 Horizontal Tarsoconjunctival Transposition Flap 179
FIG. 58.1
FIG. 58.5
FIG. 58.2
FIG. 58.6
FIG. 58.3
FIG. 58.7
FIG. 58.4
FIG. 58.8
7/12/2012 1:37:30 PM
59
INDICATIONS: Reconstruction of the upper or lower eyelid where the defect is of shallow to moderate depth, where
replacement of up to two-thirds of the posterior tarsoconjunctival lamella is required, and where the ipsilateral or contralateral upper eyelid is available for donor tissue.
FIG. 59.1. Place a 4-0 silk suture across the marginal

tarsus of the donor upper eyelid, and evert the lid over a
Desmarres retractor. Make a horizontal incision through the
tarsus 3 to 4 mm from the lid margin and equal to the smallest length of the recipient defect when the margins are pulled
together on slight tension.
FIG. 59.2. At each end of the incision, extend the cuts vertically
to the upper border of the tarsus. With ne scissors, dissect
sharply to separate the tarsus from the levator aponeurosis.
FIG. 59.3. Make a second horizontal cut near the upper border of the tarsus to excise a rectangular block with adherent
conjunctiva. It is not necessary to close the donor wound.
FIG. 59.5. Advance the levator aponeurosis downward and

suture it to the upper border of the tarsal graft with several
6-0 prolene stitches.
FIG. 59.6. Mark a subciliary incision line from the lateral
edge of the defect to the lateral canthal angle and continue
downward as a lateral semicircular ap. Cut the skin along
the marked line with a scalpel blade.
FIG. 59.7. Cut through the orbicularis muscle layer with
scissors and dissect a skinmuscle ap off the underlying
temporalis fascia and the periosteum. If necessary, excise a
Burows triangle at the inferotemporal corner of the defect to
prevent it from buckling.
FIG. 59.4. Insert the donor tarsoconjunctival graft into the

recipient defect with the mucosal side toward the globe,
and the cut ends of the meibomian glands toward the lid
margin. Suture the edges of the graft to the remnants of
the tarsus at the medial and lateral ends of the defect with
interrupted 6-0 Vicryl sutures. Place the sutures through
three-fourths thickness of the tarsus only. Pass a 6-0 silk suture
across the margin of the tarsus to align the edges.
FIG. 59.8. Advance the ap medially to cover the defect

and the graft. Thin the muscle slightly from the portion of
the ap over the tarsoconjunctival graft. Recess the ap 1 mm
proximal to the graft margin and suture it with a running
7-0 chromic stitch. Close the orbicularis muscle with deep
interrupted 6-0 Vicryl stitches and the skin with 6-0 Vicryl or
prolene.
POSTOPERATIVE CARE: Apply a dressing to the eyelids

for 24 hours. Place antibiotic ointment on the suture lines
and beneath the donor eyelid three to four times daily for
7 days. Remove all skin sutures after 7 days. Reinforce the
temporal wound with Steri-Strips for an additional 3 days
if necessary.
Eyelid retractionThis may be seen when the defect

extends up to the orbital rim, and the levator aponeurosis is advanced downward to the graft. In such cases,
the conjunctiva at the superior edge of the defect should
be advanced into the defect and sutured to the tarsal
graft. The aponeurosis is then advanced appropriately
and sutured directly to the conjunctiva with 6-0 chromic stitches.
PtosisSome degree of ptosis is normal following reconstruction because of horizontal tension. This usually
resolves over several weeks to months.
Corneal abrasionThis results from placing the tarsal
graft sutures through the conjunctival surface. Take care
to place these through partial-thickness tarsus only.
180
7/12/2012 1:35:05 PM
CHAPTER 59 Free Tarsoconjunctival Graft 181
FIG. 59.1
FIG. 59.5
FIG. 59.2
FIG. 59.6
FIG. 59.3
FIG. 59.7
FIG. 59.4
FIG. 59.8
7/12/2012 1:35:05 PM
60
Lower Eyelid Single Bridged Advancement

Flap (Cutler-Beard)
INDICATIONS: Reconstruction of 60% to 100% horizontal upper eyelid defects.
FIG. 60.1. Trim the upper eyelid defect into an approximate

rectangular shape. Mark a horizontal line along the lower
eyelid 4 mm from the margin at the inferior tarsal border, and
equal in width to the upper lid defect, or slightly less if there
is signicant laxity. Place a lid plate beneath the lower lid and
cut through all layers along the marked line centrally with a
scalpel blade. With scissors, complete the incision medially and
laterally, taking care not to injure the palpebral arteries.
FIG. 60.2. Make the vertical cuts from the ends of the horizontal incision through full thickness of the eyelid for a
distance of about 15 mm to the inferior fornix. Using scissors, dissect the conjunctiva from Mllers muscle and the
capsulopalpebral fascia to the inferior fornix.
FIG. 60.3. Pass the conjunctival ap beneath the lower
eyelid marginal bridge and suture it to the conjunctival
remnant of the upper eyelid defect with a running suture of
6-0 plain gut.
FIG. 60.4. Fashion a piece of autogenous auricular cartilage
or donor sclera to t the defect. Suture the graft medially and
laterally to the tarsal remnants or to the canthal ligaments with
6-0 Vicryl stitches. Advance the edge of the levator aponeurosis
downward and attach it to the upper edge of the graft with a
running 6-0 Vicryl stitch.

the suture lines three to four times daily for 7 days after
both the primary procedure and secondary takedown.
Corneal abrasionThis results from keratinized epithelium or fine skin cilia at the new eyelid margin. The
conjunctiva should be rolled over the skin edge during
the second stage of reconstruction to provide a smooth
mucous membrane margin.
Upper eyelid ptosisThis is not uncommon following
separation and is preferable to lid retraction. It may
FIG. 60.5. Separate the skinmuscle ap from the orbital

septum and advance it beneath the marginal bridge
and into the defect to cover the graft. Approximate the
orbicularis muscle and skin layers with 6-0 Vicryl sutures. If
necessary, cut two triangular Burows triangles from the base of
the ap along the lower eyelid to reduce tension and allow for
upward advancement.
FIG. 60.6. Separate the ap after 2 to 3 weeks. Retract the
lower eyelid marginal bridge downward, and pass a grooved
director beneath the ap. With a scalpel blade, cut across the ap
2 mm below the desired position of the new upper lid margin.
FIG. 60.7. Trim 2 mm of skin and muscle from the new
upper eyelid margin, leaving a ap of conjunctiva
posteriorly. Roll the conjunctiva over the lid margin and
suture it to the skin edge with a running 7-0 chromic stitch.
FIG. 60.8. Excise the epithelium and scar tissue from
the inferior border of the lower lid bridge to expose all
lamellae. Undermine the lateral and medial edges of the cheek
incisions. If necessary, excise a portion of the stretched lower
lid ap. Suture the conjunctiva and lower lid retractors to the
inferior border of the tarsus with a running 6-0 chromic suture.
Close the muscle layer with 6-0 Vicryl sutures and the skin with
6-0 fast-absorbing plain gut sutures.
correct with time. If not, secondary trimming of the
margin can be performed later.
Eyelid retractionThis is caused by separating the flap
too high during the second stage of reconstruction. Sufficient lid length must be allowed for complete eyelid
closure.
Persistent edemaIt is usual for the reconstructed eyelid
to have edema for several months following separation.
This usually resolves with time.
182
7/12/2012 1:33:24 PM
CHAPTER 60 Lower Eyelid Single Bridged Advancement Flap (Cutler-Beard) 183
FIG. 60.1
FIG. 60.5
FIG. 60.2
FIG. 60.6
FIG. 60.3
FIG. 60.7
FIG. 60.4
FIG. 60.8
7/12/2012 1:33:25 PM
61
Lower Eyelid Double Bridged

Advancement Flap
INDICATIONS: Reconstruction of an upper eyelid defect or contracted scarring when the marginal eyelid and lash line
can be preserved.
FIG. 61.1. Prepare the lower lid ap as for Lower Eyelid

Single Bridged Flap Fig. 60.1 and 60.2, pp. 228229.
eyelid to reduce tension and allow for adequate upward

advancement.
FIG. 61.2. If the midportion of the upper lid is contracted,

place a lid plate beneath the eyelid and make a horizontal
full-thickness incision from the skin to conjunctiva across
the lid from medial to lateral at the upper border of the
tarsus.
FIG. 61.5. Separate the ap after 2 to 3 weeks. Retract the

lower and upper eyelid marginal bridges with Desmarres retractors, and pass a grooved director beneath the ap. With a scalpel
blade, cut across the ap in the middle of the palpebral ssure.
FIG. 61.3. Pass the full-thickness lower lid ap beneath the

lower and upper marginal bridges and suture the conjunctival layers with 6-0 plain gut.
FIG. 61.4. Approximate the orbicularis muscle and skin
layers with 6-0 Vicryl sutures. If necessary, cut two triangular
Burows triangles from the base of the ap along the lower

the suture lines three to four times daily for 7 days after
both the primary procedure and secondary takedown.
Upper eyelid ptosisThis is expected following separation and will usually require a secondary ptosis repair.
FIG. 61.6. Excise the epithelium and scar tissue from the
inferior border of the lower lid bridge and the superior
border of the upper lid bridge to expose all layers. If
necessary, excise a small portion of the stretched lower and
upper lid aps. Repair both the lower and upper eyelids by
reapproximating the conjunctiva with a running 6-0 plain gut
suture. Close the muscle with 6-0 Vicryl sutures and the skin
with 6-0 fast-absorbing plain gut.
Lower eyelid retractionThis is caused by separating the
flap too low during the second stage of reconstruction.
It is best not to trim too much of the flaps and, if necessary, perform secondary reduction of eyelid length.
Persistent edemaIt is usual for the reconstructed eyelids to have edema for several months following separation. This usually resolves with time.
184
7/12/2012 2:17:21 PM
CHAPTER 61 Lower Eyelid Double Bridged Advancement Flap 185
FIG. 61.1
FIG. 61.4
FIG. 61.2
FIG. 61.5
FIG. 61.3
FIG. 61.6
7/12/2012 2:17:21 PM
7/28/2012 12:43:05 PM
SECTION
Lower Eyelid Reconstruction

T
he surgical and anatomic principles described for

reconstruction of the upper eyelid apply equally to the
lower eyelid. Separate reconstruction of anterior and posterior
lamellae with appropriate tissue is essential. Attention to the
vertical suspension of the lower eyelid by replacing internal
stability and canthal ligament support is critical and is even
more important than in the upper lid. The effects of gravity
act to distort eyelid position, and even minimal amounts of
vertical tension or laxity can result in retraction, scleral show,
or frank ectropion.
The technique of direct closure for marginal defects
requires the same meticulous attention to the eyelid margin as described for the upper lid. Because excessive horizontal tension is less critical here, somewhat larger defects
can be closed primarily. With defects over 30% to 40%, a
lateral canthotomy and cantholysis may be required. For
larger segments, a semicircular temporal flap (Tenzel flap)
may allow closure of defects up to 60% of the horizontal lid
length. In such cases, it is important to reestablish canthal
support with a fascial or periosteal flap.
For very large defects of 80% to 100% of the lower eyelid, the tarsoconjunctival advancement flap from upper to
lower lid (Hughes flap), combined with a free skin graft or
myocutaneous flap, yields excellent functional and cosmetic results. However, this is a two-stage procedure that
requires the visual axis to be occluded for 2 to 3 weeks,
thus making it inappropriate for monocular patients or for
young children in the amblyopia-prone age group.
As with the upper eyelid, complex lower eyelid reconstructive procedures usually require a combination of techniques, which may simultaneously include advancement
flaps, free grafts, and direct closure. Complete operations
are not described below, but rather individual components
are described that can be combined as necessary to achieve
any reconstruction. Final repair strategy must be left to the
ingenuity and skill of the surgeon based on functional need
and anatomic resources.

Lateral Semicircular Rotation Flap with Periosteal Fixation
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Leone CR Jr. Periosteal flap for lower eyelid reconstruction. Am J Ophthalmol. 1992;114:513514.
Levine MR, Buckman G. Semicircular flap revisited. Arch Ophthalmol.
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Tenzel RR, Steward WB. Eyelid reconstruction by semicircular flap technique. Ophthalmology. 1978;85:11641169.
Upper to Lower Eyelid Tarsoconjunctival Advancement Flap

(Hughes Procedure)
Bartley GB, Messenger MM. The dehiscent Hughes flap: outcomes and
implications. Trans Am Ophthalmol Soc. 2002;100:6165.
Ceis WA, Bartlett RE. Modification of the Mustarde and Hughes
methods of reconstruction of the lower lid. Ann Ophthalmol. 1975;7:
14971502.
Hawes MJ, Grove AS Jr, Hink EM. Comparison of free tarsoconjunctival
grafts and Hughes tarsoconjunctival grafts for lower eyelid reconstruction. Ophthal Plast Reconstr Surg. 2011;27:219223.
Hughes WL. Reconstruction of the lid. Am J Ophthalmol. 1945;28:1203.
Hughes WL. Total lower lid reconstruction: technical details. Trans Am
Ophthalmol Soc. 1976;74:321329.
Leibovitch I. Modified Hughes flap: division at 7 days. Ophthalmology.
2004;111:21642167.
Leone CR Jr. Tarsal-conjunctival advancement flaps for upper eyelid
reconstruction. Arch Ophthalmol. 1983;101:945948.
McNab AA. Early division of the conjunctival pedicle in modified Hughes
repair of the lower eyelid. Ophthalmic Surg Lasers. 1996;27:422424.

Glatt HJ. Tarsoconjunctival flap supplementation: an approach to the
reconstruction of large lower eyelid defects. Ophthal Plast Reconstr
Surg. 1997;13:9097.
Leone CR Jr, Van Gemert JV. Lower lid reconstruction using tarsoconjunctival grafts and bipedicle skin-muscle flap. Arch Ophthalmol.
1989;107:758760.
Oestreicher JH, Pang NK, Liao W. Treatment of lower eyelid retraction
by retractor release and posterior lamellar grafting: an analysis of 659
eyelids in 400 patients. Ophthal Plast Reconstr Surg. 2008;24:207212.
Stephenson CM, Brown BZ. The use of tarsus as a free autogenous graft in
eyelid surgery. Ophthal Plast Reconstr Surg. 1985;1:4350.
187
7/28/2012 12:43:05 PM
62
Lateral Semicircular Rotation Flap with

Periosteal Fixation
INDICATIONS: Reconstruction of 30% to 50% horizontal lower eyelid defects, especially those located in the lateral or
central thirds of the lid.
FIG. 62.1. Reshape the lower eyelid defect as a pentagon,

with vertical sides from the lid margin to the lower border
of the tarsus and then converging to the inferior fornix.
FIG. 62.2. Mark a curved incision line beginning at the
lateral canthal angle and extending upward and outward to
follow the curve of the lower eyelid margin. The line should
run toward the lateral end of the eyebrow and then curve
outward and downward to end about 2 to 3 cm lateral to the
canthal angle.
FIG. 62.3. Pull the lateral lid remnant medially to
straighten the canthal ligament and perform a lateral
canthotomy by making a horizontal incision to the orbital
rim. Angle the scissors upward to follow the marked incision
line. Cut across the inferior crus of the ligament with scissors to
free the lower lid from the orbital rim.
FIG. 62.4. Incise along the marked skin line with a scalpel
blade, and cut through the orbicularis muscle with scissors.
Dissect the skinmuscle ap from the lateral orbital rim and
the temporalis fascia until it can be advanced medially enough
to close the defect.
POSTOPERATIVE CARE: Apply a firm dressing over the

lateral flap site for 24 hours. Place antibiotic ointment
on the suture lines three to four times daily for 7 days.
FIG. 62.5. Make two parallel cuts 8 mm apart through the

periosteum at the orbital rim, and extend them onto the
deep temporal fascia over the temporalis muscle. Begin at
the orbital tubercle of the bony rim and extend laterally for a
distance of 10 to 15 mm.
FIG. 62.6. Dissect the fascialperiosteal ap from the
underlying temporalis muscle and bone to just inside the
lateral orbital rim. Rotate the ap 180 degrees medially
toward the defect.
FIG. 62.7. Advance the myocutaneous ap medially, and
close the eyelid defect in layers, as for Direct Closure of
Marginal Defects, Fig. 56.1 through 56.6 (pp. 214 to 215).
Split the repaired lid laterally along the gray line for 2 to 3 mm
to expose the tarsal face. Pull the lid laterally on slight tension
and overlap the periosteal ap. Trim the excess, and suture the
ap to the tarsus with two 6-0 Vicryl sutures.
FIG. 62.8. Close the semicircular ap with subcutaneous
6-0 Vicryl sutures and close the skin with stitches of
6-0 Vicryl or prolene sutures. If necessary, cut a Burows
triangle to remove any lateral dog-ear.
Remove the skin sutures after 7 days and the marginal
mattress sutures after 10 to 14 days.
188
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CHAPTER 62 Lateral Semicircular Rotation Flap with Periosteal Fixation 189
FIG. 62.1
FIG. 62.5
FIG. 62.2
FIG. 62.6
FIG. 62.3
FIG. 62.7
FIG. 62.4
FIG. 62.8
7/28/2012 12:43:06 PM
63
Free Tarsoconjunctival Graft and

Myocutaneous Advancement Flap
INDICATIONS: Reconstruction of 40% to 60% horizontal lower eyelid defects with replacement of the posterior lamella.
FIG. 63.1. Place a 4-0 silk traction suture through the

marginal tarsus of the ipsilateral donor upper eyelid,
and evert the lid over a Desmarres retractor.
graft with a running 6-0 Vicryl stitch. Be certain that the

orbital septum is separated completely from the capsulopalpebral fascia to prevent retraction.
FIG. 63.2. Make a horizontal cut through the tarsus 3 to

4 mm from the lid margin and equal in length to the lower
lid defect when the edges are pulled together under slight
tension.
FIG. 63.6. Elevate the anterior skinmuscle lamella inferiorly

by dissecting the orbicularis muscle from the orbital septum
down to the orbital rim. Make vertical cuts from the lateral
and medial edges of the lid defect to form a rectangular myocutaneous advancement ap. Cut triangular Burows wedges from
the outer corners of the ap base to reduce vertical tension.
Alternatively, a horizontal skin-muscle ap can be used.
FIG. 63.3. Extend the incision vertically from each end of

the horizontal cut for a distance of 4 to 5 mm toward the
upper tarsal border. With ne scissors, carefully dissect the
tarsoconjunctival ap from the levator aponeurosis, and
complete the rectangular block excision with a horizontal cut
near the upper edge of the tarsus. Do not close the donor site.
FIG. 63.4. Transfer the graft to the lower lid defect with
the mucosal side toward the globe. Suture the graft to the
tarsal edges of the defect with partial-thickness, interrupted
6-0 Vicryl stitches. The margins should be aligned.
FIG. 63.5. Advance the conjunctiva and capsulopalpebral
fascia upward and suture them to the lower edge of the
POSTOPERATIVE CARE: Apply a firm dressing for 48

hours to hold the flap against the graft. Apply antibiotic
ointment three to four times daily for 7 days.
Eyelid laxityThis may be seen from placement of a
graft that is too large for the defect. The graft should be
slightly smaller than the defect and sutured under slight
horizontal tension.
FIG. 63.7. Excise a strip of orbicularis muscle from the ap

edge to make it thinner, and advance the ap upward to
cover the tarsoconjunctival graft.
FIG. 63.8. To relieve tension, close the Burows triangles
with deep 6-0 Vicryl sutures. Suture the remaining ap to
the edges of the defect. Close the orbicularis muscle with
interrupted 6-0 Vicryl sutures and the skin with stitches of
6-0 fast-absorbing plain gut. Recess the skin 1 mm from the
marginal edge of the graft and suture it to the tarsus with a
running 7-0 chromic stitch.
EctropionThis is caused by excessive vertical tension on
the myocutaneous advancement flap. Fashion the flap
with sufficient vertical length and large enough Burows
triangles to eliminate tension. If this is not possible,
single or double opposing advancement flaps are developed horizontally from the sides.
190
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CHAPTER 63 Free Tarsoconjunctival Graft and Myocutaneous Advancement Flap 191
FIG. 63.1
FIG. 63.5
FIG. 63.2
FIG. 63.6
FIG. 63.3
FIG. 63.7
FIG. 63.4
FIG. 63.8
7/12/2012 2:26:30 PM
64
Upper-to-lower Eyelid Tarsoconjunctival

Advancement Flap (Hughes Procedure)
INDICATIONS: Reconstruction of 50% to 100% horizontal marginal lower eyelid defects.

CONTRAINDICATIONS: Repair of defects in the only seeing eye because this requires closure of the lids for 2 to 3 weeks.
FIG. 64.1. Reshape the lower eyelid defect if necessary so

the tarsal edges are perpendicular to the lid margin. Grasp
the edges of the lower eyelid defect and pull them toward
each other under slight tension to measure the length of the
segment to be reconstructed.
FIG. 64.5. Gently pull the conjunctiva and the

capsulopalpebral fascia upward from the inferior fornix
and suture them to the lower edge of the tarsal graft with a
running 6-0 Vicryl stitch.
FIG. 64.2. Place a 4-0 silk traction suture through the

marginal tarsus of the ipsilateral upper eyelid, and evert
the lid over a Desmarres retractor. Make a horizontal incision
through the tarsus 3-4 mm from the lid margin and equal in
length to the measured lower lid defect.
FIG. 64.6. Dissect a temporally based muscle ap by separating the preseptal and orbital portions of the orbicularis
from below the defect. Rotate the muscle ap upward to
cover the tarsal graft and suture it into position with 6-0 Vicryl
stitches. It is not necessary to cover the tarsal graft with muscle; therefore, this step may be omitted.
FIG. 64.3. Make a vertical cut from each end of the previous
horizontal incision and extend it to the upper border of the
tarsus. Separate the tarsus from the levator aponeurosis with
ne scissors. At the superior tarsal border, disinsert Mllers
muscle and continue the dissection between the conjunctiva
and the underlying muscle up to the superior fornix. Extend
the vertical incisions through the conjunctiva to the fornix.
FIG. 64.7. Harvest a full-thickness skin graft from

the contralateral upper eyelid or a retroauricular or
supraclavicular site. Thin the graft by cutting away all subcutaneous fat and fascia. Suture the skin graft over the defect
with 6-0 Vicryl sutures. Suture the upper edge of the graft to
the marginal edge of the tarsus with a running 7-0 chromic
stitch.
FIG. 64.4. Advance the tarsoconjunctival ap downward

into the lower lid defect. Carefully align the upper edge of the
tarsal graft with the lower eyelid margin and suture it to the tarsus of the recipient defect with interrupted 6-0 Vicryl stitches.
FIG. 64.8. Alternatively, if the lower lid defect is shallow, a

myocutaneous vertical advancement ap can be mobilized
from below, as described for the Free Tarsoconjunctival
Graft, Fig. 63.6 through 63.8, (pp. 238 to 239).
192
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CHAPTER 64 Upper-to-lower Eyelid Tarsoconjunctival Advancement Flap (Hughes Procedure) 193

FIG. 64.1
FIG. 64.5
FIG. 64.2
FIG. 64.6
FIG. 64.3
FIG. 64.4
FIG. 64.7
FIG. 64.8
7/12/2012 2:52:36 PM
194 SECTION M Lower Eyelid Reconstruction

FIG. 64.9. After 2 weeks, evert the upper lid, and with scissors cut the
conjunctival pedicle ap ush from where it joins the tarsus. Leave a 2- to 3-mm
ap of conjunctiva attached to the lower eyelid.
FIG. 64.10. Dissect the anterior granulation tissue from the conjunctival ap to
the level of the skin graft. Excise a marginal strip of this skin graft to create a fresh
edge. Trim the conjunctiva, leaving it 1 to 2 mm longer than the tarsus.
FIG. 64.11. Roll the conjunctival ap over the tarsus at the lid margin and suture
it to the skin. Alternatively, the conjunctival ap can be cut from the tarsus along
the desired lower lid margin. It is not necessary to cover the new eyelid margin with
conjunctiva.
POSTOPERATIVE CARE: If a skin graft is used, place

a Telfa or nonadherent pad over the graft. Place a firm
dressing to immobilize the graft. Change the dressing after
4 days and remove it after 10 days. If an advancement flap
is used, apply a dressing for 24 hours and antibiotic ointment three to four times daily for 7 days.
margin. If excessive, hypertrophic conjunctiva may be

removed with light bipolar or laser cautery.
Upper lid retractionThis may be caused by failure to
completely separate Mllers muscle from the conjunctival pedicle, with resultant advancement of Mllers
muscle. It may be corrected by undermining Mllers
muscle after the second stage separation of the flap and
allowing the muscle to retract upward.
Conjunctival hypertrophy of the eyelid marginThis

results from excess conjunctiva or granulation at the lid
7/12/2012 2:52:47 PM
CHAPTER 64 Upper-to-lower Eyelid Tarsoconjunctival Advancement Flap (Hughes Procedure) 195

FIG. 64.9
FIG. 64.11
FIG. 64.10
7/12/2012 2:52:47 PM
SECTION
Medial and Lateral Canthal

Reconstruction
A
natomic deformities involving the canthal angles may

result from congenital malformations, such as epicanthal
folds or telecanthus, or from traumatic disruption of canthal
ligaments and scar contraction. In some cases, repair may be
achieved with relatively simple soft tissue rearrangement. In
others, however, more complex reconstructive procedures,
including resection of bone, may be required.
Defects involving the medial and lateral canthal areas
mostly result from excision of periorbital tumors and less
commonly from trauma. These may be pure canthal defects
or may include loss of adjacent portions of the upper and
lower eyelids. In the latter situation, reconstruction is considerably more difficult because of the great anatomic and functional differences between the eyelid and the canthal tissues.
The surgeon must be able to utilize a wide variety of reconstructive techniques, frequently in multiple combinations,
to achieve adequate repair. The exact approach will depend
upon (1) the extent and depth of the wound; (2) involvement
of other structures, such as canthal ligaments and lacrimal
drainage system; (3) laxity of periorbital skin; and (4) the
availability of adjacent tissues for the development of flaps.
Spontaneous granulation of canthal defects is a useful technique that can be utilized in areas where skin is
more firmly adherent to underlying tissue. Contraction
will always occur to some extent, so application of this
method near the mobile eyelids may cause significant eyelid malpositions. For very deep wounds, especially on the
nasal bridge area and at the lateral canthus, initial granulation to fill the defect, followed by placement of a fullthickness skin graft to prevent contraction, gives excellent
results. When adjacent portions of the eyelids are also
missing, repair of the mobile lids and canthal ligaments is
achieved with any of the eyelid reconstruction techniques
described previously. The remaining canthal defect can be
allowed to granulate.
Full-thickness skin grafts may be applied over canthal
defects when they are more superficial and contain an adequate vascular bed. When the defect is deep or largely avascular, such as over bare bone, local myocutaneous flaps of
various designs give better results. Relatively thick flaps, such
as median forehead flaps, are excellent for deep medial canthal defects but do not provide enough mobility for simultaneous upper eyelid reconstruction. Tension must always be
considered, especially around the lower lid, where retraction
and ectropion may result from even minimal vertical forces.
In reconstruction of defects following excision of
malignant tumors, potential recurrence is an important
consideration in determining the choice of procedures.

Repair using thick flaps may mask recurrent tumor and
allow undetected retrobulbar extension. In such cases, it is
often better to settle for a less acceptable cosmetic result by
using a thin skin graft.
Reduction of Epicanthal Folds
Callahan MA, Callahan A. Ophthalmic Plastic and Orbital Surgery.
Birmingham, UK: Aesculapius; 1979.
Choi HY, Kwag DR. Simple, safe, and tension-free epicanthoplasty.
JKorean Soc Plast Reconstr Surg. 1998;25:13701374.
Del Campo AF. Surgical treatment of the epicanthal fold. Plast Reconstr
Surg. 1984;73:566570.
English FP, Smith B. Restoration of the canthal region by Z plasty. Aust N
Z J Ophthalmol. 1989;17:321322.
Jordan DR, Anderson RL. Epicanthal folds. Arch Ophthalmol.
1989;107:15321535.
Jung JH, Kim HK, Choi HY. Epiblepharon correction combined with
skin redraping epicanthoplasty in children. J Craniofac Surg. 2011;22:
10241026.
Khan JA, Garden VS. Combined flap repair of moderate lower eyelid
defects. Ophthal Plast Reconstr Surg. 2002;18:202204.
Kim MS, Lee DS, Woo KI, et al. Changes in astigmatism after surgery
for epiblepharon in highly astigmatic children: a controlled study.
JAAPOS. 2008;12:597601.
Mustarde JC. Repair and Reconstruction in the Orbital Region. 2nd ed.
Edinburgh, UK: Churchill Livingstone; 1980.
Park JI. Root Z-epicanthoplasty in Asian eyelids. Plast Reconstr Surg.
2003;111:24762477.
Roveda JM. Epicanthus et blepharophimosis: notre technique de correction. Ann doculist. 1967;200:551.
Canthoplasty
Alfano C, Chiummariello S, De Gado F, et al. Lateral canthoplasty
10-year experience. Acta Chir Plast. 2006;48:8588.
Carmine A, Stefano C, Cristiano M, et al. Lateral canthoplasty by the
Micro-Mitek Anchor System: 10-year review of 96 patients. J Oral
Maxillofac Surg. 2011;69:17451749.
Dailey RA, Chavez MR. Lateral canthoplasty with acellular cadaveric dermal matrix graft (AlloDerm) reinforcement. Ophthal Plast Reconstr
Surg. 2012;28:e29e31.
Glat PM, Jelks GW, Jelks EB, et al. Evolution of the lateral canthoplasty: techniques and indications. Plast Reconstr Surg. 1997;100:
13961405.
Shin YH, Hwang K. Cosmetic lateral canthoplasty. Aesthetic Plast Surg.
2004;28:317320.
Shorr N, Goldberg RA, Eshaghian B, Cook T. Lateral canthoplasty. Ophthal Plast Reconstr Surg. 2003;19:345352.
Taban M, Nakra T, Hwang C, et al. Aesthetic lateral canthoplasty. Ophthal
Turk JB, Goldman A. SOOF lift and lateral retinacular canthoplasty.
Yi SK, Paik HW, Lee PK, et al. Simple epicanthoplasty with minimal scar.
Aesthet Plast Surg. 2007;31:350353.
196
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SECTION N Medial and Lateral Canthal Reconstruction 197

Glabellar Rotational Flap
Bertelmann E, Rieck P, Guthoff R. Medial canthal reconstruction by a
modified glabellar flap. Ophthalmologica. 2006;220:368371.
Emsen IM, Benlier E. The use of the super thinned inferior pedicled glabellar flap in reconstruction of small to large medial canthal defect.
Koch CA, Archibald DJ, Friedman O. Glabellar flaps in nasal
reconstruction. Facial Plast Surg Clin North Am. 2011;19:113122.
Maloof AJ, Leatherbarrow B. The glabellar flap dissected. Eye.
2000;14:597605.
Median Forehead Transposition Flap
Dortzbach RK, Hawes MJ. Midline forehead flap in reconstructive procedures

of the eyelids and exenterated socket. Ophthal Surg. 1981;12:257268.
Gzel MZ. The turnover subdermal-periosteal median forehead flap.
Kazanjian VH, Roopenian J. Median forehead flaps and the repair of
defects of the nose and surrounding areas. Trans Am Acad Ophthalmol. 1956;60:557566.
Kleintjes WG. Forehead anatomy: arterial variations and venous link of the
midline forehead flap. J Plast Reconstr Aesthet Surg. 2007;60:593606.
McCarthy JG, Lorenc ZP, Cutting C, Rachesky M. The median forehead
flap revisited: the blood supply. Plast Reconstr Surg. 1985;76:866869.
Mombaerts I, Gillis A. The tunneled forehead flap in medial canthal and
eyelid reconstruction. Dermatol Surg. 2010;36:11181125.
Sharma RK. Supratrochlear artery island paramedian forehead flap for
reconstructing the exenterated patient. Orbit. 2011;30:154157.
Bennett SP, Richard BM, Graham KE. Median forehead flaps for eyelid
reconstruction. Br J Plast Surg. 2001;54:733734.
7/12/2012 2:50:56 PM
65
1
Reduction of Epicanthal Folds

with Y to V Advancement Flap
INDICATIONS: Reduction of mild to moderate nontraumatic congenital epicanthal folds.
FIG. 65.1. Mark a horizontal V-shaped incision line with

the point of the V about 5 to 7 mm medial to the medial
canthal angle and the arms running parallel to the upper
and lower lid margins for a distance of 8 to 10 mm. Draw
a horizontal line from the point of the V, and extend it 5 mm
toward the nasal bridge to form a Y-shaped incision.
FIG. 65.2. Cut the skin along the marked line with a scalpel
blade, and dissect a skinmuscle ap to expose the medial
canthal ligament.
through the ligament near the canthal angle and then

through its insertion at the frontal process of the maxillary
bone. Tie the suture to tuck the ligament. If necessary, excise
excessive subcutaneous tissue to allow medial displacement of
the canthal angle.
FIG. 65.4. Advance the skinmuscle ap into the medial
apex of the incision and approximate the edges with
interrupted 6-0 Vicryl sutures or 6-0 chromic gut if the
patient is a young child.
FIG. 65.3. If there is mild telecanthus, shorten the canthal

ligament by passing a double-armed 5-0 prolene suture
198
7/12/2012 2:50:56 PM
CHAPTER 65 Reduction of Epicanthal Folds with Y to V Advancement Flap 199
FIG. 65.1
FIG. 65.3
FIG. 65.2
FIG. 65.4
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66
Reduction of Epicanthal Fold

by Four-ap Technique
INDICATIONS: Reduction of moderate to severe congenital epicanthal folds.
FIG. 66.1. Flatten the epicanthal fold by pulling the skin

medially. Place one mark at the existing canthal angle (A).
Release tension on the skin and place a second mark at the
desired position of the new canthal angle (B). Draw a straight
line between these two marks (A-B).
FIG. 66.2. Draw all additional incision lines 2 mm shorter
than this horizontal segment. Beginning at the midpoint of
the horizontal line, and forming an angle of 60 degrees with
it, draw one line toward the upper lid and another toward
the lower lid. From the ends of each of these two lines, and
making a 45-degree angle with them, draw another line toward
the nose. From the old medial canthal mark (point A), draw
two lines laterally, parallel to, and 2 mm from the lid margins.
Thisresults in a Y-V plasty and two Z-plasty incision patterns.
POSTOPERATIVE CARE: Apply an antibiotic steroid

combination ointment to the suture line. A small, firm
pressure dressing may be placed over the medial canthus
for 24 hours, but this is generally not needed.
FIG. 66.3. Incise along the marked lines. Undermine and

gently elevate all skinmuscle aps. Excise subcutaneous tissue
as needed to advance the canthal angle nasally. If necessary,
tuck the medial canthal ligament with a 5-0 prolene suture to
correct mild telecanthus, as in the Y to V procedure, Fig. 65.3
(pp. 248-249).
FIG. 66.4. Transpose the four skinmuscle aps and close
them with interrupted 6-0 fast-absorbing plain gut sutures
if the patient is a young child.
Hypertrophic scar formationThis may be especially
prominent in young children, 4 to 6 weeks after surgery.
Warm compresses and massage with steroid cream will
help reduce scar formation.
200
7/12/2012 2:49:16 PM
CHAPTER 66 Reduction of Epicanthal Fold by Four-flap Technique 201
FIG. 66.1
FIG. 66.3
FIG. 66.2
FIG. 66.4
7/12/2012 2:49:16 PM
67
Lateral Augmentation Canthoplasty
INDICATIONS: Lengthening of the horizontal eyelid fissure for correction of ankyloblepharon and severe
blepharophimosis.
FIG. 67.1. Gently pull the eyelids medially to put the lateral canthal ligament on stretch. With scissors, cut a lateral
canthotomy the desired distance necessary to widen the
interpalpebral ssure.
FIG. 67.3. Smooth the lid contours if necessary by excising

small triangular areas of skin and muscle at the junctions of
the intact lid margins and the canthotomy incision. Leave
the conjunctival aps untrimmed.
FIG. 67.2. Separate the conjunctiva from along the cut lid
margins to raise mucosal aps 1 to 2 mm in width.
FIG. 67.4. Roll the conjunctival aps over the reformed

lidmargins and suture them to the skin with a running
7-0chromic stitch.
202
7/12/2012 2:44:26 PM
CHAPTER 67 Lateral Augmentation Canthoplasty 203
FIG. 67.1
FIG. 67.3
FIG. 67.2
FIG. 67.4
7/12/2012 2:44:27 PM
68
Lateral Reduction Canthoplasty
INDICATIONS: Shortening of the horizontal interpalpebral fissure in euryblepharon and mild congenital ectropion
syndrome, or in thyroid eye disease patients with globe prolapse.
FIG. 68.1. Beginning at the canthal angle, split the lower lid
along the gray line to a depth of 2 mm and for a horizontal
distance of about 5 mm. Adjust the latter distance as needed
to correct the deformity. Continue the dissection around the
angle and onto the upper lid for a similar distance.
FIG. 68.2. Trim the marginal conjunctival epithelium from
the posterior lamella around the canthal angle and from
the tarsus along the area of the split lids to expose bare
edges of the canthal ligament and tarsus. Remove any
marginal cutaneous epithelium with all lash bulbs from the

anterior skinmuscle lamella of both upper and lower lids.
FIG. 68.3. Approximate the upper and lower tarsal edges
with three to four interrupted 6-0 Vicryl sutures to shorten
the palpebral ssure.
FIG. 68.4. Close the orbicularis muscle across the lateral
commissure with interrupted 6-0 Vicryl stitches and the
skin aps with 6-0 fast-absorbing plain gut.
sutures three to four times daily for 5 to 7 days.
204
7/12/2012 2:41:38 PM
CHAPTER 68 Lateral Reduction Canthoplasty 205
FIG. 68.1
FIG. 68.3
FIG. 68.2
FIG. 68.4
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69
Correction of Vertical Canthal Angle

Dystopia
INDICATIONS: Correction of congenital or traumatic vertical canthal angle dystopia.
FIG. 69.1. Outline a Z-plasty at the canthus so the present

position of the canthal angle is included in the apex of one
triangular ap (A). The opposing triangular ap is based
away from the lids with its free arm ending at the desired new
position of the canthal angle (B).
FIG. 69.2. Cut along the marked lines with a scalpel blade
and open the orbicularis muscle with scissors. Elevate the
myocutaneous aps with blunt and sharp dissection, and
undermine around their bases.
FIG. 69.3. Identify the canthal ligament and cut across it

close to the periosteum. If necessary, free the lid further by
excising scar tissue or by dividing the lateral portion of the
lower eyelid retractors. Transpose the triangular aps. Place
two 4-0 Mersilene or prolene sutures through the canthal ligament stump and then into the periosteum along the internal
surface of the lateral orbital rim at the desired new position.
FIG. 69.4. Close the incision line with interrupted
6-0 Vicryl stitches across the orbicularis muscle and
6-0fast-absorbing plain gut sutures across the skin edges.
206
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CHAPTER 69 Correction of Vertical Canthal Angle Dystopia 207
FIG. 69.1
FIG. 69.3
FIG. 69.2
FIG. 69.4
7/12/2012 2:40:00 PM
70
Glabellar Rotation Flap
INDICATIONS: Reconstruction of medium-size, nonmarginal medial canthal defects.
FIG. 70.1. Mark a V-shaped incision over the glabellar

region with the apex superior and with one arm extending
into the medial canthal defect.
FIG. 70.2. Cut through the skin with a scalpel blade and
mobilize a skinmuscle ap. Undermine around the base of
the nasal bridge and between the eyebrows.
midline. Rotate the ap 90 degrees into the medial canthal

defect. Trim the ap to t if needed.
FIG. 70.4. Close the donor site rst. Approximate the deep
fascia and dermis with interrupted sutures of 4-0 Vicryl. Close
the skin with 5-0 prolene, using everting vertical mattress
sutures. Similarly, suture the ap to the recipient bed in layers.
FIG. 70.3. Undermine the edges of the donor glabellar

defect for a distance of 2 cm and slide the brows toward the
208
7/12/2012 2:37:00 PM
CHAPTER 70 Glabellar Rotation Flap 209
FIG. 70.1
FIG. 70.3
FIG. 70.2
FIG. 70.4
7/12/2012 2:37:00 PM
71
Median Forehead Transposition Flap
INDICATIONS: Reconstruction of large medial canthal and lower eyelid defects.
FIG. 71.1. Mark the median forehead ap from the glabella

toward the hairline for a distance of 4 to 8 cm as needed
to close the recipient defect and 1.5 to 3 cm wide. Do not
extend the line below the medial brow on the intact side to
avoid injury to the angular vascular supply. Cut along the
marked line with a scalpel blade into the subgaleal plane.
FIG. 71.4. Suture the ap to the edges of the recipient bed

with 5-0 Vicryl stitches across the subcutaneous layer and
5-0 prolene through the skin margins. It may be necessary to
slightly thin the ap where it lies in the lower eyelid, taking care
not to compromise its blood supply. A tubed hump will usually
remain over the nasal bridge.
FIG. 71.2. Elevate the skinmuscle ap with scissors.

Undermine over the nasal bridge and along the edges of the
forehead donor site for 4 to 5 cm. Transpose the ap over the
brow and into the medial canthal defect, trimming it to t as
necessary.
FIG. 71.5. After 2 to 3 weeks, make a vertical cut from the

apex of the tubed hump laterally and around the superior
base. Extend the incision superiorly along the original incision
line for a distance of 1 to 2 cm.
FIG. 71.3. Close the forehead donor site with deep

4-0Vicryl stitches across the deep fascia and dermis, and
everting vertical mattress sutures of 5-0 prolene across the
skin. Thewound will be under considerable tension.
POSTOPERATIVE CARE: Apply a dressing over the

flap for 24 hours and antibiotic ointment to the suture
line three to four times daily for 7 days. Remove the skin
sutures after 7-10 days.
FIG. 71.6. Undermine the ap and rotate it upward into

the glabellar defect to separate the brows. Trim the sides
as needed. Close the wound in layers with 6-0 Vicryl sutures.
Alternatively, the excess hump tissue can simply be excised.
dissection may compromise vascular supply. Care must

be taken not to rotate the flap with a harsh kink at its
base, which will compress feeding vessels.
Flap necrosisDevelopment of a flap that is too long for
its width or injury to the angular vascular pedicle during
210
7/12/2012 3:12:19 PM
CHAPTER 71 Median Forehead Transposition Flap 211
FIG. 71.1
FIG. 71.4
FIG. 71.2
FIG. 71.5
FIG. 71.3
FIG. 71.6
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7/12/2012 3:12:28 PM
II
Lacrimal
Drainage
System
Surgery
HE LACRIMAL SYSTEM IS A COMPLEX GROUP OF STRUCTURES THAT MEDIATES
the secretion, transcorneal ow, and drainage of tears. Proper function of the
system depends on normal tear production and chemical composition, adequate eyelid position and pump mechanism physiology, and an anatomically patent
drainage conduit. Defects in any portion of the system may result in signicant symptomatology. The nature of the symptoms depends upon the balance between tear production and tear drainage. Hypersecretion, even with normal drainage, could result in
epiphora. Thus, appropriate therapy is aimed at elimination of the ocular irritation or
other sources of secondary overproduction. When tear secretion is normal or reduced,
the patient may be asymptomatic or may experience epiphora or dry eyes, depending on the status of the drainage system. Even in the presence of signicant drainage
obstruction, a patient may experience bothersome dry eye symptoms.
Appropriate management of lacrimal system dysfunction demands careful evaluation for the precise etiology. Attention is directed toward the ocular surface and anterior
segment, possible eyelid malpositions, the physiologic pump function, and anatomic
blockages anywhere along the drainage system. Marginal blepharitis, conjunctivitis,
keratitis, and iritis all may cause secondary hypersecretion syndrome. Therapy in these
cases is usually medical. Lower eyelid entropion with associated corneal abrasion from
inturned lashes also produces excessive reex tearing. The same is true for ectropion
with corneal exposure. In these cases of hypersecretion, surgical management of the
anatomic eyelid malposition is required.
Defects affecting the physiologic pump mechanism may result from eyelid laxity, in
which signicant orbicularis muscle tone is lost, or from seventh nerve palsies. Scarring
or mass lesions of the eyelids that impair horizontal movement also reduce pumping
action. Malpositions of the eyelids, even when not associated with corneal irritation,
can interfere with tear drainage because of punctal eversion or drooping lateral eyelid
contour. In all such cases, initial therapy is directed toward the anatomic defect, utilizing any of the eyelid reconstructive procedures discussed earlier in this volume.
Physical obstruction of tear drainage may occur anywhere along the lacrimal outow system, from the puncta to the nasolacrimal ostium. A delayed dye disappearance
test, palpation of a dilated sac, reux of mucopurulent material on sac compression,
and echographic imaging of a dilated sac and duct conrm nasolacrimal duct (NLD)
obstruction. More specic clinical tests, such as the Jones dye tests, and occasionally
canalicular probing will identify the site of obstruction in most cases.
The dye disappearance test provides an accurate assessment of tear outow. Several
drops of 2% uorescein are placed into the inferior conjunctival cul-de-sac over several
minutes, and the amount of dye remaining after 5 minutes is graded on a 0 to 4+ scale,
with 0 equal to no dye remaining and 4+ equal to all the dye remaining. In the presence of normal outow, little or no dye should remain after 5 minutes. In the Jones
I test, the dye is placed in the eye, and after 5 to 10 minutes, an attempt is made to
8/3/2012 6:48:01 PM
recover it in the inferior meatus of the nose. In up to 20% of normal individuals, however, no dye will be recovered after 20 minutes. A negative (no dye recovered) test, with
a delayed dye disappearance test, and symptomatic epiphora are strongly suggestive
of a nasolacrimal duct obstruction. The Jones II test is a nonphysiologic evaluation of
absolute nasolacrimal duct patency. After performing the dye disappearance or Jones
I test, saline solution is irrigated through the lacrimal drainage system. It is important
for complete evaluation of this test to collect any irrigant that enters the nose or pharynx. If the irrigant does enter the nose, only an incomplete obstruction is present that
can be overcome with increased hydrostatic pressure. The presence of uorescein dye
in the irrigant demonstrates a low lacrimal sac or duct obstruction because the dye
had to have entered during the previous dye disappearance test. This suggests that the
puncta and canaliculi, as well as the pump mechanism, are functioning normally. In
the absence of dye in the irrigant, it is more likely that canalicular or punctal stenosis
is present, or there is a defect in the lacrimal pump mechanism, because dye was prevented from entering the sac during the previous dye disappearance test. If no irrigant
enters the nose, then a high-grade or absolute obstruction is present that cannot be
overcome with increased hydrostatic pressure.
Becker BB. Tricompartment model of the lacrimal pump mechanism. Ophthalmology. 1992;99:1139
1145.
Benger R. Surgical management of the lacrimal drainage system. Aust N Z J Ophthalmol.
1988;16:281290.
Camara JG, Santiago MD, Rodriguez RE, et al. The Micro-Reflux Test: a new test to evaluate nasolacrimal duct obstruction. Ophthalmology. 1999;106:23192321.
Doane M. Blinking and the mechanics of the lacrimal drainage system. Ophthalmology. 1981;88:844
851.
Dutton JJ. Diagnostic tests and imaging techniques. In: Linberg JV, ed. Lacrimal Surgery. New York:
Churchill Livingstone; 1988:1948.
Dutton JJ. Standardized echography in the diagnosis of lacrimal drainage dysfunction. Arch
Ophthalmol. 1989;107:10101012.
Haefliger IO, Keskinaslan I, Piffaretti JM, Pimentel AR. Improvement of chronic epiphora symptoms
after surgery in patients with different preoperative Schirmer-test values. Klin Monatsbl Augenheilkd. 2011;228:318321.
Lee MJ, Kyung HS, Han MH, et al. Evaluation of lacrimal tear drainage mechanism using dynamic
fluoroscopic dacryocystography. Ophthal Plast Reconstr Surg. 2011;27:164167.
Mandeville JT, Woog JJ. Obstruction of the lacrimal drainage system. Curr Opin Ophthalmol.
2002;13:303309.
Maurice DM. The dynamics and drainage of tears. Int Ophthalmol Clin. 1973;13:103116.
Meyer DR. Lacrimal disease and surgery. Curr Opin Ophthalmol. 1993;4:8694.
Rose GE. Lacrimal drainage surgery in a patient with dry eyes. Dev Ophthalmol. 2008;41:127137.
Weil D, Aldecoa JP, Heidenreich AM. Diseases of the lacrimal drainage system. Curr Opin
Ophthalmol. 2001;12:352356.
Yeatts RP. Current concepts in lacrimal drainage surgery. Curr Opin Ophthalmol. 1996;7:4347.
214
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SECTION
Surgical Anatomy of the

LacrimalDrainage System
215
8/3/2012 6:48:02 PM
72
T
Surgical Anatomy of the Lacrimal

Drainage System
he lacrimal drainage system bridges the space between the

anterior orbit and the nose. The lacrimal sac lies within its
own anatomic compartment, separate from the orbit and the
eyelids. Nevertheless, it has an intimate anatomic association
with adjacent structures, such as the orbicularis muscle, canthal ligaments, and orbital septum, all of which contribute to
the lacrimal pump mechanism.
The lacrimal drainage conduit begins at the lacrimal
puncta, one in each eyelid. These openings are 0.2 to
0.3mm in diameter and lie at the apex of a small or inconspicuous elevated lacrimal papillae on the mucocutaneous
border of the upper and lower eyelids. The upper papilla
lies 5 mm, and the lower papilla 6 mm, from the medial
canthal angle. From each punctum, the canaliculus initially passes perpendicular to the lid margin for a distance
of 2mm. Here it dilates to form the ampulla, an irregular
sac 2 mm in diameter. From the ampullae, the canaliculi
turn horizontally and run medially, parallel to the lid margin for a distance of about 8 mm. In 90% of individuals, the
two canaliculi join at an angle of about 25 degrees to form
a common canaliculus 3 to 5 mm in length. In the other
10% of individuals, the two canaliculi join the sac independently. Just before entering the lacrimal sac, the common
canaliculus dilates slightly to form the sinus of Maier. At
the entrance to the sac, the common internal canalicular punctum is associated with a variably formed fold of
mucosa known as the valve of Rosenmller. This tends to
be less competent with advancing age, and its function in
adults is quite variable. In the presence of acute nasolacrimal duct obstruction, a competent valve of Rosenmller
may be responsible for significant sac distention and pain,
thereby requiring decompression. With a less competent
valve, reflux of mucopurulent discharge becomes a prominent symptom.
The lacrimal sac lies in a bony fossa between the anterior and posterior lacrimal crests. The orbital processes of
the maxillary bone and the thin lacrimal bone each contribute equally to the fossa, with the maxillolacrimal suture
line running vertically within the center of the depression.
In some individuals, especially in Asians, this suture line
lies more posterior, so that the thicker maxillary bone may
form nearly the entire bed of the lacrimal sac fossa. In such
cases, entrance into the nose during lacrimal surgery may
be more difficult. The anterior ethmoid air cells normally
extend forward only to the level of the posterior lacrimal
crest. In about 10% to 15% of individuals, however, an anterior extension of the ethmoid labyrinth, the agger nasi cells,
may underlie the entire lacrimal sac fossa to the anterior
crest. Nasal examination will usually demonstrate a very
narrow middle meatus where the lateral nasal wall is in
contact with the middle turbinate. In such cases, attempted

creation of a bony ostium during dacryocystorhinostomy
surgery may enter these ethmoid cells instead of the middle
nasal meatus. Passage of a cotton-tipped applicator into the
middle meatus and application of gentle pressure laterally
will confirm failure to communicate with the nose because
of the presence of a thin shell of bone on the medial side of
these mucosal-lined sinus cavities. In such cases, the surgical ostium is continued through this medial sinus wall to
the nose.
The lacrimal sac is covered with a dense fascia, formed
from the splitting of periorbita as it passes around the sac
from the posterior to anterior lacrimal crests. Posteriorly
this fascia is joined by the posterior crus of the medial
canthal ligament and by the deep heads of the pretarsal
(Horners muscle) and preseptal orbicularis muscle fibers.
Anteriorly the medial canthal ligament passes over the sac
to insert onto the orbital process of the maxillary bone.
The superficial heads of the pretarsal and preseptal orbicularis muscles divide in complex fashion to insert onto
the anterior crest and the lacrimal sac fascia. The sac itself
is about 12 to 15 mm in length, 2 to 3 mm wide, and 4to
6mm deep. It is lined with mucosal epithelium and is generally in a partially collapsed state. This may make it difficult to cut into the sac during dacryocystorhinostomy
surgery because the mucosa pushes away from the somewhat firmer fascia. Before anastomosis with the nasal
mucosa, visualization of a probe passed through the canaliculus is essential to confirm that an opening was made
into the sac.
The lacrimal sac passes inferiorly to the membranous lacrimal duct just above the entrance to the lacrimal canal. The
bony canal is 12 mm in length and 3 to 5 mm in width. It is
bounded anteriorly, laterally, and posteriorly by the maxillary
bone, superomedially by the ethmoid bone, and inferomedially by the inferior turbinate of the maxillary bone. Intranasally the canal forms the lacrimal ridge, which runs vertically
just in front of the middle turbinate and the medial wall of the
ethmoid labyrinth. It may be incomplete, closed over only by
the periosteum and nasal mucosa. Transnasal sinus surgery
and polypectomy may injure the duct within the canal, causing obstruction in its midportion. In adults, the canal and
duct form a nearly straight conduit angled backward about
15 to 30 degrees and usually outward about 5 degrees to the
midsagittal plane. The latter is variable and depends on the
intercanthal distance. In children, the duct is more angulated
at the sacduct junction and forms a J-shaped bend distally
where the duct enters the nose. This configuration accounts
for the often traumatic and unsuccessful probings in congenital nasolacrimal duct obstructions.
216
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CHAPTER 72 Surgical Anatomy of the Lacrimal Drainage System 217

The membranous lacrimal duct runs within the osseous canal to the inferior meatus. It extends into the meatus
some 3 to 5 mm before opening at the membranous valve
of Hasner. The nasal opening is located 15 mm posterior to
the tip of the inferior turbinate and 30 to 35 mm from the
external nares and 4 to 18 mm above the nasal floor.
The medial superior and inferior palpebral arteries are
terminal branches of the ophthalmic artery. These arteries
enter the eyelids medial to the end of the tarsal plates 4 to
5 mm from the lid margins. They generally are not encountered in lacrimal system surgery. The angular vessels are
branches of the facial artery and vein that course diagonally
across the face from the jaw to the medial canthus. Here
the vessels turn vertically and run between the skin and the
periosteum, near the insertion of the medial canthal ligament. The incision for surgery on the lacrimal sac lies close
to these vessels and therefore may result in brisk bleeding. A superficial incision and blunt dissection through
the orbicularis fibers parallel to the vessels usually help to
avoid cutting them, although rupture of small muscular
branches sometimes occurs.

Anderson RL. Medial canthal tendon branches out. Arch Ophthalmol.
1977;95:20512052.
Bailey JH. Surgical anatomy of the lacrimal sac. Am J Ophthalmol.
1923;6:665.
Busse H, Muller KM, Kroll P. Radiologic and histology findings of the lacrimal passages of newborns. Arch Ophthalmol. 1980;98:528532.
Dutton JJ. Standardized echography in the diagnosis of lacrimal drainage
dysfunction. Arch Ophthalmol. 1989;107:10101012.
Dutton JJ. Orbital complications of paranasal sinus surgery. Ophthal Plast
Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. 2nd ed.
London, UK: Elsevier Saunders; 2011:165174.
Jones LT. An anatomical approach to problems of the eyelids and lacrimal
apparatus. Arch Ophthalmol. 1961;66:111124.
Jones LT. Anatomy of the tear system. Int Ophthalmol Clin. 1973;13:322.
Linberg JV. Surgical anatomy of the lacrimal system. In: Linberg JV, ed.
Lacrimal Surgery. New York: Churchill Livingstone; 1988:118.
Werb A. The anatomy of the lacrimal system. In: Milder B, Weil BO, eds.
The Lacrimal System. Norwalk, CT: Appleton-Century-Crofts; 1982.
Takahasi Y, Kakizaki H, Nakano T, et al. Anatomy of the vertical lacrimal canaliculus and lacrimal punctum: a macroscopic study. Ophthal
8/3/2012 6:48:03 PM
218 SECTION A Surgical Anatomy of the LacrimalDrainage System

FIG. 72.1. Anatomy of the lacrimal drainage system in frontal view. 1, Superior
canaliculus. 2, Superior ampulla. 3, Superior papilla. 4, Superior and inferior puncta.
5,Inferior papilla. 6, Common canaliculus. 7, Lacrimal sac. 8, Membranous lacrimal
duct. 9, Valve of Hasner. 10, Inferior nasal meatus. 11, Frontal bone. 12, Posterior
crusof medial canthal ligament. 13, Lacrimal bone. 14, Anterior crus of medial canthal ligament. 15, Nasal bone. 16, Maxillary bone. 17, Middle turbinate. 18, Inferior
turbinate.
8/3/2012 6:48:03 PM
CHAPTER 72 Surgical Anatomy of the Lacrimal Drainage System 219

FIG. 72.1
11
12
1
13
2
3
4
14
5
15
6
16
7
8
17
9
10
18
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SECTION
Surgery on the Lacrimal

Puncta and Canaliculi
T
he etiology of epiphora frequently results from defects in

the proximal portion of the drainage system. The lacrimal puncta may be stenotic or completely occluded by a thin
epithelial membrane. Occlusion is not an uncommon sequel
of disuse associated with ectropion. Treatment consists of
simple perforation of the membrane or dilatation, if stenotic.
A two- or three-snip punctoplasty will enlarge the opening
and position it more posterior so it will lie within the tear lake.
When necessary, this is combined with correction of any eyelid malposition, such as medial ectropion or horizontal laxity.
Canalicular stenosis or frank obstruction may follow
trauma, fungal or viral infections, or the use of some topical medications, such as epinephrine or some chemotherapeutic agents like tamoxifen that are secreted in the tears.
It is also fairly common in the elderly, in which case it may
be associated with lower nasolacrimal duct obstruction.
Congenital atresia of the puncta and canaliculi is rare and
usually requires more complex reconstructive techniques.
Repair of a stenotic canaliculus may be achieved with progressive dilatation and placement of silicone stents. When
narrow high-grade focal obstructions are found, it is sometimes possible to excise the involved region with microanastomotic repair of the remaining portions. Localized
obstructions at the common canaliculus may be repaired
with an internal punctoplasty or canaliculoplasty. When
associated with lower nasolacrimal duct blockage, a canaliculodacryocystorhinostomy may be indicated. More
extensive obstructions, especially when also involving the
common canaliculus, require a conjunctivodacryocystorhinostomy bypass procedure with placement of a Jones
Pyrex or similar replacement conduit.
Traumatic lacerations of the canaliculi are common.
Although epiphora is unusual with the loss of only one
canaliculus, attempted repair is always justified and is
easier as a primary procedure than as a secondary reconstruction. The canaliculus cannot be anastomosed without placement of a stent because stenosis at the repaired
segment will usually lead to late failure. During any repair,
meticulous attention must be paid to avoid injury to the
intact ipsilateral canaliculus. It is preferable to leave the
transected canaliculus unrepaired rather than to risk loss
of both.
Excision of medial canthal tumors frequently must sacrifice the punctum or portions of the canaliculus. As with
laceration injuries, attempts at primary reconstruction are
justified and preferable to the later placement of a Jones
tube. As with eyelid reconstruction, the possibility of tumor
recurrence dictates the choice of operative procedure.
Lacrimal drainage surgery may be performed under
local or general anesthesia, except in children, in which
case general or inhalation anesthesia is necessary. Packing of the nose with neurosurgical cottonoid sponges
soaked in 4% cocaine and 0.5% phenylephrine is helpful
to shrink the nasal mucosa for visualization and hemostasis. It also provides adequate nasal anesthesia for local
cases. Cocaine in children should be used with caution, if
at all, because of systemic toxicity. The medial canthus is
infiltrated with 1 mL of local anesthetic with epinephrine
down to the level of the periosteum for local anesthesia
and hemostasis.
Nasal mucosal bleeding can be a problem in lacrimal
surgery. It is important to instruct the patient to avoid the
use of platelet-inhibiting medications, such as aspirin and
other anticoagulation agents. In some cases, this may not
be possible because of complicating medical conditions.
Punctoplasty
Caesar RH, McNab AA. A brief history of punctoplasty: the 3-snip revisited. Eye. 2005;19:1618.
Chak M, Irvine F. Rectangular 3-snip punctoplasty outcomes: preservation of the lacrimal pump in punctoplasty surgery. Ophthal Plast
Guercio B, Keyhani K, Weinberg DA. Snip punctoplasty offers little additive benefit to lower eyelid tightening in the treatment of pure lacrimal
pump failure. Orbit. 2007;26:1518.
Hughes WI, Maris CSG. A clip procedure for stenosis and eversion of
the lacrimal punctum. Trans Am Acad Ophthalmol Otolaryngol.
1967;71:653655. Jones LT. Epiphora: its causes and new surgical procedures for its cure. Am Ophthalmol. 1954;38:824831.
Jones LT. Epiphora. II. Its relation to the anatomic structures and surgery
of the medial canthal region. Am J Ophthalmol. 1957;43:203212.
Kashkouli MB. 3-Snip punctoplasty. Eye. 2006;20:517.
Shahid H, Sandhu A, Keenan T, Pearson A. Factors affecting outcome
of punctoplasty surgery: a review of 205 cases. Br J Ophthalmol.
2008;92:16891692.
220
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SECTION B Surgery on the Lacrimal Puncta and Canaliculi 221

Repair of Canalicular Lacerations
Chu YC, Ma L, Wu SY, Tsai YJ. Comparing pericanalicular sutures with
direct canalicular wall sutures for canalicular laceration. Ophthal
Della Rocca DA, Ahmad SM, Della Rocca RC. Direct repair of canalicular
lacerations. Facial Plast Surg. 2007;23:149155.
Dortzbach RK, Anguist RA. Silicone intubation for lacerated canaliculi.
Ophthalmic Surg. 1985;16:639642.
Gupta VP, Gupta P, Gupta R. Repair of canalicular lacerations using
monostent and Mini-Monoka stent. Ann Plast Surg. 2011;66:216.
Hawes MJ, Segrest DR. Effectiveness of bicanalicular silicone intubation in the repair of canalicular lacerations. Ophthal Plast Surg.
1985;1:185190.
Jordan DR, Gilberg S, Mawn LA. The round-tipped, eyed pigtail probe for
canalicular intubation: a review of 228 patients. Ophthal Plast Reconstr Surg. 2008;24:176180.
Jordan DR, Mawn L. Repair of canalicular lacerations. Am J Ophthalmol.
2008;146:792793.
Leibovitch I, Kakizaki H, Prabhakaran V, Selva D. Canalicular lacerations:
repair with the Mini-Monoka monocanalicular intubation stent.
Ophthalmic Surg Lasers Imaging. 2010;41:472477.
Neuhaus RW. Silicone intubation of traumatic canalicular lacerations.

Ophthal Plast Reconstr Surg. 1989;5:256260.
Saunders DH, Shannon CM, Flanagan JC. The effectiveness of the pigtail probe method of repairing canalicular lacerations. Ophthal Surg.
1978;9:3340.
Slonim CB. Dog bite-induced canalicular lacerations: a review of 17 cases.
Viers ER. The Lacrimal System: Clinical Applications. New York: Grune
& Stratton; 1955.
Canalicular Reconstruction
Hurwitz J. The slit canaliculus. Ophthal Surg. 1982;13:572575.
McCord CD Jr. Canalicular resection and repair by canaliculostomy. Ophthal Surg. 1980;11:440445.
Pratt DV, Patrinely JR. Reversal of iatrogenic punctal and canalicular
occlusion. Ophthalmology. 1996;103:14931497.
Zoumalan CI, Maher EA, Lelli GJ Jr, Lisman RD. Balloon canaliculoplasty for acquired canalicular stenosis. Ophthal Plast Reconstr Surg.
2010;26:459461.
7/12/2012 3:13:20 PM
73
Two-snip Punctoplasty
INDICATIONS: Epiphora attributable to punctal stenosis.
FIG. 73.1. Anesthetize the stenotic punctum with a

cotton-tipped applicator soaked in 4% topical lidocaine
anesthetic. Hold the applicator at the medial canthus for 3 to
5 minutes.
FIG. 73.2. Pull the lid laterally to straighten the canaliculus
and widen the punctum with a punctal dilator. Place one
blade of a pointed micro-Westcott scissors into the stenotic
punctum and then into the ampulla for a distance of 2mm. Push
the scissors slightly medially and direct the point downward.
Make a sharp cut through the posterior lip of the punctum.
FIG. 73.3. Replace the scissors into the canaliculus and

ampulla. Push the scissors slightly laterally and direct the point
of the scissors downward and medially toward the end of the
rst incision. Make a sharp cut and remove a triangular segment from the posterior wall of the punctum and the ampulla.
Alternatively, a three-snip excision can be performed by making the second cut from the punctum medially along the canaliculus along the eyelid margin for a distance of 2-3 mm, and
then excising the resulting triangular ap.
POSTOPERATIVE CARE: Apply an antibiotic and steroid combination solution to the eye three times daily for
7days.
222
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CHAPTER 73 Two-snip Punctoplasty 223

FIG. 73.1
FIG. 73.3
FIG. 73.2
7/12/2012 3:13:20 PM
74
Repair of Canalicular Lacerations
INDICATIONS: Laceration of the canaliculus lateral to the common segment.
FIG. 74.1. Anesthetize the medial canthus with 1-2%

lidocaine. Gently dry and separate the lacerated tissues at
the medial canthus under magnication to identify the cut
proximal end of the canaliculus. If the proximal end cannot
be found, irrigation of saline solution through the ipsilateral
punctum may show its location. If there is signicant edema,
delay surgery and apply iced compresses every few hours for
several days.
FIG. 74.2. Dilate the punctum with a punctal dilator and
identify the cut ends of the lacerated canaliculus.
FIG. 74.3. Pass a silicone intubation stent on a wire
introducer through the punctum and out the distal cut
surface of the canaliculus and then into the proximal
opening of the transected canaliculus. Dilate the latter if
necessary. Thread the stent down the nasolacrimal duct and
into the nose. Pass the other end of the silicone stent through
the opposite canalicular system and into the nose. Alternatively,
amonocanalicular Minoka or other stent can be used.
FIG. 74.4. Repair the eyelid wound in layers, as for Direct
Primary Closure of Marginal Eyelid Defects, Fig. 56.1 to 56.6
(pp. 214-215). If possible, microanastomose the canalicular
mucosal ends with several deep sutures of 7-0 Vicryl. If not
possible, place several deep sutures to approximate the eyelid
wound close to the cut edges around the stent.
FIG. 74.5. As an alternative procedure, carefully pass a

pigtail probe through the ipsilateral intact punctum and
the canaliculus. Pull the upper and lower lids apart medially
to widen the angle where the upper and lower canaliculi join
the common canal. Gently rotate the pigtail probe around
themedial canthus, through the common canal and out the
proximal cut end of the lacerated canaliculus. Do not apply
force. If the probe does not pass easily or repeatedly enters the
sac, use an alternative method of repair.
FIG. 74.6. Thread a 6-0 nylon suture through the terminal
eyelet in the pigtail probe and withdraw the probe so
the suture passes from the cut canaliculus to the intact
punctum.
FIG. 74.7. Dilate the punctum of the lacerated lid and pass
the pigtail probe through it to the distal cut end of the
canaliculus. Thread the end of the 6-0 nylon suture emerging
from the proximal cut canaliculus into the probe eyelet and
pull the probe through to the punctum.
FIG. 74.8. Cut the end of a piece of soft hollow silicone
tubing to a bevel, and thread the tubing over the nylon
suture for a distance of about 4 to 5 cm. Clamp the tubing
with a needle holder to secure the suture.
224
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CHAPTER 74 Repair of Canalicular Lacerations 225
FIG. 74.1
FIG. 74.5
FIG. 74.2
FIG. 74.6
FIG. 74.3
FIG. 74.7
FIG. 74.4
FIG. 74.8
7/12/2012 3:15:33 PM
226 SECTION B Surgery on the Lacrimal Puncta and Canaliculi

FIG. 74.9. Gently pull the nylon suture and silicone tubing through the
canalicular system so the free ends emerge at the two puncta.
FIG. 74.10. Release the needle holder. Lay this end of thesilicone tubing on a hard
surface, such as the handle of a forceps. Carefully cut through the walls of the silicone
tubing with a pointed scalpel blade, leaving the nylon suture intact. Slide the excess
tubing off the suture. The silicone tubing should now form a loop through the upper
and lower canaliculi via the common canal, and the nylon suture should emerge from
its two ends.
FIG. 74.11. Repair the eyelid wound in layers, as for Direct Primary Closure of
Marginal Defects, Fig. 56.1 through 56.6 (pp. 214-215), making certain the cut
ends of the canaliculus are well apposed.
FIG. 74.12. Pull the silicone tubing so that only 2 mm extends out from one
punctum. Cut the tubing 2 mm from the end emerging from the opposite punctum,
leaving the internal suture intact. Tie the nylon suture so the silicone ends are in
contact and cut the suture ends close to the knot.
FIG. 74.13. Rotate the silicone circular loop so the suture knot lies within the
common canaliculus or lacrimal sac.
POSTOPERATIVE CARE: Apply an antibiotic and steroid

combination solution to the eye and an antibiotic ointment to the skin suture line three to four times daily for 7
days. Remove the silicone stent after 3 months.
Canalicular stenosis at the laceration siteThis will
result if the canaliculus is not stented at the time of
repair. Even with microanastomosis, stenting is required
for success.
Injury to the opposite canaliculusCare should be
taken when probing or irrigating the ipsilateral intact
canaliculus. The pigtail probe must be used with

extreme caution and should be abandoned if it cannot
be passed atraumatically.
Punctal erosion and canalicular slittingThis is
caused by tying the silicone stents too tight. If only a
small amount of erosion is present, the stent should be
removed to prevent progression. If the slit is larger, it
can be repaired by cutting along the mucocutaneous
border along the margins of the slit and the cut surfaces
sewn over the stent.
7/12/2012 3:15:46 PM
CHAPTER 74 Repair of Canalicular Lacerations 227

FIG. 74.9
FIG. 74.12
FIG. 74.10
FIG. 74.13
FIG. 74.11
7/12/2012 3:15:46 PM
75
Canalicular Reconstruction
INDICATIONS: Loss of one or more canaliculi from trauma or surgical excision of tumor.
FIG. 75.1. For medial eyelid defects that can be repaired

with primary direct closure, pass a silicone intubation
stent through the intact ipsilateral punctum and canaliculus to the proximal end of the cut canaliculus, using a
pigtail probe as described above for Repair of Canalicular
Lacerations, Fig. 74.5 through 74.11 (pp. 274 to 276).
FIG. 75.2. With a scalpel blade, split the medial portion of
the remaining eyelid along the gray line for a distance of 3to
4 mm and to a depth of 3 mm. Dissect around the proximal
opening of the canaliculus to allow some lateral stretching.
FIG. 75.3. Dissect toward the posterior lacrimal crest to expose
the posterior crus of the medial canthal ligament. Pull the cut
surface of the tarsus medially and suture it to the stump of the posterior canthal ligament or to the residual medial eyelid tarsus with
two interrupted 5-0 Vicryl stitches.
FIG. 75.4. Lay the silicone stent into the bed between the
split anterior and posterior eyelid lamellae. Loosely x the
cut end of the canaliculus to epitarsus with one or two 6-0
Vicryl sutures. The canaliculus may not reach the site of the
proposed new punctum.

the lid margin and suture line three to four times daily for
7 days. Remove the silicone tubing after 6 months.
Canalicular obstructionThe success rate for this procedure is only about 50% but is worth attempting as an
alternative to placing a Jones tube.
Canalicular slittingThis will occur when the silicone
tubing is tied too tightly to allow the lids to open without tension on the puncta. Enough slack must be left to
eliminate all tension.
FIG. 75.5. Bring the silicone tubing to the lid margin at

the end of the split gray line incision. Advance the eyelid
medially and x the orbicularis muscle to the anterior crus of
the medial canthal ligament with two 6-0 Vicryl sutures.
FIG. 75.6. Close the skin with interrupted stitches of 6-0 Vicryl
and the lid margin with a running 7-0 chromic suture. Leave
the silicone tubing to emerge at the site of the new punctum.
FIG. 75.7. Cut the silicone tubing 2 mm from each punctum,
leaving the central 6-0 nylon suture intact, as for Repair of
Canalicular Lacerations, Fig. 74.12 (pp. 214-216). Tie the nylon
suture ends together to form a continuous circular loop of silicone
tubing and rotate the loop so the knot lies beneath the lid surface.
FIG. 75.8. If other repair techniques are used for the
anterior lamella, such as a myocutaneous ap, sandwich
the silicone tubing between the original tarsus and the
reconstructed anterior lamella before closure.
Corneal irritationIf too much slack is left in the silicone

tubing loop, corneal touch may become a problem. It is
helpful to rotate the nylon suture knot away from the
conjunctiva to minimize discomfort.
Canalicular stenosisThe new canaliculus around the
silicone tubing will epithelialize over time, but scar maturation at the reconstructed portion of the eyelid may
take many months. The tubing should remain in place
for 6 months unless canalicular slitting or other complications demand early removal.
228
7/12/2012 3:15:03 PM
CHAPTER 75 Canalicular Reconstruction 229
FIG. 75.1
FIG. 75.5
FIG. 75.2
FIG. 75.6
FIG. 75.3
FIG. 75.7
FIG. 75.4
FIG. 75.8
7/12/2012 3:15:03 PM
SECTION
Surgery on the Lacrimal

Sac and Duct
O
bstruction at the level of the lacrimal sac is not common

but may be associated with tumors such as transitional
cell, squamous cell, and undifferentiated carcinomas. In early
stages, these tumors may present with epiphora attributable
to narrowing of the sac lumen. Eventually, however, these
tumors may fill the entire sac and duct and extend beyond
the lacrimal system into adjacent structures. Management
generally requires surgical excision with or without adjunctive radiotherapy or chemotherapy. Sac blockage may also be
seen with inflammatory lesions such as Wegeners granulomatosis, inflammatory pseudotumor, and sarcoidosis or as a
sequel to severe dacryocystitis. These conditions are usually
treated medically. Dacryoliths frequently form within the sac
as a result of chronic, often asymptomatic dacryocystitis and
may result in epiphora, even when the drainage system is otherwise patent.
In adults, nasolacrimal system obstruction is more frequently seen at the level of the mid or lower duct. This
usually results from chronic, low-grade inflammation with
ultimate fibrosis of the duct walls. Early in the inflammatory process, when symptoms are intermittent, steroids
delivered systematically or placed directly into the sac as a
gel may relieve epiphora temporarily. Simple probing with
placement of silicone stents may also temporarily improve
drainage but is typically unsuccessful as a long-term solution. Once occlusive fibrosis has supervened, however, correction is only achieved with reconstructive surgery. The
dacryocystorhinostomy (DCR) establishes a drainage fistula between the lacrimal sac and the middle nasal meatus,
thus bypassing the obstructed lower duct. Routine placement of stents as part of this operation is not essential but,
in our experience, increases the success rate, which can be
as high as 85% to 90%. The surgeon must be alert to the
association of eyelid laxity and other malpositions, punctal
stenosis, or canalicular obstructions, in addition to lower
duct blockage. Failure to recognize and correct these other
conditions will lead to poor postoperative results.
Nasolacrimal duct obstruction may also follow facial
trauma or paranasal sinus surgery. In some cases, placement
of stents may be useful, but usually a bypass procedure will
be necessary.
Congenital nasolacrimal duct obstruction is a common problem seen in 2% to 4% of newborn infants. In rare
instances, anatomic abnormalities of the bony lacrimal
canal may be responsible. However, in most cases, obstruction is caused by failure of the nasal mucosa to perforate
distally at Hasners membrane, where the lacrimal duct
enters the vault of the inferior meatus. In 80% to 90% of such

cases, the membrane opens spontaneously or with gentle
massage within 6 to 8 months of birth. For those that fail to
open, careful nasolacrimal duct probing results in cure in
90% to 95% of affected children. This procedure should be
performed between 8 and 12 months of age because probings after 18 months of age are associated with decreased
success rates. When the first probing fails, a second probing with silicone intubation is indicated and is successful in
most cases. Where the inferior meatus is excessively narrow, infracturing of the inferior turbinate away from the
nasolacrimal osteum may improve the chances of success.
In very rare instances of multiple failed probings, a DCR
may be necessary, especially in children over 2 to 3 years
of age. In many cases, such failures result from duct stenosis caused by iatrogenic traumatic injury from improper
probing technique.
Dutton JJ. Orbital complications of paranasal sinus surgery. Ophthal Plast
Jones LT, Wobig JL. Surgery of the Eyelids and Lacrimal System. Birmingham, England: Aesculapius; 1976.
Katowitz JA, Walsh MG. Timing of initial probing and irrigation in
congenital nasolacrimal duct obstruction. Ophthalmology. 1987;94:
698705.
Linberg JV, McCormick SA. Primary acquired nasolacrimal duct obstruction: a clinicopathologic report and biopsy technique. Ophthalmology.
1986;93:10551063.
Mandeville JT, Woog JJ. Obstruction of the lacrimal drainage system.
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Perry LJ, Jakobiec FA, Zakka FR. Bacterial and mucopeptide concretions
of the lacrimal drainage system: an analysis of 30 cases. OphthalPlast
Takahashi Y, Kakizaki H, Chan WO, Selva D. Management of congenital
nasolacrimal duct obstruction. Acta Ophthalmol. 2010;88:506513.
Watkins LM, Janfaza P, Rubin PA. The evolution of endonasal dacryocystorhinostomy. Surv Ophthalmol. 2003;48:7384.
Wesley RE. Inferior turbinate fracture in the treatment of congenital nasolacrimal duct obstructions and congenital nasolacrimal duct anomaly.
Ophthalmic Surg. 1985;16:368.
Nasolacrimal System Probing

Duane TD. Clinical Ophthalmology. Vol 4. Hagerstown, MD: Harper &
Row; 1980.
Older JJ. Congenital lacrimal disorders and management. In: Linberg JV,
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Schaefer AJ, Cambell AB, Flanagan JC. Congenital lacrimal disorders.
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Plastic and Reconstructive Surgery. St. Louis, MO: Mosby-Year Book;
1987.
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nasolacrimal duct obstruction. Acta Ophthalmol. 2010;88:506513.
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SECTION C Surgery on the Lacrimal Sac and Duct 231

Nasolacrimal System Probing with Silicone Intubation Stents
al-Hussain H, Nasr AM. Silastic intubation in congenital nasolacrimal
duct obstruction: a study of 129 eyes. Ophthal Plast Reconstr Surg.
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Anderson RL, Edwards JJ. Indications, complications and results with silicone stents. Ophthalmology. 1979;86:14741487.
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Cha DS, Lee H, Park MS, et al. Clinical outcomes of initial and repeated
nasolacrimal duct office-based probing for congenital nasolacrimal
duct obstruction. Korean J Ophthalmol. 2010;24:261266.
Crawford JS. Intubation of obstruction in the lacrimal system. Ophthal
Dortzbach RK, France TD, Kushner BJ, et al. Silicone intubation for
obstruction of the nasolacrimal duct in children. Am J Ophthalmol.
1982;94:585590.
Durso F, Hand SI, Ellis FD, Helveston EM. Silicone intubation in children with nasolacrimal obstruction. Pediatr Ophthalmol Strabismus.
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Kraft SP, Crawford JS. Silicone tube intubation in disorders of the lacrimal
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Lauring L. Silicone intubation of the lacrimal system: pitfalls, problems,
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Balloon Dacryoplasty
Couch SM, White WL. Endoscopically assisted balloon dacryoplasty
treatment of incomplete nasolacrimal duct obstruction. Ophthalmology. 2004;111:585589.
Goldstein SM, Goldstein JB, Katowitz JA. Comparison of monocanalicular stenting and balloon dacryoplasty in secondary treatment of
congenital nasolacrimal duct obstruction after failed primary probing.
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Perry JD. Balloon dacryoplasty. Ophthalmology. 2004;111:17961797.
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Dacryocystorhinostomy
Anijeet D, Dolan L, Macewen CJ. Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction. Cochrane Database
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Hurwitz JJ, Rutherford S. Computerized survey of lacrimal surgery
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Jordan DR, Anderson RL. Prevention of prolapsed silicone stents in dacryocystorhinostomy surgery. Arch Ophthalmol. 1987;105:455.
Kaynak-Hekimhan P, Yilmaz OF. Transconjunctival dacryocystorhinostomy: scarless surgery without endoscope and laser assistance.
Leong SC, Macewen CJ, White PS. A systematic review of outcomes after
dacryocystorhinostomy in adults. Am J Rhinol Allergy. 2010;24:8190.
McPherson SD Jr, Egleston D. Dacryocystorhinostomy: a review of 106

operations. Am J Ophthalmol. 1959;47:328331.
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Weil BA, eds. The Lacrimal System. Norwalk, CT: Appleton-CenturyCrofts; 1983.
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Canaliculodacryocystorhinostomy
Doucet TW, Hurwitz JJ. Canaliculodacryocystorhinostomy in the treatment of canalicular obstruction. Arch Ophthalmol. 1982;100:306309.
Doucet TW, Hurwitz JJ. Canaliculodacryocystorhinostomy in the
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Conjunctivodacryocystorhinostomy
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Lampling K, Levine MR. Jones tubes; how good are they? Arch Ophthalmol. 1983;101:260261.
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Schwarcz RM, Lee S, Goldberg RA, Simon GJ. Modified conjunctivodacryocystorhinostomy for upper lacrimal system obstruction. Arch
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7/16/2012 9:25:55 AM
76
Nasolacrimal System Probing, with

Infracturing oftheInferior Turbinate
INDICATIONS: Congenital nasolacrimal duct obstruction unresponsive to medical therapy; secondary procedure after
failed primary probing; some cases of congenital amniocele.
FIG. 76.1. Gently dilate one punctum on the obstructed side

with a punctal dilator. Using a lacrimal canula, irrigate the
lacrimal drainage system through the dilated punctum with
1mL of uorescein-stained saline solution. Attempt to recover
the irrigant in the nose with a small suction catheter. If uid
is recovered, the system is not completely obstructed or was
opened with the increased hydrostatic pressure of irrigation.
FIG. 76.2. If no dye is recovered in the nose on irrigation,
bend one end of a number 0 Bowman lacrimal probe into
a gentle curve, approximating a 15-degree angle. Mark the
probe at 12 and 20 mm from the tip as reference points. Place
the probe tip vertically into the punctum for a distance of
2mm. Pull the lid laterally to atten any kinks in the canaliculus.
Turn the probe horizontally and advance it nasally for a distance
of 10 to 12 mm, until it meets resistance at the lacrimal
bone.
POSTOPERATIVE CARE: Apply an antibiotic and steroid

combination solution to the eye three times daily for 7
days.
Nasal bleedingBleeding may result from improper passage of the probe with creation of a false passage through
the duct or nasal mucosa. Bleeding may also follow
infracturing of the nasal turbinate, but this is unusual.
In the latter case, packing of the nose with Gelfoam is
usually sufficient.
Failure to pass the probe into the noseThis may result
from displacement of nasal mucosa in front of the probe
FIG. 76.3. Withdraw the probe 1 mm to avoid injury to the

medial wall of the lacrimal sac and turn the probe through
90 to 100 degrees so the tip is directed downward. Advance
the probe downward and slightly backward in the membranous nasolacrimal duct to the 20-mm mark. When resistance
is encountered, rm pressure will produce a sudden pop
through the nasal mucosal membrane in 85% of congenital
cases. If more than moderate pressure is required, do not force
the probe further.
FIG. 76.4. If the inferior nasal meatus is excessively narrow,
before probing, pack a cottonoid pledget or strip of gauze
soaked with 0.5% phenylephrine over the anterior one-half
of the inferior turbinate. After 10 minutes, clamp a straight
hemostat across the base of the turbinate along its anterior
one-half. Rotate the clamp 90 degrees medially toward the
midline to infracture the turbinate.
tip without perforation. The sharp end of a Freer elevator can be passed beneath the turbinate and scraped
along the probe to perforate the mucosa. In rare cases,
the bony nasolacrimal canal may not open into the nose,
and the probe will not advance to the 20-mm mark. In
this case, a DCR is necessary to relieve epiphora.
Recurrent epiphoraThis usually results from unsuccessful probing. If the tip of the probe or a patent nasolacrimal duct was confirmed at surgery, closure of the
mucosal perforation is assumed. Reprobing with silicone intubation stents is indicated.
232
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CHAPTER 76 Nasolacrimal System Probing, with Infracturing oftheInferior Turbinate 233
FIG. 76.1
FIG. 76.3
FIG. 76.2
FIG. 76.4
7/16/2012 9:25:55 AM
77
Nasolacrimal System Probing with

Silicone Intubation Stents
INDICATIONS: One or more failed simple probings for congenital nasolacrimal duct obstruction; acquired canalicular
stenosis.
FIG. 77.1. Irrigate and probe the system, as in Fig. 76.1

through 76.4, pp. 284-285. If necessary, dilate the puncta with
a punctal dilator. Pull the lid laterally to straighten the canaliculus and pass the wire introducer of a Crawford or similar
stent into the inferior punctum. Advance the introducer to
the lacrimal bone and withdraw it 1 mm to avoid injury to the
medial sac wall. Rotate the introducer 90 degrees downward
and advance it about 20 mm through the nasolacrimal duct
until it comes to a hard stop at the oor of the nose.
introducer to lock it in position. Gently withdraw the hook out

of the nostril, and simultaneously advance the wire probe from
above, keeping tension on both to prevent disengagement.
FIG. 77.2. Place a grooved director 20 to 30 mm into the

inferior nasal meatus. Direct the tip laterally and upward to
contact the vault of the meatus. Manipulate the introducer and
grooved director until metal-on-metal contact is felt and the
introducer is seated in the central groove of the director. Push the
introducer along the grooved director to the nostril. Alternatively,
pass a Crawford hook into the inferior meatus. Engage the
wire shaft just above the olive tip and carefully pull up on the
FIG. 77.4. Prepare a 1-mm-thick silastic button, 5 mm

in diameter. Make two central holes in the button with an
18-gauge needle. Pass the intubation probes through the central
holes, and cut the wire introducers from the silicone tubing. Tie
the silicone ends together with multiple square knots over the
button. Pull the tubing tight enough so the knot retracts into
the nose 5 to 6 mm when released. There should be no tension
at the puncta. Cut the tubing ends 4 mm from the knot.

days. After 3 to 6 months, remove the silicone tubing by
cutting the loop at the medial canthus and pulling the tubing out the nose with a bayonet forceps.
canthus. This may be corrected by pulling the knot downward in the nose and suturing it to the nasal wall with a
4-0 Mersilene stitch.
Dislocation of the tubing into the palpebral fissure
The use of a silastic button will prevent such dislocation. When a button is not used, a 4-0 silk or Mersilene
suture can be used to secure the tubing to the lateral
nasal wall. If the suture comes loose, the tubing may be
dislocated toward the cornea, especially in children. If
visible in the nose, it can be pulled downward with a
bayonet forceps. If the knot is pulled up into the duct, it
can sometimes be pushed into the inferior meatus with
a Bowman probe passed into the system from above. If
not, it can be removed by pulling the stent out through
the superior canaliculus.
Punctal erosion and canalicular slittingThis results
from tying the silicone tubing too tightly. Care must be
taken to secure the knot without tension in the nose. A
small amount of slitting up to 2 to 3 mm will be tolerated without functional compromise. If more than this
is noted, the stent may have to be removed early.
Corneal abrasion or discomfortIf the tubing is tied too
loosely, a large loop of tubing may be present at the medial
FIG. 77.3. Dilate the upper punctum and pass the opposite
wire introducer of the silicone stent through the superior canaliculus and down to the nose in similar fashion.
Retrieve the introducer with the grooved director or Crawford
hook and pull it out through the nostril.
234
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CHAPTER 77 Nasolacrimal System Probing with Silicone Intubation Stents 235
FIG. 77.1
FIG. 77.3
FIG. 77.2
FIG. 77.4
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78
Nasolacrimal System Balloon

Dacryoplasty
INDICATIONS: Partial nasolacrimal duct obstruction with fibrotic narrowing of the lacrimal sac/duct.
FIG. 78.1. Prepare the Lacricath pump and catheter

(Atrion Medical Products, Birmingham, AL) as directed in
the package instructions. Pass the deated balloon catheter
horizontally through the inferior canaliculus to the lacrimal sac
and then vertically into the nasolacrimal duct.
FIG. 78.2. Advance the catheter down the duct until the
highest black mark on the catheter is at the punctum. This
will position the balloon in the duct and slightly through the
opening of Hasner. Pump the water pressure to 8 atmospheres
on the dial, and maintain this pressure for 90 seconds. Deate
the balloon and then reinate for 60 seconds.
FIG. 78.3. Deate the balloon and withdraw the catheter
10mm so that the second to highest mark is aligned with
the punctum. This will reposition the balloon in the upper

days. After 3 months, remove the silicone tubing by cutting the loop at the medial canthus and pulling the tubing
out the nose with a bayonet forceps.
Punctal erosion and canalicular slittingThis results
from tying the silicone tubing too tightly. Care must be
taken to secure the knot without tension in the nose. A
small amount of slitting up to 2 to 3 mm will be tolerated without functional compromise. If more than this
is noted, the stent may have to be removed early.
Corneal abrasion or discomfortIf the tubing is tied
too loosely, a large loop may be present at the medial
duct and sac. Reinate the balloon to 8 atmospheres for 90

seconds, deate, and reinate for 60 seconds.
FIG. 78.4. Placement of silicone stents is optional. If these
are placed, pass the introducers through the upper and
lower canaliculi, down the nasolacrimal duct, and into the
inferior nasal meatus as described under Nasolacrimal System
Probing with Silicone Intubation Stents, Fig. 77.1 through 77.4,
pp.286-287.
FIG. 78.5. If a silicone stent is used, pass the wire introducers through a silicone button and cut the introducers from
the tubing. Tie the silicone tube ends together making sure to
adjust the position of the knot so that the stent does not hang
out of the nose, nor is it so tight as to cheese wire the puncta.
canthus. This is corrected by pulling the knot downward in the nose and suturing it to the nasal wall with a
4-0 Mersilene stitch.
Dislocation of the tubing into the palpebral fissure
The use of a silicone button will prevent such dislocation. When a button is not used, a 4-0 silk or Mersilene
suture can be used to secure the tubing to the lateral
nasal wall. If the suture comes loose, the tubing may be
dislocated toward the cornea, especially in children. If
visible in the nose, it can be pulled downward with a
bayonet forceps. If the knot is withdrawn into the duct,
it can sometimes be pushed into the inferior meatus
with a Bowman probe passed into the system from
above. If not, it can be removed through the superior
canaliculus.
236
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CHAPTER 78 Nasolacrimal System Balloon Dacryoplasty 237

FIG. 78.3
FIG. 78.1
FIG. 78.2
FIG. 78.4
FIG. 78.5
7/12/2012 3:11:33 PM
79
Dacryocystorhinostomy
INDICATIONS: Acquired nasolacrimal duct (NLD) obstruction, where the canaliculi are patent; congenital NLD
obstruction after two or more failed probings with intubation.
FIG. 79.1. Pack the middle nasal turbinate with cottonoid

strips soaked in 4% cocaine (or substitute) and 0.25%
phenylephrine. Mark an incision line 6 mm from the medial
canthal angle. Begin the line at the medial canthal ligament,
and extend it inferiorly and laterally in the tear trough for a
distance of 8 to 10 mm in children and 12 to 15 mm in adults.
FIG. 79.2. Incise the skin with a scalpel blade. Tent up the
skin edges with forceps and cut through the orbicularis muscle
with Westcott scissors.
FIG. 79.3. Bluntly separate the muscle layer to the nasal
bone with Stevens scissors. The angular vessels usually lie on
the medial side of the wound.
FIG. 79.4. With a Freer elevator, push the orbicularis muscle
off the periosteum up to the level of the canthal ligament. With a scalpel blade, make a vertical cut through the
periosteum 2 mm medial to the anterior lacrimal crest.
FIG. 79.5. Elevate the periosteum upward to expose the
nasal bone and downward over the entire anterior crest.
Slide the Freer elevator upward to the canthal ligament and
downward to the entrance of the NLD to widely expose the

lacrimal sac fossa.
FIG. 79.6. Remove the nasal packing. Place a curved
hemostat into the midportion of the lacrimal sac fossa and
gently push the tip through the lacrimal bone. If the bone is
too thick, repeat the attempt more posteriorly. Very rarely, a
burr will need to be used to thin the bone in the fossa until a
hemostat can fracture through it.
FIG. 79.7. Place the jaw of a 2-mm 45-degree Kerrison
rongeur into the puncture site and begin to enlarge the
opening. Take care to gently push the nasal mucosa in front
of the rongeur to avoid lacerating it. Complete a 10- to 15-mm
circular osteum with graded rongeurs.
FIG. 79.8. Dilate the inferior punctum with a punctal
dilator, and pass a number 1 Bowman probe into the
lacrimal sac. With a curved scalpel blade, make a superior to
inferior cut in the sac wall where the probe pouches out the
medial wall. Enlarge the opening with scissors.
238
7/12/2012 3:10:45 PM
CHAPTER 79 Dacryocystorhinostomy 239
FIG. 79.1
FIG. 79.5
FIG. 79.2
FIG. 79.6
FIG. 79.3
FIG. 79.7
FIG. 79.4
FIG. 79.8
7/12/2012 3:10:46 PM
240 SECTION C Surgery on the Lacrimal Sac and Duct

FIG. 79.9. Explore the sac for stones and other abnormalities. If there is any bleeding from the mucosa, apply packing with epinephrine to both sides for a few minutes.
Make a vertical cut in the nasal mucosa with a ne needle monopolar cautery, cutting
against the cotton applicator to avoid injury to the nasal septum. The cut should be
parallel to that in the lacrimal sac.
FIG. 79.10. In the nasal mucosa, make a short, anteroposterior incision on either
side of the rst cut to form a large anterior and smaller posterior H-ap.
FIG. 79.11. Suture the posterior lacrimal sac ap to the posterior nasal mucosal
ap with one or two interrupted 4-0 Vicryl sutures. Use of a small, half-curved
needle, such as the P-2 or S-2, facilitates placement in the small surgical opening.
FIG. 79.12. Pass the wire probe of a Crawford or similar silicone intubation
tube through the superior canaliculus until the olive tip emerges at the surgical
osteum. Retrieve it with a grooved director or a Crawford hook. In similar fashion,
pass the other end of the tubing through the inferior canaliculus.
FIG. 79.13. Suture the anterior sac ap to the anterior nasal mucosal ap with
two interrupted 4-0 Vicryl stitches to complete a mucosal bridge over the silicone tubing.
FIG. 79.14. Close the orbicularis muscle with several
6-0 chromic sutures. If desired, pass the stitch through the nasal mucosal ap to
keep it from collapsing into the osteum. Close the skin with interrupted 6-0 fastabsorbing plain gut sutures.
FIG. 79.15. Cut the wire probes from the silicone tubing. Place a muscle hook
beneath the silicone loop at the medial canthal angle, and tie the ends at the nostril
with several square knots. Adjust the tension so the knot will retract 6 to 8 mm into
the nasal atrium when released.
FIG. 79.16. Pass a 4-0 Mersilene suture on a small, half-curved needle through
the tubing loop behind the knot andsuture the tubing to the lateral nasal wall to
prevent dislocation. Cut the tubing ends 4 mm from the knot. Make certain there is
no tension at the puncta.

the suture line three to four times daily for 7 days. Instill a
steroidantibiotic combination solution into the eye three
times daily for 7 days. The patient is instructed not to blow
his or her nose for 5 days to avoid bleeding and may use
phenylephrine or oxymetazoline nasal spray twice daily
for any nasal congestion. Remove the silicone stent after
3 to 6 months.
Nasal bleedingAny bleeding during the surgery can
be controlled with pressure or packing for a few minutes, or with a cellulose hemostatic agent. Postoperative
bleeding is unusual and is managed with nasal compression and head elevation for 20 minutes. Rarely is nasal
packing needed.
Persistent epiphoraThis may result from the presence

of the silicone tubes in a stenotic canalicular system. In
such cases, the tubing is left in position longer to help
dilate the canaliculus. The epiphora usually resolves
after the removal of the tube.
Wound infectionThis is very rare but may be seen in
patients who are operated on during acute dacryocystitis. Warm compresses and topical and systemic antibiotics are indicated following appropriate cultures.
Recurrent obstructionOccasionally, the newly created
fistula becomes occluded after removal of the silicone
tubing. This is managed by removing any occluding
membrane with a radiosurgery cutting tip or with a
small muscle hook pushed through it. Silicone stents
may have to be replaced.
7/12/2012 3:10:54 PM
CHAPTER 79 Dacryocystorhinostomy 241
FIG. 79.9
FIG. 79.13
FIG. 79.10
FIG. 79.14
FIG. 79.11
FIG. 79.15
FIG. 79.12
FIG. 79.16
7/12/2012 3:10:54 PM
80
Canaliculodacryocystorhinostomy
INDICATIONS: Focal common canalicular obstruction located at least 8 mm proximal to the punctum, combined with
nasolacrimal duct obstruction.
FIG. 80.1. Proceed as for a standard dacryocystorhinostomy, Fig. 79.1 through 79.5 (pp. 290 to 291), to expose the
lacrimal sac fossa, except carry the incision 5 to 6 mm above
the medial canthal ligament. Transect the anterior crus of the
canthal ligament near its periosteal attachment andreect it
laterally.
FIG. 80.2. Pass the introducer of a silicone intubation
stent into the superior and inferior canaliculi up to the
obstructed segment of the common canaliculus. Using the
sharp end of a Freer elevator and the operating microscope
or loupes, dissect the canthal ligament from the common
canaliculus immediately beneath it.
FIG. 80.3. Cut through the canaliculus at the tip of the
introducers and excise the obstructed portion to the
lacrimal sac.
FIG. 80.4. Pass the stents through the canaliculus and out
the cut end of the common canaliculus.
aps as in Fig. 79.6 through 79.11 (pp. 290 to 293) for

dacryocystorhinostomy.
FIG. 80.6. Identify the opening in the lateral side of
the lacrimal sac at the site where the original common
canaliculus was excised. If necessary, enlarge the opening
to about 3 mm. Pass the silicone stent probes through this
opening, through the sac, and into the surgical osteum. Use a
grooved director orhook to retrieve the probes in the nose.
FIG. 80.7. Suture the cut edges of the canaliculi to the
lacrimal sac with two 7-0 Vicryl stitches. Approximate
the anterior aps of the sac and nasal mucosa with two
4-0Vicryl sutures. Repair the medial canthal ligament with a
5-0Mersilene mattress suture.
FIG. 80.8. Complete the orbicularis muscle and skin
closure, and secure the silicone stent in the nose as for
Dacryocystorhinostomy, Fig. 79.9 through 79.16
(pp. 292 to 293).
FIG. 80.5. Complete the DCR osteum, opening the sac and
nasal mucosa, and anastomose the posterior mucosal
POSTOPERATIVE CARE AND POTENTIAL COMPLICATIONS: See care and complications as for Dacryocystorhinostomy (p. 294).
242
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CHAPTER 80 Canaliculodacryocystorhinostomy 243
FIG. 80.1
FIG. 80.5
FIG. 80.2
FIG. 80.6
FIG. 80.3
FIG. 80.7
FIG. 80.4
FIG. 80.8
7/12/2012 3:08:48 PM
81
Conjunctivodacryocystorhinostomy
INDICATIONS: Complete obstruction of the individual and common canaliculi with or without nasolacrimal duct
obstruction.
FIG. 81.1. Proceed as for a standard dacryocystorhinostomy, Fig. 79.1 through 79.11 (pp. 290 to 293), to closing of
the posterior mucosal aps.
FIG. 81.2. If the anterior tip of the middle turbinate lies
at the level of the surgical osteum, resect it. Inject local
anesthetic with epinephrine into the anterior portion of the
turbinate. Apply a straight hemostat across its base and crush
the tissue. Apply a curved hemostat vertically at the anterior
third of the turbinate. Cut at the crush marks with nasal
scissors. Cauterize the cut surfaces.
FIG. 81.3. Resect the anterior half of the caruncle with
Westcott scissors.
FIG. 81.5. Advance the Teon catheter to the nasal septum

and then withdraw it 3 to 4 mm. With a marking pen, make
a line on the Teon catheter where it emerges at the canthal
angle. Partially withdraw the catheter to see the tip in the
osteum, and measure the distance from the tip to the ink mark.
Choose a Pyrex Jones tube equal to the marked distance on the
catheter.
FIG. 81.6. Cut the hub from the palpebral side of the Teon
catheter and push the Pyrex tube into the catheter end.
Pass a hemostat into the nose, grasp the tip of the catheter, and
pull it out while seating the Pyrex tube into position. Hold the
tube at its collar and pull the catheter free. The tip of the tube
should rest at least 2 to 3 mm from the nasal septum.
FIG. 81.4. Position the tip of a 14-gauge intravenous,

Teon-sheathed needle in the medial canthus 2 mm behind
the skinmucosal junction and angle it 35 degrees medially
and downward. Push the needle through the medial canthal
tissues into the lacrimal sac and through the surgical osteum.
Keep the needle in front of the sutured posterior mucosal
aps. Withdraw the needle while holding the Teon catheter
in place.
FIG. 81.7. Anchor the Pyrex tube by passing a 6-0 silk suture
around the collar several times, and then through the
caruncle and out the skin of the adjacent eyelid. Tie the
suture over a bolster.
POSTOPERATIVE CARE: Apply antibiotic ointment to the

suture line three to four times daily for 7 days. The patient
is asked to irrigate the tube daily by instilling several drops
of saline solution into the medial cul-de-sac and inhaling
deeply with the opposite nostril occluded. If it becomes
occluded, the tube can be flushed with saline solution
through a lacrimal canula and, if necessary, cleaned by
passing a number 2 or 3 Bowman probe through it.
too loose. It should be replaced with a shorter tube or a

tube with a modified neck collar, such as the PuttermanGladstone tube (Gunther-Weiss, Inc., Portland, OR).
Medial migration of the tubeLoss of the tube into the
medial canthal tissues occurs from laxity of the tissues and poor support of the tube. The tube should be
replaced by one with a larger collar, or the neck of the
soft tissue opening can be excised and closed tightly
around the tube with several 6-0 Vicryl sutures.
Granuloma formationConjunctival granulomas around
the Pyrex tube can occur and may sometimes be so
extensive as to completely obstruct drainage. These
should be excised and treated with topical steroids for
several weeks.
Closure of the soft tissue openingA lost tube should
be replaced within 1 week if possible. If the tube cannot be replaced, a new opening is created with a Teflonsheathed intravenous needle as before, without the need
for repeat dacryocystorhinostomy.
Failure of the tube to drainThis may result from placement of a tube that is too long and in contact with the
nasal septum. If significant septal deviation is present,
it should be corrected before lacrimal drainage surgery.
The middle turbinate occasionally extends forward, and
if not resected, there may be insufficient space for the
tube.
Lateral migration of the tubeThis may be seen with a
tube that is in contact with the septum or one that is
FIG. 81.8. Complete the DCR by suturing the anterior

mucosal aps and closing the skin as for standard
dacryocystorhinostomy, Fig.79.13 (pp. 292 to 293).
244
7/12/2012 3:19:19 PM
CHAPTER 81 Conjunctivodacryocystorhinostomy 245
FIG. 81.1
FIG. 81.5
FIG. 81.2
FIG. 81.6
FIG. 81.3
FIG. 81.7
FIG. 81.4
FIG. 81.8
7/12/2012 3:19:19 PM
7/12/2012 3:19:25 PM
III
Orbital
Surgery
S WITH ANY SURGERY, THE INITIAL STEP IN PREPARATION FOR ORBITAL SURGERY
is complete evaluation of the patient. A careful history and clinical examination

and the use of modern imaging techniques can narrow the differential diagnosis
to one or just a few possibilities. In most cases, this will make surgical exploration less
necessary than it was in the past. A detailed history of the orbital problem, including
its initial time of appearance, rate of change, and associated ndings such as proptosis,
diplopia, pain, or loss of vision, may help direct the physician to a more limited group of
diagnostic possibilities. Any past history of head trauma, sinus disease, or known previous
paraorbital tumor should be noted. A history of distant malignancy, endocrine disorder,
or other systemic disease may have a signicant bearing on current orbital complaints.
A complete ophthalmic examination must be recorded. Measurement of visual acuity with a current refraction is mandatory. Specic tests for optic nerve function, such
as pupillary reactions and color vision, are indicated to evaluate subtle visual impairment. A visual eld test is obtained on all patients with suspected orbital disease. Any
deviation from normal visual function must be explained. The presence of periorbital
edema or erythema, chemosis, ptosis, and decreased corneal or facial sensation is noted.
The degree of proptosis, if any, and the direction of globe displacement are important in localizing orbital pathologic processes. Ocular motility is carefully measured
and, if abnormal, a forced duction test is performed to distinguish between paralytic
and restrictive etiologies. Sequential changes in eyelid position, motility, or proptosis
recorded over several visits may give essential information on subtle progression of the
disease process. It is often helpful to examine old photographs or a drivers license to
help establish a time course for the orbital process.
The anterior orbit is palpated beneath the bony rim for any abnormal masses or
tenderness. The eyelids are everted and the deep fornices are examined. An intranasal exam is also performed to rule out any concurrent or contiguous nasal or sinus
pathology.
Modern orbital imaging techniques provide critical information on the specic
location of lesions and their relationship to adjacent structures. Echography allows
determination not only of topographic contours and surface characteristics but also
of consistency, gross internal structure, and vascularity, all of which may be difficult
to detect with any other techniques. However, echography is limited to the anterior
orbit due to lack of penetration of sound waves. High-resolution orbital computerized
tomography (CT) yields images based on electron density differences and is especially
useful for evaluation of bone and its relationship to any soft tissue anomalies. Orbital
CT should be obtained in axial and coronal planes, with contrast enhancement and
bone window settings. Magnetic resonance imaging with fat suppression and other
specialized techniques produces high-resolution, multiplanar soft tissue images based
on electromagnetic interactions between atomic nuclei in a magnetic eld. Weighting
of several different tissue parameters provides a variety of contrast manipulations that
8/3/2012 6:48:50 PM
can distinguish tissues based on subtle biochemical differences not separable on CT.
Finally, the plain orbital x-ray series is an inexpensive, easily obtained study that can
sometimes provide useful information at a low cost.
If it is determined that surgical intervention is necessary, such preliminary studies
will indicate the most appropriate approaches and prepare the surgeon for potential
difficulties. These imaging studies allow advanced planning for necessary consultations
and the assembly of an interdisciplinary surgical team when required.
Orbital surgery is indicated for the evaluation or treatment of orbital disease, for restoration of anatomic relationships following trauma, or for cosmetic improvement of
congenital or acquired deformity. Biopsy of mass lesions is an important technique that
may yield inadequate results unless extreme care is observed. Although some authors
advocate ne needle aspiration biopsy of orbital mass lesions under CT or echographic
guidance, cytologic evaluation on such specimens requires experience and may be
inaccurate. In addition, the procedure carries the risk of orbital hemorrhage, which may
compromise vision and might require immediate surgical intervention. In some cases,
as with lymphoproliferative diseases, larger specimens may be necessary for complete
histologic and immunologic evaluation. For most orbital lesions, an open biopsy is preferred if the lesion is accessible. Frozen section conrmation that the lesion has been
adequately sampled is recommended because some diffuse masses may not be distinguished readily from surrounding normal orbital tissues or associated inammation on
visual examination alone during surgery.
Removal of orbital masses may be indicated when they are well dened and result
in either functional compromise or cosmetic deformity. Benign tumors, such as hemangiomas, schwannomas, dermoid cysts, and mixed lacrimal gland tumors, and some
malignant lesions, can usually be dissected from adjacent structures. More inltrative
lesions, such as lymphangiomas or plexiform neurobromas, are usually impossible to
extirpate completely. When not amenable to medical therapy and when necessary to
restore function, these lesions may be carefully debulked. Some residual tumor may
have to be left behind to avoid injury to important orbital structures; therefore, recurrences are to be expected.
Orbital abscesses, either following trauma or surgery or associated with sinusitis,
require direct drainage and antibiotic therapy. When loculated within the orbit, direct
drainage to the surface is appropriate. In the presence of sinus infection, orbital and
sinus drainage through a combined orbital and transnasal approach in conjunction
with an otolaryngologist may be indicated. Because the ethmoid sinus is most frequently involved, an anterior medial orbitotomy usually gives adequate visualization.
Traumatic injury to the orbit frequently involves bony fracture or hemorrhage.
Orbital rim fractures are easily accessible through anterior approaches and may be
repaired with miniplate xation of the displaced fragments. Orbital wall fractures,
which may be associated with soft tissue injury or incarceration, must be carefully
explored and realigned or replaced when necessary to restore function or orbital volume. The exact surgical approach depends on the nature and location of the fractures.
When more complex craniofacial fractures are involved, cooperation of an otolaryngologist, plastic surgeon, or neurosurgeon may be necessary.
Diffuse orbital hemorrhage following trauma may produce massive proptosis
and occasionally increased intraocular pressure or optic nerve compression. Orbital
decompression with a lateral canthotomy is usually sufficient to manage the potential
visual loss. If this fails, drainage of loculated pockets or bony decompression may be
248
8/3/2012 6:48:50 PM
necessary. Progressive loss of vision associated with proptosis and downward displacement of the globe suggest a subperiosteal hematoma. The diagnosis is conrmed with
orbital echography or CT, and immediate drainage via an anteromedial orbitotomy
usually reverses the visual loss.
Massive proptosis associated with Graves orbitopathy may require orbital decompression for treatment of threatened visual function or for cosmetic disgurement. It is
achieved by removal of the inferior, medial, and/or lateral orbital walls. In some Graves
patients, the extraocular muscles are only minimally enlarged, but fat volume is markedly increased. Here, a fat only decompression may be sufficient. Bony decompression
may also be indicated for other expanding lesions of the orbit that cannot be surgically
extirpated.
Removal of the globe and part or all of normal orbital contents may be necessary
for management of neoplastic processes or for control of pain in a blind or phthisical
eye. It is also useful for cosmetic improvement of congenital or traumatic ocular or
orbital deformities. If only the globe is involved, enucleation or evisceration is indicated.
Neoplasms that extend into the orbit from the globe or eyelids may require more radical exenteration of orbital soft tissues for cure.
Byrne SF, Green RL. Ultrasound of the Eye and Orbit. St. Louis, MO: Mosby; 2002,505p.
Doxanas MT, Anderson RL. Clinical Orbital Anatomy. Baltimore, MD: Williams & Wilkins; 1984, 232p.
Conneely MF, Hacein-Bey L, Jay WM. Magnetic resonance imaging of the orbit. Semin Ophthalmol.
2008;23:179189.
DiBernardo CW, Greenberg EF. Ophthalmic Ultrasound. A Diagnostic Atlas. 2nd ed. New York:
Thieme; 2006,154p.
Dutton JJ, Proia AD, Byrne SF. Diagnostic Atlas of Orbital Diseases. London, UK: WB Saunders;
2000,179p.
Dutton JJ. Radiographic evaluation of the orbit. In: Doxanas MT, Anderson RL, eds. Clinical Orbital
Anatomy. Baltimore, MD: Williams & Wilkins; 1984, pp. 35-56.
Dutton JJ. Radiology of the Orbit and Visual Pathways. London, UK: Saunders Elsevier; 2010, 408p.
Goh PS, Gi MT, Charlton A, et al. Review of orbital imaging. Eur J Radiol. 2008;66:387395.
Kennerdell JS, Dekker A, Johnson BL, Dubois PJ. Fine-needle aspiration biopsy: its use in orbital
tumors. Arch Ophthalmol. 1979;97:13151317.
Krohel GB, Tobin DR, Chavis R. Inaccuracy of fine needle aspiration biopsy. Ophthalmology.
1985;92:666670.
Lemke AJ, Kazi I, Felix R. Magnetic resonance imaging of orbital tumors. Eur Radiol. 2006;16:2207
2219.
Nerad JA. Techniques in Ophthalmic Plastic Surgery. A Personal Tutorial. London: Elsevier, Saunders;
2010:301486.
Rootman J. Diseases of the Orbit. A Multidisciplinary Approach. Philadelphia, PA: JB Lippincott;
1988:628.
Rootman J, Stewart B, Goldberg RA. Orbital Surgery. A Conceptual Approach. Philadelphia, PA:
Lippincott-Raven; 1995:378.
Shields JA, Shields CL. Eyelid, Conjunctival, and Orbital Tumors. Philadelphia, PA: Lippincott, Williams & Williams; 2008:782805.
Spoor TC, Kennerdell JS, Dekker A, et al. Orbital fine needle aspiration biopsy with B-scan guidance.
Am J Ophthalmol. 1980;89:274277.
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SECTION
Surgical Anatomy of
the Orbit
251
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82
T
Surgical Anatomy of the Orbit
he human orbit is a small, roughly pear-shaped cavity.

Within it is a complex array of tightly packed, juxtaposed structures subserving visual function. Filling the spaces
between the muscles, nerves, and vascular elements are cushions of orbital fat and connective tissue fascia, within which
even experienced orbital surgeons rarely see more than occasional glimpses of anatomic detail. Yet the surgeon must have
an intimate knowledge of structural and functional relationships within the orbit, if surgery is to be performed successfully and without complication.
The bony orbit is composed of seven bones that are simplified from a complex of dermal and endochondral elements of earlier vertebrates. The orbital roof is composed
of the orbital plate of the frontal bone with a small contribution from the lesser wing of the sphenoid at the apex. The
roof is a thin lamina separating the orbit anteriorly from
the frontal sinus and posteriorly from the anterior cranial
fossa. The roof slopes backward and downward toward the
apex and ends at the optic foramen and the superior orbital
fissure.
The lateral wall is formed by the greater wing of the sphenoid bone posteriorly and by the zygomatic process of the
frontal bone and the orbital process of the zygomatic bone
anteriorly. It lies at a nearly 45-degree angle to the midsagittal plane. The lateral wall is bounded below by the inferior
orbital fissure and medially by the superior orbital fissure.
Behind the thick lateral orbital rim, the wall becomes quite
thin where the zygomatic bone joins the greater sphenoid
wing at a vertical suture line. During a lateral orbitotomy,
cutting the rim through to this thin plate allows easy outward fracture of the bone. The convoluted frontozygomatic
suture line runs approximately horizontal and crosses the
superotemporal rim near the lacrimal gland fossa. About
5 to 15 mm above this line, the frontal bone widens as it
passes around the front end of the anterior cranial fossa.
The surgeon must make note of this broadening contour
when planning the position of the superior bone cut in a
lateral orbitotomy. About halfway along the lateral wall,
in the sphenoid wing near the frontosphenoid suture, is a
small canal carrying an anastomotic branch between the
lacrimal and meningeal arteries. Elevation of the periorbita during lateral orbital dissection may result in brisk
bleeding from this vessel, but the bleeding is usually easily
controlled with pressure. Just behind the zygomaticosphenoid suture line, the greater wing widens as it passes
around the anterior tip of the middle cranial fossa. While
the greater wing is removed during lateral orbitotomy procedures, the appearance of cancellous bone warns of the
imminent approach of dura.
The orbital floor is composed primarily of the maxillary

bone, with the zygomatic bone forming the anterolateral
portion, and the palatine bone lying at the posterior extent
of the floor. It is bounded laterally and posteriorly by the
inferior orbital fissure. The floor ends at the posterior limit
of the maxillary sinus and therefore does not extend to the
orbital apex. The infraorbital groove begins at the inferior
orbital fissure and runs forward in the maxillary bone.
At about 15 mm from the orbital rim, this groove usually
becomes bridged over with a thin lamina of bone to form
the infraorbital canal. Within this canal runs the maxillary
division of the trigeminal nerve with the maxillary artery.
These exit just below the central orbital rim at the infraorbital foramen. Surgery on the orbital floor during blow-out
fracture repair or orbital decompression must include special attention to these structures to avoid injury. The orbital
floor is thinnest just medial to the canal, and this area is the
most common site for blow-out fractures.
The medial orbital wall is composed largely of the lamina
papyracea of the ethmoid bone. This thin plate separates
the orbit from air cells of the ethmoid sinus labyrinth. It
is a frequent site of fracture in orbital trauma and is easily
breached during transnasal ethmoid sinus surgery. The lamina papyracea offers little resistance to expanding ethmoid
sinus mucoceles and commonly transmits inflammatory
and infectious processes from sinusitis into the orbit.
Posterior to the ethmoid, the body of the sphenoid bone
completes the medial wall to the apex. This portion of the
wall is quite thick and is only rarely involved in orbital
trauma or sinus pathology. The medial wall ends at the
optic foramen, where the sphenoid forms the medial wall
of the optic canal.
Anterior to the ethmoid is the lacrimal bone, a thin plate
that contains the posterior lacrimal crest and forms the posterior one-half of the lacrimal sac fossa. In the midportion
of the fossa, the lacrimal bone joins the orbital process of
the maxillary bone. The latter is a thick bone that forms
the medial orbital rim. During lacrimal bypass surgery,
entrance into the nose can be achieved easily with a hemostat by applying gentle pressure on the lacrimal portion
of the fossa. In some individuals, the lacrimalmaxillary
suture is situated farther posterior so the maxillary bone
underlies most of the fossa. In such cases, a burr may be
necessary to remove enough bone to create a DCR osteum.
Within the frontoethmoid suture line in the superomedial orbit are two openings, the anterior and posterior ethmoidal foramina. The former lies about 20 mm from the
anterior lacrimal crest, and the latter about 32 to 35 mm
behind the anterior crest and 6 to 10 mm anterior to the
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CHAPTER 82 Surgical Anatomy of the Orbit 253

optic canal. These foramina transmit branches of the ophthalmic artery and nasociliary nerve into the ethmoid sinus
and nose. These ethmoidal vessels are frequently injured in
orbital trauma and are the major sources of subperiosteal
hematomas. During surgery on the medial orbital wall, the
position of these foramina must be kept in mind to avoid
injury and hemorrhage. In addition, these openings mark
the approximate level of the roof of the ethmoid labyrinth
and the floor of the anterior cranial fossa. The cribriform
plate may lie as much as 10 mm below this level, just medial
to the root of the middle turbinate, and therefore can be
fractured during medial wall surgery.
The orbit is lined with the periorbita (periosteum plus
layers of fascia), which is loosely adherent to the orbital
bones. It is firmly attached only at the arcus marginalis
along the orbital rim, at the lateral orbital tubercle, adjacent
to the trochlea, around the optic foramen, and along the
inferior and superior orbital fissures. Where the periorbita
joins the margin of the optic canal and the superior orbital
fissure, it is fused to dura, so trauma or surgery in these
areas may be complicated by cerebrospinal fluid leakage.
Suspended from the periorbita and forming a complex radial and circumferential web of interconnecting
slings are the connective tissue septa. These septa form
fine capsules around the intraconal and extraconal fat
lobules. They also surround the extraocular muscles, the
optic nerve, and the neurovascular elements, and suspend
these structures to the adjacent orbital walls. These fascial
slings provide support and maintain constant spatial relationships between the anatomic structures during ocular
movements. The presence of these septa is responsible
for transmission of restrictive forces from incarcerated or
hemorrhagic inferior orbital fat to extraocular muscles following trauma, even in the absence of true muscle entrapment. Encircling septa around the optic nerve may serve to
confine hemorrhage, resulting in compressive optic neuropathy following trauma.
Within the orbital space are a number of structures
whose function is to provide support, movement, and sensory innervation to the globe. The eye is an approximate
sphere that measures about 24 mm in diameter and is
situated in the anterior one-half of the orbit. Attached to
it are the six striated extraocular muscles. The four rectus
muscles arise posteriorly from the annulus of Zinn, a
fibrous band that is continuous with periorbita and dura at
the optic foramen. The annulus surrounds the optic foramen and the central one-third of the superior orbital fissure, through which neurovascular structures pass from the
middle cranial fossa into the intraconal orbital space. The
muscles run forward with only a thin layer of extraconal
fat separating them from periorbita along the orbital walls.
The superior oblique muscle arises above the annulus, just superior and medial to the optic foramen. It runs
forward along the superomedial orbital wall to the cartilagenous trochlea, through which its ligament slides,
before turning sharply laterally to insert on the superoposterior aspect of the globe. Removal of the trochlea with
periosteum during medial orbital surgery can be achieved

easily, but care must be taken to reattach it by closing the
periorbita along the orbital rim.
The inferior oblique muscle arises anteriorly from a
small depression just below and lateral to the lacrimal sac
fossa. It passes laterally and slightly backward to insert on
the inferoposterior surface of the globe near the macula.
Along its course, the sheath of the inferior oblique muscle
joins that of the inferior rectus muscle and Tenons capsule
just behind the orbital rim to form Lockwoods inferior
suspensory ligament. Slips of this structure pass laterally to
periosteum of the orbital wall and medially to join the posterior crus of the medial canthal ligament. The capsulopalpebral fascia extends anteriorly from this ligament to the
inferior tarsal plate. During surgery in the inferior orbit,
additional care must be taken while opening the orbital
septum because the inferior oblique muscle and Lockwoods ligament lie immediately behind the orbital rim.
The levator superioris palpebrae muscle originates from
the annulus of Zinn and the lesser sphenoid wing. It runs
forward along the orbital roof in close approximation to
the superior rectus muscle. Fine check ligaments interconnect the levator to the superior rectus and to periosteum
of the frontal bone. Near the orbital rim, fine suspensory
ligaments extend from the levator sheath to the superior
conjunctival fornix. In addition, a horizontal condensation
within the muscle sheath forms the prominent transverse
ligament of Whitnall. This ligament fuses to the orbital wall
near the trochlea and around the lacrimal gland. Whitnalls
ligament is an important suspensory structure for the
superior orbit and eyelid and should not be cut.
Anterior to Whitnalls ligament, the levator muscle
passes into a thin, fibrous aponeurosis that turns inferiorly and fans out into the eyelid. It inserts onto the inferior
two-thirds of the anterior tarsal face. Medially and laterally,
the aponeurosis joins the canthal ligaments via extensions
known as the horns. The levator muscle is unusually sensitive to any superior orbital disease, such as mass lesions
or inflammation. This sensitivity results in upper eyelid ptosis. The latter is, therefore, a frequent early sign of
orbital pathologic processes.
The extraocular muscles are innervated by the third,
fourth, and sixth cranial nerves. The oculomotor nerve
(N. III) arises from the oculomotor nuclear complex in
the midbrain and exits at the medial border of the cerebral peduncle. It passes forward in the lateral cavernous
sinus, where it divides into a superior and inferior division just before entering the intraconal space through the
superior orbital fissure. The superior branch innervates the
superior rectus and levator muscles. The inferior branch
sends fibers to the inferior rectus, the medial rectus, and
the inferior oblique muscles. These branches are applied to
the inner surface of the muscles, where they are cushioned
and protected by the fibrous muscle sheaths. However, the
branches may be injured during deep orbital surgery near
the apex, where they run free within the orbital fat. Running with the inferior division of the oculomotor nerve
8/3/2012 6:48:51 PM
254 SECTION A Surgical Anatomy of the Orbit

are parasympathetic fibers that arise from the EdingerWestphal subnucleus. These synapse in the ciliary ganglion
just lateral and inferior to the optic nerve, about 1.5 to 2cm
behind the globe. They progress via the short ciliary nerves
to the ciliary body and the iris sphincter. There is no redundancy to these nerves and they are easily injured during
orbital dissection, thus resulting in disturbances of pupillary function and accommodation.
The trochlear nerve (N. IV) arises in the midbrain, exits
below the inferior colliculus, and passes forward in the lateral cavernous sinus. It enters the extraconal space of the
superior orbit through the superior orbital fissure above
the annulus of Zinn. It crosses over the superior rectus and
levator muscle complex and runs along the external surface
of the superior oblique muscle before penetrating its substance in the posterior third of the orbit. In this position
against the orbital roof, the trochlear nerve is easily damaged during blunt trauma and from lateral displacement of
periorbita during deep medial wall surgery.
The abducens nerve (N. VI) arises in the pons and passes
forward in the cavernous sinus below the trochlear nerve.
It enters the orbit through the superior orbital fissure and
annulus of Zinn to enter the intraconal space. The nerve
runs laterally to supply the lateral rectus muscle.
The optic nerve is a central nervous system tract that
arises from the retinal ganglion cells. Nasal fibers decussate in the optic chiasm. Fibers in the optic tracts continue
backward and synapse in the lateral geniculate nuclei, from
which they radiate to the occipital cortex. The orbital portion of the nerve is somewhat redundant to allow for ocular
movement. It measures about 3 cm in length, takes a sinusoidal path from the globe, curving downward and then
upward to the optic canal. In close approximation to the
nerve are the ophthalmic artery near the orbital apex and
the superior ophthalmic vein in the midorbit. Both of these
vessels lie superior to the nerve in most individuals. The
central retinal artery runs along the inferolateral side of the
nerve to enter the dura at about 1 cm behind the globe.
The short and long posterior ciliary arteries lie close to the
nerve for much of its length and are highly convoluted and
redundant near the globe.
Sensory innervation to the orbit is primarily from the
ophthalmic division of the trigeminal nerve (N. V). The
maxillary division supplies portions of the inferior orbit.
The ophthalmic division divides in the cavernous sinus just
as the latter passes into the superior orbital fissure. The lacrimal nerve enters above the annulus of Zinn and proceeds
in the extraconal space just inside periorbita along the
superolateral orbit to the lacrimal gland and upper eyelid.
The frontal nerve runs forward between the levator muscle
and the superior periorbita and exits the orbit at the supraorbital notch. At about the level of the posterior globe, it
gives rise to the supratrochlear nerve, which exits the orbit
at the superomedial rim.
The nasociliary nerve, which is a branch of the ophthalmic division of the trigeminal, enters the orbit through the
superior fissure and annulus of Zinn. It crosses from lateral
to medial over the optic nerve after sending small sensory

branches that pass through the ciliary ganglion without
synapse and continue to the globe with the short ciliary
nerves. As it passes to the lateral side of the optic nerve,
the nasociliary gives off the long posterior ciliary nerves
that extend to the posterior globe. The nasociliary nerve
continues forward in the medial orbit, where it gives rise
to the posterior and anterior ethmoidal nerves. It exits the
anterior orbit at the superomedial rim as the infratrochlear
nerve.
The arterial supply to the orbit is from the internal
carotid system through the ophthalmic artery, with anastomotic flow anteriorly from the external carotid system
through the superficial facial vessels. The ophthalmic artery
enters the orbit through the optic canal, inferotemporal
to the optic nerve. In about 83% of individuals, the vessel
crosses over the nerve to the medial side; in the remaining
17%, it crosses below the nerve. Shortly after entering the
orbit, the ophthalmic artery gives off a number of branches
with some variability in the sequence. The central retinal
artery is usually the first branch. It runs along the inferior aspect of the optic nerve to penetrate the dura 1 cm
behind the globe. The lacrimal artery generally arises next
and courses upward and forward, pierces the intermuscular septum, and runs extraconally to the lacrimal gland just
above the lateral rectus muscle. It gives rise to the zygomaticotemporal artery, which penetrates the lateral wall
at about the midorbit, and to the zygomaticofacial artery,
which runs inferolaterally to exit through a small foramen
in the zygomatic bone. Through the latter vessels, the lacrimal artery anastomoses with the external carotid system
via the transverse facial and superficial temporal arteries.
The lacrimal artery terminates in the lids as the lateral inferior and superior palpebral arteries.
The lateral and medial long posterior ciliary arteries
arise on either side of the lacrimal artery and run forward
parallel to the optic nerve. Each branches into one long and
8 to 10 short posterior ciliary arteries that penetrate the
sclera near the exit of the optic nerve. A number of nutrient branches are given off in this region to the extraocular
muscles.
As the ophthalmic artery passes toward the medial orbit,
the supraorbital branch is given off. This passes through
the intermuscular septum medial to the levator muscle
and runs forward with the frontal nerve to the supraorbital
notch. In the medial orbit, the ophthalmic artery gives rise
to the posterior and anterior ethmoidal arteries, which
enter the ethmoidal foramina. It then continues forward
as the nasofrontal artery to exit just above the medial canthus. It gives off the inferior and superior medial palpebral
arteries to the eyelids and terminates as the supratrochlear
and dorsal nasal arteries, with anastomotic connections to
the angular vessels.
Venous drainage is through the superior and inferior
ophthalmic veins. The superior ophthalmic vein originates
at the superomedial orbital rim from branches of the angular, supratrochlear, and supraorbital veins. As it passes
8/3/2012 6:48:51 PM

backward along the medial orbit, it is joined by branches
from the medial and superior rectus muscles, the levator
muscle, the superior vortex veins, the anterior ethmoidal
vein, and collateral branches from the inferior ophthalmic
vein. At about the midorbit, it crosses to the lateral orbit
just below the superior rectus muscle. It is joined by the
lacrimal vein and continues posteriorly to enter the cavernous sinus through the superior orbital fissure.
The inferior ophthalmic vein has an indistinct origin in a
plexus of small vessels in the inferior orbit. It passes backward along the inferior rectus muscle, picking up branches
from the inferior rectus muscle, the inferior oblique muscle, the inferior vortex veins, and the lateral rectus muscle.
A branch exits through the inferior orbital fissure to join
the pterygoid plexus before the vessel terminates at the
superior ophthalmic vein just before the last enters the
cavernous sinus.
Abed SF, Shams P, Shen S, et al. A cadaveric study of the morphometric
and geometric relationships of the orbital apex. Orbit. 2011;30:7276.
Doxanas MT, Anderson RL. Clinical Orbital Anatomy. Baltimore, MD:
Williams & Wilkins; 1984,232p.
Dutton JJ. Radiology of the Orbit and Visual Pathways. London, UK:
Saunders Elsevier; 2010:3248.
Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. 2nd ed. London, UK: Elsevier; 2011,262p.
Hayreh SS. The ophthalmic artery, III: branches. Br J Ophthalmol. 1962;
46:212247.
Hayreh SS, Dass R. The ophthalmic artery, II: intraorbital course. Br J
Ophthalmol. 1962;46:165185.
Kakizaki H, Takahashi Y, Asamoto K, et al. Anatomy of the superior
border of the lateral orbital wall: surgical implications in deep lateral orbital wall decompression surgery. Ophthal Plast Reconstr Surg.
2011;27:6063.
Koornneef L. Details of the orbital connective tissue system in the adult.
Acta Morphol Neerl Scand. 1977;15:134.
Koornneef L. The architecture of the musculofibrous apparatus in the
human orbit. Acta Morphol Neerl Scand 1977;15:3564.
Koornneef L. Orbital septa, anatomy and function. Ophthalmology.
1979;86:876880.
Rootman J, Stewart B, Goldberg RA. Orbital Surgery. A Conceptual
Approach. Philadelphia, PA: Lippincott-Raven; 1995:79146.
Sacks JG. Peripheral innervation of the extraocular muscles. Am J
Ophthalmol. 1983;95:520527.
Sevel D. The origins and insertions of the extraocular muscles: development, histologic features, and clinical significance. Trans Am Ophthalmol Soc. 1986;84:488526.
Takahashi Y, Kakizaki H, Nakano T. Accessory ethmoidal foramina: an
anatomical study. Ophthal Plast Reconstr Surg. 2011;27:125127.
Whitnall SE. Anatomy of the Human Orbit and Accessory Organs of
Vision. 2nd ed. London, UK: Oxford Medical Publishers; 1932,467p.
Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York: Raven;
1985,75p.
8/3/2012 6:48:51 PM

FIG. 82.1. Bony anatomy of the orbit in frontal view. 1, Frontal bone. 2, Sphenoid
bone. 3, Frontozygomatic suture. 4, Sphenozygomatic suture. 5, Zygomatic bone.
6,Inferior orbital ssure. 7, Infraorbital sulcus. 8, Infraorbital foramen. 9, Supraorbital
notch. 10, Superior orbital ssure. 11, Optic canal. 12, Posterior ethmoidal
foramen.13,Anterior ethmoidal foramen. 14, Ethmoid bone. 15, Lacrimal bone.
16,Lacrimal sac fossa. 17, Maxillary bone.
FIG. 82.2. The lateral orbital wall, external view. 1, Greater wing of the sphenoid
bone. 2, Squamous portion of the temporal bone. 3, Zygomatic arch of the temporal
bone. 4, Frontal bone. 5, Frontozygomatic suture. 6, Zygomatic bone. 7, Maxillary
bone.
FIG. 82.3. The medial orbital wall, intraorbital view. 1,Anterior ethmoidal
foramen. 2, Posterior ethmoidal foramen. 3, Optic canal. 4, Foramen rotundum.
5,Sphenoid bone. 6, Pterygopalatine foramen. 7, Infraorbital groove. 8, Maxillary sinus.
9,Frontal bone. 10, Ethmoid bone (retroilluminated to show air cells). 11, Nasal bone.
12,Lacrimal bone. 13, Fossa. 14,Maxillary bone. 15, Infraorbital foramen.
8/3/2012 6:48:51 PM

FIG. 82.1
9
1
2
10
11
12
3
4
13
14
15
16
7
8
17
FIG. 82.2
4
6
7
FIG. 82.3
1
2
10
11
12
13
14
15
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FIG. 82.4. Coronal cross section through the periorbital region at the level of
the ocular equator. 1, Frontal bone. 2,Periorbita. 3, Zygomatic bone. 4, Infraorbital
neurovascular bundle. 5, Maxillary sinus. 6, Maxillary bone. 7, Cerebrum. 8,Anterior
ethmoid sinus cells. 9, Ethmoid bone. 10, Middle turbinate. 11, Inferior turbinate.
FIG. 82.5. Coronal cross section through the orbit at the level of the ocular
equator. 1, Supraorbital neurovascular bundle. 2, Superior rectus muscle. 3, Lacrimal
gland. 4, Lateral rectus muscle. 5, Inferior oblique muscle. 6, Inferior rectus muscle.
7, Levator palpebrae superioris muscle. 8, Superior oblique muscle. 9, Optic disc.
10,Medial rectus muscle. 11,Sclera. 12, Inferior extraconal orbital fat.
8/3/2012 6:48:56 PM

FIG. 82.4
3
9
10
11
6
FIG. 82.5
1
7
2
8
3
9
4
10
11
5
12
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FIG. 82.6. Supercial anatomy of the orbit in lateral view. 1,Superior rectus
muscle. 2, Lacrimal nerve. 3, Ophthalmic division of the trigeminal nerve. 4, Cavernous
sinus. 5, Trigeminal (semilunar) ganglion. 6, Maxillary division of trigeminal nerve.
7,Lateral rectus muscle. 8, Levator palpebrae superioris muscle. 9, Levator aponeurosis. 10, Lacrimal gland. 11, Zygomaticofacial nerve and artery. 12, Zygomatic nerve.
FIG. 82.7. Anatomy of the intraconal orbital space in lateral view. 1, Superior
division of the oculomotor nerve. 2, Optic nerve. 3, Annulus of Zinn. 4, Inferior
division of the oculomotor nerve. 5, Infraorbital nerve. 6, Superior rectus muscle.
7, Tendon of the superior oblique muscle. 8, Lateral rectus muscle (cut). 9,Inferior
oblique muscle. 10, Inferior rectus muscle.
8/3/2012 6:49:06 PM

FIG. 82.6
2
3
4
10
5
11
12
FIG. 82.7
1
8
9
4
10
5
8/3/2012 6:49:06 PM

FIG. 82.8. Sensory and motor nerves of the orbit in lateral view. 1, Posterior
ethmoidal nerve. 2, Nasociliary nerve. 3,Superior division of the oculomotor nerve.
4, Oculomotor nerve. 5, Trochlear nerve. 6, Inferior division of the oculomotor nerve.
7, Ciliary ganglion. 8, Short posterior ciliary nerves. 9, Anterior ethmoidal nerve.
10, Superior oblique muscle. 11,Infratrochlear nerve. 12, Medial rectus muscle.
13,Lacrimal sac. 14, Long posterior ciliary nerves. 15, Inferior rectus muscle.
FIG. 82.9. Arterial system of the orbit in lateral view. 1, Lacrimal artery. 2, Anterior
ethmoidal artery. 3, Posterior ethmoidal artery. 4, Internal carotid artery. 5, Ophthalmic
artery. 6, Central retinal artery. 7, Maxillary artery. 8, Supraorbital artery. 9, Nasofrontal
artery. 10, Infratrochlear artery. 11, Dorsal nasal artery. 12, Medial palpebral artery.
13,Medial posterior ciliary artery. 14, Lateral posterior ciliary artery. 15, Infraorbital
artery.
8/3/2012 6:49:13 PM

FIG. 82.8
1
10
11
12
5
13
6
14
7
15
FIG. 82.9
1
2
8
9
3
10
4
5
11
12
13
14
15
8/3/2012 6:49:13 PM

FIG. 82.10. Venous system of the orbit in lateral view. 1, Superior ophthalmic
vein. 2, Anterior ethmoidal vein. 3, Cavernous sinus. 4, Central retinal vein. 5, Inferior
ophthalmic vein. 6, Infraorbital vein. 7, Supraorbital vein. 8, Supratrochlear vein.
9,Infratrochlear vein. 10, Lacrimal vein. 11, Superior vortex veins. 12, Inferior vortex
veins. 13, Angular vein.
FIG. 82.11. Supercial anatomy of the orbit in superior view. 1, Trochlea,
2,Superior oblique muscle. 3, Trochlear nerve. 4, Optic nerve. 5, Ophthalmic
artery. 6, Oculomotor nerve. 7, Levator palpebrae superioris muscle. 8, Lacrimal
gland. 9,Superior rectus muscle. 10, Lateral rectus muscle. 11, Abducens nerve.
12,Ophthalmic division of the trigeminal nerve. 13, Trigeminal (semilunar) ganglion.
8/3/2012 6:49:21 PM

FIG. 82.10
8
9
10
11
12
5
13
FIG. 82.11
1
7
2
8
9
10
11
3
4
5
12
6
13
8/3/2012 6:49:22 PM

FIG. 82.12. Neurovascular anatomy of the supercial orbital space in superior
view. 1, Supratrochlear nerve. 2, Supratrochlear vein. 3, Infratrochlear vein.
4,Supraorbital vein. 5, Supraorbital artery. 6, Frontal nerve. 7, Supraorbital nerve,
medial branch. 8, Supraorbital nerve, lateral branch. 9, Lacrimal nerve. 10, Lacrimal
artery. 11, Lacrimal vein.
FIG. 82.13. Sensory and motor nerves of the deep intraconal orbital space in
superior view. 1, Infratrochlear nerve. 2, Anterior ethmoidal nerve. 3, Long posterior
ciliary nerve. 4, Posterior ethmoidal nerve. 5, Nasociliary nerve. 6, Superior division
of the oculomotor nerve. 7, Oculomotor nerve. 8, Short posterior ciliary nerve.
9,Abducens nerve. 10, Ciliary ganglion. 11, Inferior division of the oculomotor nerve.
12,Frontal nerve (cut). 13, Trochlear nerve (cut).
8/3/2012 6:49:29 PM

FIG. 82.12
1
2
3
7
8
4
5
9
10
6
11
FIG. 82.13
8
2
9
3
4
10
11
12
7
13
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FIG. 82.14. Arterial system of the intraconal orbital space in superior view.
1,Medial palpebral artery. 2, Dorsal nasal artery. 3, Nasofrontal artery. 4,Anterior
ethmoidal artery. 5, Posterior ethmoidal artery. 6, Internal carotid artery.
7,Supraorbital artery. 8, Lacrimal artery. 9, Zygomaticofacial artery. 10, Lateral
posterior ciliary artery. 11, Medial posterior ciliary artery. 12, Ophthalmic artery.
FIG. 82.15. Venous system of the intraconal orbital space in superior view.
1,Supratrochlear vein. 2, Infratrochlear vein. 3, Supraorbital vein. 4, Anterior
ethmoidal vein. 5, Central ophthalmic vein. 6, Superior vortex veins. 7, Lacrimal vein.
8, Inferior ophthalmic vein. 9, Superior ophthalmic vein.
8/3/2012 6:49:36 PM

FIG. 82.14
7
1
2
3
4
9
10
5
11
12
FIG. 82.15
1
2
3
4
8
5
9
8/3/2012 6:49:36 PM
SECTION
Orbitotomy Procedures
T
he orbitotomy procedures include a number of operations for access into the various orbital soft tissue compartments. The specific approach selected depends on the
type and location of the pathologic process, involvement of
adjacent bone or paraorbital areas, the need for wide surgical
margins, and the requirements for adequate exposure.
There are three surgical spaces of interest to the orbital
surgeon and each requires specific consideration for appropriate visualization. The subperiosteal compartment is a
potential space between the orbital bony walls and periorbita. Access to this space is necessary for repair of orbital
wall fractures or for decompression of expanding orbital
volume, as in Graves orbitopathy. This compartment is
the location for accumulation of subperiosteal hematomas
following blunt trauma and for subperiosteal abscesses
associated with ethmoid or frontal sinusitis. Expanding
mucoceles and some intracranial lesions, such as sphenoid
wing meningiomas, may involve only this compartment.
Bone lesions, such as epidermoid and aneurysmal bone
cysts, cholesterol granulomas, and eosinophilic granulomas are also frequently largely confined to the subperiosteal space. Access is through a transperiosteal anterior
or lateral orbitotomy, or via a transcaruncular medial
approach.
The extraconal or peripheral orbital space lies between
the periorbita and the fascial septa that interconnect the
extraocular muscles. This septal system is far more complex than once believed, and it is unusual for lesions to be
precisely confined to the extraconal space alone. Access
to the extraconal orbital space may be through a transcutaneous transseptal orbitotomy if in the anterior orbit or
through a lateral orbitotomy if deeper.
The intraconal, or central orbital, space is delimited by the
extraocular muscle cone from the annulus of Zinn to posterior Tenons capsule. It is not a clearly defined compartment, however, because the intermuscular septum is largely
incomplete posteriorly and poorly defined anteriorly. Lesions
frequently extend between the extraconal and intraconal
compartments without regard to these artificial boundaries. Optic nerve gliomas and sheath meningiomas are typically located within the muscular cone. Any surgery on the
optic nerve, for example, biopsy or sheath decompression,
requires access to this compartment. The surgical approach
is via a lateral orbitotomy for deep lesions or an anterior orbitotomy for lesions immediately behind the globe. A superior
transcranial orbitotomy is necessary for lesions that involve
the orbital apex or for those extending intracranially into the
cavernous sinus or middle cranial fossa.
Between the intraconal and extraconal spaces are the

extraocular muscles that may be the sites for orbital pathology, such as myositis, or metastatic tumors. They are usually approached by the anterior or lateral routes, depending
on the depth of the lesion.
The specific surgical procedures described here give
direct access to certain structures to minimize trauma
to adjacent tissues. The anterior orbitotomies are used
for lesions in the anterior orbit to the level of the posterior globe. The transcutaneous anterior orbitotomy gives
excellent exposure in all quadrants. In the lower eyelid, the
incision is best placed in a subciliary position for better
cosmesis. A transconjunctival incision combined with disinsertion of the inferior crus of the lateral canthal ligament
will give wide exposure to the inferior orbit for access to the
subperiosteal space and orbital floor. In the upper eyelid,
the incision may be placed within the eyelid crease. Transperiosteal or transseptal entrance to the orbit is achieved
by dissecting upward beneath the orbicularis muscle to the
appropriate layer.
The lateral orbitotomy involves removal of the lateral
orbital rim and varying amounts of the greater sphenoid
wing. It allows wide access to the deep orbital contents
and optic nerve and is preferred for excision of most retrobulbar lesions. Superior extension of the superior bony
cut gives better exposure to the lacrimal gland for en bloc
excision within its fossa. The lateral orbitotomy may be
combined with other approaches, for example, the medial
orbitotomy, for better visualization of the deep medial wall.
The superior orbitotomy is performed through a transfrontal or temporofrontal osteoplastic craniotomy. It
requires the joint efforts of the orbital surgeon and a neurosurgeon. This route provides the only adequate and safe
exposure to the orbital apex and is mandatory for lesions
that extend between the orbit and the intracranial compartment.
For anterior orbitotomies, local infiltrative anesthetic
may be used if the lesion is small and situated close to the
orbital rim. However, for lengthy procedures or for those
deeper in the orbit, general anesthesia is preferred. Intraoperative hypotension monitored by the anesthesiologist
may be of some benefit in reducing the risk of hemorrhage.
More so than in any other procedures in ophthalmology,
knowledge of anatomic detail and precise technique is necessary for successful orbital surgery. Meticulous attention
to hemostasis must be assured throughout surgery for visualization and before closure to prevent postoperative complications. For many deeper dissections in the extraconal
270
7/12/2012 3:27:04 PM
SECTION B Orbitotomy Procedures 271

or intraconal spaces, particularly with lateral orbitotomies,
low suction drainage may be used for 24 hours if complete
hemostasis cannot be assured.
After adequate exposure is achieved, dissection proceeds slowly and with great deliberation. Magnification and
microdissecting instruments are used to gently separate
the lesion from adjacent normal structures. Light traction
on the lesion is usually necessary to allow posterior dissection. This may be achieved with forceps, but for more vascular lesions, a cryoprobe allows traction without surface
bleeding. Dissection around the optic nerve is particularly
hazardous because of delicate pial vessels that penetrate its
surface and the close approximation of the posterior ciliary
nerves.
Anterior Orbitotomy
Priel A, Oh S-R, Kikkawa DO, Korn BS. Surgical approaches to the orbit
and optic nerve. In: Black EH, Nesi FA, Calvano CJ, et al., Smith and
Nesis Ophthalmic Plastic and Reconstructive Surgery. New York:
Springer; 2012:793810.
Leone CR. Surgical approaches to the orbit. Ophthalmology. 1979;86:
930941.
Rootman J. Diseases of the Orbit: A Multidisciplinary Approach. London,
UK: JB Lippincott; 1988:3350.
Medial Orbitotomy
Cheng JW, Wei RL, Cai JP, Li Y. Transconjunctival orbitotomy for orbital
cavernous hemangiomas. Can J Ophthalmol. 2008;43:234238.
Krohel GB. Orbital surgery. In: Smith BC, Delia Rocca RC, Nesi FA, Lisman RD, eds. Ophthalmic Plastic and Reconstructive Surgery. St.
Louis, MO: Mosby-Year Book; 1987.
McCord CD. Oculoplastic Surgery. New York: Raven Press; 1981.
Edgin WA, Morgan-Marshall A, Fitzsimmons TD. Transcaruncular
approach to medial orbital wall fractures. J Oral Maxillofac Surg
2007;65:23452349.
Lateral Orbitotomy
Berke RN. A modified Kronlein operation. Arch Ophthalmol. 1954;51:
609632.
Halli RC, Mishra S, Kini YK, et al. Modified lateral orbitotomy approach:
a novel technique in the management of lacrimal gland tumors.
Harris GJ, Logani SC. Eyelid crease incision for lateral orbitotomy.
Jones BR. Surgical approaches to the orbit. Trans Ophthalmol Soc UK.
1970;90:269281.
Kennerdell JS, Maroon JC. Microsurgical approaches to intraorbital
tumors: technique and instrumentation. Arch Ophthalmol. 1976;94:
13331336.
Kim JW, Yates BS, Goldberg RA. Total lateral orbitotomy. Orbit.
2009;28:320327.
Leone CR. Surgical approaches to the orbit. Ophthalmology. 1979;86:
930941.
Mariniello G, Maiuri F, de Divitiis E, et al. Lateral orbitotomy for removal
of sphenoid wing meningiomas invading the orbit. Neurosurgery.
2010;66:287292.
McCord CD. A combined lateral and medial orbitotomy for exposure of
the optic nerve and orbital apex. Ophthal Surg. 1978;9:5866.
McNab AA, Wright JE. Lateral orbitotomya review. Aust N Z J Ophthalmol. 1990;18:281286.
Nemet A, Martin P. The lateral triangle flapnew approach for lateral
orbitotomy. Orbit. 2007;26:8995.
Rootman J, Stewart B, Goldberg RA. Orbital Surgery. A Conceptual
Approach. Philadelphia, PA: Lippincott-Raven; 1995:151392.
Wright JE. Orbital surgery. In: Silver B, ed. Ophthalmic Plastic Surgery.
3rd ed. San Francisco, CA: American Academy of Ophthalmology;
1977.
Wright JE. Surgical exploration of the orbit. Trans Ophthalmol Soc UK.
1979;99:238240.
Yuen HK, Chong YH, Chan SK, et al. Modified lateral orbitotomy for
intact removal of orbital dumbbell dermoid cyst. Ophthal Plast Reconstr Surg. 2004;20:327329.
7/12/2012 3:27:04 PM
83
Transcutaneous, Transseptal Anterior

Orbitotomy
INDICATIONS: Access to the anterior extraconal orbital space for biopsy or excision of small lesions.

for access to the superior orbit or 2 mm below the lower
eyelid lash line for access to the inferior orbit. Place the
incision line temporally, nasally, or across the eyelid width,
depending on the size of the lesion.
FIG. 83.2. With a scalpel blade, cut the skin along the
marked line. Tent up the skin edges with forceps and cut
postorbicular fascial plane. Identify the orbital septum as the
glistening white membrane with yellowish fat visible behind it.
FIG. 83.3. Dissect along the orbital septum toward the
orbital rim, freeing attachments to the orbicularis muscle.
FIG. 83.4. With a scalpel or scissors, make a horizontal
cut through the orbital septum over the lesion to enter
the extraconal orbital space. The lesion may be visible or if
somewhat more posterior, orbital fat will prolapse through the
septal defect.
FIG. 83.5. If the lesion is not immediately visible, carefully
palpate through the wound to locate the structure. Gently
POSTOPERATIVE CARE: Place a firm dressing over the

wound for 12 to 24 hours. Apply antibiotic ointment to the
suture line three to four times daily for 1 week.
Lower eyelid ectropionThis is caused by injury to the
capsulopalpebral fascia with loss of tarsal stability. It is
more common in older patients who have preexisting
eyelid laxity.
Lower eyelid epiblepharonThis may result from failure
to reform the lid crease and failure to fix the preseptal
orbicularis muscle to the eyelid retractors. If noted postoperatively, a secondary crease formation is curative.
DiplopiaInjury to the inferior oblique muscle may follow inferior anterior orbital dissection. In the superior
medial orbit, the superior oblique trochlea is easily
injured by overly aggressive dissection.
separate the fat lobules with narrow malleable retractors and

a Freer periosteal elevator, taking care not to injure vascular
structures. In the upper eyelid, the levator muscle lies on the
inferior side of the wound. In the lower eyelid, the inferior
oblique and inferior rectus muscles lie at the upper side of the
wound.
FIG. 83.6. Perform a biopsy of the lesion or carefully
dissect around its surface to separate adherent tissues.
Meticulously cauterize any bleeding points with bipolar
electrode forceps. Take care not to put excessive traction on
the orbital fat.
FIG. 83.7. Do not repair the orbital septum. If a lower eyelid
subciliary incision was used, reform the eyelid crease by xing
the orbicularis muscle to the capsulopalpebral fascia with several interrupted 7-0 chromic stitches about 4 to 5 mm below
the lid margin.
FIG. 83.8. Close the cutaneous wound with a running suture
of 6-0 fast-absorbing plain gut stitches. In the upper eyelid,
reform the lid crease by passing every second or third bite of
the skin suture through the levator aponeurosis.
Upper eyelid ptosisLesions in the superior anterior
orbit may be adherent to the levator aponeurosis or
muscle. Transient ptosis following surgery is quite common and usually resolves after several weeks. Permanent ptosis may result from injury to the aponeurosis or
to Whitnalls ligament.
Lacrimal gland injuryThe lacrimal gland lies in the anteriorsuperior orbit just behind the septum. It may be
displaced forward by mass lesions. Injury to the gland usually does not cause problems, but damage to the lacrimal
secretory ducts may result in epiphora or a retention cyst.
LagophthalmosAttempted closure of the orbital septum or postoperative scarring and shortening may cause
lagophthalmos on attempted lid closure. This may be
repaired secondarily by lysis of scar bands or opening of
the septum and placing the lid on a Frost traction suture
for 4 to 5 days.
272
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CHAPTER 83 Transcutaneous, Transseptal Anterior Orbitotomy 273
FIG. 83.1
FIG. 83.5
FIG. 83.2
FIG. 83.6
FIG. 83.3
FIG. 83.7
FIG. 83.4
FIG. 83.8
7/12/2012 3:27:05 PM
84
Transcutaneous, Transperiosteal Anterior

Orbitotomy
INDICATIONS: Access to the extraperiosteal orbital space for biopsy or excision of lesions adjacent to the periosteum
and orbital bones, for drainage of subperiosteal hematomas or subperiosteal abscesses, or for repair of orbital wall
fractures.
FIG. 84.1. Mark an incision line 2 mm below the lower

eyelid lash line for access to the orbital oor and the
inferior orbit. For access to the superior orbit or orbital roof,
mark the incision line along the lower edge of the brow or
within the upper eyelid crease.
FIG. 84.5. If access to the extraconal space is desired,

make a small cut in the periorbita with a scalpel blade
while avoiding the rectus muscles and continue the cut
posteriorly with scissors. Take care to cut only periorbita to
avoid injuring deeper orbital structures.
marked line. Tent up the skin edges with forceps and
cut through orbicularis muscle with scissors to enter the
postorbicular fascial plane.
FIG. 84.6. Retract orbital fat and the levator muscle with
narrow malleable retractors for visualization. Following
biopsy or excision of the lesion, use gentle bipolar cautery to
attain complete hemostasis.
FIG. 84.3. Dissect in the postorbicular fascial plane along

the anterior surface of the orbital septum to the orbital
rim. With a scalpel blade, make a cut in the periosteum 2 mm
anterior and parallel to the orbital rim edge, along the entire
width of the incision.
FIG. 84.7. Close the periorbita over the orbital rim with
interrupted 4-0 Vicryl sutures.
FIG. 84.8. Close the orbicularis muscle with several
interrupted 6-0 chromic sutures and the skin with a
running stitch of 6-0 fast-absorbing plain gut.
FIG. 84.4. Dissect the periosteum over the orbital rim with
a Freer periosteal elevator. Continue elevating the periosteum
from the orbital bones until the site of pathologic process is
visible. In the medial superior orbit take care to avoid injuring
the trochlea while separating it and periorbita from the frontal
bone.
POSTOPERATIVE CARE: Apply a moderately firm dressing to the eye and orbit for 24 hours and intermittent iced
compresses for another 24 hours. Avoid excessive pressure. Place antibiotic ointment on the suture line three
to four times daily for 1 week. If a paranasal sinus was
entered during surgery, appropriate systemic antibiotics
are administered for 7days.
Postoperative orbital hemorrhageThis rare complication can be avoided by meticulous attention to hemostasis during surgery. An expanding hematoma is
heralded by progressive proptosis, deep orbital pain,
and decreasing vision. A CT scan and an echogram
help localize the blood pocket. Treatment may require
immediate surgical decompression, either through the

original surgical wound or through an alternate, more
direct route to the hematoma.
Extraocular muscle paresisThis is caused by excessive
manipulation or traction on the muscle during surgery.
It is usually temporary and function recovers after several days to weeks. When permanent, later strabismus
surgery may be needed to correct residual diplopia.
Eyelid edema and ptosisThis is seen frequently, particularly with superior orbital surgery because upper eyelid
function is more vulnerable to fluid accumulation and
inflammatory processes. Iced compresses are applied
for 48 hours to help minimize edema. The ptosis usually
resolves after several days to weeks.
274
7/12/2012 3:29:43 PM
CHAPTER 84 Transcutaneous, Transperiosteal Anterior Orbitotomy 275
FIG. 84.1
FIG. 84.5
FIG. 84.2
FIG. 84.6
FIG. 84.3
FIG. 84.7
FIG. 84.4
FIG. 84.8
7/12/2012 3:29:43 PM
85
Lateral Orbitotomy
INDICATIONS: Access to the deeper intraconal orbital space, lacrimal gland, and optic nerve.
FIG. 85.1. Mark an S-shaped incision line from the inferior

lateral brow, along the lateral orbital rim, and inferolaterally along a laugh line at the upper border of the zygomatic
arch. Alternatively, the incision line is placed in the upper eyelid crease and extended laterally 1 to 2 cm beyond the orbital
rim (see Fig. 89.1 to 89.5, p. 352-353).
marked line. With scissors, complete the cut through
orbicularis muscle and deep fascia to the periosteum of the
orbital rim.
FIG. 85.3. Incise the periosteum 2 mm outside the bony rim
around the lateral orbit from the superior to the inferior
corners of the wound. Separate periosteum from bone with a
periosteal elevator.
FIG. 85.4. Elevate periorbita from the lateral orbital wall
fora distance of 3 to 4 cm. If bleeding is encountered from
vessels penetrating the lateral wall, insert a small sponge and
apply gentle pressure for several minutes.
FIG. 85.5. Place six half-length 4-0 silk sutures around the
wound edges and clamp the sutures to the drapes for better
exposure. Separate periosteum over the lateral orbital rim and
into the temporalis fossa. With a Freer elevator, push a gauze
sponge between periosteum and the bone of the temporalis
fossa to facilitate clean dissection of the muscle. Allow several
minutes for hemostasis.
FIG. 85.6. At the level of the frontozygomatic suture line,
place wide malleable retractors on either side of the bony
orbital rim to protect the soft tissues. Cut through the bone
with an oscillating saw, angling the cut slightly inferiorly and
parallel to the orbital roof. Make the cut 1 cm deep and extend
it to the thin bone along the sphenozygomatic suture.
FIG. 85.7. Move the malleable retractors inferiorly to the
upper surface of the zygomatic arch. Make a cut 1.5 cm deep
through the orbital rim just above the arch. Angle the cut
slightly upward.
FIG. 85.8. Drill a hole 1 mm in diameter near the rim on
either side of each cut. Use a malleable retractor to protect
periorbita.
276
7/12/2012 3:31:59 PM
CHAPTER 85 Lateral Orbitotomy 277
FIG. 85.1
FIG. 85.5
FIG. 85.2
FIG. 85.6
FIG. 85.3
FIG. 85.7
FIG. 85.4
FIG. 85.8
7/12/2012 3:31:59 PM
278 SECTION B Orbitotomy Procedures

FIG. 85.9. With a sturdy rongeur, grasp the bony rim and fracture the bone
outward. Cut any adherent tissue from the bone with scissors. Wrap the bone in
saline-soaked gauze and place it aside.
FIG. 85.10. Remove the thin bone of the greater sphenoid wing from the lateral
orbital wall with rongeurs. Normally, removal is not extended beyond the level of
cancellous bone. If necessary for greater apical exposure, continue removing bone
with extreme caution to avoid injury to dura that is overlying the temporal lobe.
Bleeding from the bone is controlled with surgical wax.
FIG. 85.11. Identify the lateral rectus muscle by grasping its insertion at the
globe and rotating the eye medially. With scissors, open the periorbita by making a
vertical cut just inferior or superior to the muscle.
FIG. 85.12. Dissect through the orbital fat by bluntly separating the interlobular
capsules with a Freer elevator or dissectors. Magnication with loupes or an
operating microscope is important. Gentle palpation helps identify the lesion or optic
nerve.
FIG. 85.13. Carefully dissect around the lesion, staying close to its capsule,
and bluntly separate it from adjacent orbital tissues. If more rm adhesions are
present, cut them with scissors after bluntly separating them into thin bers to
identify any structures that might be running through them. Traction on the lesion
may be achieved with application of a retinal cryoprobe to its surface.
FIG. 85.14. After biopsy or removal of the lesion, close periorbita with interrupted 6-0 Vicryl sutures. Leave several gaps in the closure for drainage. If adequate
hemostasis cannot be assured, place a low-vacuum drain into the temporalis fossa
and out a cutaneous puncture wound adjacent to the incision inferiorly.
FIG. 85.15. Replace the lateral orbital rim and secure it with 4-0 prolene or nylon
sutures passed through the predrilled holes. If future magnetic resonance imaging
studies will not be needed, 28-gauge stainless steel wire may be used.
FIG. 85.16. Close periosteum over the orbital rim with interrupted 4-0 Vicryl
stitches. Repair the orbicularis muscle with 6-0 Vicryl and the skin with 6-0 fastabsorbing plain gut or prolene sutures.
7/12/2012 3:32:04 PM
CHAPTER 85 Lateral Orbitotomy 279
FIG. 85.9
FIG. 85.13
FIG. 85.10
FIG. 85.14
FIG. 85.11
FIG. 85.15
FIG. 85.12
FIG. 85.16
7/12/2012 3:32:04 PM
280 SECTION B Orbitotomy Procedures

POSTOPERATIVE CARE: Place a firm but not tight dressing over the globe for 24 hours. Intravenous steroids may
be administered for 24 hours if there was any manipulation around the optic nerve. If a drain is placed, apply
minimal continuous suction. Remove the drain after 24
hours. Apply antibiotic ointment to the suture line three
to four times daily for 1 week. Remove any nonabsorbing
skin sutures after 5 to 7 days.
Lateral rectus muscle paresisThis is caused by excessive traction on the muscle during lateral orbital exposure. It is best not to displace the muscle with a suture
loop but rather to use a broad retractor. Muscle weakness is typically temporary. Any permanent deficit can
be repaired with strabismus surgery after 4 to 6 months.
Upper eyelid ptosisSome edema and ptosis are inevitable following deep orbital surgery. These usually resolve
after several days to weeks. It is unusual for ptosis to
be permanent unless injury to the levator has occurred
during superior orbital surgery. Permanent ptosis can
be corrected by any appropriate ptosis repair after 4 to

6 months.
Orbital hemorrhageMeticulous hemostasis during surgery is mandatory, and excessive traction on orbital fat
and other structures must be avoided. A drain in the
temporalis fossa should be placed if there is persistent
oozing. If there is significant bleeding postoperatively,
the wound is opened and the bleeding point controlled
directly.
Pupillary paralysisDeep orbital dissection near the optic
nerve may cause injury to the ciliary nerves. Extreme
care is used and magnification is essential. Patients with
postoperative pupillary paralysis will frequently recover,
but recovery may take many months to a year or more.
BlindnessThis unfortunate complication is exceptionally rare and is associated with deep dissection of lesions
in contact with the optic nerve, or exploration into the
orbital apex. It may result from compression of the
nerve with retractors or injury to the small vessels along
the pia. Any postoperative bleeding must be decompressed immediately.
7/12/2012 3:32:08 PM
SECTION
Surgery on the Orbital Walls

S
urgery directed at the bony orbital walls is indicated for

a variety of conditions that frequently involve traumatic
fractures. Clinical signs that suggest bony disruption include
orbital edema, emphysema and hemorrhage, enophthalmos,
motility disturbance, and infraorbital anesthesia. Orbital fractures may be simple or complex, depending on the source of
injury, the force of impact, and the direction of the compressive vectors applied. Fractures are frequently associated with
soft tissue injury, particularly of the globe. A thorough ocular
examination is essential before any surgical manipulation.
Clinical evaluation includes radiographic studies to
confirm and delineate the fracture boundaries and to rule
out the presence of retained foreign bodies. The plain
orbital series, including the Waters and Caldwell frontal
projections and both lateral views, can provide some useful information where computed tomography (CT) is not
available. Multiplanar CT with bone windows allows much
better evaluation of soft tissue relationships to the fracture
site. Magnetic resonance imaging (MRI) offers little here
because the proton density of bone is too low to yield a
significant signal. However, if significant soft tissue injury
is suspected, especially intracranial, an MRI is a valuable
adjunct study.
Simple orbital rim fractures usually result in cosmetic
deformity only, without causing visual threat unless the
bone fragment is displaced into the orbit. They are best
repaired primarily, typically through cutaneous incisions
with miniplate fixation. Rim fractures frequently involve
adjacent bones such as the maxillary or frontal sinuses, or
the zygomatic arch, so that cooperation with an otolaryngology colleague may be appropriate.
Blow-out fractures of the orbital floor result from
hydraulic compression of orbital contents. These fractures occur most frequently just medial to the infraorbital
canal where the bone is thinnest. Anesthesia of the cheek
and upper gum suggests injury to the infraorbital nerve.
Spontaneous recovery of sensation is usual over several
months. Vertical diplopia and a positive forced duction test
may result from entrapment of the inferior rectus muscle
or, more likely, its fascial attachments in the fracture site.
These complications are also seen with contusion injuries
to the muscle. In the latter case, motility function typically
improves over several weeks, while the hematoma resolves.
Failure to improve over several weeks suggests mechanical
restriction, which requires surgical exploration.
Early enophthalmos is caused by an inward displacement of the orbital tissues from an increase in volume of
the orbital cavity. It may be associated with downward
displacement of the globe when the fracture site primarily

involves the floor. Enophthalmos and hypo-ophthalmos
alone usually do not cause diplopia but may be of cosmetic
consequence. When these conditions are significant, early
surgical intervention is indicated. Associated orbital hemorrhage may initially mask enophthalmos, which becomes
manifest only after several weeks when the hematoma
resolves. Late enophthalmos, which may occur after several
years or even after several decades, results from progressive fat atrophy. It is repaired with volume augmentation of
the orbital contents.
Medial wall fractures are often associated with those of
the floor and more commonly result in orbital emphysema.
Medial rectus muscle entrapment is uncommon but when
present may produce a horizontal diplopia. Enophthalmos
may be significant even with pure ethmoid fractures. Injury
to the lacrimal drainage system can be seen with more
anterior medial rim or nasomaxillary fractures across the
nasolacrimal canal. If injury is suspected, lacrimal system
intubation is performed with silicone stents. Some cases
require later dacryocystorhinostomy.
Orbital decompression is indicated to expand the bony
walls when increased orbital soft tissue volume is present. The procedure is used most frequently for Graves
orbitopathy associated with optic nerve compression or
severe proptosis and lagophthalmos. However, this operation is also commonly performed for aesthetic reduction
of disfiguring proptosis. The operation involves intentional
outfracturing of selected orbital walls, usually into adjacent
paranasal sinuses. The transorbital route via anteriorinferior orbitotomy is used for removal of the orbital floor.
Medially, the transcaruncular approach provides excellent
access for an ethmoidectomy. This begins just posterior to
the origin of the inferior oblique muscle and the posterior
lacrimal crest and extends backward to the posterior ethmoid and sphenoid sinuses. Extirpation of the ethmoid air
cells should not extend higher than the ethmoidal foramina, which serve as an anatomic guide to the lowest approximate level of the cribriform plate.
In decompression for cosmetic reduction of proptosis only, it is sufficient to remove bone from the anterior
two-thirds of the orbit and thus avoid the potential complications of more posterior apical surgery. However, for
compressive optic neuropathy, expansion closer to the apex
is frequently needed. Here medial and/or lateral wall surgery should be carried back as close to the apex as possible.
Although the medial wall can be decompressed through
a lower eyelid incision, in most cases, a transcaruncular
281
7/16/2012 10:18:48 AM
282 SECTION C Surgery on the Orbital Walls

incision gives much better medial wall exposure and a
more predictable apical exenteration of the posterior ethmoid cells.
Some authors have advocated superior wall removal to
augment the effect of decompression. The additional benefit is minimal, however, and in general does not justify
the added risk. Removal or thinning of the lateral wall may
be useful and can add several millimeters to decompression of the globe. In addition, lateral wall decompression
may allow greater exposure of the medial wall and more
complete ethmoid exenteration in very congested orbits.
Removal of both the lateral and medial walls, but not the
floor, is currently preferred by many surgeons as a balanced
decompression to minimize vertical globe displacement.
In the procedures below, we describe a standard combined
medial and floor decompression, as well as individual
decompressions of the medial, lateral, and inferior walls
that can be combined in any combination.
In all operations for orbital decompression, periorbita
must be opened widely to allow fat lobules to prolapse into
the bony defects. Without this step, surgery is likely to be
ineffective. In Graves orbitopathy, fibrosis of the interlobular fascial septa may prevent prolapse. Careful blunt dissection to separate these is necessary, but in some cases,
the effect of decompression is still disappointing.
Most surgery on the orbital walls is performed under
general anesthesia. The nasal cavity is packed with cottonoid strips soaked in 4% cocaine or substitute and 0.25%
phenylephrine for vasoconstriction, and to aid sinus drainage. Because of the small but definite risk of visual loss,
unilateral surgery is preferred at any one time. If there are
no visual complications, the second orbit can be decompressed several days or weeks later.
One additional procedure along the orbital walls is volume augmentation of the orbital contents or reduction of
the bony contour. Typically, this is indicated for anophthalmic enophthalmos and superior sulcus deformity caused by
progressive fat atrophy. Although the ocular prosthesis can
be modified within limits, it is unwise to make it too thick
and heavy because doing so only accelerates orbital and eyelid laxity. Volume augmentation can also be done for enophthalmos with a seeing eye. Reduction of orbital bony volume
is commonly achieved with subperiosteal implantation of
alloplastic materials such as a preformed acrylic implant or
layered sheets of polyethylene. A transperiosteal approach
to the floor or other wall is utilized, and the implant is fixed
to the orbital rim to prevent forward migration.
Orbital Decompression
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Graham SM, Brown CL, Carter KD, et al. Medial and lateral orbital wall
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SECTION C Surgery on the Orbital Walls 283

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7/16/2012 10:18:49 AM
86
Orbital Decompression, Inferior

and Medial Walls
INDICATIONS: Expansion of the bony orbital contour, primarily in thyroid orbitopathy for cosmetic reduction of
proptosis or optic nerve compression, when extraocular muscles are enlarged.
FIG. 86.1. Pack the inferior and middle nasal meatus with
cottonoid strips soaked in 4% cocaine or substitute and
0.25% phenylephrine for vascular constriction.
FIG. 86.2. Mark a subciliary incision 2 mm below the
lower eyelid lash line from just inferior to the punctum
to the lateral canthus. Incise the skin with a scalpel blade.
Alternatively, a transconjunctival incision may be used, placed
just below the tarsus (see Orbital Decompression, Inferior Wall,
Transconjunctival, Fig. 88.1, pp. 350-351).
FIG. 86.3. Tent up the skin edges with forceps and
transect the orbicularis muscle with scissors to enter the
postorbicular fascial plane.
FIG. 86.4. Dissect inferiorly in the postorbicular fascial
plane, anterior to the orbital septum, to the inferior orbital
rim.
FIG. 86.5. Incise periosteum 2 mm outside the orbital rim
with a scalpel and dissect it over the bony rim with a Freer
elevator. Continue elevating periorbita off the orbital oor for
a distance of 3.5 to 4 cm posterior to the rim. Use malleable

retractors to hold periorbita away from the bones. Periodically
check the pupil to ensure it is not dilated from iatrogenic optic
nerve compression.
FIG. 86.6. Locate the thinnest part of the oor. It is usually
medial to the infraorbital canal and will appear translucent.
Punch a small hole through this area with a hemostat.
FIG. 86.7. With rongeurs, take out the orbital oor medial
to the infraorbital canal. Remove bone back to the posterior
wall of the maxillary sinus, medially to the thick bone at the
maxillary strut, and laterally to the edge of the infraorbital
canal.
FIG. 86.8. With a Freer elevator, gently fracture the roof
of the infraorbital canal upward. Take care not to injur the
infraorbital neurovascular bundle. Remove the fractured bone
with forceps. Fracture the oor of the canal downward in
similar fashion. Alternatively, the bony infraorbital canal and
groove can be left intact to support the maxillary nerve and
globe.
284
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CHAPTER 86 Orbital Decompression, Inferior and Medial Walls 285
FIG. 86.1
FIG. 86.5
FIG. 86.2
FIG. 86.6
FIG. 86.3
FIG. 86.7
FIG. 86.4
FIG. 86.8
7/16/2012 10:18:49 AM

FIG. 86.9. With rongeurs, remove the remainder of the orbital oor between the
infraorbital canal and the lateral wall of the maxillary sinus.
FIG. 86.10. Move the malleable retractors medially and elevate periorbita from
the medial orbital wall. Do not disturb periorbita anterior to the posterior lacrimal
crest to avoid injury to the lacrimal sac and inferior oblique muscle. Do not extend
dissection of periorbita more than 5 mm superior to the medial canthal ligament
because this carries risk of injury to the ethmoidal arteries.
FIG. 86.11. Punch through the lamina papyracea with a hemostat and exenterate
the anterior and posterior ethmoid cells with ethmoidectomy or pituitary
forceps. Do not extend the dissection through the medial wall of the ethmoid
labyrinth. Take care not to extend the dissection more than 5 cm posterior to
the medial orbital rim unless decompression into the sphenoid sinus is desired.
Alternatively, the medial wall can be performed through a transcaruncular incision
(see chapter 87, p. 348-349).
FIG. 86.12. Pack the exenterated ethmoid sinus with cottonoid strips soaked
in local anesthetic with epinephrine for 10 minutes or until bleeding has been
controlled. Remove the packs.
FIG. 86.13. Place two narrow malleable retractors to expose the inferior periorbita. With scissors, make several longitudinal cuts in periorbita, medial and lateral to
the inferior rectus muscle. Extend the cuts posteriorly toward the orbital apex. Orbital
fat should prolapse through the wound. If necessary, gently tease apart the interlobular septa using scissors in a spreading maneuver but do not put excessive traction on
the fat.
FIG. 86.14. Move the malleable retractors to the medial wall and open periorbita
just below the medial rectus muscle. Remove the retractors and massage the globe
with gentle, intermittent pressure to further prolapse the orbital fat through the
incisions in periorbita.
FIG. 86.15. Approximate periorbita to periosteum over the inferior orbital rim
with 4-0 Vicryl sutures.
FIG. 86.16. Reform the lower eyelid crease if necessary by xing orbicularis
muscle to the orbital septum with several 7-0 chromic stitches 4 mm below the
incision line. Close the skin with interrupted stitches of 6-0 fast-absorbing plain gut.
7/16/2012 10:19:00 AM
CHAPTER 86 Orbital Decompression, Inferior and Medial Walls 287
FIG. 86.9
FIG. 86.13
FIG. 86.10
FIG. 86.14
FIG. 86.11
FIG. 86.15
FIG. 86.12
FIG. 86.16
7/16/2012 10:19:00 AM

POSTOPERATIVE CARE: A drain is not necessary if
adequate hemostasis has been assured. A moderately
firm dressing is applied for 24 hours. Antibiotic ointment
is placed on the suture line three to four times daily for
7 days. Systemic antibiotics and nasal decongestants are
prescribed for 1 week.
Inadequate decompressionOpening of the periorbita
to allow prolapse of orbital fat significantly enhances the
decompressive effect. With longstanding orbital inflammation, excessive fibrosis may prevent prolapse of fat
resulting in poor decompression. Blunt separation of fat
with scissors during surgery may help.
SinusitisPostoperative sinusitis is rare and is due to
drainage obstruction from blood clots and mucosal
debris. It is effectively treated with systemic antibiotics.
Nasal bleedingThis results from inadvertent entrance
into the nose and laceration of nasal mucosa during
ethmoidectomy. Chemical cautery may be helpful, but
control of bleeding may require nasal packing for several days.
DiplopiaBilateral orbital decompression in patients

who do not have preexisting motility disturbance rarely
results in diplopia. When it is seen, it is usually transient. Persistent strabismus after 4 to 6 months requires
surgery for correction.
Infraorbital nerve anesthesiaThis results from trauma
to the infraorbital nerve during removal of the bony
infraorbital canal. It is usually transient with function
recovering after several weeks to months.
Visual lossThis uncommon, dreaded complication may
result from excessive compression on the optic nerve and
its vascular supply when retractors are placed deep into
the apex. Care should also be taken not to apply continuous pressure on the globe. The pupil should be monitored
throughout the case. Hemostasis is mandatory.
Cerebrospinal fluid leakThe position of the cribriform
plate is quite variable and may lie as much as 1.5 cm
below the roof of the ethmoid sinus. Small leaks can be
managed by packing fat against the dural tear, and resolution may be hastened with the use of a lumbar drain
for several days. Appropriate antibiotics are administered for 10 days.
7/16/2012 10:19:08 AM
7/16/2012 10:19:08 AM
87
Orbital Decompression, Transcaruncular

Medial Wall
FIG. 87.1. Place a speculum beneath the eyelids to expose

the medial canthus. Grasp the caruncle with a toothed
forceps and transect it along its mid-vertical line.
FIG. 87.2. With a Westcott scissors, extend the wound
several millimeters superiorly and inferiorly. Take care to
remain in the fornix so as not to injure the canaliculi.
FIG. 87.3. With a Steven scissors, spread the wound and
continue the dissection behind Horners muscle to the
posterior lacrimal crest.
Keep all dissection inferior to this level to avoid injury to the

cribriform plate.
FIG. 87.6. With the Freer elevator, fracture the lamina
papyracea outward. Then using a Kerrison rongeur, remove
the lamina and air cells of the ethmoid sinus. Alternatively,
we often place a moistened cottonoid sponge against the
lamina, and using the Freer, depress the thin bone into the
sinus.
FIG. 87.4. With a narrow malleable retractor, pull the orbital

tissues laterally to expose the medial orbital wall for a distance of about 2 cm behind the posterior lacrimal crest.
FIG. 87.7. Once hemostasis has been achieved, open medial

periorbita with slits above and below the medial rectus
muscle. With a blunt scissors, gently separate the interlobular
fascial membranes to allow the orbital fat to prolapse into the
exenterated sinus.
FIG. 87.5. Using a scalpel or periosteal elevator, make a

2-cm cut just behind the posterior lacrimal crest to expose
the lamina papyracea. Elevate periosteum off the medial wall
and carefully identify the anterior ethmoid foramen and artery.
FIG. 87.8. Reapproximate the caruncle with an interrupted

suture of 6-0 fast-absorbing plain gut, and repair the
conjunctival incision above and below with a running or
several interrupted sutures of the same material.
POSTOPERATIVE CARE AND POTENTIAL COMPLICATIONS: See care and complications as for Orbital
Decompression, Inferior and Medial Walls, p. 346.
290
7/12/2012 3:35:19 PM
CHAPTER 87 Orbital Decompression, Transcaruncular Medial Wall 291
FIG. 87.1
FIG. 87.5
FIG. 87.2
FIG. 87.6
FIG. 87.3
FIG. 87.7
FIG. 87.4
FIG. 87.8
7/12/2012 3:35:19 PM
88
Orbital Decompression, Transconjunctival

InferiorWall
FIG. 88.1. Place a 4-0 silk suture through the lower eyelid
margin and evert the lid over a Desmarres retractor. Make a
horizontal incision through the conjunctiva and capsulopalpebral
fascia with a scalpel blade 1 to 2 mm below the inferior tarsus.
FIG. 88.2. Using Westcott scissors, carry the dissection inferiorly between the orbital septum and the orbicularis muscle.
FIG. 88.3. Expose the inferior orbital rim from medial to
lateral to visualize the arcus marginalis. If extraconal fat is to
be removed, it can be dissected from the orbital oor and the
intermuscular septum and removed en bloc with cautery and
cutting.
FIG. 88.4. Using a scalpel blade, incise periosteum along
the orbital rim just outside the arcus. With a Freer dissector,
elevate periorbita from the orbital oor back for a distance
of about 3 to 4 cm. A small anastomotic vessel will often be
encountered extending from the inferior periorbita to the
infraorbital bundle. Cauterize this and cut it.
FIG. 88.5. Break a small hole through the maxillary bone
with a small hemostat or elevator medial to the infraorbital
canal. If possible, try not to tear the sinus mucosa to avoid

excessive bleeding.
FIG. 88.6. Expand the opening by removing additional bone
with a Kerrison rongeur. Extend this opening from the thicker
bone at the maxillary strut medially, to the infraorbital canal in
the central orbit. Take care not to injure the infraorbital nerve
or vessels. Similarly, make an opening through the oor lateral
to the infraorbital canal and remove bone to the lateral wall of
the maxillary sinus.
FIG. 88.7. Open the inferior periorbita with scissors by
making several slits medial and lateral to the inferior rectus
muscle to allow fat prolapse. Apply gentle pressure on the
globe with the eyelids closed to help further prolapse the fat
into the sinus. A spreading maneuver with scissors can help
tear the membranes between fat lobules.
FIG. 88.8. Reapproximate the periosteum along the orbital
rim with several interrupted sutures of 4-0 Vicryl. Close the
conjunctival incision with a running stitch of 6-0 fast-absorbing
plain gut.
292
7/12/2012 3:34:49 PM
CHAPTER 88 Orbital Decompression, Transconjunctival InferiorWall 293
FIG. 88.1
FIG. 88.5
FIG. 88.2
FIG. 88.6
FIG. 88.3
FIG. 88.7
FIG. 88.4
FIG. 88.8
7/12/2012 3:34:49 PM
89
Orbital Decompression, Lateral Wall

and extend it laterally within a lateral rhytid for a distance
of about 1 cm.
FIG. 89.5. Continue elevating periorbita toward the

superior orbital ssure. Here periorbita is more rmly
attached to bone.
FIG. 89.2. Incise the skin and orbicularis muscle with

scissors and cauterize any bleeding points.
FIG. 89.6. Retract the orbital contents medially with a

broad malleable retractor, and grind down the lateral wall
with a drill and diamond burr. Irrigate with water during
drilling to cool the bone. Remove bone to the level of marrow,
leaving the cranial table intact. If bleeding occurs, press some
bone wax onto the surface of the burred bone.
FIG. 89.3. Follow the orbital septum laterally to the orbital

rim, and expose the rim superiorly and inferiorly from the
frontozygomatic suture to the maxillozygomatic suture.
Incise the periosteum along the orbital rim just outside the
orbital septum with a scalpel blade and dissect periorbita from
the zygomatic bone with a Freer elevator.
FIG. 89.4. Using a malleable retractor and a dissector,
elevate periorbita along the lateral orbital wall onto the
greater wing of the sphenoid bone for a distance of about
35to 40mm.
FIG. 89.7. Remove the bone from the entire greater

sphenoid wing upward to the lacrimal gland fossa.
FIG. 89.8. Replace orbital tissues against the lateral wall
and close periosteum with interrupted 5-0 Vicryl sutures.
Close orbicularis muscle with interrupted stitches of 6-0 Vicryl
and the skin with interrupted and a running suture of 6-0
fast-absorbing gut.
294
7/12/2012 3:45:19 PM
CHAPTER 89 Orbital Decompression, Lateral Wall 295
FIG. 89.1
FIG. 89.5
FIG. 89.2
FIG. 89.6
FIG. 89.3
FIG. 89.7
FIG. 89.4
FIG. 89.8
7/12/2012 3:45:20 PM
90
Repair of Orbital Floor Fracture
INDICATIONS: Repair of any size blow-out fractures of the orbital floor associated with inferior rectus muscle entrapment
or significant enophthalmos; large floor fractures without entrapment or enophthalmos.
FIG. 90.1. Perform a forced traction test to determine

the degree of muscle entrapment. Proceed as for Orbital
Decompression Fig. 88.1 through 88.4 (pp. 350 to 351) to
expose the orbital oor. Visualize the anterior edge of the
fracture site and note the extent of incarceration of periorbita
and fascial tissues.
FIG. 90.2. If orbital tissues are incarcerated within bony
fragments, gently depress or elevate fragments of bone
while teasing periorbita and fat lobules free with a
periosteal elevator and microdissectors. Carefully separate
orbital tissues from the infraorbital nerve and vessels. Expose
the entire fracture site to its posterior limit if possible. Repeat
the forced traction test to conrm freedom of ocular motility.
FIG. 90.3. Cut a piece of Supramyd, Teon, Medpor, or other
implant material so it is large enough to overlap the defect
by at least 5 mm on all sides.
POSTOPERATIVE CARE: Place a light pressure dressing for 24 hours and apply iced compresses to the eyelids
intermittently for 24 hours after the dressing is removed.
Antibiotic ointment is applied to the suture line three to
four times daily for 7 days. Systemic antibiotics are prescribed for 1 week.
Visual lossThis is exceedingly rare unless the floor
exploration is carried too far to the orbital apex. Care
must be used in upward retraction of the globe and
pressure must be released intermittently. The implant
should not exceed 3.5 cm in anteroposterior depth
because longer implants may compress the optic nerve
posteriorly.
FIG. 90.4. If a full oor implant is used, drill a small hole

through the orbital rim and the front of the implant and
secure it into position with a 4-0 prolene suture to prevent
forward displacement.
FIG. 90.5. If a smaller implant is used, cut a ap on the
anterior edge and place the implant with the ap tongue
pushed into the defect to prevent anterior migration.
Repeat the forced traction test to be certain soft tissues have
not been trapped beneath the implant posteriorly.
FIG. 90.6. Close periosteum over the orbital rim with
interrupted 4-0 Vicryl sutures. Reform the lower eyelid
crease if necessary by xing orbicularis muscle to the orbital
septum with several 7-0 chromic stitches 4 mm below the
incision line.The skin wound is repaired with a running stitch
of 6-0fast-absorbing plain gut.
Motility restrictionThis may be caused by trapping of

orbital tissues beneath the implant posteriorly. Malleable retractors should be used to confirm tissue freedom
from around the implant, and the forced traction test
must be repeated after the implant has been positioned.
Entropion of the lower eyelidOccasionally the preseptal
orbicularis fails to fibrose to the underlying orbital septum
and eyelid retractors. This results in upward migration over
tarsus, producing an induced epiblepharon. Refixation of
preseptal orbicularis to deeper tissues will prevent this.
Migration of the floor implantWhen it displaces, the
implant usually migrates anteriorly and appears as a
bulge in the lower eyelid. This complication is minimized with proper fixation, either with a suture through
the rim or with flaps cut into the implant.
296
7/12/2012 3:47:06 PM
CHAPTER 90 Repair of Orbital Floor Fracture 297
FIG. 90.1
FIG. 90.4
FIG. 90.2
FIG. 90.5
FIG. 90.3
FIG. 90.6
7/12/2012 3:47:06 PM
91
Miniplate Fixation for Orbital Rim

Fracture
INDICATIONS: Realignment of displaced orbital rim or other bony fragments following fracture.
FIG. 91.1. Mark an incision line 2 mm below the lower eyelid

margin beginning 1 mm temporal to the inferior punctum
and extending laterally to the lateral canthal angle.
FIG. 91.2. Cut through the orbicularis muscle with scissors
to enter the postorbicular fascial plane.
FIG. 91.3. Separate the inferior orbicularis retaining
ligament from the orbital rim to elevate the orbicularis
muscle and supercial musculoaponeurotic system (SMAS)
off of the upper check for a distance of about 1 to 2 cm,
depending upon the extent of the fracture. Carefully identify
the infraorbital foramen and neurovascular bundle to avoid
injury to these structures.
FIG. 91.5. Continue the dissection as necessary to expose

the entire limit of the fractured bone pieces.
FIG. 91.6. Realign the fractured segments so that the
fractured margins are repositioned. Place an appropriately
sized and shaped miniplate across the fracture, drill pilot holes
as needed, and tighten screws into the holes. Place at least two
screws on either side of the fracture.
FIG. 91.7. Reapproximate the periosteum over the plate and
close it with interrupted sutures of 4-0 Vicryl.
FIG. 91.8. Close the skin incision with a running stitch of 6-0
fast-absorbing gut.
FIG. 91.4. Incise periosteum just anterior to the arcus

marginalis and elevate the periosteum from the underlying
bone anteriorly and posteriorly to expose the rim.
298
7/12/2012 3:47:50 PM
CHAPTER 91 Miniplate Fixation for Orbital Rim Fracture 299
FIG. 91.1
FIG. 91.5
FIG. 91.2
FIG. 91.6
FIG. 91.3
FIG. 91.7
FIG. 91.4
FIG. 91.8
7/12/2012 3:47:50 PM
92
Subperiosteal Orbital Volume

Augmentation
INDICATIONS: Correction of enophthalmos in the anophthalmic socket. With modification, the procedure may be used
in the presence of a seeing eye, but with extreme caution.
FIG. 92.1. Proceed as for Orbital Decompression Fig. 88.1

through 88.4 (pp. 350 to 351) to expose the orbital oor.
FIG. 92.2. Elevate periorbita off the orbital oor from the
inferior orbital ssure laterally to the maxillaryethmoid
suture medially, and posteriorly for a distance of about
3.5to 4 cm.
FIG. 92.3. Insert an orbital alloplastic implant or polyethylene sheets along the oor so its anterior edge sits behind
the orbital rim.
FIG. 92.5. If correcting enophthalmos in an orbit with

a seeing eye, use one or two 2-mm thick silastic or
polyethylene sheets, or strips of cancellous bone graft.
FIG. 92.6. If possible, close periorbita to periosteum over
the rim with interrupted 4-0 Vicryl sutures. Reform the
lower eyelid crease by xing orbicularis muscle to the orbital
septum or retractors with several interrupted 7-0 chromic
sutures 4 mm below the incision line. Reapproximate the skin
edges with interrupted stitches of 6-0 fast-absorbing plain gut.
FIG. 92.4. The implant may be stabilized by drilling a hole

through the orbital rim and implant, and securing it with a
4-0 prolene suture.
POSTOPERATIVE CARE: Place a pressure dressing over

the orbit for 24 hours. Apply antibiotic ointment to the
Extrusion of the implantAlloplastic subperiosteal
implants tend to displace anteriorly unless firmly
anchored into position. It is unwise to rely upon periosteal closure alone to secure the implant. If minimal
displacement does occur, it may not require repair.
However, protrusion into the lower eyelid will necessitate repositioning and refixation.
Muscle imbalanceWhen volume augmentation is performed on a socket with a seeing eye, displacement of
the inferior oblique and rectus muscles may result in
postoperative diplopia and hyperophthalmia. This usually resolves after several months. If it does not, the
implant may have to be removed or strabismus surgery
performed.
300
7/12/2012 3:49:16 PM
CHAPTER 92 Subperiosteal Orbital Volume Augmentation 301
FIG. 92.1
FIG. 92.4
FIG. 92.2
FIG. 92.5
FIG. 92.3
FIG. 92.6
7/12/2012 3:49:16 PM
SECTION
Enucleation, Evisceration,
andExenteration
R
emoval of the eye may be indicated for extensive trauma,

for intraocular malignancy, for uncontrolled pain in an
eye with no vision, or for a cosmetically disfigured blind globe.
Enucleation is usually performed under general anesthesia
because of the psychologic stress involved in the loss of an eye.
However, it can be done under local retrobulbar anesthesia
without difficulty. Even when performed under general anesthesia, retrobulbar anesthetic injection containing epinephrine significantly reduces bleeding during the procedure and
reduces the incidence of the oculocardiac reflex. In all cases,
the pathologic process should be confirmed visually before
surgery. For intraocular lesions, such as malignant melanoma,
the pupil must be dilated and the lesion observed before surgery to avoid the catastrophic consequences of removing the
wrong eye.
In enucleation for intraocular malignancy, the risk
of intraoperative dissemination of tumor cells remains
unknown. Nevertheless, a minimal-touch technique has
been advocated and should be used for all eyes that contain
malignancies. In this modification, the extraocular muscles are gently cut free at their insertions without hooking
because the latter step is associated with excessive elevation of intraocular pressure. If the check ligaments are not
stripped, the muscles will not retract but remain attached
to anterior Tenons capsule. The muscles can easily be
retrieved after removal of the globe, sutured to Tenons,
or attached to an ocular implant. The optic nerve is not
clamped before cutting. If minimal extrascleral extension
is noted, a posterior tenonectomy is performed.
In most cases, a primary ocular implant is placed into
the enucleated socket. This procedure is necessary to
restore orbital volume. Acrylic or silicone spheres have
given consistent results with few complications. However, over the past several decades, the biointegrated
porous implants have gained in popularity and represent
the major implant types in use today. We prefer to placethe
ocular implant within Tenons capsule in the same anatomic
space occupied by the globe. It is rarely necessary to place
the implant behind posterior Tenons capsule as a primary
procedure. With careful wound closure and absence of tension, implant extrusion is uncommon. An implant should
not be inserted in the presence of orbital infection or
trauma with foreign matter contamination. In such cases,
Tenons and conjunctiva should be closed primarily, and a
secondary implant placed at a later date.
Early exposure of the ocular implant is associated with
poor wound closure and the use of an oversized implant,
causing wound tension. Infection and hematoma also
contribute to exposure. Implant migration resulting in

poor prosthetic fit results in erosion of conjunctiva and
Tenons, with eventual exposure. Except in cases of infection or tumor recurrence in the orbit, an exposed implant
should be replaced with a secondary implant of smaller
size. The smaller implant may be covered with donor sclera
or autogenous fascia and placed behind posterior Tenons
for added support.
Although the nonporous spheres are associated with
a low complication rate, they provide only limited prosthetic motility in most patients. Several types of integrated
implants have been introduced since 1985 to increase
motility, including coralline hydroxyapatite, porous polyethylene, and aluminum oxide. Extraocular muscles are
attached, and a peg can be placed some months after
surgery that couples with the overlying prosthesis. This
arrangement gives superior prosthetic motility. However,
peg-related complications have been reported in 20% to
60% of cases, so that fewer than 8% of porous implants are
currently being pegged in the United States and the United
Kingdom. Studies have shown that prosthetic motility of
unpegged porous implants is not any better than for nonporous implants. This has led some authors to question the
value of using porous implants, given their greater cost and
the increased preparation time.
The use of a dermis-fat graft as a primary implant following enucleation is advocated by some. Loss of graft
volume is less after primary than after secondary implantation; nevertheless, fat atrophy over time is common. In
children, however, orbital fat grafts may show growth over
time. This procedure requires a separate incision for harvesting the graft. Dermis-fat implantation finds its greatest
value where there is insufficient conjunctiva and Tenons
capsule to allow complete closure over a standard implant.
It should not be used in any orbit with compromised vascular supply, such as after severe trauma, or irradiation,
because the risk of graft atrophy and loss is significantly
increased.
The fitting of a custom-molded ocular prosthesis following enucleation is a procedure equal in importance to the
surgery itself. The surgeon must develop a close working
relationship with an ocularist, and both must remain active
in the continuing care of the patient. Six weeks are generally allowed for healing and resolution of edema before
prosthetic fitting.
Evisceration of the globe differs from enucleation in that
the patients scleral shell and attached extraocular muscles
are left intact, but the intraocular contents are removed.
302
7/16/2012 9:33:07 AM
SECTION D Enucleation, Evisceration, andExenteration 303

Although the cornea may be left in place, its preservation may be associated with chronic ocular surface pain.
Weprefer removal of the cornea, which also allows more
room for a deeper prosthesis and more natural-appearing
anterior chamber depth. Evisceration has the advantage of
giving good cosmetic results and excellent motility. The
risk of postoperative enophthalmos is less because there is
little trauma to orbital fat. Larger implants can be placed
for restoration of volume if the posterior sclera is opened
with several full-thickness slits to allow it to gape.
The significant disadvantage of evisceration is the
largely theoretic consideration of sympathetic ophthalmia induced in the contralateral eye. In numerous studies, the incidence of sympathetic ophthalmia following
the modern technique of evisceration is not significantly
higher than with enucleation. Nevertheless, the patient
must be informed of the possible risk of sympathetic with
this operation. Some cases of unsuspected intraocular
malignancy following evisceration have been reported.
In most cases, these predated the availability of ophthalmic ultrasound, and for later cases, most patients were
either not imaged or the surgeon disregarded intraocular abnormalities suggestive of tumor. Nevertheless, this
risk, although very small, must be kept in mind. Evisceration should not be considered in a patient with opaque
media without adequate imaging. In most cases, evisceration is an appropriate alternative to enucleation. It has
been considered the procedure of choice in the presence
of endophthalmitis to prevent orbital contamination and
bacterial access to the subarachnoid space with potential
for meningitis.
Exenteration is a radical procedure in which part or all
of the orbital soft tissues are removed. It is used primarily for life-threatening disease processes not treatable by
more conservative methods, such as primary malignant
tumors of the conjunctiva and eyelids that involve deeper
orbital tissues. Some orbital tumors previously treated
with exenteration, such as rhabdomyosarcoma, are more
successfully managed with chemotherapy and radiotherapy. Nonmalignant diseases, such as orbital mucormycosis, can be managed medically in selected cases but may
also require exenteration when diffuse or associated with
extensive orbital necrosis. Patients who have severe proptosis and orbital pain from diffuse lymphangiomas or
other benign tumors may also benefit from exenteration
for control of symptoms.
In standard exenteration techniques, the eyelids and all
orbital soft tissues are removed as a unit, leaving the bare
bony socket. In some cases, such as adenoid cystic carcinoma of the lacrimal gland, resection of adjacent bone may
be necessary for complete excision of the tumor. Limited
forms of exenteration also have been utilized. In some
cases, this is no more than an extended enucleation with
removal of conjunctiva, some orbital fat and portions of
extraocular muscles. This procedure is particularly useful
for anterior or ocular surface malignancies. The cosmetic
results are less devastating than with the radical procedure,

and the recovery time is shortened significantly. Other procedures attempt to salvage the eyelids while removing all
other orbital tissues. This type of approach adds little to the
final cosmetic result. However, preservation of upper and
lower eyelid skin, if not involved in the pathologic process,
is useful to help cover the orbital defect and aid in more
rapid healing.
Attempts to fill the exenterated socket with alloplastic implants or transposed temporalis muscle have been
proposed but may only mask deep recurrences of tumor.
It is best to cover the bony socket with a split-thickness
skin graft, which allows rapid healing yet is thin enough so
any recurrent tumor may be seen early. Alternatively, the
socket may be allowed to spontaneously granulate and epithelialize over several months. An oculofacial prosthesis
may be fitted after healing is complete.
Enucleation
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Chalasani R, Poole-Warren L, Conway RM, Ben-Nissan B. Porous orbital
implants in enucleation: a systematic review. Surv Ophthalmol.
2007;52:145155.
Custer PL. Enucleation: past, present, and future. Ophthal Plast Reconstr
Surg. 2000;16:316321.
Custer PL, Trinkaus KM. Porous implant exposure: incidence, management, and morbidity. Ophthal Plast Reconstr Surg. 2007;23:17.
Frueh BR, Felker GV. Baseball implant, a method of secondary insertion
of an intraorbital implant. Arch Ophthalmol. 1976;94:429430.
Jordan DR, Klapper SR. Surgical techniques in enucleation: the role of
various types of implants and the efficacy of pegged and nonpegged
approaches. Int Ophthalmol Clin. 2006;46:109132.
McCord CD Jr. The extruding implant. Trans Acad Ophthalmol Otolaryngol. 1976;81:OP587OP590.
Migliori ME. Enucleation versus evisceration. Curr Opin Ophthalmol.
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Moshfeghi DM, Moshfeghi AA, Finger PT. Enucleation. Surv Ophthalmol. 2000;44:277301.
Sami D, Young S, Petersen R. Perspective on orbital enucleation implants.
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87:196197.
Wells TS, Harris GJ. Direct fixation of extraocular muscles to a silicone
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Dermis-Fat Graft
Aguilar GL, Shannon GM, Flanagan JC. Experience with dermis-fat grafting: an analysis of early postoperative complications and methods of
prevention. Ophthal Surg. 1982;13:204209.
Bengoa-Gonzlez A, Dolores Lago-Llins M, et al. The use of autologous dermis grafts for the reconstruction of the anophthalmic socket.
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Guberina C, Hornblass A, Meltzer MA, et al. Autogenous dermis-fat
orbital implantation. Arch Ophthalmol. 1983;101:15861590.
Lee MJ, Khwarg SI, Choung HK, et al. Dermis-fat graft for treatment of
exposed porous polyethylene implants in pediatric postenucleation
retinoblastoma patients. Am J Ophthalmol. 2011;152:244250.
Lisman RD, Smith BC. Dermis-fat grafting. In: Smith BC, Delia Rocca RC,
Nesi FA, Lisman RD, eds. Ophthalmic Plastic Reconstructive Surgery.
St. Louis, MO: Mosby-Year Book; 1987.
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Migliori ME, Putterman AM. The domed dermis-fat graft orbital implant.
Nunery WR, Hetzler KJ. Dermal-fat graft as a primary enucleation technique. Ophthalmology. 1985;92:12561261.
Przybyla VA, LaPiana FG, Bergin DJ. Fitting of the dermis-fat grafted
socket. Ophthalmology. 1981;88:904907.
Smith B, Bosniak S, Lisman R. An autogenous kinetic dermis-fat graft
for orbital implant: an updated technique. Ophthalmology. 1982;89:
10671071.
Smith B, Bosniak S, Nesi F, Lisman R. Dermis-fat orbital implantation,
118 cases. Ophthal Surg. 1983;14:941943.
Evisceration
Berens C, Breakey AS. Evisceration utilizing an intrascleral implant. Br J
Ophthalmol. 1960;44:665671.
Bernardino CR. Evisceration vs. enucleation. Ophthalmology. 2007;114:
1959.
Brown SM. Evisceration of blind, painful eyes with occult uveal melanoma
not a crime. Arch Ophthalmol. 2009;127:12281229.
Eagle RC Jr, Grossniklaus HE, Syed N, et al. Inadvertent evisceration of eyes
containing uveal melanoma. Arch Ophthalmol. 2009;127:141145.
Georgescu D, Vagefi MR, Yang CC, et al. Evisceration with equatorial sclerotomy for phthisis bulbi and microphthalmos. Ophthal Plast Reconstr Surg. 2010;26:165167.
Goisis M, Guareschi M, Miglior S, Giann AB. Evisceration vs. enucleation. Ophthalmology. 2007;114:1960.
Green WR, Maumenee AE, Sanders TE, Smith ME. Sympathetic uveitis following evisceration. Trans Am Acad Ophthalmol Otolaryngol.
1972;76:625644.
Huang D, Yu Y, Lu R, et al. A modified evisceration technique with scleral
quadrisection and porous polyethylene implantation. Am J Ophthalmol. 2009;147:924928.
Jordan DR, Khouri LM. Evisceration with posterior sclerotomies. Can J
Ophthalmol. 2001;36:404407.
Kostick DA, Linberg JV. Evisceration with hydroxyapatite implant.
Surgical technique and review of 31 case reports. Ophthalmology.
1995;102:15421548.
Massry GG, Holds JB. Evisceration with scleral modification. Ophthal
Park YG, Paik JS, Yang SW. The results of evisceration with primary
porous implant placement in patients with endophthalmitis. Korean
J Ophthalmol. 2010;24:279283.
Perry JD, Lewis CD, Levine M. Evisceration after complete evaluation; an
acceptable option. Arch Ophthalmol. 2009;127:12271228.
Ruedemann AD Jr. Sympathetic ophthalmia after evisceration. Trans Am
Sales-Sanz M, Sanz-Lopez A. Four-Petal evisceration: an new technique.
Tawfik HA, Budin H. Evisceration with primary implant placement in
patients with endophthalmitis. Ophthalmology. 2007;114:11001103.
Tawfik HA, Dutton JJ. Primary peg placement in evisceration with the
spherical porous polyethylene orbital implant. Ophthalmology.
2004;111:14011406.
Exenteration
Ben Simon GJ, Schwarcz RM, Douglas R, et al. Orbital exenteration: one
size does not fit all. Am J Ophthalmol. 2005;139:1117.
Coston TO, Small RG. Orbital exenteration simplified. Trans Am
Gass JDM. Technique of orbital exenteration utilizing methylmethacrylate implant. Arch Ophthalmol. 1969;82:789791.
Goldberg RA, Kim JW, Shorr N. Orbital exenteration: results of an individualized approach. Ophthal Plast Reconstr Surg. 2003;19:229236.
Levin PS, Dutton JJ. A 20-year series of orbital exenteration. Am J Ophthalmol. 1991;112:496501.
Mohr C, Esser J. Orbital exenteration: surgical and reconstructive strategies. Graefes Arch Clin Exp Ophthalmol. 1997;235:288295.
Nemet AY, Martin P, Benger R, et al. Orbital exenteration: a 15-year study
of 38 cases. Ophthal Plast Reconstr Surg. 2007;23:468472.
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Manchester experience. Br J Ophthalmol. 2005;89:13351340.
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Spaeth EB. Information learned from fifty years of orbital exenteration.
Trans Ophthalmol Soc UK. 1971;91:611634.
Tyers AG. Orbital exenteration for invasive skin tumours. Eye. 2006;20:
11651170.
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152153.
Exposed Ocular Implant

Baylis H, Schorr N. Correction of problems of the anophthalmic socket.
In: McCord CD Jr, ed. Oculoplastic Surgery. New York: Raven Press;
1981.
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hydroxyapatite orbital implants. Ophthalmology. 1994;101:17091715.
Lee BJ, Lewis CD, Perry JD. Exposed porous orbital implants treated with
simultaneous secondary implant and dermis fat graft. Ophthal Plast
Martin P, Ghabrial R. Repair of exposed hydroxyapatite orbital implant by
a tarsoconjunctival pedicle flap. Ophthalmology. 1998;105:16941697.
Massry GG, Holds JB. Frontal periosteum as an exposed orbital implant
cover. Ophthal Plast Reconstr Surg. 1999;15:7982.
McCord CD Jr. The extruding implant. Trans Am Acad Ophthalmol Otolaryngol. 1976;81:OP587OP590.
Pelletier CR, Jordan DR, Gilberg SM. Use of temporalis fascia for
exposed hydroxyapatite orbital implants. Ophthal Plast Reconstr Surg.
1998;14:198203.
Sagoo MS, Rose GE. Mechanisms and treatment of extruding intraconal
implants: socket aging and tissue restitution (the Cactus Syndrome).
Soll DB. Donor sclera in enucleation surgery. Arch Ophthalmol. 1974;
92:494495.
Soll DB. The use of sclera in surgical management of extruding implants.
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Tawfik HA, Budin H, Dutton JJ. Repair of exposed porous polyethylene
implants utilizing flaps from the implant capsule. Ophthalmology.
2005;112:516523.
Wang JK, Liao SL, Lai PC, Lin LL. Prevention of exposure of porous orbital
implants following enucleation. Am J Ophthalmol. 2007;143:6167.
Wu AY, Vagefi MR, Georgescu D, et al. Enduragen patch grafts for exposed
orbital implants. Orbit. 2011;30:9295.
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7/16/2012 9:33:08 AM
93
Enucleation with Primary Acrylic or

Silicone Implant
INDICATIONS: Removal of the eye for chronic pain, traumatic disruption, endophthalmitis, intraocular malignancy, or
cosmetic improvement of a blind, disfigured eye.
FIG. 93.1. Place an eyelid speculum beneath the lids to

expose the globe. Tent up the conjunctiva with forceps and
make a small cut with scissors near the corneal limbus.
FIG. 93.6. Identify and expose the insertions of the rectus

muscles but do not strip the intermuscular septum or
check ligaments for more than 3 to 4 mm.
FIG. 93.2. Insert the closed scissors into the subconjunctival

space parallel to the limbus and gently spread the blades to
bluntly dissect conjunctiva from sclera.
FIG. 93.7. Place a muscle hook beneath the insertion of the

medial rectus muscle. Weave the needle of a double-armed
6-0 Vicryl suture through the muscle tendon 4 mm from its
insertion, and tighten with a locking stitch on each side. Cut
the muscle from the globe, leaving 3 mm of tendinous stump
attached to sclera for traction. Place the muscle hook beneath
the insertion of the lateral rectus muscle and pass a suture
through the tendon near the sclera. Cut the muscle from sclera
close to its insertion.
FIG. 93.3. Remove the scissors and reinsert one blade

beneath conjunctiva. Make a cut to separate conjunctiva
from its limbal attachments.
FIG. 93.4. Continue to bluntly separate conjunctiva from
sclera, and then cut it from around the limbus for 360
degrees.
FIG. 93.5. Insert the closed blades of the scissors along the
sclera in each of the four quadrants between the rectus
muscles and bluntly separate conjunctiva and Tenons from
sclera with a spreading motion to the equator of the globe.
FIG. 93.8. Pass the two arms of the lateral rectus muscle
suture through anterior Tenons capsule 5 mm from the
lateral canthal angle and tie the ends on the conjunctival
surface. In similar fashion, suture the medial rectus muscle to
Tenons capsule.
306
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CHAPTER 93 Enucleation with Primary Acrylic or Silicone Implant 307
FIG. 93.1
FIG. 93.5
FIG. 93.2
FIG. 93.6
FIG. 93.3
FIG. 93.7
FIG. 93.4
FIG. 93.8
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308 SECTION D Enucleation, Evisceration, andExenteration

FIG. 93.9. The superior and inferior rectus muscles can be sutured in similar fashion or
cut from the globe without a xation suture. If enucleation is performed for an intraocular
tumor, do not hook any of the muscles. Gently grasp each of the four muscles with a forceps
one at a time without applying excessive traction and cut them from sclera with scissors.
FIG. 93.10. Grasp the medial rectus muscle stump with sturdy toothed forceps.
Pull the globe upward and rotate it laterally. Pass an enucleation or Metzenbaum
scissors behind the globe on the medial side and swing the scissors tip back and forth
to identify the optic nerve. The nerve is felt as a tense cord that extends back from the
posterior surface of the globe 180 degrees from the central cornea.
FIG. 93.11. As the tip of the scissors passes over the optic nerve, open the blades
enough to pass around the nerve, but not so much to include orbital fat and
other structures. Push the tips of the scissors toward the lateral orbit to ensure a
complete cut and then slide it backward toward the apex so the nerve is transected
at least 4 to 5 mm behind the globe. Maintain forward traction on the globe and
cut through the optic nerve with one stroke. If the eye contains a retinoblastoma or
perioptic melanoma, cut the nerve at least 10-15 mm behind the globe.
FIG. 93.12. As the nerve is being severed, the globe will lift partially out of the
orbit. Cut the superior and inferior oblique muscles from sclera at their attachments
and remove the globe.
FIG. 93.13. Quickly pack the orbit with cottonoid strips soaked in local anesthetic
with epinephrine and apply digital pressure for several minutes. Slowly remove
the packs and directly cauterize any residual bleeding points. Several malleable
retractors will facilitate exposure.
FIG. 93.14. Place an 18- to 22-mm acrylic or silicone sphere into the orbital
cavity. Placement of the ocular implant is facilitated with an introducer. It is not
necessary to open the posterior Tenons capsule.
FIG. 93.15. Close anterior Tenons capsule with interrupted 5-0 Vicryl sutures. Do
not leave any visible gaps. There should not be any tension across the wound.
FIG. 93.16. Grasp the edges of conjunctiva at the medial and lateral extents of
the wound and gently pull the edges outward to dene the conjunctival margins.
Close conjunctiva with a running stitch of 6-0 plain gut.
POSTOPERATIVE CARE: Place a medium-size plastic

conformer, coated on its inside surface with antibiotic
ointment, under the eyelids. Apply a firm dressing over
the orbit for 48 hours. Apply antibiotic ointment to the
inferior fornix three to four times daily after the dressing
is removed and continue for two weeks. A custom-made
prosthesis may be fitted after 6 weeks.
Orbital hemorrhagePostoperative orbital bleeding may
be from the central retinal artery, the cut extraocular
muscles, or vessels within the orbital fat. A retrobulbar
hemorrhage usually reabsorbs after several weeks.
Displacement or extrusion of ocular implantMinor
displacement of the implant usually requires no treatment except for modification of the prosthesis. Early
extrusion is most commonly caused by too large an
implant with tension on Tenons or conjunctiva, or by
poor wound closure. If extrusion does occur, allow

the socket to heal and place a secondary implant
later.
PtosisUpper eyelid ptosis is typical following enucleation or orbital surgery. It usually resolves over several
weeks. If persistent after 3 months, it can be repaired by
levator aponeurosis advancement.
Shallow fornicesThis may result from too tight an
imbrication of Tenons during closure or from loss of
fornix fixation. It may be repaired by placement of double-armed 4-0 chromic fornix sutures through conjunctiva, periosteum of the orbital rim, and out through the
eyelid skin to reform the inferior fornix.
EnophthalmosLoss of orbital fat from trauma, previous orbital surgery, or progressive atrophy may result
in postoperative enophthalmos. If minimal, this is corrected by enlarging the prosthesis. If significant, however, orbital volume augmentation is needed.
7/16/2012 9:33:15 AM
CHAPTER 93 Enucleation with Primary Acrylic or Silicone Implant 309
FIG. 93.9
FIG. 93.13
FIG. 93.10
FIG. 93.14
FIG. 93.11
FIG. 93.15
FIG. 93.12
FIG. 93.16
7/16/2012 9:33:15 AM
94
Enucleation with Biointegrated Porous

Ocular Implant
INDICATIONS: As a primary ocular implant following enucleation or evisceration, or as a secondary implant when
improved prosthetic mobility is desired. Also, following multiple extrusions where stabilization of the implant is necessary.
FIG. 94.1. Proceed as for standard enucleation, Fig. 93.1

through 93.13 (pp. 366 to 369), except place a double-armed
6-0 Vicryl suture through all four rectus muscles. If the
enucleation is performed for intraocular tumor, gently cut the
muscles from the slcera without hooking and place sutures after
the eye is removed.
FIG. 94.2. If the implant is to be covered with sclera, prepare an enucleated donor scleral shell by making two
relaxing incisions 180 degrees apart. Place a 20-mm porous
implant into the shell and close the incisions with a running
5-0 Vicryl suture. Newer implants, such as hydroxyapatite and
aluminum oxide, can be purchased prewrapped. Porous polyethylene implants do not have to be wrapped.
FIG. 94.3. With the optic nerve stump facing forward, cut
four 2 by 3 mm windows in the scleral shell. Place these
windows 90 degrees apart and 4 to 6 mm from the center
of the optic nerve stump. Optionally, drill a 1-mm diameter
hole to the center of the implant at each window and at the
posterior corneal defect for vascularization.
FIG. 94.4. Using an introducer, place the implant into
the enucleated socket. Turn the implant to align the scleral
POSTOPERATIVE CARE: Place antibiotic ointment into

the socket and fit a medium- to large-size conformer
beneath the eyelids. Place a firm dressing for 48 hours.
After the dressing is removed, apply antibiotic ointment to
the socket three to four times daily for 2 weeks. A custom
prosthesis is fitted after 6 weeks.
POTENTIAL COMPLICATIONS: All the complications
seen with standard enucleation may also be seen in this
procedure. In addition:
windows with the rectus muscles. Attach each muscle to the

anterior lip of its respective window, using the previously
placed 6-0 Vicryl suture. With porous polyethylene spheres
pass the sutures through the pre-existing tunnels.
FIG. 94.5. Close Tenons capsule with interrupted 5-0 Vicryl
stitches and the conjunctiva with a running suture of 6-0
plain gut.
FIG. 94.6. If the implant is to be pegged, allow 6 to
12months for complete vascularization. Mark the center
of the implant in primary position and inject 0.1 mL of local
anesthetic beneath conjunctiva at this point. Excise a small
window of conjunctiva and Tenons 2 to 3 mm in diameter to
expose the implant.
FIG. 94.7. Stabilize the implant with forceps. Using a 4-mm
cutting burr on a rotary drill or graded 18- to 14-gauge needles,
cut a radially aligned hole 9 mm deep to the center of the
implant.
FIG. 94.8. Screw a titanium peg provided with the implant
into the hole. The prosthesis will have to be modied with a
matching posterior depression to accept the peg.
Granulation tissue in the motility peg holeThis occurs
with excessive irritation around the peg. It may be
removed by excision or a CO2 laser. Application of topical steroid ointment may retard regrowth.
Poor motilityThis is seen mostly in secondary implants,
where the rectus muscles are contracted or scarred.
Final motility is limited by the status of the extraocular
muscles and is usually better in the horizontal direction.
310
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CHAPTER 94 Enucleation with Biointegrated Porous Ocular Implant 311
FIG. 94.1
FIG. 94.5
FIG. 94.2
FIG. 94.6
FIG. 94.3
FIG. 94.7
FIG. 94.4
FIG. 94.8
7/12/2012 3:52:57 PM
95
Dermis-fat Orbital Implant Graft
INDICATIONS: As a primary ocular implant following enucleation especially in children, or as a secondary implant after
implant exposure with partial loss of conjunctiva and Tenons capsule.
FIG. 95.1. For a primary implant, proceed as for standard

enucleation, as described in Fig. 93.1 through 93.13
(pp. 366 to369), except place 6-0 Vicryl xation sutures
through the tendons of all four rectus muscles before
enucleating the globe. Open posterior Tenons capsule widely
to expose the intraconal fat compartment.
FIG. 95.2. For a secondary implant, proceed with removal
of the exposed sphere. If possible, identify the four rectus
muscles and pass a 6-0 Vicryl suture through the tendon of
each. Do not risk injury to the muscles if not easily done; their
brotic attachment to Tenons will provide motility.
FIG. 95.3. Mark the donor site on the posterior hip or
abdomen. Draw a circle 20 mm in diameter and extend it into
an ellipse for easier closure.
FIG. 95.5. Cut around the exposed dermis with a scalpel and
extend the cut through the underlying fat to the level of the
muscular fascia.
FIG. 95.6. Transfer the graft to the recipient orbit. Pass both
arms of the preplaced 6-0 Vicryl suture on the medial rectus
muscle through one edge of the dermis plug and tie it down.
Suture the conjunctiva and Tenons adjacent to the muscle to
the dermis graft with interrupted stitches of 6-0 Vicryl.
FIG. 95.7. Continue placing sutures around the graft
perimeter inferiorly and superiorly, gently pushing the fat
into the orbit as you go. As each rectus muscle is approached,
suture it to the dermis plug. If muscle were not retrieved, just
suture the graft to Tenons. Before closing the lateral quadrant,
if the graft volume appears too large, excise some of the fat.
FIG. 95.4. With a scalpel blade, incise the skin along the
marked line. Dissect the epidermis from underlining dermis
with a scalpel blade or scissors.
FIG. 95.8. Close the donor site by cutting the marked

triangular segments from the edges to form an ellipse.
Undermine along the deep fascia and close subcutaneous
tissues with interrupted 4-0 Vicryl stitches. Reapproximate the
dermis with interrupted 4-0 Vicryl sutures and close the skin
with vertical mattress sutures of 4-0 prolene.
POSTOPERATIVE CARE: Place antibiotic ointment and

a conformer on the conjunctiva, and tape a dressing over
the orbit for 48 hours. After removal of the dressing, apply
antibiotic ointment to the graft three to four times daily
until completely epithelialized. Systemic antibiotics are
administered for 10 days. Remove the donor site skin
sutures after 14 days.
Volume lossGraft shrinkage from fat atrophy is usual

but is increased with traumatic manipulation during
surgery or from poor vascular supply in the host bed.
Atrophy is a more significant problem in secondary
implants than in primary procedures.
Hair growth and conjunctival irritationGrowth of hair
from the dermis graft may remain subconjunctival or
extend through it, causing chronic socket irritation. Electroepilation may be needed for elimination of offending hairs.
Prosthetic revisionBecause of progressive fat atrophy,
repeated modification of the prosthesis may be required
in some cases.
Graft failureTotal graft failure is uncommon but
may be seen where vascular supply is compromised
such as after irradiation or in cases of severe socket
contracture.
312
7/12/2012 3:56:04 PM
CHAPTER 95 Dermis-fat Orbital Implant Graft 313
FIG. 95.1
FIG. 95.5
FIG. 95.2
FIG. 95.6
FIG. 95.3
FIG. 95.7
FIG. 95.4
FIG. 95.8
7/12/2012 3:56:04 PM
96
Repair of the Exposed Ocular Implant
INDICATIONS: Exposure of an ocular implant after enucleation or evisceration without significant loss of Tenons
capsule or conjunctiva.

the conjunctiva and exposed implant. With scissors, make
a cut medially and laterally through conjunctiva and Tenons
capsule into the cavity holding the implant.
FIG. 96.2. Hold the edges of Tenons capsule apart with
forceps and remove the implant with forceps.
FIG. 96.3. Because it may be difficult to identify
epithelialization that may have occurred around the
extruding implant, completely excise the brous capsule
lining the implant cavity. Create a fresh edge around the
opening of conjunctiva and Tenons capsule by excising a
narrow strip of tissue.
FIG. 96.4. Open posterior Tenons with scissors, using a
spreading motion to expose the intraconal orbital fat. If
Tenons capsule is inadequate to cover the new implant, use a
smaller implant or convert to a dermis-fat graft implantation.
POSTOPERATIVE CARE: Place a conformer beneath the

eyelids. Apply a firm dressing for 24 hours. Place antibiotic ointment under the lids three to four times daily for 7
days. A new prosthesis will need to be fitted after 6 weeks.
Orbital hemorrhageDissection into the intraconal
space carries the risk of injury to deep orbital vessels. As
with enucleation, hemostasis and a firm postoperative
dressing are important.
FIG. 96.5. Place a new implant into the orbit behind

posterior Tenons capsule. If the previous implant has been
exposed for a while, irrigate the socket with 10 cc of antibiotic
solution. In the presence of frank orbital infection, do not place
a secondary implant for at least several months after resolution
of the problem.
FIG. 96.6. Close posterior Tenons capsule with interrupted
5-0 Vicryl stitches.
FIG. 96.7. Approximate the edges of anterior Tenons
capsule with 5-0 Vicryl sutures. If Tenons is thinned or
absent, a graft of autogenous temporalis fascia or epicranium
can be placed over the implant to serve as a buffer between
the implant and conjunctiva.
FIG. 96.8. Close conjunctiva with a running suture of 6-0
plain gut.
Shallow fornicesNecrosis and loss of Tenons capsule

and conjunctiva over the central part of the extruding
implant may make closure difficult without shortening the fornices. In such cases, a dermis-fat graft is a
more appropriate procedure. If inadequate fornices are
noted postoperatively, a mucous membrane graft may
be placed at a later date.
314
7/12/2012 3:57:58 PM
CHAPTER 96 Repair of the Exposed Ocular Implant 315
FIG. 96.1
FIG. 96.5
FIG. 96.2
FIG. 96.6
FIG. 96.3
FIG. 96.7
FIG. 96.4
FIG. 96.8
7/12/2012 3:57:58 PM
97
Evisceration
INDICATIONS: For removal of a blind painful, or cosmetically undesirable eye from trauma, end-stage disease, or
endophthalmitis.
CONTRAINDICATIONS: The presence of any intraocular malignancy.

the globe. Perform a 360-degree peritomy of conjunctiva and
Tenons capsule with scissors, using blunt and sharp dissection.
Bluntly undermine Tenons capsule from the underlying sclera
to the level of the rectus muscle insertions.
FIG. 97.2. With a scalpel blade, make an incision into sclera
2-3 mm behind the corneal limbus. Extend the incision
around 360 degrees, cutting to the level of the suprachoroidal
space. Take care not to enter the anterior chamber or to cut
through the choroid.
FIG. 97.5. Cauterize the central retinal artery and the vortex
veins. Use a suction catheter for visualization.
FIG. 97.6. Scrub the inside of the scleral shell with
cotton-tipped applicators soaked in 100% alcohol to
remove all traces of uvea. Irrigate the shell copiously several
times with saline solution.
FIG. 97.3. Separate the choroid from sclera with an evisceration

spoon and continue the dissection back to the optic nerve.
Mild bleeding will be encountered from the vortex veins.
FIG. 97.7. Make a cut through the sclera superonasally and

inferotemporally for a distance of about 1 cm. Insert a 14- to
16-mm diameter nonporous sphere into the shell. There should
be no tension on the scleral edges on attempted closure.
A larger implant of 18-20 mm can be used if the posterior
sclera is incised around the optic nerve and several relaxing
incisions are made to gape the scleral shell.
FIG. 97.4. With the evisceration spoon, transect the uvea

from the optic nerve head as close as possible to the
sclera and remove the intraocular contents, including the
attached cornea, in one piece.
FIG. 97.8. Close the scleral wound with interrupted 5-0

Vicryl sutures. Trim any dog-ears at the extremities of the
scleral incisions. Close Tenons with 5-0 Vicryl stitches and
conjunctiva with a running stitch of 6-0 plain gut.
POSTOPERATIVE CARE: Place a conformer beneath the

lids. Apply a pressure bandage over the orbit for 24 hours.
Apply an antibiotic ointment three to four times daily for 7
days. A custom prosthesis is fitted after 6 weeks.
can be resected or the eviscerated shell can be enucleated and a secondary ocular implant placed.
Sympathetic ophthalmiaThe true incidence of this
disease with modern evisceration techniques remains
unknown but is exceedingly rare and may not be much
higher than with enucleation. However, evisceration
should be undertaken only with informed consent after
penetrating injuries with uveal prolapse. Treatment of
sympathetic ophthalmia is medical, with use of systemic
steroids.
Wound dehiscenceAs with enucleation, this results
most commonly from poor wound closure or the
placement of too large an implant. Early dehiscence
is repaired immediately, replacing the implant with a
smaller size if necessary.
Chronic painThis may be seen after evisceration with
retention of the cornea. When intractable, the cornea
316
7/12/2012 4:02:20 PM
CHAPTER 97 Evisceration 317
FIG. 97.1
FIG. 97.5
FIG. 97.2
FIG. 97.6
FIG. 97.3
FIG. 97.7
FIG. 97.4
FIG. 97.8
7/12/2012 4:02:20 PM
98
Orbital Exenteration
INDICATIONS: Removal of the orbital contents for control of ocular and adnexal malignancies, for eradication of uncontrolled Mucor orbital cellulitis, for severe orbital contracture, for painful infiltrative benign orbital lesions, or for congenital deformities.
FIG. 98.1. Mark an incision line around the orbit just inside
the orbital rim. If necessary because of tumor extension in the
skin, mark the line outside this limit to allow at least 5 mm of
normal tissue beyond the tumor edges. Cut through the skin
and muscle with a scalpel blade or cautery needle.
FIG. 98.2. Dissect beneath the orbicularis muscle to the
orbital rim. Incise periosteum along the rim. At the medial
and lateral rims, disinsert the canthal ligaments from their
attachments to bone.
FIG. 98.3. Separate periorbita from the orbital walls with a
Freer elevator. Firm attachments will be encountered at the
trochlea and along the superior and inferior orbital ssures.
Transect the lacrimal duct as it enters the lacrimal canal just
inside the inferomedial orbital rim. If the tumor involves the
lacrimal sac and duct, remove the anterior wall of the canal
with rongeurs and transect the duct at its entrance into the
nose.
FIG. 98.4. Pass enucleation scissors medially around the
orbital tissues to the apex. Transect the tissues and remove
the specimen. Alternatively, a wire snare allows clean separation of the orbital contents closer to the apex.
POSTOPERATIVE CARE: Cover the donor site with fine

mesh gauze or a commercially available graft dressing. After
5-7 days, the anterior half of the orbital packing can be
removed. The remainder is removed after 10-14 days. The
orbital cavity is irrigated daily with a dilute solution of
hydrogen peroxide, and crusts are dbrided with a forceps.
An oculofacial prosthesis may be fitted after 8 weeks or
the patient can wear a black eye patch.
Graft failure or delayed healingThis results from bleeding beneath the graft caused by inadequate hemostasis,
low-grade infection, or poor approximation of the graft
to the orbital walls. If small areas of the graft become
necrotic, these areas are dbrided. If the graft does not
FIG. 98.5. Pack the orbit with gauze sponges soaked with
epinephrine and apply pressure for 10 minutes. Remove the
sponges and cauterize any residual bleeding vessels. Perforating
vessels through the orbital bones are controlled with bone wax.
FIG. 98.6. Harvest a split-thickness skin graft from the
upper, outer quadrant of the thigh with a dermatome. Place
the graft in the orbit and trim excess skin from the wound
margins. If the graft was not meshed, excise the dog-ear aps
that develop when the graft is folded into the orbital concavity.
FIG. 98.7. Suture the graft to skin at the orbital rim with
interrupted and running 6-0 Vicryl stiches.
FIG. 98.8. Lay multiple 2-inch strips of Telfa or nonadherent
gauze to cover the graft and overlap the orbital rim. Pack
the orbit rmly with cotton balls soaked to dripping in saline
solution that contains gentamicin. Press the cotton into the
cavity to mould it into the crevices, while removing all excess
saline solution with suction. Cover the wound with a rm
dressing.
survive, it can be removed and the socket irrigated daily

with 50% hydrogen peroxide and antibiotic ointment
until it heals by spontaneous granulation.
Facial numbnessNumbness of the forehead is inevitable because the frontal and supratrochlear nerves are
excised with the orbital contents.
Sinusorbital fistulaOpenings in the lamina papyracea of the ethmoid bone may be present from
tumor involvement or from spontaneous dehiscence,
or from iatrogenic perforation during surgery. If
the sinus mucosa is breached or has been biopsied,
it may grow into the orbit beneath the skin graft,
resulting in failure. A graft should not be placed over
the opening. The fistula can be closed later by marsupialization.
318
7/16/2012 9:34:44 AM
CHAPTER 98 Orbital Exenteration 319
FIG. 98.1
FIG. 98.5
FIG. 98.2
FIG. 98.6
FIG. 98.3
FIG. 98.7
FIG. 98.4
FIG. 98.8
7/16/2012 9:34:44 AM
7/16/2012 9:35:02 AM
Index
Note: Page numbers in Italics denote figures
A
Abducens nerve, 254, 264267, 265, 267
Abrasion, corneal (see Corneal abrasion)
Abscesses, orbital, 248
Acquired entropion, 123
Advancement
levator aponeurotic for ptosis, 81, 8891, 89, 91
myocutaneous, free tarsoconjunctival graft for
lower eyelid reconstruction, 190, 191
myocutaneous for superficial non-marginal
eyelid defects, 158
single bridged, of lower eyelid, for upper
eyelid reconstruction, 182, 183
tarsoconjunctival, upper to lower eyelid,
192195, 193, 195
Y to V, for reduction of epicanthal folds, 198,199
Advancement flap, 162, 163
double bridged, of lower eyelid, for upper
Adynamic brow, as complication of direct brow
lift, 72
A-frame Mllers muscle aponeurectomy, 81
Agger nasi cells, 216
Alloplastic ocular implant, in enucleation, 303,
306309, 307, 309
Alopecia, as complication of endoscopic forehead lift, 78
Ampulla, 216, 218219, 218
Anesthesia
for brow elevation, 72, 73
for enucleation, 72, 73, 302
forehead, as complication of transblepharoplasty endotine brow fixation, 74
infraorbital nerve, as complication of orbital
decompression, 288
inhalation, 5
in ophthalmic plastic surgery, 45
retrobulbar, 4
scalp
as complication of endoscopic forehead
lift, 78
as complication of transblepharoplasty
endotine brow fixation, 74
supraorbital as complication of direct brow
lift, 72
Anesthetic agent, choice of, 4
Angle, canthal (see Canthal angle)
Angular artery, 8, 14, 15
Angular vein, 14, 15, 264, 265
Annulus of Zinn, 254, 260, 261
Antibiotics for hordeolum, 25
Aponeurosis, levator, 260, 261
horn of, 12, 13
recession of, with Mllers muscle extirpation, 150153, 151, 153
Aponeurotic advancement/levator, for ptosis,
81, 8891, 89, 91
Aponeurotic ptosis, 80
Arcus marginalis, 7
Arterial arcades, 9
Artery(ies)
angular, 8, 14, 15
carotid, 268, 269
internal, 262, 263
ciliary, 262, 263, 268, 269
ethmoidal, 262, 263, 268, 269
facial, 9, 14, 15
infraorbital, 14, 15, 262, 263
infratrochlear, 262, 263
lacrimal, 14, 15, 254, 262, 263, 266269,
267, 269
maxillary, 262, 263
nasal, 262, 263, 268, 269
nasofrontal, 262, 263, 268, 269
ophthalmic, 8, 254, 262265, 263, 265
palpebral, 14, 15, 217, 262, 263, 268, 269
retinal, central, 254, 262, 263
supraorbital, 262, 263, 266269, 267, 269
supratrochlear, 14, 15
temporal superficial, 9
zygomaticofacial, 14, 15, 260, 261, 268, 269
zygomaticotemporal, 254
Asian upper eyelid blepharoplasty, 46, 47
Aspirin, use before ophthalmic surgery, 1
Asymmetry
as complication of direct brow lift, 72
as complication of transconjunctival excision
of herniated orbital fat,68
eyelid crease
as complication of aponeurotic advancement, 90
as complication of Asian upper eyelid
blepharoplasty, 46
as complication of upper eyelid blepharoplasty with fat excision,44
Augmentation canthoplasty, lateral, 202,203
Augmentation of orbital volume subperiosteal,
300, 301
Autogenous fascia lata
frontalis muscle suspension with, 98101,
99, 101
harvesting, 96, 97
B
Balloon dacryoplasty, nasolacrimal system,
236, 237
Biointegrated porous ocular implant, with
enucleation, 310, 311
Bleeding, nasal
as complication of dacryocystorhinostomy, 240
as complication of nasolacrimal system
probing, 232
as complication of orbital decompression, 288
Blepharoplasty
cosmetic, 3869
etiology and associated deformities, 40, 41
lower eyelid
with canthopexy, 5255, 53, 55
with eyelid shortening, 6063, 61, 63
with fat excision, 5255, 53, 55
with fat redraping, 5659, 57, 59
upper eyelid
Asian upper eyelid, 46, 47
refixation of prolapsed lacrimal gland, 48, 49
Blepharoptosis, 80103
external levator aponeurosis advancement,
8891, 89, 91
frontalis muscle suspension with autogenous
fascia lata, 98101, 99, 101
frontalis muscle suspension with silicone rod,
102, 103
harvesting autogenous fascia late, 96, 97
posterior Mllers muscle-conjunctival resection, 86, 87
posterior tarsoconjunctival resection, 84, 85
Supra-Whitnalls ligament levator muscle
resection, 9295, 93, 95
Blepharotomy, horizontal, with marginal rotation, 142, 143
Blindness (see Vision, loss of )
Block(s)
nerve, orbital, for ophthalmic surgery, 5
retrotarsal, for ophthalmic surgery, 5
subcutaneous, pretarsal for ophthalmic
surgery, 5
Blow-out fractures of orbit, 306
Bone
ethmoid, 253, 256259, 257, 259
frontal, 218, 219, 253, 256259, 257, 259
lacrimal, 218, 219, 253, 256, 257
maxillary, 218, 219, 252, 253, 256259,
257,259
nasal, 218, 219, 256, 257
palatine, 252
sphenoid, 256, 257
temporal, 256, 257
zygomatic, 252, 256259, 257, 259
Bony orbit, 252
Bridged advancement flap
double bridged, of lower eyelid, for upper
eyelid reconstruction, 184,185
lower eyelid single, for upper eyelid reconstruction, 182, 183
Brow
adynamic, as complication of direct brow
lift, 72
contour defects, as complication of posterior
tarsoconjunctival resection, 84
Brow contour, poor, as complication of direct
brow lift, 72
321
Dutton_Index.indd 321
7/12/2012 4:02:53 PM
322 Index
Brow elevation
direct, 70, 72, 73
endoscopic forehead elevation, 7679, 77, 79
transblepharoplasty endotine fixation, 74, 75
Brow fixation, endotine, 74, 75
Brow ptosis, 7079 see also Brow elevation and
Brow fixation
causes of, 70
correction of, 70
Buccal branch of the facial nerve, 16, 17
Bulbar conjunctiva, 22, 23
Bulging of medial fat pocket, 40, 41
C
Canalicular injury
as complication of medial spindle tarsoconjunctival resection, 110
as complication of modified Lazy-T procedure, 114
Canalicular occlusion as complication of medial
canthal ligament plication, 116
Canalicular slitting, as complication of canalicular reconstruction, 228
Canaliculodacryocystorhinostomy, 220, 242,243
Canaliculus
common, 216, 218, 219
lacerations, repair of, 224227, 225, 227
lacrimal puncta and surgery on, 220229
obstruction of, 220
reconstruction of, 228, 229
slitting of
balloon dacryoplasty, 236
as complication of nasolacrimal system probing with silicone intubation stents, 234
erosion of lacrimal puncta as complication
of canalicular repair, 226
stenosis of, 220
as complication of canalicular reconstruction, 228
at laceration site as complication of
repair,226
superior, 218, 219
Canthal angle
lateral, dystopia of
as complication of lateral tarsal strip
fixation, 108
as complication of SMAS midface
elevation and fixation, 156
as complication of temporal fascia lower
eyelid suspension, 118
lateral, ectropion of
as complication of retractor reinsertion and
lateral tarsal strip eyelid fixation, 136
elevation of, as complication of retractor
reinsertion with lateral tarsal strip
eyelid fixation, 136
rounded, as complication of lower eyelid
blepharoplasty, 54
medial, 10, 11
rounded, as complication of retractor reinsertion with lateral tarsal strip eyelid
fixation, 136
vertical dystopia correction of, 206, 207
Canthal angle dystopia, 66
Canthal ligament
lateral, 202
medial
crus of, 218, 219
plication, 116, 117
Canthoplasty
augmentation, lateral, 202, 203
reduction, lateral, 204, 205
Canthus
lateral
reconstruction, 196211
trichiasis at, as complication of lateral
tarsal strip fixation, 108
medial, reconstruction, 196211
Capsulopalpebral fascia, 78, 253
Carotid artery, internal, 262, 263, 268, 269
Cartilage graft, posterior lamellar lengthening
with, 144, 145
Caruncle, 10, 11
Cavernous sinus, 260, 261, 264, 265
Cells
agger nasi, 216
ethmoid sinus, 258, 259
Central orbital space, 270
Central retinal artery, 254, 262, 263
Central retinal vein, 264, 265, 268, 269
Cerebrospinal fluid leak, as complication of
orbital decompression, 288
Cerebrum, 258, 259
Cervical nodes, 18, 19
Chalazion, 25
hordeolum and, 2529
incision and drainage of
transconjunctival approach to, 28, 29
transcutaneous approach to, 2627
recurrence of following incision and drainage
procedures, 26
Check ligaments, 253
Chronic pain, as complication of evisceration,
316
Cicatricial ectropion, 104 (see also Ectropion)
as complication of Z-plasty transpositional
flaps, 170
Cilia
loss of, complicating incision and drainage of
chalazion, 26, 28
marginal, superior, 10, 11
Ciliary artery, 262, 263, 268, 269
Ciliary ganglion, 262, 263, 266, 267
Ciliary nerve, 262, 263, 266, 267
Closure
direct of elliptical defect, simple, 160,161
layered, direct, of marginal defects of upper
eyelid, 174, 175
of soft-tissue opening as complication of lost
Jones tube, 244
Cocaine, use of, 220
Common canaliculus, 216, 218, 219
Computerized tomography of orbit, 246
Congenital ectropion syndrome, 204
Congenital nasolacrimal duct obstruction, 230
Conjunctiva, 8
bulbar, 22, 23
lymphatic vessels, 9
palpebral, 22, 23
prolapse of, as complication of supra-Whitnalls levator muscle resection, 94
Conjunctival fornix, 20, 21
Conjunctival hypertrophy of eyelid margin as
complication of tarsoconjunctival
advancement flap, 194
Conjunctival irritation as complication of

dermis-fat orbital graft, 312
Conjunctival resection, posterior Mllers
muscle, 81, 86, 87
Conjunctivodacryocystorhinostomy, 220, 244, 245
Connective tissue septa of periorbita, 253
Contour defects, as complication of posterior
tarsoconjunctival resection, 84
Coralline hydroxyapatite ocular implant, 302
Corneal abrasion
as complication of free tarsoconjunctival
graft, 180
as complication of full-thickness marginal
wedge resection, 112
as complication of horizontal blepharotomy,
with marginal rotation, 142
as complication of lower eyelid single bridged
as complication of nasolacrimal system surgery
probing with silicone intubation stents, 234
as complication of posterior lamellar lengthening
with free tarsoconjunctival graft, 144
with mucous membrane graft, 146
as complication of posterior tarsoconjunctival resection, 84
as complication of retractor reinsertion with
horizontal eyelid shortening, 134
Corneal discomfort
as complication of balloon dacryoplasty, 236
as complication of nasolacrimal system probing with silicone stents, 234
Corneal injury as complication of marginal
rotation by anterior horizontal tarsal
groove resection, 140
Corneal irritation as complication of canalicular
reconstruction, 228
Corneal staining as complication of posterior
Mllers muscle-conjunctival resection, 10
Corrugator supercilii muscle, 10, 11
Corticosteroids, for chalazion, 25
Cosmetic blepharoplasty, 3869
Cryodestuction for trichiasis, 30
Cryosurgery for trichiasis, 32, 33
Cutler-Beard procedure for upper eyelid reconstruction, 182, 183
D
Dacryocystorhinostomy, 230, 238241, 239,
241
Dacryoliths, 230
Decompression, orbital
inadequate, as complication of orbital
decompression, 288
inferior and medial walls, 284288, 285,287
Dehiscence, wound
as complication of evisceration, 316
as complication of lateral semicircular rotational flap, 176
eyelid shortening, 134
Delayed healing, as complication of orbital
exenteration, 318
Depigmentation as complication of cryosurgery, 32
Dermatochalasis of upper eyelid, 40, 41
Dermis-fat orbital implant graft, 312, 313
7/12/2012 4:02:54 PM
Index 323
Diplopia
as complication of orbital decompression,
288
as complication of anterior orbitotomy, 272
Direct brow lift, 70, 72, 73
Direct closure of elliptical defect, simple,
160, 161
Direct layered closure of marginal defects of
upper eyelid, 174, 175
Disc, optic, 258, 259
Disinsertion of lower eyelid retractor, with
scleral graft, 154, 155
Displacement of implant as complication of
enucleation with primary alloplastic
implant, 308
Distichiasis, 30
electrohyfrecation for, 30
trichiasis and, 3037
Donor eyelid
retraction of, as complication of posterior
lamellar lengthening with free tarsoconjunctival, 144
upper, lagophthalmos of, as complication of
anterior lamellar lengthening with
skin graft, 120
Donor site, granulation over growth as complication of posterior lamellar lengthening with free tarsoconjunctival, 144
Double bridged advancement flap, lower eyelid,
for upper eyelid reconstruction, 184,
185
Drainage, incision and, of chalazion
transconjunctival approach to, 28, 29
transcutaneous approach to, 2627
Duct, lacrimal
membranous, 217, 218, 219
surgery on, 213245
Dye disappearance test, 213
Dystopia, canthal angle
lateral
as complication of lateral tarsal strip fixation, 108
vertical correction of, 206, 207
E
Echography of orbit, 247, 248
Ectropion, 104121
causes of, 104
cicatricial, 104
as complication of Z-plasty transpositional
flaps, 170
graft and myocutaneous advancement
flap, 190
as complication of frontalis muscle suspension
with autogenous fascia lata, 102
with silicone rod, 102
congenital, 204
involutional, 104
lateral canthal angle
mechanical, 104
paralytic, 104
persistent or recurrent, as complication of
skin graft, 120
residual lower eyelid, as complication of
SMAS midface elevation, 156
Edema
eyelid
as complication of cryosugery for trichiasis, 32
as complication of transcutaneous transperiosteal anterior orbitotomy, 274
persistent, as complication of lower eyelid
double bridged advancement flap, 184
single bridged advancement flap, 182
Electrohyfrecation for trichiasis and distichiasis, 30
Elevation of lateral canthal angle as complication of retractor reinsertion with
Elliptical defect, simple direct closure of, 160, 161
Endoscopic forehead elevation, 7679, 77, 79
Endotine
brow fixation, 74, 75
palpable
as complication of endoscopic forehead
lift, 78
as complication of transblepharoplasty
endotine brow fixation, 74
Enophthalmos
as complication of enucleation, 308
and subperiosteal orbital volume augmentation, 300, 301
Entropion, 123147
acquired, 123
cicatricial, 124
classification of, 123
congenital, 123
involutional, 123
marginal, as complication of horizontal tarsoconjunctival transposition flap, 178
mechanical, 123
overcorrection of
as complication of anterior lamellar shortening with epitarsal fixation, 138
as complication of full-thickness eyelid
sutures, 126
as complication of horizontal blepharotomy with marginal rotation, 142
recurrence of
sutures, 126
as complication of lower eyelid retractor
reinsertion, 132
spastic chronic, 123
undercorrection of
as complication of marginal rotation by
anterior horizontal tarsal groove
resection, 140
Enucleation, 302319
with biointegrated porous ocular implant,
310, 311
with dermis-fat graft, 312, 313
with primary acrylic or silicone implant,
306309, 307, 309
Epiblepharon
acquired, 123
reinsertion, 132
correction of, lower eyelid crease reformation
for, 130, 131
induced, 7
lower eyelid, as complication of anterior
orbitotomy, 272
repair of, modified full-thickness eyelid
sutures for, 128, 129
Epicanthal folds, reduction of, 198, 199, 200, 201
Epinephrine
lidocaine with, for ophthalmic surgery, 5
systemic effects of, 5
Epiphora
persistent, as complication of dacryocystorhinostomy, 240
recurrent, as complication of nasolacrimal
system probing, 232
surgery to correct, 220
Epitarsal fixation, anterior lamellar shortening
with epitarsal fixation, 138, 139
Erosion, of lacrimal puncta
and canaliculus slitting as complication of
canalicular repair, 226
balloon dacryoplasty, punctal, 236
Ethmoid bone, 252, 256, 257, 258, 259
Ethmoid foramina, 252, 256, 257
Ethmoid sinus cells, 258, 259
Ethmoidal artery, 262, 263, 268, 269
Ethmoidal nerve, 262, 263, 266, 267
Ethmoidal vein, 264, 265, 268, 269
Euryblepharon, interpalpebral fissure, 204
Evisceration, 316, 317
enucleation and exenteration, 302319
Excision
of excess eyelid skin, 38
of fat
lower eyelid blepharoplasty, 5255, 53, 55
upper eyelid blepharoplasty, 4245, 43, 45
of lash bulbs, internal, 32
transconjunctival, of herniated lower eyelid
orbital fat, 68, 69
Exenteration
enucleation and evisceration, 302319
orbital, 318, 319
Exposed ocular implant, repair of, 314,315
External tarsoaponeurectomy, 81
Extirpation, Mllers muscle, levator aponeurosis recession with, 150153, 151, 153
Extraconal orbital fat, 258, 259
Extraconal space, 270
Extraocular muscle(s), 253, 254, 270
anatomy, 258265, 259, 261, 263, 265
congenital fibrosis, 80
paresis of, as complication of anterior orbitotomy, 274
Extrusion of ocular implant
as complication of enucleation with primary
acrylic or silicone implant, 308
as complication of subperiosteal orbitalvolume augmentation contents, 300
Eyebrow (see Brow)
Eyelash bulb
internal resection, 36, 37
internal excision of, 32
7/12/2012 4:02:54 PM
324 Index
Eyelid
anatomy, 724, 11, 13, 15, 17, 19, 2123
arterial supply to, 89, 14, 15
contour of, poor
as complication of frontalis muscle suspension with autogenous fascia lata, 100
as complication of lateral semicircular
rotational flap, 176
as complication of levator aponeurosis
recession with Mllers muscle extirpation, 152
as complication of levator aponeurotic
advancement, 90
as complication of supra-Whitnalls, levator muscle resection, 94
defects of, non marginal superficial, repair of,
158171
donor
retraction of, as complication of posterior
lamellar lengthening with graft, 144
edema of
as complication of cryosurgery for trichiasis, 32
as complication of transcutaneous transperiosteal anterior orbitotomy, 274
excess skin of, excision of, 108
fixation of, lateral tarsal strip, retractor reinsertion with, 136, 137
lamellae of, vascular supply, 8
lateral skin redundancy of, as complication of
eyelid shortening by lateral tarsal strip
fixation, 108
laxity
graft, 190
overcorrection of, as complication of
lateral tarsal strip fixation, 108
persistent as complication of lateral tarsal
strip fixation, 108, 109
lower (see Lower eyelid)
lymphatic vessels, 9, 18, 19
margin of
conjunctival hypertrophy, as complication
of upper to lower eyelid tarsoconjunctival advancement flap, 194
distortion of, as complication of electrohyfrecation for trichiasis, 30
notching of, as complication of lower
eyelid blepharoplasty combined with
eyelid shortening, 62
necrosis of, as complication of cryosugery for
trichiasis, 32
normal position of, 7
notching of
as complication of direct layered closure of
marginal defects, 174
as complication of incision and drainage of
chalazion, 26, 28
overcorrection of
disinsertion with scleral graft, 154
periorbital structures, external anatomy, 10, 11
persistent eyelid fullness, as complication of
refixation of lacrimal gland prolapse, 48
ptosis of, as complication of anterior orbitotomy, 274
retraction of
graft, 180
as complication of horizontal tarsoconjunctival transposition flap, 178
as complication of lower eyelid double
bridged advancement flap, 184
reinsertion, 132
as complication of lower eyelid single
correction of, 148157
lower eyelid recession with Mllers
muscle extirpation, 150153, 151,
153
lower eyelid retractor disinsertion with
scleral graft, 154, 155
SMAS midface elevation, 156, 157
shortening of
horizontal full-thickness, retractor reinsertion with, 134, 135
by lateral tarsal strip fixation, 108, 109
lower eyelid blepharoplasty with canthopexy, 6467, 65, 67
lower eyelid blepharoplasty with, 6063,
61, 63
skin of
residual redundant, as complication of
upper eyelid blepharoplasty with fat
excision, 44
undercorrection of
recession with Muellers muscle extirpation, 152
vascular supply to, 89, 14, 15
venous supply to, 9, 14, 15
Eyelid crease, 10, 11
asymmetric
blepharoplasty, 46
as complication of upper eyelid blepharoplasty with fat excision, 44
fixation of, after cosmetic blepharoplasty,
38
inferior, 10, 11
irregular
blepharoplasty, 44
lower, reformation of, for epiblepharon correction, 130, 131
poor, as complication of supra-Whitnalls,
levator muscle resection, 94
upper, 7
reformation of, 50, 51
Eyelid margin notch
Eyelid margin scarring, 36
Eyelid sutures, full-thickness, 126, 127
modified, for epiblepharon repair,
128,129
F
Face, numbness of, as complication of orbital
exenteration, 318
Facial and orbicularis oculi muscles, superficial,
10, 11
Facial artery, 14, 15
Facial nerve, 7
branches of, 16, 17
Facial vein, 14, 15
Fascia, capsulopalpebral, 78, 12, 13, 253
Fascia lata, autogenous
frontalis muscle suspension with, 98103,
99, 101
harvesting, 122124, 123
Fascia lower eyelid suspension, temporal, 96,
97, 119
Fascial plane, postorbicular, 7
Fascial suspension procedure for ectropion,
105, 118, 119
Fat excision
lower eyelid blepharoplasty, 5255, 53,55
upper eyelid blepharoplasty, 4245, 43,45
Fat, orbital
extraconal, 258, 259
lower eyelid, herniated, transconjunctival
excision of, 68, 69
Fat pad
inferior, 12, 13
orbital, precapsulopalpebral, 22, 23
preaponeurotic, 7,
orbital septum and, 12, 13
precapsulopalpebral, 7, 22, 23
superior, 12, 13
Fat pocket, medial, bulging of, 40, 41
Fat redraping, lower eyelid blepharoplasty with,
5255, 53, 55
Fissure(s)
inferior orbital, 252255, 257
interpalpebral, 7, 204
palpebral, dislocation of tubing into, as complication of nasolacrimal system
superior orbital, 252255, 257
Fistula, sinus-orbital, as complication of orbital
exenteration, 318
Fixation
epitarsal, anterior lamellar shortening with,
138, 139
eyelid, lateral tarsal strip, retractor reinsertion with, 136, 137
frontalis muscle, with autogenous fascia lata,
98100, 99, 101
lateral tarsal strip, eyelid shortening, 108, 109
orbital rim fracture, miniplate of, 298, 299
periosteal, lateral semicircular rotation flap,
188, 189
Flap
advancement (see Advancement flap)
rhombic, 168, 169
rotational
lateral semicircular, for upper eyelid reconstruction, 176, 177
myocutaneous, 164, 165
skin, for repair of superficial non-marginal
eyelid defects, 158171
transposition
horizontal tarsoconjunctival, for upper
7/12/2012 4:02:54 PM
Index 325
median forehead, necrosis, 210, 211
Z-plasty, 170, 171
Fold(s)
epicanthal, reduction of, 198, 199, 201
malar, 10, 11
nasojugal, 10, 11
Foramen(ina)
ethmoidal, 252, 256, 257
infraorbital, 256, 257
pterygopalatine, 256, 257
rotundum, 256, 257
Forehead lift
endoscopic, 7678, 77, 79
temporal, 70
Forehead transposition flap, median, 210, 211
necrosis of, 210
Fornix(ces)
conjunctival, 20, 21, 174, 175
inferior, suspensory ligament of, 7, 22, 23
lacrimal, 216
lacrimal sac, 256, 257
shallow
as complication of enucleation with primary acrylic or silicone implant, 308
as complication of repair of exposed ocular
implant, 314
superior, suspensory ligament of, 8, 2023,
21, 23
Four-flap technique for reduction of epicanthal
folds, 200, 201
Fractures
miniplate fixation for orbital rim, 298,299
orbital, 281
blow-out, 252
repair of, orbital floor, 296, 297
Free tarsoconjunctival graft
and myocutaneous advancement flap for
for posterior lamellar lengthening with, 144,
145
for upper eyelid reconstruction, 180,181
Frontal bone, 218, 219, 252, 256, 257, 258, 259
Frontal nerve, 266, 267
Frontal nerve block for ophthalmic surgery, 5
Frontal vein, 14, 15
Frontalis muscle
suspension of, with autogenous fascia lata,
98101, 99, 101
suspension with, silicone rod, 102, 103
Frontoethmoid suture, 252
Frontozygomatic suture, 252, 256, 257
Full-thickness eyelid shortening with retractor
reinsertion with, 134,135
Full-thickness eyelid sutures
overcorrection of, 126
modified, for epiblepharon repair, 128,129
G
Ganglion
ciliary, 2, 263, 266, 267
semilunar, 260, 261, 264, 265
trigeminal, 260, 261, 264, 265
General anesthesia
for ophthalmic surgery, 4
Glabellar, rotation flap, 208, 209
Gland
lacrimal (see Lacrimal gland)
meibomian, chronic obstruction

complicating incision and drainage of
chalazion, 28
Graft
dermis-fat, as orbital implant graft, 312,313
failure, 312
mucous membrane, posterior lamellar
lengthening with, 144, 145, 146,147
scleral, lower eyelid retractor disinsertion
with, 154, 155
tarsoconjunctival, free
myocutaneous advancement flap for lower
scleral or cartilage, posterior lamellar
lengthening with, 144, 145
for upper eyelid reconstruction, 180,181
Graft failure
as complication of anterior lamellar lengthening with skin graft, 120
as complication of orbital exenteration, 318
as complication of posterior lamellar lengthening with mucous membrane graft,
144, 146
Granulation overgrowth of donor site as complication of tarsoconjunctival graft,
144
Granulation tissue in central hole as complication of porous ocular implant, 310
Granuloma(s), as complication of conjunctivodacryocystorhinostomy, 244
Graves orbitopathy, 270, 282
proptosis with, 148, 249, 281
Growth of hair, as complication of dermis-fat
orbital implant graft, 312
H
Hair growth as complication of dermis-fat
Harvesting autogenous fascia lata, 96, 97
Hasner, valve of, 217, 218, 219
Healing, delayed, as complication of orbital
exenteration, 318
Hematoma
as complication of endoscopic forehead lift, 78
as complication of transblepharoplasty endotine brow fixation, 74
Hemorrhage, orbital
as complication of horizontal blepharotomy
with marginal rotation, 142
as complication of lateral orbitotomy, 280
as complication of lower eyelid blepharoplasty with fat excision, 54
implant, 314
Herniated lower eyelid orbital fat, transconjunctival excision of, 68, 69
Hooding of eyelid skin, temporal, 40, 41
Hordeolum, 25
and chalazion, 2529
drainage of, 25
external treatment, 25
internal treatment, 25
Horizontal blepharotomy, with marginal rotation, 142, 143
Horizontal full-thickness eyelid shortening,

retractor reinsertion with, 134, 135
Horizontal tarsal groove resection, anterior
marginal rotation by, 140, 141
Horizontal tarsoconjunctival transposition flap for
upper eyelid reconstruction, 178,179
Horners muscle, 7, 10, 11
Horners syndrome, 8
Horns of levator aponeurosis, 253
Hypertrophic scar(s)
a complication of four-flap technique for
epicanthal fold, 200
chalazion, 26
I
Imaging, magnetic resonance, of orbit, 281
Implant, ocular (see Ocular implant)
Incision and drainage of chalazion
transconjunctival approach, 28, 29
transcutaneous approach, 26, 27
Infection
as complication of harvesting autogenous
fascia lata, 96
wound, as complication of dacryocystorhinostomy, 240
Infraorbital artery, 14, 15, 262, 263
Infraorbital canal, 252
Infraorbital foramen, 256, 257
Infraorbital groove, 252, 256, 257
Infraorbital nerve, 9, 260, 261
anesthesia of, as complication of orbital
decompression, 288
Infraorbital neuralgia as complication of orbital
decompression, 288
Infraorbital neurovascular bundle, 258,259
Infraorbital sulcus, 256, 257
Infraorbital vein, 264, 265
Infratrochlear artery, 262, 263
Infratrochlear nerve, 9, 16, 17, 254, 262265,
263, 265
Infratrochlear vein, 266269, 267, 269
Inhalation anesthesia, 5
Injury
canalicular
as complication of medial spindle tarsoconjunctival resection, 110
as complication of modified Lazy-T
procedure, 114
corneal, as complication of marginal rotation
by anterior horizontal tarsal groove
resection, 140
lacrimal gland, as complication of anterior
orbitotomy, 272
to orbit, traumatic, 248
Internal carotid artery, 262, 263
Internal resection of lash bulbs for trichiasis,
36, 37
Interpalpebral fissure, 7
euryblepharon, 204
Intraconal space, 270
Intubation stents, silicone, nasolacrimal system
probing with, 234, 235
Involutional ectropion, 104
Irregular eyelid crease(s)
as complication of Asian upper eyelid blepharoplasty, 44
7/12/2012 4:02:54 PM
326 Index
Irregular eyelid crease(s) (Continued)
as complication of reformation of the upper
eyelid crease, 50
Irritation
conjunctival, as complication of dermis-fat
corneal, as complication of canalicular reconstruction, 228
Ischemia of Z-plasty transpositional flaps,170
J
Jones I test, 213
Jones II test, 213
Jones pyrex tube
in conjunctivodacryocystorhinostomy, 244,245
L
Lacerations, canalicular, repair of, 224227,
225, 227
Lacrimal artery, 14, 15, 254, 262, 263, 266269,
267, 269
Lacrimal bone, 218, 219, 252, 256, 257
Lacrimal drainage system, 9
anatomy of, 216219, 219
surgery on, 213245
Lacrimal duct
membranous, 217219, 219
surgery on, 213, 220229
Lacrimal fossa, 216
Lacrimal gland, 12, 13, 258269, 259, 261, 263,
265, 267, 269,
injury to, as complication of anterior orbitotomy, 272
prolapse of, 38
refixation, 48, 49
Lacrimal nerve, 9, 16, 17, 260, 261, 266, 267
Lacrimal papillae, 216, 218, 219
Lacrimal puncta, 9, 216, 218, 219
and canaliculi, surgery on, 220229
erosion of
and canalicular slitting as complication of
canalicular repair, 234
probing with silicone stents, 234
recurrent obstruction of, as complication of
dacryocystorhinostomy, 240
Lacrimal ridge, 216
Lacrimal sac, 9, 10, 11, 216219, 219
surgery on, 213245
Lacrimal sac fossa, 256, 257, 262, 263
Lacrimal vein, 266269, 267, 269
Lagophthalmos
as complication of frontalis muscle suspension
with silicone rod, 102
advancement, 90
of donor upper eyelid as complication of
skin graft, 120
Lamellar lengthening
anterior, with skin graft, 120, 121
posterior
with free tarsoconjunctival, 144, 145
with mucous membrane graft, 146,147

Lamellar shortening, anterior, with epitarsal
fixation, 138, 139
Lamina papyracea, 252
Lateral augmentation canthoplasty, 202,203
Lateral canthal ligament, 18, 19, 202
Lateral canthopexy, lower eyelid blepharoplasty,
6467, 65, 67
Lateral reduction canthoplasty, 204, 205
Lateral wall, orbital decompression, 294,295
Laxity, eyelid (see Eyelid, laxity of )
Layered closure of marginal defects of upper
eyelid, direct, 174, 175
Leak, cerebrospinal fluid, as complication of
orbital decompression, 288
Levator aponeurosis, 8, 12, 13, 260, 261
advancement or repair of, for ptosis, 81
horn of, 12, 13
recession of, with, Mllers muscle extirpation, 150153, 151, 153
Levator muscle, 253255
for ptosis, 81
Supra-Whitnalls ligament levator muscle
resection, 9295, 93, 95
Levator palpebrae superioris muscle, 253,
258261, 259, 261, 264, 265
Lid margin distortion, 34
Lidocaine with epinephrine for ophthalmic
surgery, 4
Lift
direct brow, 70, 72, 73
forehead
midforehead, 70
temporal, 70
Ligament
check, 306, 307
Lockwoods, 8, 12, 13, 253
suspensory
of inferior fornix, 8, 22, 23, 253
of superior fornix, 8, 20, 21, 22, 23
Whitnalls, 8, 12, 13, 253
Local anesthesia
for ophthalmic surgery, 4, 5
Lockwoods ligament, 8, 12, 13, 253
Lower eyelid
blepharoplasty of
with eyelid shortening, 6063, 61, 63
with fat redraping, 5659, 57, 59
crease, reformation of, for epiblepharon correction, 130, 131
double bridged advancement flap of, for
upper eyelid reconstruction, 184, 185
ectropion of as complication of
repair of orbital floor fractures, 296
transcutaneous transseptal anterior orbitotomy, 272
epiblepharon, as complication of transcutaneous transseptal anterior orbitotomy,
272
major retractors of, 12, 13
margin of, 7
orbital fat of, herniated, transconjunctival
excision of, 68, 69
reconstruction of, 186195
retraction of
as complication of transconjunctival excision of herniated lower eyelid orbital

fat, 68
retractor of
disinsertion with scleral graft, 154,155
reinsertion, 132, 133
single bridged advancement flap of, for upper
temporal fascia, suspension of, 118, 119
Lower lacrimal papilla, 216, 218, 219
Lymphatic drainage from eyelids, 18, 19
Lymphatic vessels of eyelids and conjunctiva, 9
Lymphedema from disruption of lymphatic
vessels, 9
M
Maier, sinus of, 216
Malar fold(s), 10, 11
Marginal arterial arcades, 9, 14, 15
Marginal cilia, superficial, 10, 11
Marginal defects of upper eyelid, direct layered
closure of, 174, 175
Marginal entropion as complication of horizontal tarsoconjunctival transposition
flap, 178
Marginal rotation
by anterior horizontal tarsal groove resection, 140, 141
horizontal blepharotomy with, 142, 143
Marginal wedge resection, full-thickness,
112,113
Maxillary artery, 262, 263
Maxillary bone, 218, 219, 252, 256259,
257,259
Maxillary division of the trigeminal nerve,9
Maxillary sinus, 256259, 257, 259
Meatus, nasal, inferior, 218, 219
Mechanical ectropion, 104 (see also Ectropion)
Mechanical ptosis, 81
Medial canthal ligament plication, 116, 117
Median forehead transposition flap, 210,211
Meibomian gland, chronic obstruction complicating incision and drainage of
chalazion, 28
Membrane, mucous, graft of, posterior lamellar
lengthening with, 146,147
Membranous lacrimal duct, 217219, 219
Middle turbinate, 218, 219
Midface elevation and fixation of SMAS, 156,157
Midforehead lift, 70
Migration of floor implant as complication of
orbital floor fractures repair, 296
Modified full-thickness eyelid sutures for epiblepharon repair, 128, 129
Modified Lazy-T procedure for ectropion,
114, 115
Motility, ocular, restriction of, as complication
of repair of orbital floor fractures, 296
Motor innervation to the eyelid protractors,
16, 17
Mucous membrane graft, posterior lamellar
lengthening with, 146, 147
Mllers muscle, 8, 2123
aponeurectomy, A-frame, 81
conjunctival resection, 81, 86, 87
extirpation of, levator aponeurosis recession
with, 150153, 151, 153
Muscle(s)
corrugator supercilii, 10, 11
7/12/2012 4:02:54 PM
Index 327
extraocular, 253, 254, 270
paresis of, as complication of anterior
orbitotomy, 274
facial and orbicularis oculi, superficial, 10, 11
frontalis, 10, 11, 16, 17
suspension of, with autogenous fascia lata,
98101, 99, 101
suspension with, silicone rod, 102, 103
Horners, 7, 10, 11
lamella, 205
levator palpebrae superioris, 8, 253255,
258261, 259, 261, 264, 265
resection for ptosis, 8182
Mllers, 8, 2223
Mllers, extirpation of, levator aponeurosis
recession with, 150153, 151, 153
oblique, 253255, 258265, 259, 261, 263,
265
orbicularis, 9, 16, 17, 204, 205
orbicularis oculi, medial canthal insertions
of, 10, 11
procerus, 10, 11
rectus (see Rectus muscle(s)
of Riolan, 9, 10, 11
sympathetic smooth, muscle of Mller, 8, 22,
2223, 150153, 151, 153
Muscle sheath of levator palpebrae superioris
muscle, 8
Myocutaneous advancement flap, 162, 163
and free tarsoconjunctival graft, 190,191
Myocutaneous rotational flap, 164, 165
Myocutaneous transposition flap, 166, 167
Myogenic ptosis, 80
N
Nasal artery, 262, 263, 268, 269
Nasal bleeding
as complication of dacryocystorhinostomy,
240
as complication of nasolacrimal system probing, 232
as complication of orbital decompression,
288
Nasal bone, 218, 219, 256, 257
Nasal meatus, inferior, 218, 219
Nasociliary nerve, 253, 254, 262, 263, 266, 267
Nasofrontal artery, 262, 263, 268, 269
Nasofrontal vein, 14, 15
Nasolacrimal drainage system
anatomy, 216219, 219
balloon dacryoplasty, 236, 237
canalicular reconstruction, 228, 229
canaliculodacryocystorhinostomy, 242, 243
conjunctivodacryocystorhinostomy, 244, 245
dacryocystorhinostomy, 238241, 239, 241
obstruction of, 230
probing of, 232, 233
punctoplasty, 222, 233
Necrosis of Z-plasty transpositional flaps, 170
Nerve(s)
abducens, 254, 264267, 265, 266
ciliary, 262, 263, 266, 267
ethmoidal, 262, 263, 266, 267
facial, 7
frontal, 266, 267
infraorbital, 9, 16, 17, 260, 261
infratrochlear, 9, 254, 262, 263, 266, 267
lacrimal, 9, 16, 17. 260, 261, 266, 267
maxillary division of the trigeminal nerve, 9
nasociliary, 253, 254, 262, 263, 266, 267

oculomotor, 253, 260267, 261, 263, 264, 267
optic, 254, 260, 261, 264, 265
superficial parotid nerve, 9
supraorbital, 9, 16, 17, 266, 267
supratrochlear, 9, 16, 17, 266, 267
temporal nerve, superficial, 9
trigeminal, 9, 252, 254, 260, 261, 264,265
trochlear, 254, 262267, 263, 265, 267
zygomatic, 260, 261
zygomaticofacial, 9, 260, 261
zygomaticotemporal, 9, 16, 17
Nerve blocks, orbital, for ophthalmic
surgery,5
Neurogenic ptosis, 80
Neurovascular bundle, 258, 259
Nitrous oxide for ophthalmic surgery, 5
Nodes
cervical, 18, 19
parotid, 9, 18, 19
submandibular, 9, 18, 19
Nonmarginal eyelid defects, superficial, repair
of, 158171
Notch, supraorbital, 256, 257
Notching of eyelid margin
as complication of lower eyelid blepharoplasty combined with eyelid shortening, 62
Numbness, facial, as complication of orbital
exenteration, 318
O
Oblique muscle(s), 253255, 258265, 259, 261,
263, 265
Obstruction
canaliculi, 220
of lacrimal puncta, recurrent, as complication of dacryocystorhinostomy, 240
nasolacrimal system, 230
Occlusion, canalicular, as complication of
medial canthal ligament plication, 116
Ocular implant(s)
displacement of, as complication of enucleation 308
enucleation with biointegrated porous, 310,
311
extrusion of
as complication of subperiosteal orbital
volume augmentation, 300
floor, migration of implant in, as complication
of orbital floor fractures repair, 296
primary acrylic or silicone, enucleation with,
306309, 307, 309
repair of exposed, 314, 315
Ocular motility
poor, as complication of porous ocular
implant, 310
restriction of, as complication of orbital floor
fractures repair, 296
Oculomotor nerve, 253254, 260267, 261,
263, 265, 267
Ophthalmia, sympathetic, as complication of
evisceration, 316
Ophthalmic artery, 8, 254, 262265, 263, 265,

268, 269
Ophthalmic division of the trigeminal nerve, 9
Ophthalmic plastic surgery, anesthesia in, 45
Ophthalmic vein(s), 254, 255, 264, 265, 268, 269
Optic canal, 256, 257
Optic disc, 258, 259
Optic nerve, 253, 254, 260, 261, 264, 265
Orbicularis muscle, 7, 1013, 11, 13, 1823, 17,
19, 21, 23, 204
and facial muscles, superficial, 10, 11
medial canthal insertions, in lower eyelid, 10, 11
motor supply, 9, 16, 17
pretarsal, 9, 10, 11
Orbit
anatomy, 252269, 257, 259, 261, 263, 265,
267, 269
arterial system of, 262, 263, 268, 269
blow-out fractures of, 252
bones, 252253, 256, 257
extraocular muscles, 253, 258263, 259, 261,
263
floor of, migration of implant in, as complication of orbital floor fractures repair,
296, 297
neurovascular anatomy of, 266, 267
sensory and motor nerves of, 262, 263
surgery, 247319
venous system of, 264, 265, 268, 269
walls of, 252, 253
surgery on, 281301
Orbit fissures, 252, 256, 257
Orbital decompression
inferior and medial walls, 284288,
285, 287
lateral wall, 294, 295
transconjunctival inferior wall, 292, 293
transcaruncular medial wall, 290, 291
Orbital exenteration, 318, 319
Orbital fat
extraconal, 258, 259
lower eyelid herniated, transconjunctival
excision of, 6869
Orbital fractures, 296299, 297, 299
Orbital hemorrhage
as complication of lower eyelid blepharoplasty, 54
implant, 314
Orbital implant graft, dermis-fat, 312, 313
Orbital ligament of Whitnall, 8, 12, 13, 2023,
21, 23, 253
Orbital nerve blocks for ophthalmic surgery, 5
Orbital portion of orbicularis muscle,
7, 10, 11
Orbital rim, miniplate fixation, 298, 299
Orbital septum, 8, 12, 13
inferior, 20, 21
and preaponeurotic fat pads, 12, 13
superior, 20, 21
Orbital space, 253, 270
Orbitotomy, 372, 273
lateral, 276280, 277, 279
transcutaneous, transperiosteal anterior,
274, 275
transcutaneous, transseptal anterior,
272, 273
7/12/2012 4:02:54 PM
328 Index
Overcorrection
as complication of lateral tarsal strip fixation,
108
as complication of frontalis muscle suspension with silicone rod, 102
of entropion
sutures, 126
as complication of horizontal blepharotomy with marginal rotation, 142
of eyelid retraction
of ptosis
as complication of frontalis muscle suspension, 100
advancement, 90
as complication of supra-Whitnalls levator
muscle resection, 94
Overgrowth, granulation, of donor site as
complication of posterior lamellar
lengthening with free tarsoconjunctival graft, 144
P
Pain
chronic, as complication of evisceration, 316
at endotine site, 74
leg, as complication of harvesting autogenous
fascia lata, 96
Palatine bone, 252
Palpable endotine
Palpebral artery(ies), 14, 15, 217, 262, 263, 268,
269
Palpebral fissure, 7
dislocation of silicone tubing into
Palpebral portion of orbicularis oculi, 7, 10, 11
Papillae, lacrimal, 266, 218, 219
Paralysis, pupillary, as complication of lateral
orbitotomy, 280
Paresis
extraocular muscle of, as complication of
anterior orbitotomy, 274
lateral rectus muscle, as complication of
lateral orbitotomy, 280
Parotid (preauricular) nodes, 9, 18, 19
Periorbita, 253, 258, 259
Periosteal fixation, with lateral semicircular
rotation flap with, for lower eyelid
reconstruction, 188, 189
Peripheral arterial arcade, 9, 15, 16
Peripheral orbital space, 270
Persistent eyelid fullness, and lacrimal gland
prolapse, 48
Persistent eyelid laxity, as complication lateral
Pinch test for eyelid redundancy, 104
Plastic surgery, ophthalmic, anesthesia, 45
Plication, medial canthal ligament, 116, 117

Poor motility, as complication of porous ocular
implant, 310
Postorbicular fascial plane, 7
Preaponeurotic fat pads, 8, 12, 13
Preauricular nodes, 9, 18, 19
Premedication for local and general anesthesia, 4
Preoperative evaluation of patient, 4
Primary acrylic or silicone implant, enucleation
with, 306309, 307, 309
Probing, nasolacrimal system
with infracturing of inferior turbinate, 232, 233
with silicone intubation stents, 234, 235
Prolapse
of conjunctiva, as complication of supraWhitnalls levator muscle resection, 94
of lacrimal gland, 48, 49
Prosthetic revision as complication of dermisfat orbital implant graft, 312
Pseudoptosis, 81
Pterygopalatine foramen, 256, 257
Ptosis
aponeurotic, 8081
brow, 7078
cause of, determination of, 80
classification of, 80
graft, 180
mechanical, 81
myogenic, 80
neurogenic, 80
overcorrection of
as complication of frontalis suspension
advancement, 102
patient evaluation, 8182
pseudoptosis, 81
surgery for
external levator aponeurosis advancement,
8891, 89, 91
frontalis muscle suspension with autogenous fascia lata, 98101, 99, 101
frontalis muscle suspension with silicone
rod, 102, 103
harvesting autogenous fascia late, 96, 97
posterior Mllers muscle-conjunctival
resection, 86, 87
posterior tarsoconjunctival resection, 84, 85
supra-Whitnalls ligament levator muscle
resection, 9295, 93, 95
undercorrection of
as complication of frontalis suspension
advancement, 90
as complication of posterior Mllers
muscleconjunctival resection, 86

upper eyelid
as complication of lower eyelid double
as complication of lower eyelid single
Puncta, lacrimal, 10, 216, 218, 219
erosion of
probing with silicone stents, 234
surgery of, 220229
Punctate corneal staining, as complication of
posterior Mllers muscle-conjunctival resection, 10
Punctoplasty, 222, 223
Pupillary paralysis, as complication of lateral
orbitotomy, 280
R
Radiosurgery for trichiasis, 34, 35
Recession, levator aponeurosis, with Mllers
muscle extirpation, 150153, 151, 153
Reconstruction
lower eyelid, 186195
of medial and lateral canthi, 196211
upper eyelid, 172177
Reconstruction of canthal defect, 202211
Rectus muscle(s), 253255, 258319, 259, 261,
263, 265
imbalance of, as complication of subperiosteal orbital volume augmentation, 300
paresis, as complication of lateral orbitotomy,
280
Reduction canthoplasty, lateral, 204, 205
Reduction of epicanthal folds, 198201, 199, 201
Refixation of lacrimal gland prolapse, 48, 49
Reinsertion
lower eyelid retractor, 132, 133
retractor
with horizontal full-thickness eyelid shortening, 134, 135
with lateral tarsal strip fixation, 136, 137
Repair of exposed ocular implant, 314,315
Resection
eyelash bulb, internal, 36, 37
levator muscle
for ptosis, 8182
Supra-Whitnall, 9295, 93, 95
medial spindle, 110, 111
posterior Mllers muscle-conjunctival, 81,
86, 87
tarsal groove, anterior horizontal, marginal
rotation, 140, 141
tarsoconjunctival graft, 190, 191
transconjunctival for ptosis, Fasanella-Servat,
84, 85
wedge, marginal, full-thickness, 112,113
Residual redundant eyelid skin
Retinal artery, central, 254
7/12/2012 4:02:55 PM
Index 329
Retinal vein, central, 264, 265, 268, 269
Retraction
donor eyelid, as complication of free tarsoconjunctival, 144
eyelid (see Eyelid, retraction of )
Retractor(s)
of eyelid, 12, 13
lower eyelid
disinsertion of, with scleral graft, 154, 155
reinsertion of, 132, 133
reinsertion of
with horizontal full-thickness eyelid shortening, 134, 135
with lateral tarsal strip eyelid fixation, 136,137
Retrobulbar anesthesia, 4
Rhombic flap, 168, 169
Riolan muscles of, 9
Rosenmller, valve of, 216
Rotation flap
glabellar, 208, 209
lateral semicircular
with periosteal fixation, for lower eyelid
for upper eyelid reconstruction, 176, 177
Rotation, marginal
by anterior horizontal tarsal groove resection, 140, 141
horizontal blepharotomy with, 142, 143
Rounded canthal angle as complication of
retractor reinsertion with lateral tarsal
strip eyelid fixation, 136
Rounded lateral canthal angle as complication
of lower eyelid blepharoplasty with fat
excision, 54, 62
Rounded lateral eyelid contour as complication of
lateral semicircular rotational flap, 176
S
Sac, lacrimal (see Lacrimal sac)
Scalp anesthesia
Scar formation
hypertrophic
chalazion, 26
as complication of four-flap technique for
reduction of epicanthal fold, 200
poor, as complication of harvesting autogenous fascia lata, 96
Scarring
eyelid margin, as complication of internal
eyelash bulb resection, 36
visible, as complication of direct brow lift, 72
Sclera, 258, 259
Scleral graft
free posterior lamellar lengthening with, 120,
121
lower eyelid retractor disinsertion with, 154,
155
Scleral show, as complication of transconjunctival excision of lower eyelid herniated
orbital fat, 68
Semicircular rotation flap, lateral
with periosteal fixation, for lower eyelid
Semilunar ganglion, 260, 261, 264, 265

Septum, orbital
inferior, 12, 13
lateral, 18, 19
and preaponeurotic fat pads, 12, 13
superior, 12, 13
Shallow fornices, as complication of repair of
exposed ocular implant, 314
Shortening
eyelid
horizontal full-thickness, retractor reinsertion with, 134, 135
by lateral tarsal strip fixation, 108,109
lamellar, anterior, with epitarsal fixation,
108,109
lower eyelid blepharoplasty combined with,
6467, 65, 67
Silicone intubation stents, nasolacrimal system
probing, 234, 235
Silicone rod, frontalis muscle suspension with,
102, 103
Simple direct closure of elliptical defect, 160,161
Single bridged advancement flap, lower eyelid, for upper eyelid reconstruction,
182,183
Sinus
cavernous, 260, 261, 264, 265
ethmoid, cells of, 258, 259
of maier, 216
maxillary, 256259, 257, 259
Sinusitis, as complication of orbital decompression, 288
Sinus-orbital fistula, as complication of orbital
exenteration, 318
Skin, eyelid
excess of, excision of, 108
lateral redundancy of, as complication of
lateral tarsal strip fixation, 108
residual redundant, as complication of
upper eyelid blepharoplasty, 44
Slitting, canalicular
erosion of lacrimal puncta and, as complication of canalicular repair, 226
SMAS midface elevation and fixation, 156, 157
Soft-tissue opening, closure of, as complication of
conjunctivodacryocystorhinostomy, 244
Sphenoid bone, 256, 257
Sphenozygomatic suture, 256, 257
Split-level tarsectomytarsoaponeurectomy, 81
Squamous portion of temporal bone, 256, 257
Staining, corneal punctate as complication of
Mllers muscle-conjunctival, resection, 86
Stenosis, canalicular, 220
as complication of canalicular reconstruction, 228
at laceration site as complication of repair, 226
Stents, silicone intubation, nasolacrimal system
probing with, 234, 235
Stye, treatment of, 25
Subcutaneous block, pretarsal, for ophthalmic
surgery, 5
Submandibular nodes, 9, 18, 19
Subperiosteal compartment, 270
Subperiosteal orbital volume augmentation of
orbit, 300, 301
Sulcus
superior, 10, 11
Sunken hollow appearance as complication of
transconjunctival excision of herniated lower eyelid orbital fat, 68
Superficial facial and orbicularis oculi muscles,
10, 11
Superficial nonmarginal eyelid defects, repair
of, 158170
Superficial parotid nerve, 9
Superficial temporal artery, 9
Superficial temporal vein, 14, 15
Supraorbital anesthesia as complication of
direct brow lift, 72
Supraorbital artery, 262, 263, 266269, 267, 269
Supraorbital nerve, 9, 16, 17
Supraorbital notch, 256, 257
Supraorbital vein, 266269, 267, 269
Supratrochlear artery, 14, 15
Supratrochlear nerve, 9, 16, 17, 266, 267
Supratrochlear nerve block for ophthalmic
surgery, 5
Supratrochlear vein, 266269, 267, 269
Supra-Whitnall levator muscle resection,
9295, 93, 95
Surgery
eyelid, 1211
lacrimal drainage system, 213245
on lacrimal puncta and canaliculi, 220229
on lacrimal sac and duct, 230245
orbital, 247319
on orbital walls, 281301
plastic, ophthalmic, anesthesia, 45
Surgical anatomy
of eyelid, 623
of lacrimal drainage system, 216219, 219
of orbit, 252269
Suspension, temporal fascia lower eyelid, 118, 119
Suspensory ligament
Lockwoods, 8, 12, 13, 253
Whitnalls, 8, 12, 13, 20, 21, 23, 253
Suture(s)
eyelid, full-thickness, 126, 127
modified, for epiblepharon repair, 128, 129
frontoethmoid, 252
frontozygomatic, 252, 256, 257
sphenozygomatic, 256, 257
zygomaticosphenoid, 252
Sympathetic muscle, Mller, 8, 2223, 150153,
151, 153
Sympathetic ophthalmia as complication of
evisceration, 316
Syndrome
congenital ectropion, 204
Horners, 8
T
Transconjunctival inferior wall, orbital decompression, 292, 293
Tarsal groove resection, anterior horizontal,
marginal rotation by, 140, 141
Tarsal plate(s), 8, 11, 12, 1822, 19, 21, 23
Tarsal strip eyelid fixation, lateral
eyelid shortening by, 108, 109
retractor reinsertion with, 136, 137
Tarsectomytarsoaponeurectomy, split-level, 81
Tarsoaponeurectomy, external, 81
7/12/2012 4:02:55 PM
330 Index
Tarsoconjunctival advancement flap, upper to
lower eyelid, 192195, 193, 195
Tarsoconjunctival graft, free
and myocutaneous advancement flap for
posterior lamellar lengthening with, 144, 145
Tarsoconjunctival resection, 81
medial spindle, 110, 111
posterior, 84, 85
Tarsoconjunctival transposition flap, for upper
Tarsorrhaphy, lateral, 106, 107
Tear outflow, test of, 213
Tears, drainage, obstruction, 213
Temporal artery superficial, 78, 79, 254
Temporal bone, 256, 257
Temporal branch of facial nerve, 16, 17, 70
Temporal fascia lower eyelid suspension, 118, 119
Temporal forehead lift, 70
Temporal hooding of eyelid skin, 40, 41
Temporal nerve, superficial, 9
Temporal vein, superficial, 14, 15
Temporalis muscle, 118, 119, 188, 189
Tendon, canthal
medial
crus of, 218, 219
plication of, 116, 117
Test
dye disappearance, 213
Jones I, 213
Jones II, 213
pinch, for eyelid redundancy, 104
Thickening of Z-plasty transpositional flaps, 170
Tissue, granulation in central hole as complication of porous ocular implant, 310
Tomography, computerized, of orbit, 281
Transblepharoplasty Endotine brow fixation, 74, 75
Transcaruncular medial wall, orbital decompression, 284, 285
Transconjunctival approach to incision and
drainage of chalazion, 28, 29
Transconjunctival excision of lower eyelid
herniated orbital fat, 68, 69
Transconjunctival resection for ptosis, 84, 85
Transcutaneous approach to incision and drainage of chalazion, 2627, 27
Transcutaneous, transperiosteal anterior orbitotomy, 274, 275
Transcutaneous, transseptal anterior orbitotomy, 272, 273
Transperiosteal anterior orbitotomy, 274,275
Transposition flap
horizontal tarsoconjunctival, for upper eyelid
median forehead, 210, 211
necrosis, 210
Z-plasty, 170, 171
Transseptal anterior orbitotomy, 272, 273
Transverse facial artery, 9, 14, 15
Transverse facial vein, 14, 15
Transverse ligament of Whitnall, 8, 12, 13, 20,
21, 23, 253
Tarsoconjunctival advancement flap, upper to
lower eyelid, 192195, 193, 195
Triamcinolone acetonide for chalazion, 25
Trichiasis, 30
cryodestruction for, 30
cryosugery for, 32, 33
and distichiasis, 3037

electrohyfrecation for, 30
eyelash bulb, internal resection, 36, 37
at lateral canthus as complication of by lateral
medical management of, 30
primary, 30
radiosurgery for, 34, 35
recurrence of
following cryosurgical treatment, 30
following electohyfrecation, 30
secondary, 30
surgical management of, 30
Trigeminal ganglion, 260, 261, 264, 265
Trigeminal nerve, 252, 254, 260, 261
ophthalmic division, 260, 261, 264, 265
branches of sensory nerves from eyelids, 16, 17
Trochela, 264, 265
Trochlear nerve, 254, 262267, 263, 265,267
Tumors, orbital, 148, 303
Turbinates, 258, 259
Two-snip punctoplasty, 222, 223
U
Undercorrection
as complication of frontalis muscle suspension with silicone rod, 102
of entropion
as complication of marginal rotation by
anterior horizontal tarsal groove
resection, 140
of eyelid retraction
of ptosis
as complication of frontalis muscle suspension with autogenous fascia lata, 100
advancement, 90
as complication of posterior Mllers
muscleconjunctival resection, 86
Upper eyelid
blepharoplasty, with fat excision, 4245, 43, 45
donor, lagophthalmos of, as complication of
skin graft, 120
major retractors of, 12, 13
margin of, 7
marginal defects of, direct layered closure of,
174, 175
ptosis of
as complication of lower eyelid bridged
reconstruction of, 172185
Upper eyelid crease, 7
reformation of, 50, 51
Upper lacrimal papilla, 216, 218, 219
Upper to lower eyelid tarsoconjunctival
advancement flap, 192195, 193, 195
V
Valve
of Hasner, 217
of Rosenmller, 216
Vein(s)
angular, 14, 15, 264, 265
central retinal, 264, 265, 268, 269
ethmoidal, 264, 265, 268, 269
facial, 14, 15
frontal, 14, 15
infratrochlear, 266269, 267, 269
lacrimal, 266269, 267, 269
nasofrontal, 14, 15
ophthalmic, 254, 255, 264, 265, 268, 269
superficial temporal, 14, 15
supraorbital, 14, 15, 266269, 267, 269
supratrochlear, 266269, 267, 269
temporal, superficial, 14, 15
vortex, 264, 265, 268, 269
Vertical canthal angle dystopia, correction of,
206, 207
Visible scar as complication of direct brow
lift, 72
Vision, loss of
as complication of orbital decompression, 288
as complication of repair of orbital floor
fractures, 296
as complication of upper eyelid
blepharoplasty with fat excision,44
Volume orbital, loss as complication of dermisfat orbital graft, 312
Vortex vein, 264, 265, 268, 269
W
Wedge resection, marginal, full-thickness, 112,
113
Whitnalls ligament, 8, 12, 13, 20, 21, 23, 253
Wies procedure for entropion, 142, 143
Wound dehiscence
as complication of evisceration, 316
horizontal eyelid shortening, 134
Wound infection as complication of dacryocystorhinostomy, 240
Y
Y to V advancement flap for reduction of epicanthal folds, 198201, 199, 201
Z
Zinn, annulus of, 253, 260, 261
Z-plasty for repair of superficial nonmarginal
eyelid defects, 158
Z-plasty transpositional flaps, 170, 171
Zygomatic arch of temporal bone, 256,257
Zygomatic bone, 252, 256259, 257, 259
Zygomatic branch of facial nerve, 7, 9, 16,17
Zygomatic furrow, 10, 11
Zygomatic nerve, 260, 261
Zygomaticofacial artery, 260, 261, 268, 269
Zygomaticofacial nerve, 9, 16, 17, 260, 261
Zygomaticosphenoid suture, 252
Zygomaticotemporal artery, 254
Zygomaticotemporal nerve, 9, 16, 17
7/12/2012 4:02:55 PM

Atlas of Oculoplastic and Orbital Surgery

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Atlas of Oculoplastic and Orbital Surgery

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ATLAS OF

THOMAS G. WALDROP, M.S.M.I.

Senior Executive Editor: Jonathan W. Pine, Jr.

Library of Congress Cataloging-in-Publication Data

About the Author

About the Illustrator

JONATHAN J. DUTTON, M.D., Ph.D., is professor

THOMAS G. WALDROP, M.S.M.I., received his

and vice chair in the Department of Ophthalmology at

23. External Levator Aponeurosis Advancement

1. Anesthesia in Ophthalmic Plastic Surgery

B. Surgical Anatomy of the Eyelids

C. Hordeolum and Chalazion

3. Chalazion Incision and Drainage, Transcutaneous

D. Trichiasis and Distichiasis

5. Cryosurgery for Trichiasis

Etiology and Associated Deformities

18. Direct Brow Elevation

21. Posterior Tarsoconjunctival Resection

28. Lateral Tarsorrhaphy

36. Full-thickness Eyelid Sutures

J. Correction of Eyelid Retraction

47. Levator Aponeurosis Recession with Mllers

K. Repair of Supercal Non-marginal

L. Upper Eyelid Reconstruction

56. Direct Layered Closure of Marginal Eyelid

M. Lower Eyelid Reconstruction

62. Lateral Semicircular Rotation Flap with Periosteal

N. Medial and Lateral Canthal

Lacrimal Drainage System

A. Surgical Anatomy of the Lacrimal Drainage

B. Surgery on the Lacrimal Puncta and

C. Surgery on the Lacrimal Sac and

A. Surgical Anatomy of the Orbit

83. Transcutaneous, Transseptal Anterior

C. Surgery on the Orbital Walls

86. Orbital Decompression, Inferior

HE EYELIDS ARE COMPLEX ANATOMIC STRUCTURES THAT PERFORM A VITAL

Anesthesia in Ophthalmic Plastic Surgery

he general principles of surgical anesthesia apply in

rior orbitotomy, placement of a secondary ocular implant,

CHAPTER 1 Anesthesia in Ophthalmic Plastic Surgery

whose full function may be needed during the operation. If

Surgical Anatomy of the

urgery on the eyelids and periorbital tissues requires a

Horner's muscle. Reconstruction in the canthal areas must

SECTION B Surgical Anatomy of the Eyelids

surgically important landmarks because they help identify

Immediately posterior to the levator aponeurosis in the

CHAPTER 2 Eyelid Anatomy

from the superior division of the oculomotor nerve, and

SECTION B Surgical Anatomy of the Eyelids

CHAPTER 2 Eyelid Anatomy

SECTION B Surgical Anatomy of the Eyelids

CHAPTER 2 Eyelid Anatomy

SECTION B Surgical Anatomy of the Eyelids

CHAPTER 2 Eyelid Anatomy

SECTION B Surgical Anatomy of the Eyelids

CHAPTER 2 Eyelid Anatomy

SECTION B Surgical Anatomy of the Eyelids

CHAPTER 2 Eyelid Anatomy

SECTION B Surgical Anatomy of the Eyelids

CHAPTER 2 Eyelid Anatomy

SECTION B Surgical Anatomy of the Eyelids