Atlas of Oculoplastic and Orbital Surgery [PDF]

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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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Senior Executive Editor: Jonathan W. Pine, Jr. Senior Product Manager: Emilie Moyer Senior Manufacturing Manager: Benjamin Rivera Designer: Holly McLaughlin Production Service: SPi Global Copyright © 2013 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com Printed in China All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright.



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. Eyelids—surgery—Atlases. 2. Orbit—surgery—Atlases. 3. Lacrimal Apparatus—surgery— Atlases. 4. Ophthalmologic Surgical Procedures—methods—Atlases. 5. Reconstructive Surgical Procedures—methods—Atlases. WW 17] 617.7'71—dc23 2012011414 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: at LWW.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 1



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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 master’s 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.



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Preface



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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 patient’s 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 surgeon’s 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.



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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-Whitnall’s 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



3



1. Anesthesia in Ophthalmic Plastic Surgery



B. Surgical Anatomy of the Eyelids 2. Eyelid Anatomy



4



6



H. Ectropion



7



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 Refixation 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 Müller’s Muscle–Conjunctival 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. Modified 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. Modified Full-thickness Eyelid Sutures for Epiblepharon Repair 128 38. Lower Eyelid Crease Reformation for Epiblepharon Correction 130 39. Lower Eyelid Retractor Reinsertion 132 40. Retractor Reinsertion with Horizontal Eyelid Shortening 134 41. Retractor Reinsertion with Lateral Tarsal Strip Fixation 136 42. Anterior Lamellar Shortening with Epitarsal Muscle Fixation 138 43. Marginal Eyelid Rotation by Anterior Horizontal Tarsal Groove 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 Membrane Graft 146



J. Correction of Eyelid Retraction



148



47. Levator Aponeurosis Recession with Müller’s Muscle Extirpation 150



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Contents 48. Lower Eyelid Retractor Disinsertion with Scleral Graft 154 49. SMAS Midface Elevation and Fixation 156



K. Repair of Superfical 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-flap 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 of the Inferior 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 Inferior Wall 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, and Exenteration 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



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P



A



R



T



I Eyelid Surgery



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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 film. 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 significantly 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 patient’s cardiologist or primary



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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 Schirmer’s 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 field 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 specific 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 specific diagnostic tests. ▼



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SECTION



Anesthesia



A



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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.



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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 Müller'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,



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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;21:3–26. Cohen AJ. Oculoplastic and orbital surgery. Ophthalmol Clin N Am. 2006;19:257–267. Covino BG. Pharmacology of local anesthetic agents. Ration Drug Ther 1987;21:1–9. Deleuze A, Gentili ME, Bonnet F. Regional anesthesia for head and neck surgery. Ann Fr Anesth Reanim. 2009;28:818–823. Ehlert TK, Arnold DE. Local anesthetic agents. Br J Anesth. 1990;23: 831–844. Harmatz A. Local anesthetics: uses and toxicities. Surg Clin N Am. 2009;89:587–598. Kaweski S. Topical anesthetic creams. Plast Reconstr Surg. 2008;121: 2161–2165. Mustoe TA, Buck DW II, Lalonde DH. The safe management of anesthesia, sedation, and pain in plastic surgery. Plast Reconstr Surg. 2010;126:165e–176e. Quaba O, Huntley JS, Bahia H, McKeown DW. A users guide for reducing the pain of local anesthetic administration. Emerg Med J. 2005; 22:188–189. Ramos-Zabala A, Perez-Mencia MT, Fernandez-Garcia R, et al. Anesthesia techniques for outpatient laser resurfacing. Lasers Surg Med. 2004; 34:269–272. 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;53:543–546. Shapiro FE. Anesthesia for outpatient cosmetic surgery. Curr Opin Anaesthesiol. 2008;21:704–710. Suresh S, Voronov P. Head and neck blocks in children: an anatomical and procedural review. Paediatr Anaesth 2006;16:910–918. Thorne AC. Local anesthetics. In: Aston SJ, Beasley RW, Thorne CHM, eds. Grabb and Smith's Plastic Surgery. Philadelphia, PA: LippincottRaven; 1997:99–103.



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SECTION



Surgical Anatomy of the Eyelids



B



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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 skin–muscle 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 septum–levator 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



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8



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.



Dutton_Chap02.indd 8



Immediately posterior to the levator aponeurosis in the upper eyelid and the capsulopalpebral fascia in the lower eyelid is the sympathetic smooth muscle of Müller. 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, Müller'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 Müller's muscle anterior to the tarsus and may be considered as its tendon. In the lower eyelid, Müller'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 Müller 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



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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



Dutton_Chap02.indd 9



9



from the superior division of the oculomotor nerve, and Müller'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.



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10



SECTION B ▲ Surgical Anatomy of the Eyelids 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. Superficial facial and orbicularis oculi muscles. 1, Frontalis muscle. 2, Procerus muscle. 3, Corrugator supercilii muscle. 4–9: 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, Superficial head of preseptal portion. 6, Superficial head of orbital portion.



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CHAPTER 2 ▼ Eyelid Anatomy



11



FIG. 2.1



1



7



2 3



8 4 9 5 10 6



FIG. 2.2



FIG. 2.3



1 2 3 4



1 2



5



3



6



4



7 8



5 6



9 10



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12



SECTION B ▲ Surgical Anatomy of the Eyelids 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.



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CHAPTER 2 ▼ Eyelid Anatomy



13



FIG. 2.4



1



6



7 2



8



3 4



5



9 10 11 12



FIG. 2.5



5 1



6



2



7



3 8 4



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14



SECTION B ▲ Surgical Anatomy of the Eyelids 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, Superficial temporal vein. 3, Transverse facial vein. 4, Frontal vein. 5, Supratrochlear vein. 6, Nasofrontal vein. 7, Angular vein. 8, Anterior facial vein.



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CHAPTER 2 ▼ Eyelid Anatomy



15



FIG. 2.6



9 1



10



2 11 3 12 4 5 6 7



8



13 14 15 16 17



FIG. 2.7 1 2



4 5 6



7 3 8



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16



SECTION B ▲ Surgical Anatomy of the Eyelids 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.



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CHAPTER 2 ▼ Eyelid Anatomy



17



FIG. 2.8



1



4 5



2



6



3 7



FIG. 2.9



4



1



2



5



3



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18



SECTION B ▲ Surgical Anatomy of the Eyelids FIG. 2.10. Lymphatic drainage from the eyelids. 1, Superficial and deep parotid (preauricular) nodes. 2, Submandibular nodes. 3, Superficial 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.



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CHAPTER 2 ▼ Eyelid Anatomy



19



FIG. 2.10



1



2



3



FIG. 2.11



1



9



2 3 4 5 6 7



10 11 12 13 14



8



15 16



17



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20



SECTION B ▲ Surgical Anatomy of the Eyelids 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.



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CHAPTER 2 ▼ Eyelid Anatomy



21



FIG. 2.12 10 1



11



2 3



12 13



4 5 14 15



6 16 7



17



8



18



9



19 20



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22



SECTION B ▲ Surgical Anatomy of the Eyelids 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, Müller's muscle. 3, Inferior sympathetic muscle of Müller. 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 Müller's muscle. 1, Whitnall's ligament. 2, Cut edge of the levator aponeurosis. 3, Müller'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 Müller. 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



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CHAPTER 2 ▼ Eyelid Anatomy



23



FIG. 2.14



1



2 3 4 5



6 7 8 9



FIG. 2.15



1 2



3 4



5



6



7 8



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SECTION B ▲ Surgical Anatomy of the Eyelids



SUGGESTED FURTHER READING Bilyk JR. Periocular and orbital anatomy. Curr Opin Ophthalmol. 1995;6:53–58. Burkat CN, Lemke BN. Anatomy of the orbit and its related structures. Otolaryngol Clin North Am. 2005;38:825–856. Doxanas MT, Anderson RL. Clinical Orbital Anatomy. Baltimore, MD: Williams & Wilkins; 1984:57–89. Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. 2nd ed. London, UK: Elsevier; 2011:129–164. Kakizaki H, Malhotra R, Madge SN, Selva D. Lower eyelid anatomy: an update. Ann Plast Surg. 2009;63:344–351. Kakizaki H, Malhotra R, Selva D. Upper eyelid anatomy: an update. Ann Plast Surg. 2009;63:336–343.



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Kleinjes WG. Forehead anatomy: arterial variations and venous link of the midline forehead flap. J Plast Reconstr Aesthet Surg. 2007;60:593–606. Most SP, Mobley SR, Larrabee WF Jr. Anatomy of the eyelids. Facial Plast Surg Clin North Am. 2005;13:487–492. Oh SR, Priel A, Korn BS, Kikkawa DO. Applied anatomy for the aesthetic surgeon. Curr Opin Ophthalmol. 2010;21:404–410. Ridgway JM, Larrabee WF. Anatomy for blepharoplasty and brow lift. Facial Plast Surg. 2010;26:177–185. Seiff SR, Seiff BD. Anatomy of the Asian eyelid. Facial Plast Surg Clin North Am. 2007;15:309–314. Stewart JM, Carter SR. Anatomy and examination of the eyelids. Int Ophthalmol Clin. 2002;42:1–13. Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York, NY: Raven press; 1985:21–32.



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SECTION



C



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. SUGGESTED FURTHER READING 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;16:42–44. 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: 714–718. Carrim ZI, Shields L. A simplified technique for incision and curettage of chalazia. Orbit. 2008;27:401–402. Dhaliwal U, Bhatia A. A rationale for therapeutic decision-making in chalazia. Orbit. 2005;24:227–230. 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;11:154–156. Lederman C, Miller M. Hordeola and chalazia. Pediatr Rev. 1999;20: 283–284. Mansour AM. Injections for chalazia? Ophthalmology. 2006;113:353–354. Ozdal PC, Codère F, Callejo S, et al. Accuracy of the clinical diagnosis of chalazion. Eye. 2004;18:135–138. Pizzarello LD, Jakobiec FA, Hofeldt JD, et al. Intralesional corticosteroid therapy of chalazia. Am J Ophthalmol. 1978;85:818–821. 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;27:397–398.



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3



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 formation—This 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 cilia—This 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 notching—Occasionally, 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 hordeolum—Recurrence may follow incomplete excision of the abscess cavity lining or failure to curette all loculated chambers.



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CHAPTER 3 ▼ Chalazion Incision and Drainage, Transcutaneous Approach



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FIG. 3.1



FIG. 3.3



FIG. 3.2



FIG. 3.4



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4



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 fibrous 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 flap 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. POTENTIAL COMPLICATIONS: Loss of cilia—This may occur when incisions, cautery, or excessive curettage is used within 2 to 3 mm of the eyelid margin. Marginal eyelid notch—Notching 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 glands—This 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.



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CHAPTER 4 ▼ Chalazion Incision and Drainage, Transconjunctival Approach



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FIG. 4.1



FIG. 4.3



FIG. 4.2



FIG. 4.4



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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 skin–muscle 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



D



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 freeze–thaw 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. SUGGESTED FURTHER READING Alemayehu W, Kello AB. Trichiasis surgery: a patient-based approach. Community Eye Health. 2010;23:58–59. Bartley GB, Lowry JC. Argon laser treatment of trichiasis. Am J Ophthalmol. 1992;113:71–74. Başar E, Ozdemir H, Ozkan S, et al. Treatment of trichiasis with argon laser. Eur J Ophthalmol. 2000;10:273–275. 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;245:637–640. Choo PN. Distichiasis, trichiasis, and entropion: advances in management. Int Ophthalmol Clin. 2002;42:75–87. Dutton JJ, Tawfik HA, DeBacker CM, Lipham WJ. Direct internal eyelash bulb extirpation for trichiasis. Ophthal Plast Reconstr Surg. 2000;16:142–145. 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;52:2704–2711. Kersten RC, Leiner FP, Kulwin DR. Tarsotomy for the treatment of cicatricial entropion with trichiasis. Arch Ophthalmol. 1992;110:714–717.



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SECTION D ▼ Trichiasis and Distichiasis Kezirian GM. Treatment of localized trichiasis with radiosurgery. Ophthal Plast Reconstr Surg. 1993;9:260–266. McCracken MS, Kikkawa DO, Vasani SN. Treatment of trichiasis and distichiasis by eyelash trephination. Ophthal Plast Reconstr Surg. 2006;22:349–351. Moosavi AH, Mollan SP, Berry-Brincat A, et al. Simple surgery for severe trichiasis. Ophthal Plast Reconstr Surg. 2007;23:296–297. Pham RT, Biesman BS, Silkiss RZ. Treatment of trichiasis using an 810-nm diode laser: an efficacy study. Ophthal Plast Reconstr Surg. 2006;22:445–447. 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;35:116–122.



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31



Sodhi PK, Verma L. Surgery for trichiasis. Ophthalmology. 2004;111: 2147–2148. Vaughn GL, Dortzbach RK, Sires BS, Lemke BN. Eyelid splitting with excision or microhyfrecation for distichiasis. Arch Ophthalmol. 1997;115:282–284. Wojno TH. Lid splitting with lash resection for cicatricial entropion and trichiasis. Ophthal Plast Reconstr Surg. 1992;8:287–289. Wu AY, Thakker MM, Wladis EJ, Weinberg DA. Eyelash resection procedure for severe, recurrent, or segmental cicatricial entropion. Ophthal Plast Reconstr Surg. 2010;26:112–116. Yeung YM, Hon CY, Ho CK. A simple surgical treatment for upper lid trichiasis. Ophthalmic Surg Lasers 1997;28:74–76.



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5



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 −20°C. 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 −20°C.



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. Depigmentation—This is more common in darkly pigmented skin, and an alternative treatment modality should be considered in such individuals. Treatment failure—Partial 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 of failure is involved, internal surgical excision of lash bulbs would be more appropriate.



POTENTIAL COMPLICATIONS: Eyelid edema—This 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 necrosis—The risk of necrosis is greater with temperatures below −30°C. Epidermal necrosis is more common with cryoprobe application to the skin surface.



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CHAPTER 5 ▼ Cryosurgery for Trichiasis



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FIG. 5.1



FIG. 5.3



FIG. 5.2



FIG. 5.4



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6



Radiosurgery for Trichiasis



INDICATIONS: One to a few trichitic or distichitic cilia.



FIG. 6.1. Infiltrate 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 failure—This 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.



POTENTIAL COMPLICATIONS: Lid margin distortion—This 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.



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CHAPTER 6 ▼ Radiosurgery for Trichiasis FIG. 6.1



Dutton_Chap06.indd 35



35



FIG. 6.2



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7



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. Infiltrate 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 fine 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. POTENTIAL COMPLICATIONS: Treatment failure—This is caused by inadequate excision of all offending lash bulbs in the affected area. If



FIG. 7.5. Reform the eyelid crease by fixing 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 scarring—This 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.



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CHAPTER 7 ▼ Internal Eyelash Bulb Resection



Dutton_Chap07.indd 37



FIG. 7.1



FIG. 7.4



FIG. 7.2



FIG. 7.5



FIG. 7.3



FIG. 7.6



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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 patient’s 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



E



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 skin–muscle 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.



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SECTION E ▼ Cosmetic Blepharoplasty SUGGESTED FURTHER READING Upper Eyelid Blepharoplasty with Fat Excision Baker TJ, Gordon HL, Mosicnko P. Upper blepharoplasty. Clin Plast Surg. 1981;8:635–641. Chen PD. Upper blepharoplasty. In: Chen PD, Khan JA, McCord CD, eds. Color Atlas of Cosmetic Oculofacial Surgery. Philadelphia, PA: Butterworth Heinemann; 2004:43–59. Damasceno RW, Cariello AJ, Cardoso EB, et al. Upper blepharoplasty with or without resection of the orbicularis oculi muscle: a randomized double-blind left-right study. Ophthal Plast Reconstr Surg. 2011;27:195–197. Gentile RD. Upper lid blepharoplasty. Facial Plast Surg Clin North Am. 2005;13:511–524. Available from: http://www.ncbi.nlm.nih.gov/ pubmed/16253838. Lelli GJ Jr, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg. 2010;125:1007–1017. Morax S, Touitou V. Complications of blepharoplasty. Orbit. 2006;25: 303–318. Parikh S, Most SP. Rejuvenation of the upper eyelid. Facial Plast Surg Clin North Am. 2010;18:427–433. Purewal BK, Bosniak S. Theories of upper eyelid blepharoplasty. Ophthalmol Clin North Am. 2005;18:271–278. Putterman AM. Treatment of upper eyelid dermatochalasis and orbital fat: skin flap approach. In: Putterman AM, ed. Cosmetic Oculoplastic Surgery. Philadelphia, PA: WB Saunders; 1999:77–90. Sheen JH. Supratarsal fixation in upper blepharoplasty. Plast Reconstr Surg. 1974;54:424–431. Webster RC, Davidson TM, Smith RC. Determination of the range of reasonable results in cosmetic blepharoplasty. Trans Am Acad Ophthalmol Otolaryngol. 1977;84:769–784.



The Asian Eyelid Blepharoplasty Chee E, Choo CT. Asian blepharoplasty—an overview. Orbit 2011;30:58–61. Chen PD. Upper blepharoplasty in the Asian patient. In: Chen PD, Khan JA, McCord CD, eds. Color Atlas of Cosmetic Oculofacial Surgery. Philadelphia, PA: Butterworth Heinemann; 2004:73–108. Kim DW, Bhatki AM. Upper blepharoplasty in the Asian eyelid. Facial Plast Surg Clin North Am. 2007;15:327–335. Kruavit A. Asian blepharoplasty: an 18-year experience in 6215 patients. Aesthet Surg J. 2009;29:272–283. Nguyen MQ, Hsu PW, Dinh TA. Asian blepharoplasty. Semin Plast Surg. 2009;23:185–197. Scawn R, Joshi N, Kim YD. Upper lid blepharoplasty in Asian eyes. Facial Plast Surg. 2010;26:86–92. Takayanagi S. Asian upper blepharoplasty double-fold procedure. Aesthet Surg J. 2007;27:656–663. Takayanagi S. Case studies in Asian blepharoplasty. Aesthet Surg J. 2011;31:171–179.



Repositioning of Prolapsed Lacrimal Gland Beer GM, Kompatscher P. A new technique for the treatment of lacrimal gland prolapse in blepharoplasty. Aesthetic Plast Surg. 1994;18:65–69. Friedhofer H, Orel M, Saito FL, et al. Lacrimal gland prolapse: management during aesthetic blepharoplasty: review of the literature and case reports. Aesthet Plast Surg. 2009;33:647–653. Horton CE, Carraway JH, Potenza AD. Treatment of a lacrimal bulge in blepharoplasty by repositioning the gland. Plast Reconstr Surg. 1978;61:701–702. Massry GG. Prevalence of lacrimal gland prolapse in the functional blepharoplasty population. Ophthal Plast Reconstr Surg. 2011;27:410–413. Smith B, Petrelli R. Surgical repair of prolapsed lacrimal glands. Arch Ophthalmol. 1978;96:113–114.



Reformation of the Upper Eyelid Crease Choi HS, Whipple KM, Oh SR, et al. Modifying the upper eyelid crease in Asian patients with hyaluronic acid fillers. Plast Reconstr Surg. 2011;127:844–849. Sayoc BT. Plastic construction of the superior palpebral fold. Am J Ophthalmol. 1954;38:556–559. Small RC. Supratarsal fixation in ophthalmic plastic surgery. Ophthal Surg. 1978;9:73–85.



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Smith BC, Bosniak SI. Reconstructing the supratarsal crease. In: Bosniak SL, Smith BC, eds. Advances in Ophthalmic Plastic and Reconstructive 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;90:223–229. 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;37:163–178. 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; 2004:109–140. Morax S, Touitou V. Complications of blepharoplasty. Orbit. 2006;25: 303–318. 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; 99:1402–1405. 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;13:387–391. Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg. 2000;105:743–748. Goldberg RA, Edelstein C, Shorr N. Fat repositioning in lower blepharoplasty to maintain infraorbital rim contour. Facial Plast Surg. 1999;15:225–229. Momosawa A, Kurita M, Ozaki M, et al. A transconjunctival orbital fat repositioning for tear trough deformity in young Asians. Aesthet Surg J. 2008;28:265–271. Nassif PS. Lower blepharoplasty: transconjunctival fat repositioning. Otolaryngol Clin North Am. 2007;40:381–390. Stark GB, Iblher N, Penna V. Arcus marginalis release in blepharoplasty I: technical facilitation. Aesthet Plast Surg. 2008;32:785–789.



Lower Eyelid Blepharoplasty Combined with Canthopexy Beard C. Lower lid blepharoplasty. Ophthalmology 1978;85:712–715. 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;125:384–392. 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;85:705–708. Tenzel RR. Cosmetic blepharoplasty. Int Ophthalmol Clin. 1978;18:87–99.



Transconjunctival Excision of Herniated Lower Eyelid Orbital Fat Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr Surg. 2011;127:386–395. Mahe E. Lower lid blepharoplasty—the transconjunctival approach: extended indications. Aesthetic Plast Surg. 1998;22:1–8. Patel BC, Anderson RL. Transconjunctival blepharoplasty. Plast Reconstr Surg. 1996;97:1514–1515. Pechter EA. Transconjunctival lower blepharoplasty through interrupted incisions. Plast Reconstr Surg. 2009;124:166e–167e. 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; 1999:203–210.



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8



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 flat 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 reflex distance (MRD1) is reduced to