RECONSTRUCTION James F Thornton MD and Jeffrey M Kenkel MD

ANATOMY AND PHYSIOLOGY laterally. Its vascular supply is primarily via the oph- Surgery of the requires a thorough knowl- thalmic artery. The marginal artery of the eyelid courses approximately 3–3.5mm above the lid mar- edge of the periorbital anatomy. The complexity of 2 the eyelids as well as the importance of each com- gin. The inferior marginal arcade is supplied predomi- ponent to the function of the eyelid must be appre- nantly from branches of the facial artery in addition ciated. A detailed description of eyelid anatomy to a branch from the superior marginal vessel. These and the was given by Jones1 in arcades travel just anterior to the . The mar- 1961. The reader is also encouraged to peruse ginal artery courses 1mm superior and anterior to Zide and Jelks’s2 Surgical Anatomy of the for the base of the lower tarsus.3,4 Laterally the superfi- a complete description and excellent illustrations of cial network of the skin is supplied primarily by the periorbital anatomy. branches of the superficial temporal artery and the lacrimal artery. Blood Supply The extensive collateralization that exists between branches of the internal carotid artery—mainly the The rich vascular supply of the eyelids is through ophthalmic artery—and branches of the facial artery marginal and peripheral arcades.2,3 Medially a rich accounts for reversal of flow seen when the internal superficial network is formed via anastomoses from carotid artery is obstructed.2 both the internal and external carotid artery sys- tems (Fig 1). Innervation Sensation to the periorbital area is via the first and second branches of the . The motor supply to the orbicularis oculi muscle is from the temporal and zygomatic branches of the facial nerve, which enter the muscle from its deep sur- face. Ouattara and coworkers5 find three common patterns of innervation of the orbicularis (Fig 2). In the most common variant, present in 63.3% of their cases, the muscle is innervated by a superior plexus fed by temporal and superior zygomatic branches and an inferior plexus fed by inferior zygomatic and superior buccal branches. In the lower lid, Mendelson et al6 describe the situation as follows: The zygomatic branches of the facial nerve that Fig 1. Blood supply of the eyelid. ADT=anterior deep innervate the orbicularis oculi enter the pars temporal artery; DN=dorsal nasal artery; F=facial artery; orbitalis at or near its periphery and seem to do so IO=infraorbital artery; L=lacrimal artery; OA=ophthalmic in four distinct locations [Fig 3]. . . . Ultimately, the artery; SO=supraorbital artery; ST=supratrochlear artery. several branches become more superficial as they (Reprinted with permission from Tucker SM, Linberg JV: Vascular enter the suborbicularis oculi fat on the underside anatomy of the eyelids. Ophthalmology 101:1118, 1994.) of the orbicularis. The [zygomatico-facial] nerve, previously The upper marginal arcade is initially quite tortu- considered the main innervation of the orbicularis ous and then straightens out as it passes further oculi, separates from the zygomatic nerve well SRPS Volume 10, Number 8

Fig 2. Common anatomical variations in the innervation of the orbicularis oculi and their relative prevalence. T = temporal branch of facial nerve. SZ = superior zygomatic branch. IZ = inferior zygomatic branch. SB = superior buccal branch. a, 63.3%; b, 16.7%; c, 13.3%. (Reprinted with permission from Ouattara D, Vacher C, Accioli de Vasconcellos JJ, et al: Anatomical study of the variations in innervation of the orbicularis oculi by the facial nerve. Surg Radiol Anat 26:51, 2004.)

before the latter passes deep to the zygomaticus major. [The zygomatico-facial nerve] continue[s] its directly horizontal course over the outer surface of the zygomaticus major, within a centimeter of the upper edge of the muscle origin. This orbicularis branch courses immediately outside the pre- zygomatic space as it passes on the inferior surface of the same zygomatic ligament forming part of the inferior boundary of the prezygomatic space, . . . [and] continues medially onto the surface of the zygomaticus minor, . . . where it abruptly changes course, from transverse to vertical, to enter the sub- orbicularis oculi fat overlying the zygomaticus minor. It remains in this layer, in the ceiling of the space, as it ascends toward the lid margin [Fig 4]. Fig 3. Pattern of innervation of the orbicularis oculi of the lower Mendelson et al (2002) lid. The branches at 6 o’clock and 7 o’clock course from deep to the parotid-masseteric fascia to become superficial into the

7 sub-orbicularis oculi fat near the retaining ligaments. The dark In the upper lid, Hwang and colleagues follow arrows indicate the three common surgical approaches to the the course of the temporal branch of the facial nerve prezygomatic space. (Reprinted with permission from Mendelson in the orbicularis oculi muscle and designate a haz- BC, Muzaffar AR, Adams WP Jr: Surgical anatomy of the midcheek ard zone where injury to the temporal branch is and malar mounds. Plast Reconstr Surg 110:885, 2002.) likely to occur. On the basis of a study on 20 cadav- ers, the authors found the temporal branch of the Skin and Subcutaneous Tissues facial nerve coursed horizontally along the fibers of the orbicularis oculi muscle with interconnections, Eyelid skin has only 6 to 7 cell layers and averages but did not cross over the superior orbital rim. <1mm thick. The upper eyelid is even thinner than The location of the supraorbital and infraorbital the lower lid in most people. Sebaceous glands are nerves can be predicted by palpating for the more numerous on the medial half of the lids, con- supraorbital notch. Cadaver studies by Wilhelmi tributing to smoother, oilier skin on the nasal side.9 and associates8 place the vertical course of the Eccrine sweat glands are found throughout the eye- supraorbital and infraorbital nerves approximately lid, while apocrine glands (Moll) are more commonly 16–17mm from the medial along the medial found near the lid margin. The sebaceous glands of one third of the orbit. Zeis are associated with the .9

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Fig 4. The temporal approach to the prezygomatic space passes deep to the lower temporal branches of the facial nerve (TFN) to the orbicularis. The zygomatico-facial nerve (ZFN) is the only structure crossing the space, and lies directly cephalad to the zygomaticus minor muscle. (Reprinted with permission from Mendelson BC, Muzaffar AR, Adams WP Jr: Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 110:885, 2002.) In the Western upper eyelid, fascial bands from border of the tarsus. Asians usually lack a palpebral the levator palpebrae pass through the orbicularis fold because the levator expansions do not pen- oculi muscle and insert into the skin from the ciliary etrate the . In the lower eyelid of margin to the level of the palpebral furrow (Fig 5A). Europeans, fibrous bands from the orbital septum The skin superior to the furrow is nonadherent and pass through the orbicularis oculi and insert into the relatively mobile; this transition from adherent skin, forming an inferior palpebral furrow. As in the pretarsal skin to mobile preseptal skin forms the upper upper lid, Asians lack these fascial extensions and eyelid fold, which typically runs along the superior therefore show no palpebral crease (Fig 5B).

Fig 5. A. Sagittal section of upper eyelid in left, Westerners and right, Asians. The levator expansions penetrate the orbital septum and orbicularis muscle to attach to the skin in Europeans. These extensions are lacking in Asian eyelids. (Adapted from Sheen JH: Supratarsal fixation in upper . Plast Reconstr Surg 54:424, 1974.)

Fig 5. B. Sagittal section of lower eyelid in left, Westerners and right, Asians. The capsulopalpebral fascia in the lower lid corresponds to the levator in the upper lid. (Reprinted with permission from Wolfort FG, Kanter WR, eds: Aesthetic Blepharoplasty. Boston, Little Brown, 1995.)

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Orbicularis Oculi Muscle The orbicularis oculi consists of palpebral and orbital portions, with the palpebral portion further subdivided into pretarsal and preseptal portions. Medially, the orbital portion of the muscle origi- nates directly from the bony orbital rim and the medial canthal tendon. Superiorly, the orbital por- tion of the muscle overlies both the frontalis and corrugator muscles. Inferiorly, the orbicularis muscle attaches indirectly to the orbital rim by means of the orbicularis retaining ligament (Fig 6), overlying the origins of the levator muscles to the upper lip. The orbicularis retaining ligament separates the prezygomatic space from the preseptal space (Fig 7). Laterally, the ligament merges into the lateral orbital thickening.10 The upper and lower portions of the preseptal orbicularis converge at the lateral canthal raphe.2 Fig 7. The orbicularis retaining ligament (ORL) indirectly at- taches the orbicularis oculi (OO) to the periosteum of the orbital rim and separates the prezygomatic space from the preseptal space. (Reprinted with permission from Muzaffar AR, Mendelson BC, Adams WP Jr: Surgical anatomy of the ligamentous attach- ments of the lower lid and lateral canthus. Plast Reconstr Surg 110:873, 2002.)

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

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• Along the lateral half of the orbital rim, the sep- tum originates just inferior to the orbital margin, resulting in a potential space—the recess of Eisler.2

Medial Canthus Zide and McCarthy12 describe the medial can- thus as tripartite: The upper superficial preseptal and pretarsal portions of the orbicularis oculi . . . inserted into the medial canthal tendon and adjacent bone. . . . In each instance a vertical or slightly oblique component of thick tendinous fascia arose from the transverse tendon at a point nasal to the junction of the limbs that form the tendon [Fig 9]. The fibers . . . were clearly oriented in a vertical direction and were inserted firmly into an ill-defined portion of the medial orbital rim just at, inferior to, or slightly superior to the nasofrontal suture.

Zide & McCarthy (1983)

Fig 8. Anatomy of the upper and lower eyelids and periorbital structures.

Medially the septum attaches to the lower end of the anterior lacrimal crest and passes from lower to upper lid under the orbicularis muscle. Laterally the orbital septum passes just anterior to the lateral Fig 9. The suture surrounds the strong vertical component of the canthal tendon.9 medial canthal complex. (Reprinted with permission from Zide Zide and Jelks2 emphasize the following key ana- BM, McCarthy JG: The medial canthus revisited—an anatomical tomic points: basis for canthopexy. Ann Plast Surg 11:1, 1983.) • Laterally the orbital septum lies in front of the 12 lateral canthal tendon. Zide and McCarthy believe that the vertical com- ponent of the medial canthal tendon is responsible • Superomedially the arcus marginalis forms the for suspension and fixation of the medial canthus, inferior portion of the supraorbital groove. while the horizontal components are relatively weak • Medially the orbital septum passes in front of the and contribute little to medial canthal stability.12 superior oblique trochlear pulley and then runs posterior to the deep heads of the orbicularis oculi muscle to insert onto the posterior lacrimal Lateral Canthal Tendon crest. The lateral canthal tendon is more difficult to • Inferomedially the septum attaches to the ante- define than the medial canthal tendon. It attaches rior lacrimal crest and the inferior orbital rim. to both the upper and lower tarsal plates, the

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orbicularis muscle, and the fibrous portion of the septum.11 The relative contributions of these vari- ous components to the lateral canthal tendon are still unclear. Its fibers insert onto the lateral orbital tubercle of Whitnall’s approximately 5mm behind the rim.2

Tarsal Plates The superior tarsus measures approximately 10–12mm vertically from the lid margin. Anteri- orly it is covered by the pretarsal orbicularis and posteriorly it is adherent to the underlying con- junctiva. It is composed of thin sheets of con- nective tissue which maintain structural integrity of the upper lid while accommodating the con- tour of the . Within the tarsus meibomian Fig 10. Preaponeurotic orbital fat. (Reprinted with permission glands can be found that are responsible for from Putterman AM: Cosmetic Oculoplastic Surgery, 2nd Ed. 13 secretion of oil. Whitnall observed that the Philadelphia, WB Saunders, 1993.) tarsus was not a solid plate of connective tissue, but rather consisted largely of meibomian glands. Furthermore, the tarsus splays out at the lid mar- Eyelid Retractors gin and becomes a flange that is roughly triangu- Upper eyelid. The upper eyelid is responsible lar on sagittal section. for 90% of the eye-opening action. This action is The lower tarsal plate measures approximately mediated by the levator palpebrae superioris and 3.7mm vertically,4 and with the pretarsal orbicu- Müller’s muscle. The levator palpebrae originates laris maintains the support of the lower lid. under the lesser wing of the sphenoid just anterior Mustardé14 discusses the characteristics of the tar- to the optic foramen. At the level of the superior sal plate that dictate the choice of reconstructive transverse ligament of Whitnall’s the levator muscle method. While admitting that the flange effect is divides into an anterior aponeurotic layer and a responsible for the rigidity at the lid margin, posterior muscular layer. Anteriorly the aponeuro- Mustardé felt that the source of permanent sup- port for the lower lid was the orbicularis oculi sis attaches to the lower 7–8mm of the anterior muscle. His belief is reinforced by the drooping tarsus (Fig 11) and is densest 3mm above the lid of the lower eyelid that is seen when the orbicu- margin. The levator aponeurosis also sends fibers laris oculi muscle is paralyzed or anesthetized, through the orbicularis to the skin of the lid in the despite an intact lid margin. pretarsal zone. The attachment of the levator to the skin in this region forms the superior tarsal fold of the upper eyelid. The total length of the levator Preaponeurotic Fat muscle is approximately 40–45mm, with a 10– The preaponeurotic fat is located posterior to 15mm aponeurotic extension. the orbital septum and anterior to the levator apo- Posteriorly Müller’s muscle attaches 10mm away neurosis in the upper lid. In the lower lid the fat is from its origin to the upper margin of the tarsal located anterior to the inferior retractors. The plate. Müller’s muscle consists of smooth muscle upper lid contains two fat pads, a nasal and a cen- fibers which are under sympathetic control. It is tral. The lower lid contains three fat compart- normally responsible for 2–3mm of lid lift; how- ments (Fig 10). The inferior oblique separates the ever, with sympathetic stimulation an additional 1– nasal and central compartments, while a fascial 2mm of lift above baseline is possible. When sym- sheath separates the central and temporal com- pathetic tone is lost at twilight or in Horner’s syn- partments.15 drome, 2–3mm of may be seen.

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

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Fig 12. The main lacrimal glands are divided into an orbital lobe (Lo) and a palpebral lobe (Lp) by the lateral horn of the levator palpebrae superioris (LA). (Reprinted with permission from Zide BM, Jelks GW: Surgical Anatomy of the Orbit. New York, Raven Press, 1985.) Fig 13. Average lengths of the lacrimal excretory passages. (Modified from Jones LT: An anatomical approach to problems of the eyelids and lacrimal apparatus. Arch Ophthalmol 66:111, 1961.) The canaliculi are about 1cm long and join to form a single duct that opens into the lacrimal sac (Fig 13). The lacrimal sac extends inferiorly for approxi- tension is encountered on approximation of the mately 1cm and gives rise to the nasolacrimal duct, raw surfaces, 5–8mm of additional lid length can be which consists of an intraosseous portion and a gained by performing a lateral canthotomy and meatal portion. The duct usually opens just below cantholysis (Fig 15).19,20 the anterior end of the inferior nasal turbinate.18 While medial canthotomy and cantholysis for As the flow of tears moves from lateral to medial eyelid repair has been described,22 it should be with blinking and movement of the eyelids, the reserved for those defects requiring more radi- tears either evaporate from the surface of the eye cal measures. Complications of this technique or enter the excretory system. Movement of tears may include telecanthus, (due to through this system is the result of capillary pull by transection of the canaliculus), notching, and the vertical portion of the canaliculi, pumping action .22 of the orbicularis muscle, and negative pressure on inhalation.1,2 PARTIAL-THICKNESS DEFECTS

EYELID LACERATIONS Skin Eyelid lacerations with no loss of tissue should be Defects involving skin of the upper lid and medial minimally debrided and closed primarily. It is nec- canthal area are best repaired with thin full-thick- essary to meticulously align the anterior, middle, ness skin grafts. The skin of the contralateral upper and posterior lamellae properly. Malalignment of lid is the best donor site for upper lid skin defects. the wound edges must be avoided, and care should Posterior auricular skin is a good donor source for be taken to keep the knots away from the globe. reconstruction of the lower lid, while supraclavicu- Eyelid defects <25–30% of the lid substance can lar grafts are well suited to the repair of combined frequently be closed primarily19–21 (Fig 14). If undue lower lid and cheek defects.

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Fig 14. Direct closure of a defect of the lower eyelid. (Reprinted with permission from Leatherbarrow B: Oculoplastic Surgery. London, Martin Dunitz; distributed in USA by Fulfillment Center, Taylor & Francis, Independence, KY; 2002.)

Fig 15. Lateral relaxing incision and cantholysis to allow primary closure. (Reprinted with permission from Ross JJ, Pham R: Closure of eyelid defects. J Dermatol Surg Oncol 18:1061, 1992.)

Conjunctiva handle. Care must be taken to avoid compromis- Defects of conjunctival lining that cannot be ing the donor fornix. repaired by advancing the conjunctiva from the When fornix reconstruction is performed using sulcus require the use of free grafts. Free conjunc- conjunctival grafts, a conformer is required.23,24 The tival grafts from the same or opposite eyelid un- mucosa of the mouth is an alternative source of dergo considerable contraction and are difficult to donor graft for conjunctival replacement. While

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buccal mucosa is abundant and simple to harvest, it Hawes and Jamell31 discuss their complications tends to contract to approximately 50% of pregraft in 44 tarsal-conjunctival grafts. Five patients (11%) volume. On the other hand, nasal mucosa is rela- had major complications requiring reoperation. tively thick and more easily handled and contracts These problems included upper lid retraction, much less than buccal mucosa, so that graft size wound dehiscence, cicatricial ectropion, and must be only about 20% larger than the defect for excessive lower lid laxity. Thirty-two patients (73%) adequate coverage.23 Approximately 1.5–2.5cm had minor complications such as notching of the of mucosa can be harvested from a normal adult donor or recipient lid margin (most common). The nose. Skin cannot be used to replace conjunctiva authors conclude that while their patients frequently in a seeing eye because tiny hairs and the squa- manifested minor complications, free tarso- mous layer of epidermis are highly irritating to the conjunctival grafts were a useful technique in eye- sensitive cornea.23 lid reconstruction. Cohen and Shorr32 reported their results with hard palate mucosal grafts for conjunctival-tarsal Tarsal Plate losses in 18 patients. In their opinion, hard palate Losses of tarsal plate are commonly seen in com- grafts are superior to other sources of graft tissue posite lid defects involving either lining or skin- because, in addition to mucous membrane, they orbicularis in addition to tarsus. If possible, primary contain a collagen matrix that provides ample sup- repair should be performed. When the defect is port for the eyelid. Hard palate grafts also bring an too large for primary closure, the tarsus must be abundance of tissue that may be used to recon- replaced by either a composite free graft or a flap. struct the entire length of the eyelid. In their expe- Alternatives for reconstruction include chondro- rience, hard palate grafts undergo minimal shrink- mucosal grafts from the nasal septum23 or upper age and are much more pliable than grafts of ear or lateral nasal cartilages,25,26 full-thickness grafts from nasal cartilage. Biopsy results postoperatively show the contralateral lid,27–31 mucosal grafts from the that the keratinized palatal mucosal grafts undergo hard palate,32 conchal cartilage grafts, and assorted metaplasia to nonkeratinized mucosa over the first flaps.33,34 6 months. In conclusion, they found that hard pal- Nasal chondromucosal grafts have been recom- ate mucosal grafts are quite versatile for eyelid mended because of the strong hyaline cartilage of reconstruction. the nose, which is closely associated with the mucus- Tarsal reconstruction with acellular human der- secreting lining of the nasal mucosa. To prevent mis (AlloDerm) has been described.35 Either thick corneal irritation, a small fringe of nasal mucosa or thin AlloDerm grafts can be placed in the poste- must be turned anteriorly over the cartilage to meet rior eyelid as spacers to correct lower eyelid retrac- the remaining skin of the eyelid so that squamous tion. In Taban’s series, the results achieved with epithelium does not come into contact with the thick AlloDerm grafts were comparable to those globe. Mustardé23 favors septal mucosal grafts with hard palate grafts and perhaps superior to thin because of the long-term stability of this cartilage. AlloDerm grafts.35 The advantages of AlloDerm are Werner, Olson, and Putterman30 describe their lack of donor site morbidity, ready availability, and use of tarsal-conjunctival composite grafts for eye- predictability of the graft material. lid reconstruction. In their retrospective review of Chondroplast (beta-irradiated bovine cartilage) 51 patients, they note that 91% had postoperative has also been described for tarsal replacement, again symmetry of the within 2mm. Little with uniformly good results.36 Implants 1mm thick change was noted between the preoperative and are fixed to the remaining tarsal plate or canthal postoperative photographs in both donor and tendon and inserted in a preformed pocket between recipient eyelids. The most common postopera- the orbicularis muscle and skin. No loss of implant tive complication was mild punctate staining of the or complications were reported in Mullner’s series.36 cornea, but this did not lead to ulceration or persis- The advantages of Chondroplast for tarsal restora- tent epithelial defects. Only 14% of grafts main- tion are availability in large pieces, no need for tained their cilia. graft harvest, and good biocompatibility.

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Composite grafts for replacement of skin and tar- lid skin defect. According to the authors, auricular sus are taken mainly from the concha of the ear.37 composite grafts are too thick to be considered These grafts have the advantage that the donor perfect for eyelid replacement; 2 patients in their wound can be well concealed and easily controlled. series required secondary thinning of their grafts. Disadvantages include the risk of graft failure or Avram and colleagues41 describe their technique only partial take, and subsequent shrinkage of the of composite autografting for eyelid avulsion inju- graft with scarring around the wound. ries. They remove the skin and orbicularis from the Naugle, Levine, and Carroll38 describe a tech- graft while leaving the lid margin intact. The poste- nique that mobilizes the orbicularis muscle to rior lamellar graft is then sutured precisely into the improve free graft viability and appearance by defect, the levator aponeurosis is sutured to the enhancing its blood supply. Composite grafts to the anterior surface of the graft, and a flap of skin and eyelid frequently show contraction, discoloration, orbicularis is used for interior lamellar reconstruc- poor healing, depression, and immobility. In 7 tion and to provide vascularity to the underlying patients who required complex primary or second- graft. A lid margin suture between the upper and ary reconstructive techniques for difficult eyelid de- lower lids stretches the aponeurosis for a few days fects, the authors mobilized the orbicularis muscle and counteracts the tendency of the eyelids to into the recipient site before grafting. The muscle retract. From their experience the authors stress provides an improved vascular bed for placement the importance of of both skin and composite grafts. • attention to tetanus and rabies vaccinations • wound culture and prophylactic antibiotic FULL-THICKNESS DEFECTS therapy • irrigation and minimal debridement of the wound Upper Eyelid • careful layered closure when attempting autograft repair of eyelid avulsion injuries using the Composite grafts retrieved tissue Composite grafts coupled with local flaps may be used to repair full-thickness defects of the eyelid. Goldberg and others42describe a case report in 27 Putterman divides full-thickness losses into two which the patient lost approximately 75% of his components, one of the skin and one of tarsus- upper eyelid. The entire full-thickness of the avulsed conjunctiva. The tarsus-conjunctiva component of eyelid tissue including skin and orbicularis was the defect is repaired with a composite eyelid graft. replaced as a true composite autograft. This resulted This graft is then covered with a vascularized skin in a functional upper eyelid with adequate con- flap. tour; however, the lid was short, without cilia, and Budenz and associates39 report on two patients had decreased mobility. The authors studied vari- undergoing upper eyelid reconstruction with con- ous methods for preserving the avulsed eyelid tis- tralateral tarsoconjunctival grafts and ipsilateral upper sue and concluded that 1) it should not be immersed eyelid skin flap. Histologically, the healed grafts in saline and 2) it could be preserved in a moist showed a scarred tarsus and absent meibomian environment at 4°C for up to 6h or 3) in a special- glands, with one of the patients completely losing ized tissue-culture medium for up to 24h. cilia. Despite the apparent reduction in lubricating Sakai43 reported the use of composite skin- glandular elements, there were no clinical prob- muscle-mucosal grafts from the lower lid for mar- lems with the tear film. ginal defects of the upper eyelid. This method Marks and coworkers40 report posterior lamella allows for one-stage reconstruction but lacks the rreconstruction with large composite auricular grafts. middle layer cartilaginous support. The cartilage graft is secured between the remain- ing orbicularis muscle and tarsal plate and the orbital septum posteriorly. The graft is stabilized with Flaps sutures to the tarsus anteriorly and the orbital rim Full-thickness defects of the upper lid that cannot inferiorly. The posterior auricular skin fills the eye- be closed primarily are often repaired with flaps of

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local tissue. Flaps carry their own independent area and is used for interior lamellar coverage. blood supply and therefore contract less than grafts Leone’s modifications add support to the margin of after transfer. Unfortunately, flaps tend to be bulky the upper lid while avoiding full-thickness donor and less pliable than grafts and may produce a sec- site loss of the lower eyelid. As described, this ondary scar deformity. technique is best suited for shallow losses of the Lower eyelid flaps are of two basic types: upper lid margin. advancement flaps and switch flaps. Cutler and Mauriello and Antonacci47 describe a similar tech- Beard44 introduced the lower lid advancement flap nique whereby a tarsoconjunctival flap is raised on in 1955. The flap as it is classically described involves the lower lid (Fig 17). They performed the “re- advancement of a rectangular segment of full- verse” modified Hughes procedure in 10 patients thickness lower lid into the upper lid, preserving with full-thickness upper lid defects. the lower lid margin and tarsus (Fig 16). Approxi- mately 6–8 weeks later the flap is divided and returned to the lower border of the intact lid mar- gin. The upper lid margin is then fashioned from the divided edge of the flap.45 The major disadvan- tages of the Cutler–Beard technique are the neces- sary occlusion of the eye and the lack of support of the reconstructed lid margin.

Fig 17. A tarsoconjunctival flap from the lower lid is sutured to the tarsal remnants of the upper lid and covered with a skin graft. The flap pedicle is divided 5 to 8 weeks later. (Reprinted with permission from Mauriello JA Jr, Antonacci R: Single tarsoconjunctival flap (lower eyelid) for upper eyelid reconstruction [“reverse” modified Hughes procedure]. Ophthalmic Surg 25:374, 1994.)

Like Leone’s flap, it involves an incision 1.5– 2mm below the lower eyelid margin. In contrast, the Cutler-Beard procedure requires an incision 4–6mm below the lid margin to preserve the mar- ginal artery.44,46,47 The entire vertical height of the tarsus was excised in 8 of 10 patients in Mauriello’s series. Follow-up was 6–24mo. The authors report Fig 16. The Cutler-Beard technique for reconstruction of large upper lid defects. (Modified from Cole JG: Reconstruction of large excellent results with minimal complications. defects of the upper eyelid. Am J Ophthalmol 64:376, 1967.) Jordan and colleagues48 described a technique in which shallow defects of the upper lid may be repaired with a tarsoconjunctival flap fashioned from In response to these problems, Leone46 modified the superior tarsal remnant and advanced inferiorly the Cutler–Beard flap by creating a double advance- to the upper lid margin. This technique is limited ment–rotation. Following resection of the lesion, to defects involving the margin where at least a an upper lid tarsoconjunctival flap is designed and 3mm section of upper tarsus remains, and seems to elevated from the remaining tarsus and advanced be best suited for central upper eyelid defects. They toward the lid margin. This flap is then sutured to report excellent results in 13 cases. Three patients the lower lid tarsoconjunctival flap, creating sup- had corneal irritation from eyelid retraction lasting port along the upper lid margin. A full-thickness 1–3mo. Two of these patients ultimately required skin graft is then harvested from the retroauricular surgical revision.

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A semicircular (Tenzel) flap21,49 or one of its modi- require full-thickness skin grafts for closure of the fications can be pivoted on the lateral canthus (Fig donor defect. When taken from the upper lid, 18) to reconstruct the upper or lower lid. Defects primary closure of the donor site is often possible up to 70% of lid length can be repaired with this (Fig 19). semicircular flap of skin and muscle as long as some Van der Meulen50 discusses the usefulness of the tarsus remains on either side of the wound. bipedicled Tripier flap combined with buccal mucosa for lining when reconstructing the upper eyelid. The subsequent reconstructed lid requires tension on the closure to avoid sagging of the lid and retraction of the flap margins. Moschella and Cordova51 describe a method for functional reconstruction of the upper eyelid in large full-thickness lid defects. Buccal mucosal grafts are used to reconstruct the conjunctiva. A bipedicled musculocutaneous flap is designed from the preseptal or orbital portion of the lid (the superior aspect of the defect). This flap serves as the lid margin and the levator muscle is then approximated to it. The donor defect is closed by transposing a temporofrontal flap. While this reconstruction lacks Fig 18. Semicircular (Tenzel) flap used in closure of an upper marginal support, it may be useful in shallow mar- lid defect. ginal defects and for patients who are interested in single-stage reconstruction. Esser52 described a lower lid switch flap in 1919. The Tripier flap was originally described as a The flap was based on the marginal artery and bipedicled flap, but it can also be carried on one rotated 180° into the upper eyelid, as in the pedicle. If unipedicled, however, it will not cross Estlander-Abbe flap used for lip reconstruction. the reliably. Flaps raised from the lower lid McCoy and Crow53 reported reconstruction of the

Fig 19. Tripier flap used in the upper lid.

13 SRPS Volume 10, Number 8 lower lid with a switch flap from the upper lid. • large horizontal defects with significant vertical Later Mustardé14,33,43,54 pioneered the modern components can be repaired technique of a switch flap from the lower lid to • the upper lid margin is duplicated precisely in repair upper lid defects (Fig 20). the transferred margin of the lower lid, for a continuous, smooth line at the leading edge of the lid • the period of occlusion is minimized.

The foremost disadvantage of lower lid switch flaps is the deliberate sacrifice of the lower eyelid for reconstruction of the upper eyelid. In addition, an extra reconstructive procedure is required to repair the donor defect in the lower lid. Mustardé55,56 discusses flap design and dimen- sions as well as placement of the hinge or pivot point of the flap according to the size and location Fig 20. Mustardé’s laterally based (left) and medially based (right) of the defect. He emphasizes the following prin- flaps for upper eyelid reconstruction. (Modified from Mustardé ciples: JC: Reconstruction of eyelids. Ann Plast Surg 11:149, 1983.) • The width of a defect in the upper lid can be reduced by one-quarter of the upper lid length. Lower lid switch flaps can be based either later- • The remainder of the defect should be closed ally or medially. Laterally based switch flaps trace a using the switch flap. smoother arc than medially based flaps when rotated • The key to flap success is an appropriate hinge to the upper eyelid. The lower lid is restored by point for the flap. advancing cheek tissue medially. Most of the reconstruction is completed in a single operation, The reconstructed upper lid must protect the so that only a short operative session is subsequently cornea during sleep and must be capable of eleva- needed for division and inset of the hinged pedicle. tion. Mustardé56 avoids using the contralateral upper However, laterally based switch flaps suffer from lid for fear of donor site morbidity and prefers to uncertain vascularity because the pedicle is based transfer tissue from the lower lid to reconstruct the on the temporal and canthal portions of the cheek upper lid. Because defects of the upper lid up to advancement flap, whose blood supply is random. 25% of lid length may be closed primarily, the Both partial and total flap losses have been reported reconstructed lid needs to be only three fourths as when lower lids are transferred with the pedicle long as the original. based laterally. Borman and Özcan57 anchor the levator muscle In contrast, medially based switch flaps from the to the reconstructed upper eyelid using a modified lower lid are more difficult to rotate and set into adjustable suture technique. They find that pre- place than laterally based switch flaps, but main- dicting final lid height with the patient under gen- tain excellent vascularity via the marginal artery eral anesthesia often results in under- or overcor- and offer a better chance of a successful recon- rection, but a secondary lid-adjustment procedure struction. The second stage of flap transfer in- under local anesthesia achieves a functional and volves division and inset of the switch flap as well esthetically pleasing result. as lower lid reconstruction with the cheek ad- Kersten and colleagues58 described a tarsal rota- vancement flap. tional flap designed from the lid remnant. The There are considerable advantages to lower lid tarsus of the central upper lid at the edge of the switch flaps in upper eyelid reconstruction, namely defect is dissected free from Müller’s muscle and • switch flaps bring like tissue to replace the miss- conjunctiva for approximately 4mm along its proxi- ing eyelid mal superior border. Cuts in the tarsus within 2–

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3mm of the eyelid margin create a vertical tarsal Reports by Marks and associates40 and Jackson, strip 3–4mm wide and 7–10mm high. This is Dubin, and Harris63 show good stability of large then rotated 90° so that it lies horizontally and is conchal cartilage grafts for lower eyelid reconstruc- affixed to the remnant of the medial canthal ten- tion after follow-ups averaging 16 and 21 months, don or periosteum. At least a third of the lid respectively. Marks and coworkers40 find that for remnant is required for either medial or lateral each millimeter of lid retraction they must bring in wounds. 2–2.5mm of conchal cartilage. They insert the grafts Kushima et al59 described total upper eyelid to face the bulbar conjunctiva between the tarsus reconstruction with a free radial forearm flap and the contracted lid retractors. The posterior and hard palate mucosal graft. The patient had surface of the graft is left to reepithelialize. Jackson complete avulsion of the superior levator palpe- and colleagues63 suture the conchal grafts to the brae muscle and the superior orbital fat. The tarsal plate above and the periosteum of the right was exposed and infraorbital rim below to prevent graft displacement. no orbital fat was seen between the muscle and They report no loss of lid support at almost 2 years the orbital roof. The gliding surface was recon- postoperatively. structed with an adipofascial flap from the fore- Hurwitz, Corin, and Tucker64 used free periosteal arm lined with a mucosal graft from the palate. grafts for posterior lamellar reconstruction in cases Levator function was mimicked by the superior of extensive lower lid losses extending beyond the rectus muscle without frontalis suspension. Fol- confines of the lid. The periosteal graft is harvested low-up at 18 months showed a cosmetically good from the lateral orbital rim through the same wound result with essentially no ptosis and only slight as the cheek advancement flap. The graft may be . covered with a second local flap for anterior lamel- lar reconstruction. Like others, Hurwitz64reports reepithelialization of the periosteum by 3½ weeks Lower Eyelid postgrafting. Full-thickness lower eyelid reconstruction is a Leone65 reported a variation of this technique in hotly debated topic. Mustardé23 advocates using which lateral canthal defects are repaired with a tissues other than the upper lid to reconstruct the rectangular flap of periosteum from the lateral orbital lower lid, reasoning that the absence of part or rim. This periosteal flap is then used as a sling and even the whole of the lower lid may be tolerated sutured to the free edge of the lower lid. A tempo- reasonably well as long as the upper eyelid remains ral skin flap is designed for anterior lamellar cover- fully functional, but that loss or dysfunction of even age. As described, no conjunctival or lining tissue part of the upper lid may result in corneal exposure is replaced; rather, the periosteum is left to epithe- with possible ulceration and . Still lialize (Fig 21). others30,60,61 describe techniques borrowing from the upper eyelid, which they feel can safely be used to reconstruct the lower eyelid. Conjunctival flap plus skin graft Moss and colleagues66 believe, as does Mustardé,54 that the upper lid should not be used Grafts of cartilage or periosteum as donor tissue for lower eyelid reconstruction. Matsuo and associates62 feel that conchal carti- They describe their 25-year experience and lage is ideally suited for lower eyelid reconstruc- review 43 patients who underwent lower eyelid tion, as it is thin and supple and resembles the reconstruction with a conjunctival flap covered curvature of the globe.40,63 They report using con- by a full-thickness skin graft. The flap is divided 2 chal cartilage grafts alone when eyelid support and weeks later. Although the published illustrations lining are needed, placing the graft in such a way show acceptable cosmetic and functional results, that the graft perichondrium forms the posterior most surgeons would question the long-term stabil- lamella. Epithelialization from the surrounding ity of a lower lid reconstructed without tarsal or mucosa is noted in 3–4 weeks. cartilaginous support.

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undermining the cheek flap in the layer of subcu- taneous fat and repeatedly testing to see whether further extension of the incision and rotation of the cheek is necessary.”56 Tension is taken off the reconstructed lid by anchoring the deep surface of the flap to the inferior margin of the orbit. At the region of the lateral canthus a deep suture is placed in the subcutaneous tissues, anchoring them to the periosteum of the orbital margin just above the attachment of the canthal ligament. Callahan and Callahan69 provide an excellent review of the Mustardé flap based on experience with 55 lower eyelid reconstructions followed for an average of 7 years. Their most frequent com- plication was inferior descent or retraction of the flap associated with ectropion of the lid margin which did not manifest for approximately 2–3 years after surgery. The authors described occasional , lateral symblepharon, rounded canthus, and a marginal notch. Only 13 patients required subsequent surgical revision. They conclude that the two most influential factors determining the Fig 21. Technique of lower eyelid reconstruction with a outcome of reconstruction were the design of the periosteal flap. Top, the lateral orbital rim is exposed and a 5mm flap and the composition of the graft for internal wide periosteal flap is dissected and sutured to the tarsus of the remaining eyelid. Bottom, a temporal skin flap is raised, under- lining and support. They recommend a modifica- mined, and rotated into the defect. (Reprinted with permission tion of the Mustardé flap to incorporate temporal from Leone CR Jr: Periosteal flap for lower eyelid reconstruction. skin from well above the lateral canthus instead of Am J Ophthalmol 114:513, 1992.) the traditional lower rotational arc passing imme- diately lateral to the outer canthus. Composite grafts of nasal septal mucosa and cartilage proved Cheek advancement flaps superior to free buccal mucosal grafts in all cases, Rotation-advancement flaps of the cheek are ideal and the added structural support helped minimize for reconstruction of the lower lid, whose skin is postoperative collapsing of the flap. Callahan and thicker overall than the upper lid’s. Defects involv- Callahan conclude that the use of a high-arc flap, ing the lateral canthus are well suited to this recon- composite nasal cartilage-mucosal grafts, and hitch- structive technique because the skin is not only ing sutures allowed for the best postoperative thicker temporally but also more visible. results.69 Cheek advancement flaps were originally Although Callahan and Callahan did not list flap described for lower eyelid reconstruction by Pro- loss as a complication of the Mustardé flap, there is fessor Imre67 of Hungary in 1928. It was further a definite risk of tissue loss when elevating these popularized by Mustardé.23,56,68 Mustardé incorpo- large cheek flaps to repair composite lower lid and rates the cheek advancement into defects >25% of upper cheek defects. Compromised flap tissue is the lower lid up to total lower lid losses. If the usually seen at the apex of the flap, where it extends middle and posterior lamellae are deficient, he pre- into the temporal skin, the principal part of the lid fers a free composite graft of nasal septum covered reconstruction. Inclusion of the superficial muscu- by the flap. As defects become larger, the flap is loaponeurotic system (SMAS) in the flap will enhance extended superolaterally and inferiorly in front of the blood supply to this area. Similarly, when large the ear. The flap is elevated in a subcutaneous medial defects of the upper eyelid require a lower plane. Mustardé states that “in every case the final lid switch based on a lateral cheek flap, subSMAS extent of the incision can only be determined after dissection of the flap seems prudent.

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McGregor’s combined flap repair70 adds a lateral advancement–rotation flap from the outer canthus Z-plasty to Mustardé’s cheek advancement flaps for that can be used to reconstruct up to three fourths defects <60% of the lower lid (Fig 22).71 An inci- of the eyelid.73 Transection of the lower limb of the sion lateral to the eyelid is slanted gently upward lateral canthal tendon and attachments of the orbital and carried into the temple for 1.5 to 2.5X the septum is performed first, then a 1–2cm skin-muscle width of the defect. A backcut is made at the flap is elevated and advanced medially and rotated temporal end of the incision and angled medially into the defect (Fig 23). A full-thickness triangle is approximately 30°. Since the lateral 40% of the often resected from the base of the defect to facili- flap serves as Z-plasty, a second backcut is made tate flap inset, and the conjunctiva from this Burow’s parallel, medial, and superior to the first backcut to triangle may be used to line the lateral aspect of the create a second Z-plasty. This method successfully reconstructed lid. The canthal angle is reconsti- recruits vertical laxity from the lateral periorbital tuted with a through-and-through vertical mattress region to correct horizontal defects of the lower suture tied over a cotton bolster. eyelid. The semicircular flap technique is most useful in near-total central defects of the upper and lower eyelid where at least 2mm of tarsus remains on either side of the defect.73 Tenzel and Stewart73 report satisfactory results in 35 of 41 eyelids recon- structed by this method. Other authors74–76 report using this flap for partial lid reconstruction. Jordan, Anderson, and Holds76 describe a modi- fication of the semicircular flap technique for eye- lid reconstruction that uses a more vertical, tem- poral advancement flap. Dissection begins at the lateral canthus and then extends superiorly toward the lateral . The authors bevel the inci- Fig 22. Combined flap consisting of a horizontal rotation and sion to include more muscle than skin in the flap. a temporal Z-plasty for repair of moderate-sized lower eyelid They believe that the combination of a vertically defects. (Reprinted with permission from Khan JA, Garden VS: Combined flap repair of moderate lower eyelid defects. Oph- oriented flap and a preponderance of muscle “pro- thalmic Plast Reconstr Surg 18:202, 2002.) vide the upward force necessary to decrease sag- ging of the temporal lid, maintain a more normal- looking lateral canthus, and provide enough tissue Semicircular flap to reduce the chance of a lid notch.”76 They Tenzel72 first described the semicircular flap in report good to excellent results in 22 of 28 patients. 1975 for reconstruction of both the upper and lower Six cases developed notching of the lid margin at eyelid. The procedure is a modified lateral the junction of the flap and lid remnant.

Fig 23. Semicircular flap reconstruction of the lower lid. The technique requires lateral canthotomy, inferior cantholysis, and suture- suspension of the flap from the periosteum of the lateral orbital margin. (Reprinted with permission from Leatherbarrow B: Oculoplastic Surgery. London, Martin Dunitz; distributed in USA by Fulfillment Center, Taylor & Francis, Independence, KY; 2002.)

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Tarsoconjunctival flap Although switch flaps from the upper lid have been proposed for lower lid reconstruction,53 the standard technique of lower eyelid repair using upper lid tissue77 involves the sliding of an upper lid tarsoconjunctival flap into the lower lid defect. Landolt78 originally described this procedure in 1881. The technique was later expanded by Kollner79 in 1911, Dupuy-Dutemps in 1929,80 Hughes in 1937,60 and Smith19 in 1959. Hughes60 reflects on his 40-year experience with the tarsoconjunctival flap procedure, during which time he modified the original technique by cutting obliquely through the tarsus beginning at the con- junctival margin and extending to the anterior sur- Fig 24. Maximal Hughes procedure for lower eyelid reconstruc- face of the tarsus approximately 3mm above the tion. Oblique medial and lateral periosteal flaps are reflected at lid. This refinement seems to decrease the risk of the medial and lateral orbital margins. The flaps can be folded upper loss and of the lid margin. over to produce a straight horizontal attachment for the tarsus In a follow-up article, Hughes81 describes a slightly from an angled design. The extreme nasal and temporal aspects of the tarsus are not freed. (Reprinted with permission from Maloof different way of dissecting the tarsoconjunctival flap A, Ng S, Leatherbarrow B: The maximal Hughes procedure. that frees the upper lid tarsus through an incision Ophthalmic Plast Reconstr Surg 17:96, 2001.) carried along the anterior surface of the tarsus to its upper border. At this point the incision is extended to the conjunctiva, cutting through the attachments Over the years several practical modifications of Müller’s muscle, and the dissection is carried have also been reported, including the following: upward along a plane adjacent to the conjunctiva. Once the conjunctival flap is freed, the flap of • the tarsoconjunctival flap is raised at least 3– mucosa is then draped over the lower eyelid mar- 4mm above the lid margin gin and sutured to the skin of the reconstructed • Müller’s muscle and levator aponeurosis are lower eyelid.74,82,83 While this refinement is said to transected at the superior edge of the tarsal plate, help prevent retraction of the upper lid, if dissec- with the dissection proceeding subadjacent to tion is not carried high enough or the attachments the conjunctiva of the levator muscle or Müller’s muscle are not • a thin FTSG is used to cover the anterior surface severed, entropion of the lid margin and lid retrac- of the tarsoconjunctival flap tion are still probable. The “maximal Hughes procedure” combines • the flap is divided 3–6 weeks after inset and the oblique medial and lateral periosteal flaps with a mucocutaneous line is left to heal by secondary Hughes flap for the repair of large defects of the intention lower lid (Fig 24).84 In a series of 8 patients who • circulatory support is provided via the anterior had lower eyelid reconstruction by this method, lamella Maloof and colleagues84 report excellent eyelid con- tour and protection in all. One patient had mild lid Other modifications of the tarsoconjunctival flap retraction and a second patient developed medial procedure include a step incision through the upper ectropion that required subsequent revision. tarsus, with reattachment of the levator and Müller’s Rohrich and Zbar85 reviewed the evolution of muscle segments to the lower tarsal remnant, as the Hughes tarsoconjunctival flap (Fig 25) for lower suggested by Pollock et al.86 Smith19,77 and eyelid reconstruction. Central defects of the lower Macomber and coworkers87 preserve the upper lid eyelid measuring 60–80% of the total lid length can margin with an incision through the lower tarsus be successfully repaired with this flap. 3mm behind the upper border of the lid.

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Fig 25. Left, the Hughes flap as originally described in 1937. Center, the Hughes flap as modified in 1976. The new plane of dissection creates a true transconjunctival flap. Right, modified Hughes flap in which the inferior edge of the flap is designed at least 4mm from the lid margin to ensure sufficient tarsal plate remaining for support in the donor lid. (Reprinted with permission from Rohrich RJ, Zbar RIS: The evolution of the Hughes transconjunctival flap for lower eyelid reconstruction. Plast Reconstr Surg 104:518, 1999.)

Leibsohn and colleagues88 intentionally button- Lowry, Bartley, and Litchy93 studied the recon- hole their tarsoconjunctival flaps to allow vision and structed lower eyelids of 6 patients after a modified to monitor the eye by slit lamp. The buttonholes Hughes procedure as described by Doxanas.92 Elec- extend vertically from the superior tarsoconjunctival tromyographic analysis demonstrated electrical edge of the flap to a point 12–15mm above the activity in the orbicularis muscle of all reconstructed upper eyelid margin. eyelids. McNab89,90 divides the tarsoconjunctival flap Holmstrom and colleagues94 reviewed 58 cases pedicle at 2 weeks. In a prospective, randomized of lower lid reconstruction using the tarso- study of 60 patients, 32 had their flaps divided at 2 conjunctival flap. Their technique was similar to weeks and the rest at 4 weeks. All patients had full- Kollner’s,79 sparing the upper lid margin and incor- thickness skin grafts placed on the anterior lamella porating the levator and Müller’s muscle complex of the reconstructed eyelid. There was no statisti- into the pedicle. Division and inset were done 3 cal difference in postoperative eyelid position weeks after flap advancement. The authors report between the two groups. Other complications were no significant deformities of the upper lid and state uncommon and spread evenly between the two that this operation could be repeated if needed groups. because of tumor recurrence. This purported ben- It was initially thought that the risk of corneal efit, of course, is also true of the cheek advance- abrasion from keratinized skin decreased if the con- ment flap. junctiva was advanced over the eyelid margin. This, however, results in persistent hyperemia of the exposed conjunctiva along the eyelid margin. Cross-lid flap Bartley and Putterman91 divide the conjunctival Some surgeons differ with Mustardé and try to pedicle at its origin from the upper eyelid flush with uphold the principle of replacement of eyelid tis- the reconstructed lower eyelid at the desired new sue with like eyelid tissue championed by Byron eyelid margin. No excess conjunctival tissue is Smith.77 They state that when the upper eyelid is advanced to the eyelid margin, and the mucocuta- used for reconstructing the lower lid, the result is neous junction is allowed to heal spontaneously. more delicate and normal-appearing in contour and The authors have performed this technique in 70 texture than if other facial tissues are used. This patients, with satisfactory results. method also avoids additional scars on the cheek, Doxanas92 mobilizes the preseptal orbicularis nose, or forehead. oculi muscle over the tarsal flap and into the recipi- In 1966 Jones61 proposed a cross-lid flap of skin, ent beds of the skin grafts used for reconstruction of tarsus, and conjunctiva as an alternative to the anterior lamella. The transposed muscle is said tarsoconjunctival flaps for the correction of through- to enhance mobility of the reconstructed eyelid and-through marginal defects of the lower eyelid. and serves to correct cicatricial ectropion. This composite flap is elevated from the central

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portion of the upper lid as a single-pedicle or bipedicled flap. The upper and lower margins of the tarsus are not taken in the flap. The donor eyelid is closed directly. Subsequent experience with the cross-lid flap procedure95 has confirmed its applicability in long, narrow defects of the lower lid margin. As a unipedicled flap it may be based either laterally or medially, and for total marginal losses the flap can be transferred on a double-pedicle sling. Problems with the technique include postoperative retrac- tion of the lower lid and, of course, no lashes, but the presence of lashes is not considered critical in the lower lid. Anderson and associates96,97 suggest a modifica- tion of the composite flap technique that makes use of the entire upper portion of the tarsal plate and overlying tissues, preserving the microvascular blood supply to the upper eyelid margin. Flap reliability is enhanced by a persistent marginal vascular arcade. The levator aponeurosis and Müller’s muscle are recessed to prevent postoperative lagophthalmos and eyelid retraction. The flap can be raised on a single or double pedicle. The authors admit to the necessity for meticulous dissection and thorough knowledge of the anatomy. The risk of injury to the more important upper lid must be weighed against the benefits of this Fig 26. Lower eyelid reconstruction with an extended, bipedicled method. In experienced hands the upper lid-to- Tripier flap. (Adapted from Levine ML, Leone CR: Bipedicle lower lid procedures are considered safe and pose musculocutaneous flap repair of cicatricial ectropion. Ophthalmic Plast Reconstr Surg 6:119, 1990.) no great technical difficulties.

Tripier flap Elevated on one pedicle, the Tripier flap can be based either medially or laterally. In either case the Another option in the repair of very narrow predictably viable flap length is just short of the defects running as far as the entire length of the midline of the lower lid.100 When the defect is less lower eyelid is the Tripier49 bipedicled flap. The than one third the length of the lid, cartilaginous flap consists of upper lid skin and orbicularis muscle, support is usually not required. and can be lined or left unlined.55,98 The bases of The Tripier flap can be raised with a conjunctival the pedicles are revised approximately 2 weeks flap after the method of Manchester101 to bring skin after initial transposition. The operative technique cover or lining to the reconstruction. Leone and of the Tripier flap is simple, avoids facial scars, and van Gemert102 suggest yet another modification that does not interfere with vision. essentially combines Jones’s61,95 composite flap with Levin and Leone99 incorporate the pedicles of Tripier’s musculocutaneous flap for one-stage full- the Tripier flap into the wound. The incision for thickness repair of the lower lid. The technique flap elevation in the upper eyelid crease is extended involves transposition of a flap of skin and orbicu- medially and laterally to meet the ends of the lower laris from the upper lid for reconstruction of the lid defect (Fig 26) and the donor site in the upper outer lamella of the lower lid. The tarsus-conjunctiva lid is closed primarily. element is taken as a flap from the midtarsal area,

20 SRPS Volume 10, Number 8 based at the lateral fornix, and is rotated into the to the eyelid, and prevents sagging of the recon- lower eyelid defect where it is sutured to the tarsus structed elements. of the remaining lid. The donor areas are step-cut The temporoparietalis fascial flap is an option for to avoid a through-and-through defect. orbital or eyelid reconstruction in the event of com- This is an excellent option for the correction of plex deformities when cheek advancement flaps lower lid coloboma such as seen in the Treacher are not available. The flap is thin, malleable, and its Collins syndrome103 and for the repair of shallow arc of rotation reaches all the periorbital structures. horizontal defects of the lower lid. It successfully The temporoparietalis fascial flap has been used to avoids hitching of the upper eyelid margin, a com- enhance the blood supply of the orbit;106 for recon- mon sequela of full-thickness excisions of upper struction of the anatomic barriers between the orbit, eyelid. intracranial cavity, and paranasal sinuses after exenteration;107 and for lower eyelid and malar reconstruction.107 Supratrochlear artery flap A two-stage flap based on the supratrochlear artery has been described by Duman and others104 Other methods for lower eyelid reconstruction (Fig 27). The flap is Leone and Van Gemert108 also describe recon- most commonly transferred in combination with struction of the lower eyelid with a tarsoconjunctival conjunctival grafts for the treatment of complex free graft from the upper lid and a bipedicled skin– ectropion. Advantages of this method are excellent orbicularis flap from the lower lid transposed sup- vascularity of the tissues, versatility of flap design, eriorly. The procedure is recommended for patients and good color match. Disadvantages are the slightly who might be disabled by the modified Hughes bulky and less pliable coverage and the need for a technique, which obstructs the vision for 3–4 second stage to divide the flap pedicle. weeks—eg, patients with only one seeing eye. In this unique situation, Leone and Van Gemert’s tech- nique may play a role, although horizontal scarring and muscle action pulling the lid down should be expected to produce superior rotation of the bipedicled flap, causing lid retraction and ectro- pion. The flap may also need to be back-grafted, which would mar the cosmetic appearance. Doermann and associates109 use upper cheek skin advanced superiorly in a V-to-Y manner to reconstruct the lower lid. Concerns about this tech- nique include the distance that a V–Y flap can be advanced, the possibility of lid retraction and ectro- pion caused by downward pull of the cheek flap, and the potential cosmetic deformity of the cheek. The authors describe a V–Y flap that will advance as Fig 27. The supratrochlear artery flap for lower eyelid recon- far as it can be elevated out of its bed, and report struction. (Reprinted with permission from Duman H, Sengezer only two instances of ectropion in 22 patients. This M, Semanpakoglu AN, Eski M: Supratrochlear artery flap for the repair of lower eyelid defects. Ann Plast Surg 44:324, 2000.) technique was also elaborated on by Kalus and Zamora,110 who feel the V-Y advancement flap is suitable for reconstruction of the lower lid. Visible Fascial flaps in both these reports is a trapdoor deformity, fre- Holt, Holt, and Van Kirk105 report using a sling of quently seen when regional esthetic units are vio- temporalis fascia in the event of full-thickness lid lated. losses requiring trilaminar reconstruction. The Ito and associates111 report their experience with authors believe that the temporalis fascia provides total lower eyelid reconstruction in 4 patients using static suspension, assists in proper globe opposition a hard palate mucoperiosteal graft combined with a

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V–Y subcutaneous pedicle flap. The curved trian- lined with a palatal mucosal graft for one-stage gular advancement flap is designed along the reconstruction of the lower lid. relaxed skin tension lines and the eyelid unit or Moschella and coworkers115 use mutiple subcu- subunit lines, so as to make postoperative scars taneous pedicled flaps of skin and orbicularis muscle inconspicuous (Fig 28). The flap width is slightly from the lower eyelid area, supported underneath less than the horizontal span of the defect. by a free chondromucosal graft. In their hands this technique yielded good functional results in 13 patients, without ectropion or lagophthalmos. Patients did experience temporary which resolved after 2 months. The use of an island chondromucosal flap and skin graft has been described by Scuderi and Rubino.116 Their technique incorporates a strip of upper lateral cartilage and nasal mucosa to recon- struct the tarsoconjunctival plane, along with a skin graft. The donor defect is closed primarily. Härmä and Asko-Seljavaara117 describe a tempo- ral artery island flap combined with a mucosal or chondromucosal graft for reconstruction of the lower eyelid in 11 patients. The flap is based on the anterior branch of the superficial temporal artery. Fig 28. Design of curved subcutaneous V-Y advancement flaps for eyelid reconstruction. Solid line, upper eyelid. Dashed lines, The flap was found to be particularly useful in cases lower eyelid possibilities. The V-Y advancement is combined of recurring lesions when other local means of with a mucoperiosteal graft from the hard palate. (Reprinted with reconstruction had been exhausted. permission from Ito O, Suzuki S, Park S, et al: Eyelid reconstruction Large composite defects of the lateral canthus, using a hard palate mucoperiosteal graft combined with a V-Y subcutaneously pedicled flap. Br J Plast Surg 54:106, 2001.) upper and lower lids can be repaired with a Y- shaped hard palate mucoperiosteal graft and V–Y advancement flap, as suggested by Acikel and Despite the good results illustrated in this article, colleagues118 (Fig 29). In this case report there the technique drew a sharp rebuke from Van der was 100% survival of the graft and flap and excel- Meulen,112 who believes postoperative lid sagging lent cosmetic results. Eyelid closure was satisfac- is caused by overall laxity and can always be cor- tory but symptoms of dry eye persisted and led to rected by adequate redistribution of tissues without , which was later corrected the insertion of supportive material such as perios- with lateral tarsorrhaphy and punctum plug teum. Van der Meulen lists the following disadvan- insertion. tages of the Ito technique: 1) in the orbital region Porfiris and colleagues119 report lower eyelid the incisions terminate at right angles to the eyelid reconstruction by means of an island mucochon- rim, inviting retraction; 2) the skin of the cheek is drocutaneous flap from the nasojugal fold (Fig 30). much thicker than eyelid skin; and 3) the facial scars will always remain visible. The flap is raised taking the full thickness of In our department we also enjoy using modifica- the lateral nasal wall. … The raised flap contains tions of the paramedian forehead flap for total lower mucosal lining, a cartilage framework consisting of part of the upper lateral cartilage with or without eyelid reconstruction, as suggested by Hughes.113 the accessory nasal cartilages, parts of the muscles The most distal aspect of the flap is tacked to the levator labii superioris and nasalis, and the lateral lateral orbital rim to help maintain adequate sup- nasal skin. The subcutaneous pedicle is thick (up to port of the reconstructed lower eyelid. 0.5cm in diameter) and contains the periosteum of Nakajima and Yoshimura114 transfer a subcuta- the nasal bone and the subcutaneous tissue with neous pedicled flap from the lateral paraorbital the vessels. temple that pivots on the lateral canthus. The flap is Porfiris et al (1997)

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Fig 29. A, the area of resection is outlined and the V–Y advancement flap is designed. B, appearance of the defect after ablation. C, mucosal side of the Y-shape hard palate mucoperiosteal graft. The demucosalized part of the central limb is used for lateral canthal tendon reconstruction. (Reprinted with permission from Acikel C, Celikoz B, Yildiz TF: Y-shape hard palate mucoperiosteal graft and V–Y advancement flap in the reconstruction of a combined defect involving lateral canthus and upper and lower eyelids. Ann Plast Surg 52:97, 2004.)

Free flaps In severe cases of lower eyelid deficit, free tissue transfer has been described. Thai and associates120 report the case of a severely burned patient who had both upper and lower eyelid reconstruction with a staged dorsalis pedis flap augmented by con- junctival flaps and septal cartilage grafts. Following successful transfer, secondary division of the flap to create an ostium for his vision was performed.

Tissue expansion A few reports exist of successful eyelid expan- sion to repair ectropion and lagophthalmos121 or full-thickness lid deficiencies.122 An experimental study on pigs by Wieslander and Wieslander123 explored the possibility of lower eyelid/cheek reconstruction with prefabricated, capsule-lined transposition–advancement flaps from the adjacent cheek, using the expander capsule lining as conjunctiva/mucosa replacement. A tissue expander was inserted approximately 2 weeks before the surgical reconstruction and inflated to Fig 30. Anatomy, design, and transfer of nasojugal island mucochondrocutaneous flap for total lower lid reconstruction. moderate skin tension. The expander was left in (Modified from Porfiris E et al: Island mucochondrocutaneous flap place but essentially unexpanded for 2–3 weeks, for reconstruction of total loss of the lower eyelid. Plast Reconstr after which time capsule-lined cheek flaps were Surg 100:104, 1997.) raised around the expanders and transferred to the surgically created defects in the lower lid. The flap pedicle is supplied by the dorsonasal Histologic examination of the reconstructed eye- vessels and the terminal branches of the ophthalmic lid specimens showed uneventful healing at several vessels. Advantages of this method include trilami- different intervals postoperatively. At 2 weeks the nar reconstruction in one stage and a donor site transposition flap lining had changed from an that is closed with minimal difficulty. Disadvan- expander capsule to an eyelid conjunctiva with a tages include slight bulkiness and difficult dissection stratified columnar epithelium containing mucus- of the pedicle. secreting goblet cells. Giant cells were noted and

23 SRPS Volume 10, Number 8 some areas of dense fibrosis, but the pigs tolerated Isolated medial ectropion results in eversion and their eyelid reconstructions well. The authors con- lateral displacement of the punctum. This may clude that the expander capsule acted as “a tempo- progress to stenosis or occlusion of the punctum, rary conjunctiva substitute providing a physical thickening of the lower lid, and hyperkeratiniza- shield, an infection barrier, and a matrix for epithe- tion. Medial canthal tendon laxity can be best cor- lialization simultaneously with a gradual capsular rected by direct tightening of the tendon.127 How- resolution.” Clinical trials are pending. ever, plication of the medial canthal tendon may result in occlusion of the canalicular system. If the lower canalicular system is occluded, then direct ECTROPION tightening may proceed. Patients with a patent Ectropion is an eversion of the eyelid margin punctum may undergo a medial spindle procedure that commonly occurs in the lower eyelid from or diamond-shaped excision of the conjunctiva,124 gravitational pull on the unsupported lid tissue. It plicating the eyelid retractors to the tarsus and may be mechanical (involutional or senile), cica- inverting the lower punctum. tricial, or neurogenic. Involutional ectropion is Various types of wedge excision have been sug- the result of progressive laxity of the lower eyelid gested for correction of severe ectropion. and disinsertion of the lower eyelid retractors or Smith128,129 described the lazy-T operation, which capsulopalpebral fascia from the inferior border adequately corrects punctal eversion but which may of the tarsal plate.124 Signs of involutional ectro- cause notching and leave an unsightly scar in the pion include scleral show that progresses to medial portion of the lid. punctal eversion, keratinization, conjunctival O’Donnell130 combines a diamond-shaped exci- hyperemia, and finally exposure of the globe. In sion to correct punctal eversion with either a pen- contrast, cicatricial ectropion occurs secondary tagonal full-thickness excision or lateral tarsal strip to scar contracture of the anterior lamella of the to further shorten the lower lid horizontally. He eyelid. It may be seen in dermatologic condi- feels that this technique can be performed with tions such as icthyosis, atopic dermatitis, and relative safety in patients who have medial ectro- extensive actinic exposure. It is common follow- pion of the lower eyelid without excessive canthal ing burns, trauma, and overzealous lower eyelid laxity. blepharoplasty.124 Sullivan and Collin131 describe an aggressive The position of the lower eyelid is determined approach for correction of medial ectropion. They by several different factors: the integrity of the propose resection of the medial canthus, including tarsal plate, the ligamentous and tendinous attach- the tendon and inferior canaliculus. This proce- ments of the tarsus, and the forces exerted on these dure shortens the medial canthal tendon, stabilizes structures by the overlying skin and orbicularis it to the posterior lacrimal crest, and marsupializes layer.124 Lower eyelid laxity can be evaluated by the cut end of the canaliculus to maintain patency the snap-back test or the lower eyelid distraction of the lacrimal system. In their experience with 37 test.125 The snap-back test consists of placing trac- cases of severe paralytic or involutional medial ec- tion on the lower lid, then releasing it and noting tropion managed by this technique, the deformity the speed with which the lower lid returns to its was totally eliminated in 19 patients and improved resting position. Lax lids tend to return slowly or in 33. remain away from the globe until the patient As modified by Fox,132 the Kuhnt-Szymanowski blinks.126 procedure involves lid splitting and lateral wedge The status of the lateral canthal tendon is assessed resection and offers improved cosmesis, hiding the by measuring the distance between the lateral can- scar in the lateral canthal area where it is often thal angle and the lateral orbital rim. If this distance concealed by natural skin creases (Fig 31). The is >6mm, lateral canthal dehiscence is suspected. procedure may be combined with a diamond Assessment of the medial canthal tendon is done by shaped excision near the medial punctum to cor- distracting the lower eyelid laterally. If the punc- rect punctal eversion. When further support of the tum moves >5mm, then medial canthal tendon lower lid is required, the reconstructed lid can be laxity exists.125 sutured to a flap of orbital periosteum.77

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Tse, Kronish, and Buus133 report a similar tech- nique using a transconjunctival approach for the treatment of tarsal ectropion due to disinsertion or dehiscence of the lower eyelid retractors. The lower lid retractors are sutured to the inferior tarsal mar- gin without excision of palpebral conjunctiva. The looping suture pulls the tarsal plate downward to counteract any everting tendency of the lid margin. The absorbable suture also triggers an inflammatory reaction that helps to anchor the reattached struc- tures with scar. Jelks et al134 describe an inferior retinacular lat- eral canthoplasty that is said to address the prob- lems associated with lower lid laxity or malposition. The technique incorporates the lower lid compo- nent of the lateral retinaculum, which is freed and then secured to the lateral orbital rim with a perma- nent suture (Fig 32). In the authors’ hands the procedure has been particularly useful in correct- ing a negative vector relationship (when the globe is anterior to the lower eyelid and malar eminence) and for prevention of rounding of the lateral can- thus, bowing of the lateral lower lid, and scleral Fig 31. The modified Kuhnt-Szymanowski procedure for correction of ectropion. (Reprinted with permission from Fox SA: show. A modified Kuhnt-Szymanowski procedure for ectropion and Procedures designed to deal with laxity of the lateral canthoplasty. Am J Ophthalmol 62:533, 1966.) lateral canthal tendon include the tarsal tuck124,135 and the lateral tarsal strip techniques.136–138 The Although wedge resection procedures tighten the tarsal tuck procedure is commonly combined with lower eyelid, there is a tendency to create a more standard blepharoplasty and may be done through rounded lateral canthal angle, which may result in a subciliary incision. Two sutures are used to affix lid notching, phimosis, and further tension on the the lateral tarsus to the superolateral orbital rim. lateral canthal tendon without appropriate rein- Placement of these sutures inside the orbital rim forcement.124 helps create a sharp canthal angle.124,135

Fig 32. Technique of retinacular lateral canthoplasty. Left, the lower lid component of the lateral retinaculum (dotted line) is dissected from the bone. Center, a double-armed suture is passed through the free end of the lateral retinaculum and suspended to the periosteum of the lateral orbital rim. Right, after the suture is tightened, the retinaculum is fixed in its elevated position. The tissues bunched at the canthus will relax over the ensuing 2–4 weeks. (Modified from Jelks GW et al: The inferior retinacular lateral canthoplasty: a new technique. Plast Reconstr Surg 100:1262, 1997.)

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When used in conjunction with transconjunctival periosteal flap is developed at the lateral orbital lower blepharoplasty,124 the “internal” tarsal tuck is rim. The inferior crus of the lateral canthal tendon carried through a transconjunctival incision, lysing is attached to this periosteal flap and the sutures the inferior crus of the lateral canthal tendon. The pulled in a lid-tightening maneuver (Fig 34). lateral portion of the tarsus is identified and a small Cicatricial ectropion is secondary to skin or portion of the conjunctiva is removed to prevent muscle deficiency and requires replacement of the epithelial inclusion cysts. Two absorbable sutures missing elements for correction. Simply tightening are used to secure the lateral tarsus to the the eyelid will not adequately correct cicatricial superolateral orbital rim. ectropion. Most often the anterior lamella is defi- When there is significant horizontal lid laxity, a cient, and can be replaced with a full-thickness skin tarsal strip is preferred. Although the surgical tech- graft. nique is more complex than in tarsal tucks, tarsal The management of paralytic ectropion and strip reattachment is among the most useful and lagophthalmos is discussed in another issue of effective corrective procedures in lower eyelid sur- SRPS.141 Various springs and encircling prosthetic gery.139 A lateral canthotomy is performed, fol- devices142,143 have been described for the treatment lowed by an inferior crus cantholysis and exposure of upper lagophthalmos. The preferred method of of the orbital periosteum. The anterior lamella over- many seems to be insertion of a gold weight lying the lateral tarsus is then excised and the lateral implant,143,144 which effectively prevents corneal lid is secured to the periosteum of the orbital rim exposure when the patient is in the upright position. (Fig 33). At night the eye can be taped closed. A canthus-sparing technique of ectropion repair Neuman145 describes a 16-year experience with is described by Lemke and coworkers.140 An inci- gold lid loads in lagophthalmos. Of the 71 patients sion is made lateral to the lateral canthus and a treated, 56 had a satisfactory result and uneventful

Fig 33. Technique of lateral tarsal strip for shortening the lower lid. (Reprinted with permission from Nesi FA, Waltz KL: Smith’s Practical Techniques in Ophthalmic Plastic Surgery. St Louis, CV Mosby, 1994.)

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Fig 34. Technique of canthus-sparing ectropion repair. Left, the inferior crus of the right lateral canthal tendon is grasped with a needle and suture. Right, the suture is passed through the periosteal flap and tightened. (Reprinted with permission from Lemke BN, Cook BE Jr, Lucarelli MJ: Canthus-sparing ectropion repair. Ophthalmic Plast Reconstr Surg 17:161, 2001.) outcome from the procedure, four had implant or a lateral tarsal strip reattachment. They also help extrusion, three had improper position of the gold secure the lower lid after lower lid laserabrasion, weight, three had persistent eyelid edema, two had when transient cicatricial ectropion often devel- from fifth nerve palsy, and two patients ops. were still unable to close their lids after surgery, resulting in . Severe lagophthalmos with exposure keratopathy ENTROPION can be improved with lateral tarsorrhaphy tech- Entropion is a turning inward of the eyelid mar- niques. Temporary tarsorrhaphy relies on stripping gin to the point where the lashes come in contact the epithelium from the eyelid margin or creating with the cornea. Entropion may be either involu- intermarginal adhesions. This results in a defect of tional or cicatricial. Allen150 lists the following causes the lid margins or trichiasis when the tarsorrhaphy of involutional entropion: 1) dehiscence or attenu- is taken down. A reversible tarsorrhaphy for cor- ation of the capsulopalpebral fascia, which allows neal protection involves small pieces of red rubber the lower tarsal border to rotate outward; 2) hori- catheters that are sutured to the upper and lower zontal lid laxity with or without laxity of the canthal lids, 2–3mm from the margin. A silk suture is passed tendons; or 3) overlapping of preseptal orbicularis between the bolsters and tied to pull the eyelids 146 muscle fibers on the tarsus, which makes the lid closed. 142 Tanenbaum and coworkers147 describe an alter- turn inward. native “tarsal pillar” technique that sutures strips of The management of entropion typically involves conjunctiva and tarsal plate from the upper lid into • resection of a thin strip of infraciliary skin and the lower lid to narrow the interpalpebral fissure. tarsus and suturing the superior edge of the The technique was used successfully in 35 con- wound to the inferior border of the tarsus for secutive cases of keratopathy. Flowers and Caputy148 anterior rotation of the lid margin151 report using a cartilage graft and fascial sling to cor- • release of conjunctival adhesions and resurfac- rect the sagging punctum in laxity of the paralytic ing with free grafts of buccal mucosa or con- lower lid. junctival flaps Other measures to tighten the lower eyelid may 152 be taken prophylactically at the time of blepharo- • lid margin splitting and rotation plasty, and should be considered in patients over • incorporating a cartilage graft into the recon- 40 years old or who show evidence of lower lid structive flap153 laxity.149 These preventive maneuvers include Charonis and Gossman154 focus their attention wedge resection of the tarsal plate, tarsal tuck sutures, on the overaction of the preseptal and pretarsal

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portions of the orbicular oculi muscle that is com- mon in these patients. The authors cite previous studies demonstrating superior and forward migra- tion of the preseptal orbicularis, which overrides the pretarsal part of the muscle and results in entro- pion.155,156 They incorporate a subtotal orbicularis myectomy to eliminate this muscle as a source of recurrence. This, combined with a posterior lamel- lar tightening via a periosteal flap, has produced impressive results in 42 eyelids studied. There was no evidence of overcorrection in any case, and the esthetic result was described as “good.” Postop- erative complications included one patient each with , asymptomatic trichiatic eyelash, and pyogenic granuloma requiring excision. Cicatricial entropion is related to trauma, chemi- cal injuries, Stevens-Johnson syndrome, ocular pem- phigoid, and other inflammatory conditions129 that may cause symblepharon or abnormal adhesions of the palpebral and bulbar conjunctival surfaces. Entropion should be distinguished from trichiasis, Fig 35. Transverse tarsotomy and anterior rotation of the lid where only the lashes are turned against the globe; margin for entropion correction. The tarsal plate is transected distichisis, in which an extra row of lashes some- at mid-level and a double-armed suture is passed through the times irritate the cornea; and epiblepharon, a proximal cut edge of the tarsal plate, orbicularis, and skin. redundant skin fold in the lower eyelid that rolls (Reprinted with permission from Kersten RC, Kleiner FP, Kulwin DR: Tarsotomy for the treatment of cicatricial entropion with over the lower eyelid margin and causes an inver- trichiasis. Arch Ophthalmol 110:714, 1992.) sion of the lid margin.129 Kersten, Kleiner, and Kulwin157 recommend simple transverse tarsotomy followed by reposition- laris muscle. The graft creates a new, more rigid ing of the lid margin in slight eversion using a silk tarsal plate to replace the natural one, which seems suture (Fig 35). The skin and orbicularis layers are to soften and shrink with age. Drawbacks of this left undisturbed. operation include possible follicular destruction, One year after surgery, 69/81 eyelids (85%) had vascular compromise, and a palpable graft. complete resolution of trichiasis.157 Repeat tarso- Millman, Katzen, and Putterman159 describe their tomy was required in 6 eyelids due to recurrence, experience in 98 patients (152 lids) treated for cica- and it was successful in all. The success rate after tricial entropion with transverse blepharotomy and revision was 92.5%.157 lid margin rotation. The overall success rate was Ito and colleagues158 describe another technique 85%; recurrences were seen in 11 lids, 7 in patients for the correction of pediatric eyelid entropion that with ocular pemphigoid and 4 with Stevens-Johnson involves resection of a length of pretarsal orbicu- syndrome. Seven eyelids were overcorrected, while laris muscle without skin resection. Severe cases 22 lids developed subsequent conjunctival granu- also receive a lid-bracing suture. The authors lomas that required excision. An additional 10 lids believe that swelling of the orbicularis oculi muscle required electrolysis for aberrant lashes despite good at the lid margin is the underlying mechanism of lid margin position. persistent ciliary entropion in children. Unimpres- When entropion is associated with laxity of the sive results in 8 patients are illustrated. eyelid, a lid-tightening procedure should be Siegel153 offers a simple technique for the treat- included,136,137 commonly with horizontal lid short- ment of involutional entropion. A 4 x 20mm strip ening and tarsal rotation.129 If there is associated of cartilage harvested from the conchal bowl is epiblepharon, this must be corrected by careful placed within the lower lid just deep to the auricu- excision of the fold and plication of the capsulo-

28 SRPS Volume 10, Number 8 palpebral fascia to the lower border of the tarsus, Spontaneous granulation. A reasonable outcome with or without lid tightening.129 Allen150 describes may be expected when the lesion in the medial a modification of Quickert and Jones’s160 proce- canthus is allowed to heal on its own.163,164 dure for correction of lower lid entropion that com- Harrington165 noted excellent results in 75% of bines lid shortening with repair of the lower lid patients whose medial canthal defects were allowed retractor complex. to heal secondarily, but emphasizes the need for Rougraff and coworkers161 from Bascom Palmer suture-fixation of the lid margins to the nasal peri- analyzed the surgical results in a large series of osteum, believing it to be important in preventing patients with involutional lower eyelid entropion lateral retraction of the eyelids. Harrington also who were treated at their institution during a 12- advocates tension-relieving incisions and advance- year period. There were 152 eyelids with follow- ment flaps to cover as much of the defect as pos- up longer than 6 months. Group 1 (125) had com- sible. bined repair with fornix suture placement and lat- The best results with spontaneous granulation are eral tarsal strip. Group 2 (9) had repair with fornix seen in defects of the medial lower eyelid no longer sutures only. Group 3 (18) had repair with the than 5–6mm and directly over the inner canthal 163 lateral tarsal strip procedure only. After an average area. With extension of the defect onto the side follow-up of 36 months, the recurrence rate in these of the nose, there is an increasing tendency for the surgical subsets was 1.6%, 33%, and 22%, respec- spontaneously healed canthus to lie higher than the normal one and for the lids to pull away from the tively. The authors conclude that “suture advance- globe. As the wounds extend into the parapalpebral ment of the lower eyelid retractors in conjunction tissues and away from the medial canthus, prob- with a lateral tarsal strip procedure is a simple, quick, lems with spontaneous granulation also increase. physiologic, and effective approach in achieving long-lasting correction for involutional entropion.” V–Y glabellar flap. Small or moderate sized defects of the inner canthus can be resurfaced with a V–Y SURGERY ON THE MEDIAL CANTHUS glabellar flap, as recommended by Hughes.113 Larger defects may be corrected with a combined nasola- Medial Lid and Punctal Lacerations bial V–Y advancement flap and glabellar flap.166 In a series of 23 patients who underwent this medial Palpebral defects in an otherwise stable medial canthus repair after tumor resection, Yildirim and canthus are best treated as any full-thickness wound colleagues166 report good functional and cosmetic of the eyelid. Common options for repair involve a results and no complications. The technique may lower lid switch flap with lateral cheek advance- be criticized for a tendency of the V–Y advance- 54,77 ment or an upper lid tarsoconjunctival flap cov- ment flap to pincushion, for crossing anatomical 55 ered by a full-thickness skin graft or glabellar flap. lines, and for placing scars at right angles to the lid margin. Tendon Avulsion or Malposition Musculocutaneous and muscle flaps. Jelks and coworkers167 described medial canthus reconstruc- 12 Zide and McCarthy detail the anatomy of the tion in 10 patients with a medially based upper medial canthus and stress the importance of the eyelid musculocutaneous flap. The flap is incised canthal tendon, which anchors the mobile central through the skin and the preseptal and orbital part of the levator complex in the medial upper lid. orbicularis oculi muscle down to the level of the McCord162 describes the medial canthal retinacu- septum orbitale, and elevated from lateral to medial lum as consisting of “the deep head of the pretarsal in continuity with the medial fat pocket (Fig 36). Its orbicularis, the orbital septum, the medial end of blood supply is from supratrochlear, infratrochlear, Lockwood’s ligament, the medial horn of the leva- and medial palpebral perforating vessels. The flap tor aponeurosis, the check ligaments of the medial can be raised on a thin pedicle and can be rotated rectus muscle, and Whitnall’s ligament.” Injury to into several locations in the medial periorbital– the medial canthal tendon may cause lid ptosis. glabellar region. There was only one partial flap

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telecanthus. The technique involves suturing the medial ends of the upper and lower lid tarsus to the nasal periosteum;23 the point of fixation should be well below the anterior lacrimal crest to keep the lids coapted against the globe. Large tendon plica- tions, however, are associated with a high rate of recurrence rate and occasional canalicular kink- ing.137 When nasal periosteum has been removed, transnasal canthopexy affords the most stable fixa- tion. Zide and McCarthy12 feel that the tension required of a medial canthopexy is too much for the nasal periosteum to withstand and recommend a more liberal use of transnasal canthopexy.169 They describe a tripartite fixation that has anterior and posterior horizontal components as well as a verti- cal component; this results in a vector of suspen- sion directed posteriorly and superiorly to the ante- rior lacrimal crest. Freihofer170 analyzed the results of 49 transnasal canthopexies in 28 patients and concluded that transnasal canthopexy is a difficult procedure and the outcome is not always favorable. To avoid excessive tension, he locates the inner canthus 5– Fig 36. A medially based musculocutaneous flap from the upper 7mm lateral to the anterior lacrimal crest and adds a lid raised to repair defects of the medial canthus and periorbita. Left, the perforating vessel feeding the flap emerges from the lateral canthotomy or wide dissection of the medial fat pad. Right, potential arc of rotation of this versatile flap. periorbita for lateral release. A technically inad- (Reprinted with permission from Jelks GW, Glat PM, Jelks EB, equate canthopexy will invariably yield a poor result: Longaker MT: Medial canthal reconstruction using a medially The most common errors in performance are based upper eyelid myocutaneous flap. Plast Reconstr Surg incomplete removal of bone and intervening soft 110:1636, 2002.) tissue, use of catgut instead of permanent suture, and exaggerated traction during the inner canthal loss in the series, and the authors believe this flap fixation. Mustardé23 believes that a canthal fixation “offers an excellent solution to the difficult problem taken too far anteriorly will also cause problems, of medial canthal reconstruction.” and recommends placing the fixation sutures in the 168 Chiarelli and others report their experience vicinity of the posterior lacrimal crest. with a forehead flap to repair medial canthal defects involving both eyelids in 3 patients. The myofascial Canthoplasty. Leibsohn and Hahn171 report flaps were raised from the central forehead and reconstruction of the medial canthal tendon using a were combined with septal chondromucosal grafts, flap of nasal periosteum as replacement. The flap is grafts of oral mucosa, and skin grafts. The part of elevated as a horizontal rectangular strip, 6–10mm the forehead muscle taken for the flap is vascular- wide and up to 2cm long, that is hinged laterally or ized by the deep branch of the supraorbital artery as close as possible to the stump of the medial can- and by the supratrochlear artery. The authors praise thal tendon. The flap is rotated into place, split to the flap for its thin, elastic, and resistant features create the upper and lower crura of the tendon, if and recommend it for reconstruction in this diffi- necessary, and sutured to the medial eyelid(s). cult area. Although this technique seems reasonable, the nasal periosteum is extremely thin and may be insuffi- Canthopexy. Canthopexy should be made a part ciently strong for permanent reconstruction of the of the repair of medial canthal defects to prevent canthal tendon.

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An interesting approach to medial canthoplasty was described by Howard, Nerad, and Kersten.172 The authors reattached the medial canthal tendon to a titanium microplate under the lateral nasal sidewall. The plate was stabilized along the ante- rior lacrimal crest and extended onto the poste- rior lacrimal crest. On the basis of their experi- ence with 6 patients who had malpositioned or avulsed medial canthal tendons, the authors feel this technique is safer, faster, and in many cases more effective than traditional methods of recon- struction. Obviously the procedure is only appli- cable when the ipsilateral nasal sidewall is ana- tomically intact. Fig 37. Fuente del Campo’s flap technique for correction of epicanthal fold. (Reprinted with permission from Fuente del Medial tarsal strip. Jordan, Anderson, and Campo A: Surgical treatment of the epicanthal fold. Plast Reconstr Surg 73:566, 1984.) Thiese173 described the medial tarsal strip, a modi- fication of the lateral tarsal strip procedure for lid tightening. The technique can be easily combined LID RETRACTION with other procedures such as flaps or grafts. Indi- cations for medial tarsal strip are: (a) medial canthal The terms “complex ectropion” and “lid retrac- malposition; (b) marked medial ectropion associ- tion” are often interchangeable in the literature. ated with a nonfunctioning canalicular system; and They refer to a condition characterized by con- (c) cases in which loss of function of a patent canali- striction of both the inner and outer lamellae as culus is acceptable or desirable, such as dry eye well as constriction of the supporting structures of syndrome or exposure keratitis. In the isolated the lid. The eyelid itself is everted only if the outer instance where canalicular sacrifice can be toler- lamella is contracted more than the other layers. ated or should one wish to reduce the tear flow, Lid retraction is the indirect result of marked this procedure could be useful and would avoid inflammation and edema during wound healing that transnasal canthopexy. lead to fusion of the lid structures with the orbital septum. It occurs frequently after complex facial trauma, full-thickness burns, and postoperative Epicanthal Fold hematoma. An epicanthal fold that partially covers the medial The key to correction of the retracted lid defor- canthus can have a traumatic origin, represent a mity is a thorough dissection of the tissues to release developmental anomaly, or simply be an ethnic all scar, followed by insertion of a rigid lid-support- trait—see discussion below under ing element. Whether it is necessary to bring in Syndrome. Fuente del Campo174 illustrates various skin or lining to the repair is controversial. In theory historical methods for the correction of epicanthal there is no skin or conjunctival shortage, and all that folds and introduces a transposition flap based on is needed for correction is complete scar release the fold tissues. The flap curves along the edge of and insertion of a strong middle lamella, such as the epicanthal fold (first incision), toward the lower nasal septal cartilage, to withstand any subsequent palpebral margin ending 2mm below the punctum deforming forces. If the tissues have been stretched (second incision), and is transposed medially with from the inferior pole of the scar contracture, one its apex pointing toward the midline (third incision should consider adding a lid-tightening procedure perpendicular to the first) (Fig 37). The medial such as a lateral tarsal strip advancement. canthal tendon is simultaneously shortened by a In contrast to this popular opinion stands a report plication suture. by Hurwitz, Archer, and Gruss176 of 23 patients Flowers175 prefers a V-W-plasty procedure with severe lower eyelid retraction (>4mm scleral because it produces better scars. show) treated with free grafts of skin and and

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bipedicle orbicularis flaps. The operative sequence by fibrosis. The orbital pads in both upper and involved 1) infraciliary incision and lysis of adhe- lower eyelids are frequently involved in the inflam- sions; 2) homologous free scleral graft for the poste- matory process. and are com- rior lamella; 3) free retroauricular skin graft to the mon because of fibrosis of the . anterior lamella; and 4) bipedicle orbicularis flap Surgical intervention is not recommended dur- mobilization and interposition between the free ing the inflammatory stage. Stability of the disease grafts. In a follow-up of 3 to 6 years, the authors should be documented for at least 6 months before noted lid height at the inferior limbus in 21 of 26 any operative correction is undertaken. operated eyelids; the other 5 eyelids were within The pathophysiology of eyelid retraction in 2mm of the limbus. The authors emphasize com- patients with Graves’ disease is still not well delin- plete release of the supporting tarsus from the infe- eated, but several factors are thought to play an rior lid retractors as crucial to the success of the important role. Excessive sympathetic stimulation procedure. Their good results cannot be over- of Müller’s muscle can contribute to upper eyelid looked. retraction.179,180 The inflammation and fibrosis may Baylis, Nelson, and Goldberg177 reviewed 30 con- result in contracture of the secutive patients with lower eyelid retraction after and overaction of the synergistic superior rectus blepharoplasty. In addition to vertical skin short- and levator muscles.179,181,182 Proptosis certainly age, scarring in the plane of the orbital septum was contributes to the appearance of eyelid retraction. a common cause of lid retraction. Surgical correc- Corticosteroids have been used to treat the oph- tion varied with time since blepharoplasty, promi- thalmic manifestations of Graves’ disease.183,184 Ste- nence of the globe, and degree of septal or skin roid administration in the inflammatory stages involvement. Mild cases of less than 6 months’ improves the eyelid symptoms, but the effect less- duration were treated by release of the lower eye- ens as steroid doses are reduced.185 Long-term use lid retractors, thorough dissection of the scar tissue, of corticosteroids is associated with a wide range of and lateral canthal suspension. (A simple canthopexy complications.186 may actually lower an already retracted eyelid mar- Surgical management follows two different path- gin.) In slightly more severe cases, a spacer graft of ways. Mild to moderate cases of eyelid retraction cartilage was added between the tarsus and the may be treated with eyelid procedures to mask the lower eyelid retractors. Severe or long-standing ocular proptosis. More severe symptoms frequently cases had orbicularis dissection and superolateral require orbital decompression to enlarge the orbital suspension. Fixation of the orbicularis was often volume. sufficient for correction, although most patients needed more than one operation to achieve acceptable symmetry. Vertical Lid Lengthening In 1972 Putterman179 described surgical treat- ment of patients with upper eyelid retraction by Graves’ Ophthalmopathy excision of Müller’s muscle, incorporating partial Graves’ disease consists of hyperthyroidism asso- tenotomy of the levator aponeurosis as needed. A ciated with goiter, pretibial dermopathy, and infil- sensory nerve block allows the surgeon to assess the trative ophthalmopathy. Ocular manifestations degree of correction required. Excision of only the include eyelid retraction, often with a lag on down- temporal two thirds of Müller’s muscle reduces post- ward gaze; secondary to anterior dis- operative ptosis on the nasal side.180 The authors placement of the globe; disorders of ocular motil- note that eyelid retraction may develop in the con- ity; inflamed ocular surface; and rarely a compres- tralateral lid following unilateral upper eyelid sur- sive .178 gery (Haring’s law).181,187 The natural course of Graves’ ophthalmopathy is Ceisler et al186 reported their experience with usually self-limiting but may not correspond directly Müller’s myotomy and transposition of the levator with the patient’s thyroid status. The early inflam- aponeurosis for the correction of eyelid retraction matory infiltrate of the extraocular muscles, con- in patients with Graves’ disease. In their experi- nective tissues, and lacrimal gland is later replaced ence with 72 eyelids of 37 patients, 58 eyelids (30

32 SRPS Volume 10, Number 8 patients) showed excellent results, 13 eyelids (7 outfractured; the medial canthal region is left patients) had good results, and 1 eyelid had a poor undisturbed. The periorbital tissues are incised and result. Two patients required further surgery, one the herniated retrobulbar fat is excised under direct because of significant overcorrection and the other vision. because of undercorrection. The most common Garrity et al185 retrospectively reviewed 428 con- complication was a high eyelid crease (33.3%). The secutive patients with severe Graves’ ophthalm- authors stress the importance of lateral levator apo- opathy who were treated with transantral orbital neurosis transposition to lengthen the eyelid verti- decompression. The bone is removed from the 186 cally and obtain suitable eyelid contour. medial wall of the orbit to the roof of the ethmoid In contrast to the upper lid, lower eyelid retraction and, depending on the location of the infraorbital requires a scleral interpositional graft for correction.188 nerve, the orbital floor is removed either lateral or The grafts are typically made 4X wider than the mea- medial to the nerve. Numerous crosshatching inci- sured scleral show.180 This technique is reported to be sions are placed within the periorbita. Their review very effective; in one series of 30 lids, the success rate found that this technique reduced proptosis effec- was 90% after a single operation.188 tively and usually corrected optic neuropathy asso- Feldman, Putterman, and Farber180 review their ciated with Graves’ disease.185 15-year experience with the surgical treatment of Shore, Carvajal, and Westfall191 approach orbital thyroid-related lower eyelid retraction. The authors decompression by excising the lateral orbital rim conclude that residual lid retraction after scleral graft- and using a titanium miniplate to reconstruct the ing was a common occurrence. They modified lateral canthus. Their results in 18 patients (33 orbits) their procedure to include a lateral canthal suspen- showed excellent eyelid and globe position with- sion, and later incorporated both lateral tarsal strip out complications. and tarsorrhaphy. The authors note a significant decrease in persistent lower lid retraction postop- eratively following these changes. UPPER EYELID PTOSIS Orbital Decompression Blepharoptosis may be congenital or acquired. This is an important distinction to make, as the eti- The indications for orbital decompression in the ology of the deformity determines its anatomy, treatment of thyroid ophthalmopathy include: physiology, and expected outcome after surgical • a sight-threatening compressive optic neuropa- correction. Conditions that mimic eyelid ptosis thy unresponsive to immunosuppressive therapy include retraction of the opposite lid secondary to • proptosis causing severe ocular surface disease Graves’ disease, , contralateral exoph- thalmos, and any mechanical pressure on the lids • cosmetic appearance unlikely to be improved caused by heavy skin folds, eyelid edema, or by lid surgery alone tumors.192 • before strabismus surgery, if it is thought that decompression will be needed at some point169 Congenital Osteotomies are typically performed through These patients have an anomalous levator muscle either the medial wall of the orbit or the orbital at birth. Histologically there is fibrosis or absence floor to allow herniation of intraorbital contents into of striated muscle fibers consistent with a muscular the paranasal sinuses.189 dystrophy.193 The levator is stiff, which translates Thaller and Kawamoto190 propose a three-wall into poor excursion clinically. Lagophthalmos in decompression through the lateral and medial orbital down gaze-is a sign of congenital ptosis. Affected walls as well as the orbital floor. The lateral orbital children show a high incidence of coexistent stra- wall is displaced in a swinging door fashion, which bismus, , and .192 allows expansion of the intraorbital contents while The surgical repair of congenital eyelid ptosis preserving the position of the lateral orbital rim. depends on the severity of the anatomic deformity, The floor and medial wall of the orbit are carefully specifically the degree of ptosis and levator mal-

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function.194 Excision of the tarsus and Müller’s the skin to prevent prolapse of the conjunctiva post- muscle or small resection of the levator aponeurosis operatively. The medial canthal tendon is not cut may be all that is necessary for patients with mild but is plicated and affixed to the periosteum of the ptosis and good levator function. Patients with mod- frontal process of the . erate ptosis and fair levator function may require After surgery, all patients had temporary lagoph- more extensive levator resection for correction. thalmos that took 4–6 months to subside, and some Less clear is the recommended surgical tech- patients had 2–3mm of lagophthalmos during sleep nique for patients who have severe ptosis and poor for as long as 2 years postoperatively. Ophthalmic levator function.194 Beard,195 Putterman,196 and oth- lubricants and taping during sleep effectively pre- ers197 propose maximum levator resection at age 2, vented any exposure keratopathy. while Crawford198 suggests grafts of fascia lata for Krastinova and Jasinski200 describe a 16-year, 50- frontalis muscle suspension at age 3½. Saunders patient experience with orbitoblepharophimosis and Grice194 reason that early surgical repair of syndrome. They review the three forms of presen- severe congenital ptosis before 1 year of age not tation, epidemiology, genetics, and operative cor- only improves appearance but also averts future rection of the malformation. In their words, “surgi- physiological and developmental problems associ- cal treatment involves 3 to 4 operations: orbital ated with ptosis; definitive suspension with grafts is remodeling by burring and grafting (intraorbital and carried out when the child is older. Their proce- extraorbital), epicanthus correction, and ptosis dure of choice is frontalis suspension with Supramid operation.” Skin grafting was used liberally for cor- Extra sutures, which avoids a complex dissection rection of insufficient upper lid skin. Results varied yet produces the necessary improvement in func- depending on the severity of the form and the qual- tion during this critical stage in a child’s develop- ity of the tissues. ment. In their series of 12 infants, 10 achieved Nowinski201 reviews the various published tech- near-normal eyelid position and all had resolution niques for correction of epicanthal folds in blepharo- of their chin-up posture. Two slings eventually failed phimosis and promotes the five-flap technique and had to be repeated. described by Anderson.202 The procedure combines double Z-plasties with a Y-to-V flap (Fig 38). Orbitoblepharophimosis Syndrome One form of congenital ptosis is the orbito- blepharophimosis syndrome. Clinical manifesta- tions of the syndrome are bilateral upper blepharo- ptosis, epicanthal folds, and narrowing of the palpe- bral fissure. A common finding is an elongated medial canthal tendon. Associated anomalies such as skin shortage in the upper and lower lids, con- genital ectropion, telecanthus, and flattening of the glabellar area may also be present. Congenital blepharophimosis is inherited as an autosomal domi- nant trait and is said to be more common in people Fig 38. Anderson’s five-flap technique for repair of epicanthal of Asian origin than in Europeans. folds associated with the blepharophimosis syndrome. Traction has been applied medially to obliterate the fold. (Reprinted with Surgical correction of blepharophimosis should permission from Anderson RL, Nowinski TS: The five-flap tech- involve repair of the epicanthal folds as well as cor- nique for blepharophimosis. Arch Ophthalmol 107:448, 1989.) rection of the eyelid ptosis. Nakajima and col- leagues199 repair all cases of congenital eyelid pto- sis, regardless of functional status, by levator resec- Nowinski201 recommends extensive defatting of tion and medial canthoplasty in one operative stage. the flaps to allow the soft tissues of the medial can- If correction is insufficient, a fascial suspension can thus to recede posteriorly. The ideal final position be added later. A deep superior fornix is recreated of the canthus in most patients is halfway between and maintained with sutures tied over bolsters on the pupil and the center of the nasal bridge.

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Acquired upward position with the eyes fixed on a light held Upper eyelid ptosis of traumatic, myogenic, neu- at a distance. During examination of levator excur- rogenic, or mechanical origin203 is said to be acquired. sion, the effect of the frontalis muscle must be neu- 207 Common causes of acquired ptosis include surgery tralized by exerting pressure above the eyebrow. or accidental injury, tumor, myopathy, chronic pro- gressive ophthalmoplegia, third nerve palsy, Horner’s TABLE syndrome, myasthenia gravis, and mechanical Classification of Upper Eyelid Ptosis changes with anophthalmos.192 A history of increas- ing ptosis toward the end of the day is not pathogno- monic of myasthenia gravis but simply represents fatigue. It is estimated that 40–50% of cases of acquired ptosis are involutional (myopathic) in nature and 30% are posttraumatic. Conventional wisdom holds that the immediate reason for ptosis is dehiscence or disinsertion of the levator aponeurosis from the anterior lower surface of the tarsus. Martin and Tenzel204 reviewed the records of their cases of acquired ptosis and found evidence to contradict this widely held belief. A retrospective analysis of the intraoperative findings in 98 patients who had surgery for involutional pto- (Data from Souther SG, Corboy JM, Thompson JB: The Fasanella- sis using only sharp dissection revealed no Servat operation for ptosis of the upper eyelid. Plast Reconstr Surg 53:123, 1974.) disinsertions and no dehiscences of the levator apo- neurosis, which was seen to be markedly attenu- ated. The authors theorize that the formerly rec- Frueh and Musch209 found in their study of 187 ommended technique of blunt dissection during patients with ptosis that levator force (maximum levator resection surgery204 may have been respon- force generated on upward gaze) predicted the sible for the reported frequency of dehiscence and correct diagnosis 95.2% of the time. In contrast, disinsertion. Their data “support the concept that measurement of eyelid excursion predicted the most cases of acquired ptosis are secondary to a correct diagnosis 78.2% of the time. A correct stretching of the aponeurosis above the tarsus.”204 diagnosis was obtained 98% of the time when leva- A previous study by Collin205 showed that 90% of tor force was combined with a good physical patients with senile involutional ptosis associated examination.209 Patients with involutional blepharo- with aging had aponeurotic weakness and only 10% ptosis due to pure aponeurotic disinsertion typi- had degeneration of the anterior portion of the levator muscle as the cause of the ptosis. Similarly, cally have ptosis with good levator excursion, an Carroll206 found a 5% incidence of disinsertion or elevated or absent upper lid skin crease, and thin- 210 dehiscence of the aponeurosis in more than 450 ning of the upper lid tissues above the tarsal plate. consecutive eyelids with congenital or acquired pto- A complete visual field examination is manda- sis requiring levator surgery. tory when evaluating eyelid ptosis.192,211 Preopera- The severity of ptosis is graded according to tive evaluation should include a Schirmer test to upper eyelid position in primary gaze and the range assess the tear film. Adequate function of the of levator excursion (Table).203,207,208 The distance trigeminal and facial nerves should be ascertained between the upper and lower limbus measured prior to surgery. across the pupil is 11mm. The upper limbus should rest about 2mm below the superior edge of the and 2mm above the superior edge of the pupil.207 Anterior Levator Resection The functional status of the levator muscle is deter- Wobig212 details the technique of vertical lid mined by measuring the excursion of the upper lid shortening by resection of the levator muscle through margin while going from a downward gaze to an an anterior approach. This is the time-honored

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method for the correction of eyelid ptosis203 and Satisfactory correction within 1mm of the desired can be performed through a conjunctival approach result was achieved in 95% of lids. The range of in cases of mild to moderate ptosis or externally eyelid lift was 1–5.5mm. when higher corrections are needed. Doxanas218 recently described a simplified apo- neurotic ptosis repair that minimizes surgical dis- section and enhances the predictability of postop- Surgery on the Levator Aponeurosis erative eyelid position. The procedure is appli- Jones, Quickert, and Wobig213 described cor- cable in cases of minimal or mild congenital ptosis rection by plication or reattachment of the levator with good levator function, for the repair of unilat- aponeurosis using local anesthesia since the level of eral ptosis, and for reoperation after standard leva- fixation for the levator is determined by having the tor surgery. The author cautions that the technique patient move his eyes through various fields. Leva- is “best suited for surgeons who have a thorough tor excursion of at least 8mm is required for a suc- knowledge of the levator aponeurosis anatomy.”218 cessful outcome, and generally overcorrection by Jackson219 describes a simple technique combin- 1mm produces the desired result. ing conjunctiva and skin for locating the levator Wobig213 notes that lidocaine effectively blocks muscle in difficult dissections. Anderson215,216 and orbicularis oculi resting tension so that the lid will Carraway214 use the preaponeurotic fat to identify be approximately 1mm higher than the opposite the levator aponeurosis in surgical correction of side, and this must be taken into account when eyelid ptosis. setting the lid level intraoperatively. Liu220 prospectively evaluated 169 ptotic lids Carraway and Vincent214 preserve the full length whose levator function was >8mm and which were of the levator muscle and instead advocate levator repaired by a single-suture aponeurotic tuck (Fig advancement at a rate of 4mm of advancement for 39). Correction to within 1mm was achieved in each 1mm of ptosis. The authors illustrate good 95% of patients; 12 patients required reoperation. results with this approach in over 20 patients, with Overcorrection was noted in 3 patients, under- increased muscle function in some cases. correction in 6, peaking in 5, 2 had immediate Anderson and Dixon’s215 technique consists of recurrences, and 3 had late recurrences, for an reinserting the aponeurosis into the midportion of overall complication rate of 7%. Liu’s technique is the tarsal plate, preserving the tear-producing struc- simple and versatile. tures, Müller’s muscle, Whitnall’s ligament, and nor- mal anatomic planes and structures of the eyelid. “Tucking” of the aponeurosis is to be avoided because it leaves no raw surfaces for healing. The procedure is indicated in cases of acquired ptosis and also for patients with congenital ptosis who have at least 5mm of levator function. Overcorrec- tion by 1mm in acquired ptosis and 3mm in con- genital ptosis is recommended. Jordan and Anderson216 published an update of their aponeurotic approach in 228 patients (265 lids) with congenital ptosis. Advantages of the tech- nique include dissection along normal anatomic planes, minimal disruption of normal structures, no resection of the muscular levator or Müller’s muscle, and maintenance of an intact Whitnall’s ligament. Postoperatively most patients were improved. The degree of correction achieved varied with the qual- Fig 39. Suture plication of the lid aponeurosis for correction of ity of preoperative lid function. upper eyelid ptosis. (Reprinted with permission from Liu D: Ptosis 217 Older describes his experience with levator repair by single suture aponeurotic tuck. Ophthalmology 100:251, aponeurosis surgery in 113 ptotic upper eyelids. 1993.)

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Collin and O’Donnell221 recommend adjustable sutures to secure the eyelid in the proper position postoperatively. They also use this technique for repair of eyelid retraction secondary to thyroid dis- ease. Borman and Öscan57 describe a modification of Collin and O’Donnell’s adjustable-suture technique (Fig 40) for reattaching the avulsed levator muscle to the Mustardé flap used in the reconstruction. Their modification staggers two rows of sutures across the levator to allow further advancement if necessary and to add more strength to the muscle- tarsal plate abutment. Fig 41. The upper lid is everted in the Fasanella-Servat operation. (Reprinted with permission from Souther SG, Corboy JM, Thomp- son JB: The Fasanella-Servat operation for ptosis of the upper eyelid. Plast Reconstr Surg 53:123, 1974.)

period and found 90% of lids in the acquired ptosis group and 100% of those in the congenital group were within 1.5mm of the contralateral normal lid; only 2 of 232 treated lids required additional sur- gery. Candidates for the procedure have upper lids that elevate to near-normal level following instillation of 10% or 2.5% phenylephrine hydro- chloride227 drops into the upper ocular fornix—ie, patients with minimal congenital ptosis or variable degrees of acquired ptosis. Guyuron and Davies228 report excellent results with the Putterman conjunctivo-Müllerectomy in the treatment of 43 ptotic eyelids. Fig 40. Top, original levator anchoring technique as described Glatt, Putterman, and Fett229 described using the by Collin and O’Donnel. Bottom, modified adjustable suture Müller’s muscle–conjunctival resection in 6 patients technique for flap retraction. (Modified from Borman H, Õzcan with Horner’s syndrome and an average 2.3mm G: Modified adjustable technique to anchor the levator muscle to the flap used in total upper eyelid reconstruction. Br J Plast Surg ptosis. Even though denervation in Horner’s syn- 51:566, 1998.) drome renders Müller’s muscle nonfunctional, conjunctivo-Müllerectomy proved effective in cor- recting ptosis in these patients. Fasanella-Servat Procedure Lesavoy et al230 recently reported yet another Souther and colleagues207 detail the technique modification of the Fasanella-Servat operation that and applicability of the Fasanella-Servat operation, involves horizontal lenticular tarsal plate resection a milestone in ptosis surgery. In its classic form, the well within the medial and lateral edges of the tar- Fasanella-Servat procedure involves resection of sus. The amount of vertical excision is equal to the conjunctiva, tarsus, and Müller’s muscle along the degree of ptosis present and should not exceed entire length of the everted upper lid (Fig 41). 4mm. The technique is indicated for use in cases Putterman and Urist,222 Gavaris,223 Iliff,224 and of minimal ptosis (<4mm). Good results were Lauring225 attempted to circumvent some of the obtained in 6 patients and these have been main- drawbacks of the original Fasanella-Servat proce- tained for 9y or more. The primary advantages of dure by introducing certain modifications. this procedure are lack of disruption of the levator Putterman226 analyzed his results with Müller’s and Müller’s muscles, precise correction of the muscle resection for blepharoptosis over a 10-year deformity, and theoretically less strain on the muscles

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of elevation of the upper eyelid because of the reduced weight of the tarsus. Mustardé231 describes a full-thickness, split-level lid resection that includes excision of skin and preseptal muscle anteriorly as well as small, lower segments of levator aponeurosis and Müller’s muscle, conjunctiva, and most of the tarsus pos- teriorly. Atabay et al232 recommend making the tarso- conjunctival incision 5mm away from the central lid margin, as opposed to 3mm as recommended by Mustardé. They feel that this helps minimize central peaking of the eyelid margin as well as the eyelash line deformity occasionally reported with this technique. Karesh233 reports surgical correction of severe acquired ptosis in 6 eyelids through an external approach. The technique consists of a multilevel full-thickness resection of eyelid tissue combined with plication of the levator aponeurosis-Müller’s muscle complex. Fig 42. Frontalis fascial sling for correction of upper eyelid ptosis. See text for details. (Modified from Chen TH, Yang JY, Chen YR: Refined frontalis fascial sling with proper lid crease formation for Fascial Sling blepharoptosis. Plast Reconstr Surg 99:34, 1997.) Fascial sling procedures are used in patients with severe ptosis who have no levator function. The Disadvantages include asymmetry of eyelid concept of a fascial sling was first suggested by Payr motility with eyelid retraction in downward gaze; 234 and Wright and was popularized by Crawford. postoperative edema lasting 1–2mo; marked degree Since that time numerous modifications have been of induced lagophthalmos with potential for expo- 235–241 242,243 reported in the literature. Pearl’s varia- sure keratopathy; and technical complexity of the tion is designed for use in severe congenital procedure.244 blepharoptosis. His technique consists of direct Frontalis suspension using an alloplastic sling tarsal fixation, partial lid resection, and a circular (Supramid) was evaluated by Liu245 in 81 consecu- sling (Fig 42).242,243 tive patients. The author found it to give only tem- Holds, McLeish, and Anderson244 describe the porary correction for about 1 year, and concluded Whitnall sling procedure for severe, unilateral, prob- that it had a limited role in blepharoptosis surgery. lematic blepharoptosis. As described, Whitnall’s ligament is sutured to the superior portion of the tarsal plate. The authors combine this with superior BLEPHAROCHALASIS tarsectomy to enhance the long-term result. The blepharochalasis syndrome is an uncommon Advantages of this technique are said to include the disorder of young people characterized by repeated following: episodes of eyelid edema that eventually cause a • can be used as a unilateral procedure stretching of the supporting structures of the eyelid. In time, this produces the typical clinical features of • preserves the muscular elevating structures of thin and excessive lid skin, blepharoptosis, the eyelid pseudoepicanthal folds, prolapse of orbital fat and • is an anatomic procedure with some dynamic lacrimal gland, and often disinserted lateral canthal eyelid function tendons.246 The etiology of the syndrome is • produces an esthetically pleasing eyelid crease unknown, but there may be autosomal dominant

38 SRPS Volume 10, Number 8 inheritance in some cases. Jordan246 suggests a to the conjunctival sac after the nasal mucosa is relation between the blepharochalasis disorder and shrunk with a topical anesthetic, and a cotton pledget , a common dermatologic condition with is placed beneath the inferior turbinate to soak the numerous triggering mechanisms. drainage. If dye is seen, the test is said to be posi- Custer and associates247 delineate specifics of tive, meaning there is no obstruction in the lacrimal management of this problem and caution against passages and the epiphora is due to hypersecre- the tendency to overcorrect during surgery for pto- tion. If no dye stains the nasal mucosa after 5min, sis. Because of marked postoperative swelling, only the test is considered negative. one eye should be operated on at a time. The secondary dye test follows the primary dye test and consists of flushing the canalicular system with 1mL of saline through a lacrimal cannula. The LACRIMAL DRAINAGE SYSTEM presence of dye on the pledget reveals a partial obstruction in the lower canalicular system and most Pathophysiology and Incidence likely in the nasolacrimal duct. Dye in the tear sac Lacrimal duct obstruction may be silent, without denotes a patent canaliculus and punctum and a outward signs of epiphora and a dry eye. More normally functioning lacrimal pump, in which case commonly, however, the patient complains of the obstruction is probably in the nasolacrimal duct. uncontrolled tearing. Epiphora results from tran- If no dye is seen in the fluid from the nose, the test sient corneal irritation, infection in the lacrimal sac, is read as negative or proof that no dye has reached oversecretion of tears, or obstruction of the lacri- the tear sac, hence the cause of the epiphora lies in mal drainage system. O’Donnell248 found that 25% the canaliculi. of patients being evaluated for epiphora and medial Dacryocystography is not essential for assessing ectropion had lower lacrimal obstruction, and theo- the integrity of the lacrimal duct system, since it is rized that induced tear flow as a consequence of not a passive test and therefore does not measure lower lid or punctal malposition caused stasis of the the effectiveness of the lacrimal pump mechanism. ducts and secondary lower lacrimal obstruction. The primary indication for dacryocystography is Iatrogenic tear duct obstruction is usually second- persistent epiphora after unsuccessful lacrimal duct ary to insertion of orbital floor implants or orbital surgery, and may also be useful in epiphora despite decompression, and very rarely a complication of a patent nasolacrimal system. Delayed (>30min) or blepharoplasty.249 emptying of the sac is interpreted as a functional block.249,252 Scintillation scanning or dacryo- scintigraphy may be used to evaluate functional Diagnosis blocks and epiphora in children.253 The canalicular test involves injection of saline into the lower canaliculus through a lacrimal can- nula. If the saline comes out the upper canaliculus, Indications for Treatment the test is considered positive; ie, the ducts are Most authors agree that epiphora due to lacrimal patent at least as far as their union with each other hypersecretion is never an indication for surgery or with the lacrimal sac.250 on the lacrimal excretory system. Resection of the The Schirmer I test is a measure of both reflex lacrimal gland or severance of its ducts or efferent and basic secretors. A wet patch <10mm at 5min nerve supply to decrease secretion is also con- indicates hyposecretion of tears; >10mm indicates demned because of the risk of keratitis sicca.15 hypersecretion, pseudepiphora, or normal secre- Opinions diverge regarding the indications for tion. Patients who have excessive tearing yet their repair of monocanalicular lacerations in the man- Schirmer I shows <10mm are thought to have agement of epiphora. Subjective symptoms and pseudepiphora. When >10mm of wetting is seen, objective signs of impaired tear drainage may be the basic secretors are further evaluated by repeat seen with obstruction of either the superior or infe- Schirmer I with several drops of local anesthetic.251 rior canaliculus alone. Many authors, however, The primary dye test checks for intranasal stain- contend that the superior canaliculus is of little or ing from the eye. One drop of fluorescein is applied no importance in tear drainage, and repair of an

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injury to the upper canaliculus is at best superflu- canthal tendon. “If the laceration is close to the ous.254 At the root of the controversy is the fre- punctum, the medial canaliculus will be near the lid quent absence of symptoms following traumatic loss margin...For lacerations close to the lacrimal sac, of a single canaliculus. Ortiz and Kraushar255 ana- the surgeon must look deeper.”254 Corin et al260 lyzed their cases of unrepaired or failed inferior reported an atraumatic technique for identifying canalicular repair for development or recurrence the medial cut end of a lacerated canaliculus that is of epiphora, and found that while 75% of patients essentially a modification of the Seldinger method did not experience symptoms, 25% did. Because for placing catheters in vascular surgery. Injection there is no way to predict which patients will be of air,261 water,262 or sodium hyaluronate263,264 into symptomatic, Linberg256 recommends repair of all the ipsilateral intact canaliculus has been suggested 257 canalicular lacerations. Quickert and Dryden also to try to identify the medial cut end of the injured support this stance, stating that injury to a single canaliculus, but is often unnecessary. In Reifler’s254 canaliculus is worth repairing even when the other experience, “the use of loupe magnification or an 254 canaliculus is normal. As Reifler reminds us, “suc- operating microscope (as well as good retraction of cess is much more likely in primary repairs as tissues) usually obviates the need for the injection opposed to secondary repairs.” of any of these substances.” Reifler254 discusses the indications for repair of If these methods fail, then gentle, careful inser- canalicular injuries and the surgical methods that tion of a blunt-tipped pigtail probe through the fel- 258 should be employed. Holt and Holt and Della low intact canaliculus may be attempted.265–267 In 259 Rocca and coworkers review nasolacrimal disor- general, however, the uninvolved canaliculus should ders, their evaluation and treatment. The etiology not be manipulated unless absolutely necessary. of the problem with the lacrimal ductal system— Regardless of the surgical technique used, the whether congenital, infectious, or traumatic— undamaged portions of the lacrimal drainage sys- determines the type of reconstruction indicated in tem must be preserved. each case. Quickert and Dryden257 insert a 10mm flexible Veirs rod with a swaged 4-0 silk suture into the Punctal Repositioning punctum and across the area of the laceration into the medial stump of the canaliculus. The wound is If symptomatic epiphora is associated with ectro- closed over the rod and the suture protruding from pion, correction of the ectropion alone may solve the punctum is taped or tied to the side of the nose. the epiphora by moving the lower punctum into After an appropriate interval of stenting, the rod is proper position. The various techniques for ectro- easily removed by pulling on the silk. pion correction are discussed above. Another method of repair involves intubation of the lacrimal drainage system with small silicone can- Repair of Canalicular Lacerations nulas. Silicone tubing offers many advantages and Reifler254 reviews the surgical anatomy, epide- is the stent material of choice. Silicone stents can miology, clinical presentation, and management of be left in place for up to 6mo if needed. canalicular injuries. All methods of repair are equally A simple monocanalicular technique consists of successful within the first 48h. In fact, surgical re- passing the stent through a single canaliculus, pair is usually successful if performed within 5d of threading the tube into the lacrimal sac (Fig 43) or injury254 except when the laceration is from an ani- down the nasolacrimal duct and out the nasal os- mal bite, in which case immediate treatment is tium.244 The problem with this type of cannulation recommended. The functional results of late canali- is one of instability of the stent, which depends on a cular repairs tend to be disappointing, although precise fit within the punctum or fixation to the somewhat improved of late as a consequence of skin with tape or suture. using silicone tubing and microsurgical techniques. An alternative technique consists of passing the The medial end of a lacerated canaliculus may silicone tubing through both ends of the injured be difficult to identify as it lies beneath Horner’s canaliculus and into the lacrimal sac. A slit is made muscle and the posterior reflection of the medial in the lacrimal sac and overlying skin through which

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the lacerated canaliculus254 (Fig 45). The probe is removed and replaced by flexible silicone tubing over the nylon suture material, which is then tied to itself in loop fashion. This approach is very secure and does not require a separate skin incision over the lacrimal sac, but does involve manipulation with a semirigid probe.

Fig 43. Simple monocanalicular silicone stent used in canali- cular repair. (Reprinted with permission from Garber PF: Man- agement of injuries to the lacrimal system. In: Bosniak SL (ed), Advances in Ophthalmic Plastic and Reconstructive Surgery: The Lacrimal System. New York, Pergamon Press, 1984. Vol 3.) the stent is brought out to the surface and tied to itself254 (Fig 44).

Fig 44. Annular monocanalicular silicone stent used in canali- cular repair. (Reprinted with permission from Fox SA: Oph- thalmic Plastic Surgery, 5th ed. New York, Grune & Stratton, 1976.) Fig 45. Bicanalicular annular silicone stent for canalicular repair. (Reprinted with permission from Jordan DR, Nerad JA, Tse DT: The pigtail probe, revisited. Ophthalmology 97:512, 1990.) A bicanalicular annular stent technique passes an eyed pigtail probe containing nylon suture into the punctum of the intact lid. From here the probe is At this time the simplest method consists of com- passed through the uninvolved canaliculus, com- mercially available prepackaged lacrimal intubation mon canaliculus, cut medial end of the injured sets for bicanalicular stenting.257 Quickert and canaliculus, across the gap, and out the punctum of Dryden257 recommend this approach when both

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canaliculi are lacerated or avulsed from the tear operation of Ohm that involves maturation of ante- sac. Probes carrying the tubes are passed through rior and posterior flaps of tear sac to corresponding the canaliculi, down the nasolacrimal ducts, and anterior and posterior flaps of nasal mucosa. While either secured at the nasal ostia or extruded from anatomically sound, the procedure is technically the anterior nares. very difficult and may be unnecessary. Iliff272 pre- Pashby and Rathbun268 analyzed their results in fers a simpler version of dacryocystorhinostomy con- 158 patients who had canalicular repair by silicone sisting of a single anterior lacrimal flap over a #14 intubation. The authors believe intubation is indi- French catheter brought out through the nose. His cated in congenital nasolacrimal duct obstruction, success rate in 87 cases was 90%. fresh canalicular lacerations, primary canalicular dis- Casper273 proposed dacryocystorhinostomy with- ease, complicated dacryocystorhinostomies, and out flaps, and subsequently Burns and Cahill274 canalicular rhinostomies. reported excellent results with the procedure. Anderson and Edwards267 stress the importance Becker275 used a modified Casper technique (with- of accurate layered closure of the eyelid itself, which out flaps) in 50 consecutive cases and cites a suc- they believe to be functionally even more impor- cess rate of 90%. tant than meticulous canalicular repair under McLachlan and colleagues276 discuss the various microscopic control. techniques of dacryocystorhinostomy and analyze the published results with the Iliff procedure. The average failure rate is 9.4%; the authors’ own fail- Management of Canalicular Obstructions ures (18/291 patients or 6.2%) were found to have Established strictures of the canaliculi may require reobstructed at the time of the second operation. excision and reanastomosis, intramarginal splitting In 14 of these patients the obstructive lesion was at with approximation to the adjacent conjunctiva, or or proximal to the common canaliculus, and excision and reanastomosis to the tear sac.269,270 approximately half of the reobstructions were in McCord270 advocates resection of the lower lid and patients with a history of trauma as the primary reconstruction of the duct by externalizing the cause, compared with a 29% traumatic etiology residual lower canaliculus in an ostomy-type proce- overall. Omitting the posterior flap did not appear dure. This is possible even when the residual canali- to affect patient outcome. This high rate of culus is only one fourth the normal canalicular length. reobstruction may be a reflection of a general dis- Should externalization fail, three alternatives regard for the canalicular system, with overly remain for canalicular reconstruction: con- aggressive manipulation and resultant iatrogenic junctivodacryocystostomy, conjunctivodacryo- trauma. cystorhinostomy, and conjunctivorhinostomy.271 Welham and Wulc277 reviewed 208 cases of Although a conjunctivodacryocystostomy would failed dacryocystorhinostomy treated between 1970 seem appropriate when the pathology is limited to and 1985, and concluded that most patients had the canalicular system, Jones271 believes that mov- reobstruction in the common canaliculus. A prob- ing the fundus of the tear sac anteriorly and able cause of failure in 111 patients was thought to approximating it to the conjunctiva disrupts the lac- be inappropriate size or location of the rhinostomy. rimal pump mechanism and often ends in failure. There was no difference between one- and two- Conjunctivodacryocystorhinostomy with intuba- flap operations in terms of outcome, but techniques tion is thought to be a better solution.250 Pyrex without flaps did cause more scarring that made tubes exert capillary traction on tears and keep the secondary surgery more difficult. Reoperation was ducts patent. Although Jones tubes work by capil- successful in 89%. Of the 22 patients who failed lary action, they should be placed vertically to the second operation, 15 consented to a third facilitate tear drainage through gravity. A operation and 13 of these were cured of their epi- conjunctivorhinostomy is indicated when the tear phora. Apparently repeat dacryocystorhinostomy sac is absent or has been obliterated. in skilled hands deserves consideration. For obstructions of the nasolacrimal duct, dacryo- Nik and colleagues278 studied the lacrimal system cystorhinostomy is the procedure of choice. by scintigraphy after dacryocystorhinostomy and Jones250,271 advocates the traditional two-flap after insertion of a Jones tube. Dacryocystorhinos-

42 SRPS Volume 10, Number 8 tomy gave the fastest excretory times, faster even upper sac obstructions that were not amenable to than the unoperated controls. The authors found treatment by instrumentation. Indications for sur- that a lax eyelid caused lateral pooling of the lacri- gery included chronic mucopurulent discharge, mal secretions, and conversely that if the lax eyelid recurrent , and epiphora. The causes was repaired at the time of surgery, the excretory of the lacrimal disorder included developmental time was decreased. The clinical implication of this anomaly (61%), infection (24%), and trauma (12%). is that all patients with lax eyelids should have lid Probing was curative in 95% of congenital nasolacri- tightening at the time of lacrimal surgery to improve mal duct obstructions, but diminished in effective- tear flow. ness with increasing patient age and number of probings, and was rarely successful after the third time or after age 3. Conjunctival dacryocystorhinos- Canalicular Surgery in Children tomy was required in most patients with agenesis of Welham and Hughes279 found a 90% (144/160) both puncta, in which case surgery was delayed until functional success rate of lacrimal duct surgery in the child was 10 years of age and better able to children, which is similar to the adult rate, and the manage the tubes postoperatively. The prognosis for causes of failure were basically the same too. Most intubation was poor in patients with previous dacryo- failures were seen in patients with middle duct or cystitis or obstruction noted during intubation.

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1. Jones LT: An anatomical approach to problems of the 14. Mustarde JC: New horizons in eyelid reconstruction. Int eyelids and lacrimal apparatus. Arch Ophthalmol 66:111, Ophthalmol Clin 29(4):237, 1989. 1961. 15. Putterman AM: Cosmetic Oculoplastic Surgery, 2nd ed. 2. Zide BM, Jelks GW: Surgical Anatomy of the Orbit. New Philadelphia, WB Saunders, 1993. York, Raven Press, 1985. 16. Hawes MJ and Dortzbach RK: The microscopic anatomy 3. Tucker SM, Linberg JV: Vascular anatomy of the eyelids. of the lower eyelid retractors. Arch Ophthalmol 100:1313, Ophthalmology 101:1118, 1994. 1982. 4. Wesley RE, McCord CD Jr, Jones NA: Height of the tarsus 17. Jones LT: Lacrimal surgery. IN: Symposium on Surgery of the lower eyelid. Am J Ophthalmol 90:102, 1980. of the Orbit and Adnexa. St Louis, CV Mosby, 1974. 5. Ouattara D, Vacher C, Accioli de Vasconcellos JJ, et al: 18. Whitaker LA, Katowitz JA: Facial anomalies involving the Anatomical study of the variations in innervation of the nasolacrimal apparatus. IN: Tessier P, Callahan A, Mustardé orbicularis oculi by the facial nerve. Surg Radiol Anat JC, Salyer KE (eds), Symposium on Plastic Surgery in the 26:51, 2004. Orbital Region. St Louis, Mosby, 1976. Vol 12, Ch 17, p 6. Mendelson BC, Muzaffar AR, Adams WP Jr: Surgical 159. anatomy of the midcheek and malar mounds. Plast 19. Smith B: Eyelid surgery. Surg Clin North Am 39:367, 1959. Reconstr Surg 110:885, 2002. 20. Ross JJ, Pham R: Closure of eyelid defects. J Dermatol Surg 7. Hwang K, Cho HJ, Chung IH: Pattern of the temporal Oncol 18:1061, 1992. branch of the facial nerve in the upper orbicularis oculi 21. Leatherbarrow B: Oculoplastic Surgery. London, Martin muscle. J Craniofac Surg 15:373, 2004. Dunitz, 2002. 8. Wilhelmi BJ, Mowlavi A, Neumeister MW, Blackwell SJ: 22. Holds JB, Anderson RL: Medial canthotomy and Facial fracture approaches with landmark ratios to predict the location of the infraorbital and supraorbital nerves: an cantholysis in eyelid reconstruction. Am J Ophthalmol anatomical study. J Craniofac Surg 14:473, 2003. 116:218, 1993. 9. Iliff CE, Iliff WJ, Iliff NT: Oculoplastic Surgery. Philadel- 23. Mustarde JC: Repair and Reconstruction in the Orbital phia, WB Saunders, 1979. Region. Edinburgh, Churchill-Livingstone, 1966. 10. Muzaffar AR, Mendelson BC, Adams WP Jr: Surgical 24. Lubkin V: Lateral and medial fornix conformers. A new anatomy of the ligamentous attachments of the lower lid aid in the plastic repair of the conjunctival fornices. Arch and lateral canthus. Plast Reconstr Surg 110:873, 2002. Ophthalmol 79:582, 1968. 11. Carraway JH: Surgical anatomy of the eyelids. Clin Plast 25. Lipshutz H: Experiences with upper lateral nasal cartilage Surg 14:693, 1987. in reconstruction of the lower eyelid. Am J Ophthalmol 12. Zide BM, McCarthy JG: The medial canthus revisited. An 73:592, 1972. anatomical basis for canthopexy. Ann Plast Surg 11:1, 1983. 26. Paufique L, Tessier P: Reonstruction totale de la paupiere 13. Whitnall SE: The Anatomy of the Human Orbit and superieure. IN: Troutman RC, Converse JM, and Smith B Accessory Organs of Vision, 2 nd ed. London, Oxford Univ (eds), Plastic and Reconstructive Surgery of the Eye and Press, 1932. Adnexa. London, Butterworths, 1962.

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27. Putterman AM: Viable composite grafting in eyelid recon- 50. Van der Meulen JC: The use of mucosa-lined flaps in struction. Am J Ophthalmol 85:237, 1978. eyelid reconstruction: A new approach. Plast Reconstr 28. Fox SA: Autogenous free full-thickness eyelid grafts. Am J Surg 70:139, 1982. Ophthalmol 67:941, 1969. 51. Moschella F, Cordova A: Upper eyelid reconstruction 29. Callahan A: Free composite lid graft. Arch Ophthalmol with mucosa-lined bipedicled myocutaneous flaps. Br J 45:539, 1954. Plast Surg 48:294, 1995. 30. Werner MS, Olson JJ, Putterman AM: Composite grafting 52. Esser JFS: Transplanting a vertically placed pedicled for eyelid reconstruction. Am J Ophthalmol 116:11, wedge from the upper to the lower lid or vice versa. Klin 1993. Montasbl Augenh 63:379, 1919. 31. Hawes MJ, Jamell GA: Complications of tarsoconjunctival 53. McCoy FJ, Crow ML: Adaptation of the “switch flap” to grafts. Ophthalmic Plast Reconstr Surg 12:45, 1996. eyelid reconstruction. 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Kersten RC et al: Tarsal rotational flap for upper eyelid human dermis (AlloDerm) for lower eyelid reconstruc- reconstruction. Arch Ophthalmol 104:918, 1986. tion. Arch Facial Plast Surg 7:38, 2005. 59. Kushima H, Yuzuriha S, Kondo S, Osada Y: Reconstruc- 36. Mullner K, Langmann G: Chondroplast: a new material tion of an inner layer defect of the upper eyelid with for eyelid reconstruction. Ophthalmologica 213:189, avulsion of the superior levator palpebrae muscle and 1999. orbital fat. Ann Plast Surg 51:321, 2003. 37. Brent B, Ott R: Perichondro-cutaneous graft. Plast Reconstr 60. Hughes WL: A new method for rebuilding a lower lid. Surg 62:1, 1978. Report of a case. Arch Ophthalmol 17:1008, 1937. 38. Naugle TC Jr, Levine MR, Carroll GS: Free graft enhance- 61. Jones HW: One-stage composite lower lid repair. Plast ment using orbicularis muscle mobilization. Ophthalmol- Reconstr Surg 37:346, 1966. ogy 102:493, 1995. 62. Matsuo K et al: Lower eyelid reconstruction with a 39. Budenz DL, Beyer-Machule CK, Albert DM: Histology of conchal cartilage graft. Plast Reconstr Surg 80:547, 1987. partial thickness double composite eyelid grafts. Oph- 63. Jackson IT, Dubin B, and Harris J: Use of contoured and thalmic Surg 20:362, 1989. stabilized conchal cartilage grafts for lower eyelid support: 40. Marks MW et al: Conchal cartilage and composite grafts A preliminary report. Plast Reconstr Surg 83:636, 1989. for correction of lower lid retraction. Plast Reconstr Surg 64. Hurwitz JJ, Corin SM, and Tucker SM: The use of free 83:629, 1989. periosteal grafts in extensive lower lid reconstruction. 41. Avram DR, Hurwitz JJ, Kratky V: Dog and human bites of Ophthalmic Surg 20:415, 1989. the eyelid repaired with retrieved autogenous tissue. Can 65. Leone CR Jr: Periosteal flap for lower eyelid reconstruc- J Ophthalmol 26:334, 1991. tion. Am J Ophthalmol 114:513, 1992. 42. Goldberg SH, Bullock JD, Connelly PJ: Eyelid avulsion: A 66. Moss AL et al: The sanctity of the upper lid in lower eyelid clinical and experimental study. Ophthalmic Plast Reconstr reconstruction questioned. A modification of a lid sharing Surg 8:256, 1992. procedure with a long-term follow-up. Br J Plast Surg 43. Sakai S: Marginal eyelid reconstruction with a composite 40:246, 1987. skin-muscle-mucosa graft from the lower lid. Ann Plast 67. Imre J Jr: Lidplastik und plastische Operationen anderer Surg 30:445, 1993. Weichteile des Gesichts. Studium Kiadasa (Budapest), 44. Cutler NL, Beard C: A method for partial and total upper 1928. lid reconstruction. Am J Ophthalmol 39:1, 1955. 68. Mustarde JC: Major reconstruction of the eyelids: Func- 45. Cole JG: Reconstruction of large defecs of the upper tional and aesthetic considerations. Clin Plast Surg 8:227, eyelid. Am J Ophthalmol 64:376, 1967. 1981. 46. Leone CR Jr: Tarsal-conjunctival advancement flaps for 69. Callahan MA, Callahan A: Mustarde flap lower lid recon- upper eyelid reconstruction. Arch Ophthalmol 101:945, struction after malignancy. Ophthalmology 87:279, 1980. 1983. 70. McGregor IA: Eyelid reconstruction following subtotal 47. Mauriello JA Jr, Antonacci R: Single tarsoconjunctival flap resection of upper or lower lid. Br J Plast Surg 26:346, (lower eyelid) for upper eyelid reconstruction (“reverse” 1973. modified Hughes procedure). Ophthalmic Surg 25:374, 71. Khan JA, Garden VS: Combined flap repair of moderate 1994. lower eyelid defects. Ophthalmic Plast Reconstr Surg 48. Jordan DR, Anderson RL, Nowinski TS: Tarsoconjunctival 18:202, 2002. flap for upper eyelid reconstruction. Arch Ophthalmol 72. Tenzel RR: Reconstruction of the central one half of an 107:599,1989. eyelid. Arch Ophthalmol 93:125, 1975. 49. Tripier L: Musculo-cutaneous flap in the form of a bridge, 73. Tenzel RR, Stewart WB: Eyelid reconstruction by the applied to the reconstruction of the eyelids. Compt rend semicircle flap technique. 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74. McCord CD, Nunery W: Reconstructive procedures of 97. Anderson RL, Jordan DR, Beard C: Full-thickness the lower eyelid and outer canthus. In: McCord CD (ed), unipedicled flap for lower eyelid reconstruction. Arch Oculoplastic Surgery. New York, Raven Press, 1982, pp Ophthalmol 106:122, 1988. 189-209. 98. Wolfe SA: Eyelid reconstruction. Clin Plast Surg 5:525, 1978. 75. Levine MR, Buckman G: Semicircular flap revisited. Arch 99. Levin ML, Leone CR Jr: Bipedicle myocutaneous flap Ophthalmol 104:915, 1986. repair of cicatricial ectropion. Ophthalmic Plast Reconstr 76. Jordan DR, Anderson RL, Holds JB: Modifications to the Surg 6:119, 1990. semicircular flap technique in eyelid reconstruction. Can 100. Byrd HS: Personal communication, 1988. J Ophthalmol 27:130, 1992. 101. Manchester WM: A simple methor the repair of full- 77. Smith B, English FP: Techniques available in reconstruc- thickness defects of the lower lid with special reference to tive surgery of the eyelid. Br J Ophthalmol 54:450, 1970. the treatment of neoplasms. Br J Plast Surg 3:252, 1951. 78. Landolt E: Reconstruction of eyelid. Arch Ophthalmol 102. Leone CR, van Gemert JV: Lower eyelid reconstruction (Paris) 1:111, 1881. with upper eyelid transpositional grafts. Ophthalmic Surg 79. Kollner H: Reconstruction of eyelid. Munchen med 11:315, 1980. Wchnschr 58:2166, 1911. 103. Jackson IT: Reconstruction of the lower eyelid defect in 80. Dupuy-Dutemps L: Repair of entirely destroyed eyelid by Treacher Collins syndrome. Plast Reconstr Surg 67:365, cutaneous and tarso-conjunctival graft taken from other 1981. eyelid. Bull Med (Paris) 43:935, 1929. 104. Duman H, Sengezer M, Selmanpakoglu AN, Eski M: 81. Hughes WL: Total lower lid reconstruction: Technical Supratrochlear artery flap for the repair of lower eyelid details. Trans Am Ophthalmol Soc 74:321, 1976. defects. Ann Plast Surg 44:324, 2000. 82. McCord CD Jr, Nunery WR: Reconstruction of the lower 105. Holt JE, Holt GR, Van Kirk M: Use of temporalis fascia in eyelid and outer canthus. IN: McCord CD Jr, Tanenbaum eyelid reconstruction. Arch Otolaryngol 111:165, 1985. M (eds), Oculoplastic Surgery, 2nd ed. New York, Raven 106. Carstens MH et al: Clinical applications of the subgaleal Press, 1987. fascia. Plast Reconstr Surg 87:615, 1991. 83. Kohn R: Textbook of Ophthalmic Plastic and Recon- 107. Ellis DS, Toth BA, Stewart WB: Temporoparietal fascial structive Surgery. Philadelphia, Lea & Febiger, 1988. flap for orbital and eyelid reconstruction. Plast Reconstr 84. Maloof A, Ng S, Leatherbarrow B: The maximal Hughes Surg 89:606, 1992. procedure. Ophthalmic Plast Reconstr Surg 17:96, 2001. 108. Leone CR Jr, Van Gemert JV: Lower lid reconstruction 85. Rohrich RJ, Zbar RIS: The evolution of the Hughes using tarsoconjunctival grafts and bipedicle skin-muscle tarsoconjunctival flap for lower eyelid reconstruction. flap. Arch Ophthalmol 107:758, 1989. Plast Reconstr Surg 104:518, 1999. 109. Doermann A et al: V-Y advancement flaps for tumor 86. Pollock WJ, Colon GA, Ryan RF: Reconstruction of the excision defects of the eyelids. Ann Plast Surg 22:429, 1989. lower eyelid by a different lid-splitting operation. Plast 110. Kalus R, Zamora S: Aesthetic considerations in facial Reconstr Surg 50:184, 1972. reconstructive surgery: the V-Y flap revisited. Aesthetic 87. Macomber WB, Wang MKH, Gottlieb E: Epithelial tumors Plast Surg 20:83, 1996. of eyelids. Surg Gynecol Obstet 98:331, 1954. 111. Ito O, Suzuki S, Park S, et al: Eyelid reconstruction using 88. Leibsohn JM, Dryden R, Ross J: Intentional buttonholing a hard palate mucoperiosteal graft combined with a V–Y of the Hughes’ flap. Ophthalmic Plast Reconstr Surg 9:135, subcutaneously pedicled flap. Br J Plast Surg 54:106, 1993. 2001. 89. McNab AA: Early division of the conjunctival pedicle in 112. Van der Meulen JC: Re “Eyelid reconstruction using a hard modified Hughes repair of the lower eyelid. 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119. Porfiris E, Georgiou P, Harkiolakis G, et al: Island 141. Anderson RG: Facial nerve disorders. Selected Read Plast mucochondrocutaneous flap for reconstruction of total Surg 9(20), 2001. loss of the lower eyelid. Plast Reconstr Surg 100:104, 142. Jelks GW, Ransohoff J: Early correction of orbicularis oculi 1997. paralysis with an encircling silicone prosthesis. Neurosur- 120. Thai KN, Billmire DA, Yakuboff KP: Total eyelid recon- gery 12:318, 1983. struction with free dorsalis pedis flap after deep facial burn. 143. May M: Gold weight and wire spring implants as alterna- Plast Reconstr Surg 104:1048, 1999. tives to tarsorrhaphy. Arch Otolaryngol 113:656, 1971. 121. Antonyshyn O et al: Tissue expansion in head and neck 144. Sobol SM, Alward PD: Early gold weight lid implant for reconstruction. Plast Reconstr Surg 82:58, 1988. rehabilitation of faulty eyelid closure with facial paraly- 122. Tse DT, McCafferty LR: Controlled tissue expansion in sis: an alternative to tarsorrhaphy. Head Neck 12:149, periocular reconstructive surgery. Ophthalmology 1990. 100:260, 1993. 145. Neuman AR et al: The correction of seventh nerve palsy 123. Wieslander JB, Wieslander M: Prefabricated (expander) lagophthalmos with gold lid load (16 years experience). capsule-lined transposition and advancement flaps in Ann Plast Surg 22:142, 1989. reconstruction of lower eyelid and oral defects: an 146. Hallock GG: Temporary tarsorrhaphy “zipper”. Ann Plast experimental study. Plast Reconstr Surg 105:1399, 2000. Surg 28:488, 1992. 124. McLeish WM, Anderson RL: Cosmetic eyelid surgery and 147. Tanenbaum M et al: The tarsal pillar technique for the problem eyelid. Clin Plast Surg 19(2):357, 1992. narrowing and maintenance of the interpalpebral fissure. 125. Wulc AE: Oculoplastic surgery. An overview. J Dermatol Ophthalmic Surg 23:418, 1992. Surg Oncol 18:1033, 1992. 148. Flowers RS, Caputy CG: The “diamond head” graft for 126. Tenzel RR: Complications of blepharoplasty. 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Philadelphia, Saunders, 1990. Vol 2, Ch 34, pp 153. Siegel RJ: Involutional entropion: a simple and stable 1671-1784. repair. Plast Reconstr Surg 82:42, 1988. 130. O’Donnell B: Age-related medial ectropion of the lower 154. Charonis GC, Gossman MD: Involutional entropion eyelid. Aust N Z J Ophthalmol 22:183, 1994. repair by posterior lamella tightening and myectomy. 131. Sullivan TJ, Collin JRO: Medial canthal resection: an Ophthalmic Plast Reconstr Surg 12:98, 1996. effective long-term cure for medial ectropion. Br J 155. Dalgleish R, Smith JLS: Mechanics and histology of senile Ophthalmol 75:288, 1991. entropion. Br J Ophthalmol 50:79, 1966. 132. Fox SA: A modified Kuhnt-Szymanowski procedure for 156. Jelks JW, Jelks EB: The influence of orbital and eyelid ectropion and lateral canthoplasty. Am J Ophthalmol anatomy on the palpebral aperture. Clin Plast Surg 62:533, 1966. 18(1):31, 1991. 133. Tse DT, Kronish JW, Buus D: Surgical correction of lower- 157. Kersten RC, Kleiner FP, Kulwin DR: Tarsotomy for the eyelid tarsal ectropion by reinsertion of the retractors. Arch treatment of cicatricial entropion with trichiasis. Arch Ophthalmol 109:427, 1991. Ophthalmol 110:714, 1992. 134. Jelks GW, Glat PM, Jelks EB, Longaker MT: The inferior 158. Ito O, Kashiwa N, Igawa HH, et al: Surgery without skin retinacular lateral canthoplasty: a new technique. Plast resection for eyelid entropion. Ann Plast Surg 53:56, Reconstr Surg 100:1262, 1997. 2004. 135. Jordan DR, Anderson RL: The tarsal tuck procedure: 159. Millman AL, Katzen LB, Putterman AM: Cicatricial entro- avoiding eyelid retraction after lower blepharoplasty. pion: An analysis of its treatment with transverse Plast Reconstr Surg 85:22, 1990. blepharotomy and marginal rotation. Ophthalmic Surg 136. Anderson RL, Gordy DD: The tarsal strip procedure. Arch 20:575, 1989. Ophthalmol 97:2192, 1979. 160. Jones LT, Reeh MJ, Tsusimura JK: Senile entropion. Am 137. 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165. Harrington JN: Reconstruction of the medial canthus by 187. Putterman AM: Surgical treatment of thyroid-related spontaneous granulation (laissez-faire): A review. Ann upper eyelid retraction. Graded Muller’s muscle exci- Ophthalmol 14:956, 1982. sion and levator recession. Ophthalmology 88:507, 166. Yildirim S, Aköz T, Akan M, Çakir B: The use of combined 1981. nasolabial V–Y advancement and glabellar flaps for large 188. Mourits MP, Koornneef L: Lid lengthening by sclera medial canthal defects. Dermatol Surg 27:215, 2001. interposition for eyelid retraction in Graves’ ophthalm- 167. Jelks GW, Glat PM, Jelks EB, Longaker MT: Medial canthal opathy. Br J Ophthalmol 75:344, 1991. reconstruction using a medially based upper eyelid 189. Leatherbarrow B et al: Three-wall orbital decompression myocutaneous flap. Plast Reconstr Surg 110:1636, 2002. of Graves’ ophthalmopathy via coronal approach. Eye 168. Chiarelli A, Forcignanò R, Boatto D, et al: Reconstruction 5:456, 1991. of the inner canthus region with a forehead muscle flap: 190. Thaller SR, Kawamoto HK: Surgical correction of exoph- a report on three cases. Br J Plast Surg 54:248, 2001. thalmos secondary to Graves’ disease. Plast Reconstr Surg 169. Rodriguez RL, Zide BM: Reconstruction of the medial 86:411, 1990. canthus. Clin Plast Surg 15:255, 1988. 191. Shore JW, Carvajal J, Westfall CT: Miniplate reconstruc- 170. Freihofer HPM: Experience with transnasal canthopexy. tion of the lateral orbital rim after orbital decompression J Maxillofac Surg 8:119, 1980. for Graves disease. Ophthalmology 99:1433, 1992. 171. Leibsohn JM, Hahn F: Medial canthal tendon reconstruc- 192. McCord CD Jr: The evaluation and management of the tion with nasal periosteum. Ophthalmic Plast Reconstr Surg patient with ptosis. Clin Plast Surg 15:169, 1988. 8:35, 1992. 193. Berke RN, Wadsworth JAC: Histology of the levator muscle 172. Howard GR, Nerad JA, Kersten RC: Medial canthoplasty in congenital and acquired ptosis. Arch Ophthalmol with microplate fixation. Arch Ophthalmol 110:1793, 53:413, 1955. 1992. 194. Saunders RA, Grice CM: Early correction of severe 173. Jordan DR, Anderson RL, Thiese SM: The medial tarsal congenital ptosis. J Pediatr Ophthalmol Strabismus 28:271, strip. Arch Ophthalmol 108:120, 1990. 1991. 174. Fuente del Campo A: Surgical treatment of the epicanthal 195. Beard C: Ptosis, 2nd Ed. St Louis, Mosby, 1976, Chs 7, 8, fold. Plast Reconstr Surg 73:566, 1984. 10. 175. Flowers R: Discussion of “Surgical treatment of the 196. Epstein GA, Putterman AM: Super-maximum levator epicanthal fold” by A Fuente del Campo. Plast Reconstr resection for severe congenital blepharoptosis. Oph- Surg 73:571, 1984. thalmic Surg 15:971, 1984. 176. Hurwitz JJ, Archer KF, Gruss JS: Treatment of severe lower 197. Mauriello JA et al: Treatment of congenital ptosis by eyelid retraction with scleral and free skin grafts and maximum levator resection. Ophthalmology 93:466, bipedicle orbicularis flap. Ophthalmic Surg 21:167, 1986. 1990. 198. Crawford JS: Congenital ptosis: examination and treat- 177. Baylis HI, Nelson ER, Goldberg RA: Lower eyelid retrac- ment. Trans New Orleans Acad Pediatr Ophthalmol tion following blepharoplasty. Ophthalmic Plast Reconstr Strabismus 34:173, 1986. Surg 8:170, 1992. 199. Nakajima T et al: One-stage repair of blepharophimosis. 178. Austin MW, Atta HR: Surgical management of Graves’ Plast Reconstr Surg 87:24, 1991. ophthalmopathy. Br J Hosp Med 48:644, 1992. 200. Krastinova D, Jasinski MA: Orbitoblepharophimosis syn- 179. Putterman AM, Urist M: Surgical treatment of upper eyelid drome: a 16-year perspective. Plast Reconstr Surg 111:987, retraction. Arch Ophthalmol 87:401, 1972. 2003. 180. Feldman KA, Putterman AM, Farber MD: Surgical treat- 201. Nowinski TS: Correction of telecanthus in the ment of thyroid-related lower eyelid retraction: A modi- blepharophimosis syndrome. Int Ophthalmol 32:157, fied approach. Ophthalmic Plast Reconstr Surg 8:278, 1992. 1992. 202. Anderson RL, Nowinski TS: The five-flap technique for 181. Chalfin J, Putterman AM: Muller’s muscle excision and blepharophimosis. Arch Ophthalmol 107:448, 1989. levator recession in retracted upper lid. Treatment of 203. Beard C: Advancements in ptosis surgery. Clin Plast Surg thyroid-related retraction. Arch Ophthalmol 97:1487, 5:537, 1978. 1979. 204. Martin JJ, Tenzel RR: Acquired ptosis: dehiscences and 182. Hedin A: Eyelid surgery in dysthyroid ophthalmopathy. disinsertions. Are they real or iatrogenic? Ophthalmic Plast Eye 2:201, 1988. Reconstr Surg 8:129, 1992. 183. Dixon RS, Anderson RL, Hatt MU: The use of thymoxamine 205. Collin JRO: Involutional ptosis. Aust NZ J Ophthalmol in eyelid retraction. Arch Ophthalmol 97:2147, 1979. 14:109, 1986. 184. Harvey JT, Anderson RL: The aponeurotic approach to 206. Carroll RP: Cautery dissection in levator surgery. Oph- eyelid retraction. Ophthalmology 88:513, 1981. thalmic Plast Reconstr Surg 4:243, 1988. 185. Garrity JA, Fatourechi V, Bergstralh EJ, et al: Results of 207. Souther SG, Corboy JM, Thompson JB: The Fasanella- transantral orbital decompression in 428 patients with Servat operation for ptosis of the upper eyelid. Plast severe Graves’ ophthalmopathy. Am J Ophthalmol Reconstr Surg 53:123, 1974. 116:533, 1993. 208. Beard C, Sullivan JH: Ptosis. Current concepts. Int 186. Ceisler EJ, Bilyk JR, Rubin PAD, et al: Results of Mullerotomy Ophthalmol Clin 18:53, 1978. and levator aponeurosis transposition for the correction 209. Frueh BR, Musch DC: Evaluation of levator muscle of upper eyelid retraction in Graves disease. Ophthalmol- integrity in ptosis with levator force measurement. Oph- ogy 102:483, 1995. thalmology 103:244, 1996.

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210. Deady JP, Morrell AJ, Sutton GA: Recognizing apo- 234. Crawford JS: Repair of ptosis using frontalis muscle and neurotic ptosis. J Neurol Neurosurg Psychiatry 52:996, fascia lata. Trans Am Acad Ophthalmol Otolaryngol 60:672, 1989. 1956. 211. Jones LT: Anatomy of the upper eyelid and its relation to 235. Smith B, Bosniak SL: Frontalis sling complications. Oph- ptosis surgery. Am J Ophthalmol 57:943, 1964. thalmic Surg 11:614, 1980. 212. Wobig JL: Surgical technique for ptosis repair. Aust NZ J 236. Song R, Song Y: Treatment of blepharoptosis: direct Ophthalmol 17:125, 1989. transplantation of the frontalis muscle of the upper eyelid. 213. Jones LT, Quickert MH, Wobig JL: The cure of ptosis by Clin Plast Surg 9:45, 1982. aponeurotic repair. Arch Ophthalmol 93:629, 1975. 237. Downes RN, Collin JRO: The Mersilene mesh sling: a new 214. Carraway JH, Vincent MP: Levator advancement tech- concept in ptosis surgery. Br J Ophthalmol 73:498, 1989. nique for eyelid ptosis. Plast Reconstr Surg 77:394, 238. Spoor TC, Kwitko GM: Blepharoptosis repair by fascia lata 1986. suspension with direct tarsal and frontalis fixation. Am J 215. Anderson RL, Dixon RS: Aponeurotic ptosis surgery. Arch Ophthalmol 109:314, 1990. Ophthalmol 97:1123, 1979. 239. Wilson ME, Johnson RW: Congenital ptosis: long-term 216. Jordan DR, Anderson RL: The aponeurotic approach to results of treatment using lyophilized fascia lata for frontalis congenital ptosis. Ophthalmic Surg 21:237, 1990. suspensions. Ophthalmology 98:1234, 1991. 217. Older JJ: Levator aponeurosis surgery for the correction of 240. Han K, Kang J: Tripartite frontalis muscle flap transposition acquired ptosis: Analysis 113 procedures. Ophthalmol- for blepharoptosis. Ann Plast Surg 30:224, 1993. ogy 90:1056, 1983. 241. Manners RM, Tyers AG, Morris RJ: The use of Prolene as 218. Doxanas MT: Simplified aponeurotic ptosis surgery. a temporary suspensory material for brow suspension in Ophthalmic Surg 23:512, 1992. young children. Eye 8:346, 1994. 219. Jackson IT: A simple approach to identification of the 242. Pearl RM: Improved technique for fascial sling reconstruc- levator aponeurosis in the correction of eyelid ptosis. Plast tion of severe congenital ptosis. Plast Reconstr Surg 95:920, Reconstr Surg 80:448, 1987. 1995. 220. Liu D: Ptosis repair by single suture aponeurotic tuck. 243. Chen T-H, Yang J-Y, Chen Y-R: Refined frontalis fascial sling Surgical technique and long-term results. Ophthalmology with proper lid crease formation for blepharoptosis. Plast 100:251, 1993. Reconstr Surg 99:34, 1997. 221. Collin JRO, O’Donnell BA: Adjustable sutures in eyelid 244. Holds JB, McLeish WM, Anderson RL: Whitnall’s sling with surgery for ptosis and lid retraction. Br J Ophthalmol superior tarsectomy for the correction of severe unilateral 78:167, 1994. blepharoptosis. Arch Ophthalmol 111:1285, 1993. 222. Putterman AM, Urist MJ : Muller’s muscle-conjunctiva 245. Liu D: Blepharoptosis correction with frontalis suspension resection. Arch Ophthalmol 93:619, 1975. using a Supramid sling: duration of effect. Am J Ophthalmol 223. Gavaris PT: Minimal ptosis surgery. IN: Guibor P (ed), 128:772, 1999. Oculoplastic Surgery and Trauma. New York, Intercon- 246. Jordan DR: Blepharochalasis syndrome: a proposed tinental Medical Book Corp, 1976. pathophysiologic mechanism. Can J Ophthalmol 27:10, 224. Iliff CE: Ptosis surgery. IN: Duane TD (Ed), Clinical 1992. Ophthalmology. Hagerstown (Maryland), Harper and 247. Custer PL, Tenzel RR, Kowalczyk AP: Blepharochalasis Row, 1976, Vol 5, Ch 10. syndrome. Am J Ophthalmol 99:424, 1985. 225. Lauring L: Blepharoptosis correction with sutureless 248. 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258. Holt JE, Holt GR: Reconstruction of the lacrimal drainage 269. Beyer CK: Canalicular injuries. Clin Plast Surg 5:547, system. Arch Otolaryngol 110:211, 1984. 1978. 259. Della Rocca RC, Arthurs B, Silverstone P: Nasolacrimal 270. McCord CD Jr: Canalicular resection and reconstruction disorders and their treatment. Clin Plast Surg 15:195, 1988. by canaliculostomy. Ophthalmic Surg 11:440, 1980. 260. Corin SM et al: Lacrimal catheterization. Ophthalmic Surg 271. Jones LT: The cure of epiphora due to canalicular 20:202, 1989. disorders, trauma, and surgical failures on the lacrimal 261. Morrison FD: An aid to repair of lacerated tear ducts. Arch passages. Trans Am Acad Ophthalmol Otol 66:506, 1962. Ophthalmol 72:341, 1964. 272. Iliff CE: A simplified dacryocystorhinostomy. Arch 262. Campbell CB, Flanagan JC, Schaefer AJ: Acquired lacrimal Ophthalmol 85:586, 1971. disorders. In: Smith BC et al. (eds), Ophthalmic Plastic 273. Casper TC, Sergent RA, Smith B: Dacryocystorhinostomy: and Reconstructive Surgery, Vol 2. St Louis, Mosby, 1987, The Casper operation. Ann Ophthalmol 6:1333, 1974. pp 955-967. 274. Burns JA, Cahill KV: Modified Kinosian dacryocystorhi- 263. Seiff SR, Ahn JC: Locating cut medial canaliculi by direct nostomy: A review of 122 cases. Ophthalmic Surg 16:710, injection of sodium hyaluronate into the lacrimal sac. 1985. Ophthalmic Surg 20:176, 1989. 275. Becker BB: Dacryocystorhinostomy without flaps. Oph- 264. Hurwitz JJ, Nik N: Lacrimal sac identification for dacryo- thalmic Surg 19:419, 1988. cystorhinostomy: The role of sodium hyaluronate. Can 276. McLachlan DL, Shannon GM, Flanagan JC: Results of J Ophthalmol 19:112, 1984. dacryocystorhinostomy: Analysis of the reoperations. 265. Worst JG: Method for reconstructing torn lacrimal canali- Ophthalmic Surg 11:427, 1980. culus. Am J Ophthalmol 53:520, 1962. 277. Welham RAN, Wulc AE: Management of unsuccessful 266. Worst JG: Proceedings: Selected chapters from ophthal- lacrimal surgery. Br J Ophthalmol 71:152, 1987. mological surgery. Ophthalmologica 167:393, 1973. 278. Nik NA, Hurwitz JJ, Gruss JS: Management of lacrimal 267. Anderson RL, Edwards JJ: Indications, complications and injury after naso-orbito-ethmoid fractures. Adv results with silicone stents. Ophthalmology 86:1474, 1979. Ophthalmol Plast Reconstr Surg 3:307, 1984. 268. Pashby RC, Rathbun JE: Silicone tube intubation of the 279. Welham RAN, Hughes SM: Lacrimal surgery in children. lacrimal drainage system. Arch Ophthalmol 97:1318, 1979. Am J Ophthalmol 99:27, 1985.

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