vol 11 r2 eyelid

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Volume 11 Issue R2

Reconstructive

EYELID RECONSTRUCTION

Marlene Morales, MD

Rajat Ghaiy, MD

Kamel Itani, MD

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OUR EDUCATIONAL PARTNERSSelected Readings in Plastic Surgery appreciates the generous

support provided by our educational partners.

PLATINUM PARTNERS

SILVER PARTNER

facial aesthetics

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W. P. Adams, Jr, MDS. M. Bidic, MDG. Broughton II, MD, PhDS. Brown, PhD

J. L. Burns, MD

J. J. Cheng, MDA. A. Gosman, MD

K. A. Gutowski, MDR. Y. Ha, MDR. E. Hoxworth, MDK. Itani, MD

J. E. Janis, MDR. K. Khosla, MD

J. E. Leedy, MDJ. A. Lemmon, MD

A. H. Lipschitz, MDJ. H. Liu, MDR. A. Meade, MD

J. K. Potter, MD, DDSS. M. Rozen, MDM. Saint-Cyr, MDM. Schaverien, MRCS

A. P. Trussler, MDR. I. S. Zbar, MD

Senior Manuscript Editor Dori Kelly

Contributing Editors

Editor Emeritus

Editor-in-Chief

Business Managers Lynsi ChesterBecky Sheldon

Corporate Sponsorship Barbara Williams

Reconstruction Topics

Breast Reconstruction

Cleft Lip and Palate

Craniofacial

Eyelid Reconstruction

Facial Fractures

Hand: Congenital

Hand: Extensor Tendons

Hand: Flexor Tendons

Hand: Peripheral NervesHand: Soft Tissue

Hand: Wrist, Joints, Rheumatoid Arthritis

Head and Neck Reconstruction

Lip, Cheek, Scalp, and Hair Restoration

Lower Extremity Reconstruction

Nasal Reconstruction

Surgery of the Ear

Trunk Reconstruction

Vascular Anomalies

Wounds and Wound Healing

Cosmetic Topics

Blepharoplasty

Body Contouring: Excisional Surgery

Body Contouring: Noninvasive, Liposuction, Fat Graft

Breast Augmentation

Breast Reduction and Mastopexy

Brow Lift

Facelift

Injectable Agents and Dermal Fillers

Rhinoplasty

Skin Care

F. E. Barton, Jr, MD

www.SRPS.o

Selected Readings in Plastic Surgery(ISSN 0739-5523) is published approximately 5 time

per year by Selected Readings in Plastic Surgery, Inc. A volume consists of 30 issues

distributed over 6 years. Please visit us at www.SRPS.org for more information.

Published as electronic monographs.

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INTRODUCTIONWhen performing eyelid reconstruction, a thoroughunderstanding of periorbital anatomy is critical. Itis important to understand the function of eachstructure and its interplay. One must approacheyelid reconstruction with the goal of restoring thefunctionality of the structure while achieving anaesthetically pleasing result.

ANATOMYIn this section, we present summaries of theanatomy related to eyelid reconstruction. Forfurther reading on eyelid anatomy, detaileddescriptions can be found in the 2008 text,Eyelid &Periorbital Surgery, by McCord and Codner.1

Dimensions

Te palpebral ssure is the space between the upperand lower eyelid margins. Normally, the adultssure is 27 to 30 mm horizontally and 8 to 11 mmvertically (Fig 1).2 Many conditions can aect thepalpebral ssure measurement; it can be verticallyincreased in patients with Graves disease, decreasedin patients with involutional ptosis, and variable inpatients with myasthenia gravis. Horizontally, it can

be decreased in patients with blepharophimosis andin patients with laxity or disinsertion of the lateralor medial canthal tendon.

Skin and Eyelid CreaseTe eyelid skin has only six to seven cell layersand averages

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SRPS Volume 11 Issue R2 2010

eyelids have been identied:1. single eyelid: no lid crease with puness2. low eyelid crease: low-seated, nasally

tapered, inside-fold type of crease3. double eyelid: lid crease parallel to

the lid margin6

Jeong et al.7 found that there are threereasons for the absent or lower crease in the Asianupper eyelid:

1. Te orbital septum fuses to the levatoraponeurosis at variable distances belowthe superior tarsal border.

2. Preaponeurotic fat pad protrusion anda thick subcutaneous fat layer preventlevator bers from extending toward theskin near the superior tarsal border.

3. Te primary insertion of the levatoraponeurosis into the orbicularis muscleand into the upper eyelid skin occurscloser to the eyelid margin in Asians.

Te lower eyelid crease is formed by the fascialextensions of the capsulopalpebral fascia, which alsopass through the orbicularis oculi muscle and insertonto the skin.8 Lim et al.9 reported that in Asians,these fascial extensions do not extend to the skin;therefore, a palpebral crease is not found. Kakizakiet al.10 stated that the reason for the indistinctlower lid crease in Asians is the higher or indistinctseptum fusion, the anterior and superior orbitalfat projection, and the overriding of the preseptalorbicularis muscle.

Eyelid Margin and Lacrimal PumpTe eyelid margin has several signicant structures.Both the upper and lower eyelid margins have apunctum medially. Te punctum opens into thecanaliculus of the lacrimal system. ears drain via

the canaliculi and into the nasolacrimal sac andthen to the lacrimal duct by both an active and apassive mechanism. Te lacrimal pump activelysucks tears into the lacrimal sac with each blink.Te contraction of the orbicularis muscle bringsthe lower punctum medially, closes the ampulla,and displaces the lateral wall of the lacrimal saclaterally, creating a negative pressure in the sac. Tis

draws the tears from the common canaliculus intothe sac.11,12 Te loss of the active component of teardrainage is partially responsible for epiphora incases of facial nerve palsy. Malpositions of the lowereyelid and the puncti can also lead to epiphora.

Along the length of the eyelid margin is the

gray line, corresponding histologically to the mostsupercial portion of the orbicularis muscle, themuscle of Riolan, and to the avascular plane of thelid.2 Anterior to the gray line, the eyelashes or ciliaarise. Posterior to the gray line are the orices to themeibomian glands. Meibomian glands are modiedholocrine sebaceous glands that produce lipidsecretions. Oil from the openings forms a reservoiron the skin of the lid margin and is supplied to thetear lm with each blink.2 Other glands found on

the skin of the eyelids are the sweat eccrine glandsof Zeis and holocrine glands of Moll.

Orbicularis Oculi MuscleTe orbicularis muscle is arranged in concentricbands and is the main protractor of the eyelid. Itcan be separated into orbital and palpebral portions.It is innervated by cranial nerve VII. Its antagonist,the levator, is innervated by cranial nerve III. Teorbital portion is involved in forced eyelid closure.Te palpebral portion can be divided into pretarsaland preseptal parts (Fig. 2).13 Te palpebral portionsare involved in involuntary lid movements, such asblinking.13

Te pretarsal orbicularis attaches mediallyto the anterior and posterior arms of the medialcanthal ligament to surround the lacrimal sac,and the superior and inferior lacrimal canaliculiare found within its muscle bers. It plays a vitalpart in the lacrimal pump mechanism. Laterally,the pretarsal orbicularis joins the lateral canthal

ligament at the Whitnall tubercle. Te preseptal andorbital components attach medially to the medialcanthal ligament and laterally to the zygoma, lateralto the orbital rim. In addition to the formerlymentioned attachments, the orbital orbicularisattaches medially to the maxillary and frontal bonesand extends peripherally to overlie the orbital rims.A small segment of the orbicularis oculi muscle,

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Figure 1. Landmarks o the external eye. The palpebral fssure is approximately 27 to 30 mm wide and 8 to 11 mm high

in the adult. (Reprinted with permission from Cibis.2)

Figure 2. Upper eyelid anatomy. (Reprinted with permission from Kersten.13)

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called the muscle of Riolan, is separated from thepretarsal component by the eyelash follicles andforms the gray line along the eyelid margins.14,15

Muzaar et al.16 reported that the orbicularis-retaining ligament is a bilaminar septum-likestructure attaching the orbicularis oculi to the

inferior orbital rim. Te attachment is weakestcentrally and tightest over the inferolateralorbital rim.

Ghavami et al.17 further claried that theorbicularis-retaining ligament is a circumferential,periorbital structure and that the orbicularisretaining ligament of the superior orbit arises 2 to 3mm above the orbital rim in the mid orbit.

Anterior and Posterior Lamellae

Te eyelid is divided into two lamellae (Fig. 3).13

Te anterior lamella consists of skin and theorbicularis oculi muscle, and the posterior lamellaconsists of the tarsal plate and conjunctiva.15

TarsusTe tarsal plates act as the skeleton of the eyelids,providing semirigid support.18 Te tarsus iscomposed of dense regular connective tissue andcontains the Meibomian glands.4 Te superior tarsusis 10 to 12 mm at its greatest vertical dimension,and the inferior tarsus is 3 to 5 mm.18 Te upperand lower tarsal plates are similar in length (29 mm)and thickness (1 mm).2 Te Meibomian glandsare modied holocrine sebaceous glands and areoriented vertically in parallel rows through thetarsus. Te upper lid contains 25 meibomian glands,and the lower lid contains 20.13

ConjunctivaTe palpebral conjunctiva lines the inner surface

of the eyelids and is covered by a non-keratinizedepithelium. Holocrine glands known as gobletcells secrete mucous and are located throughoutthe conjunctiva. Te goblet cells are mainlyconcentrated in the conjunctival fornices and at thecaruncle. Te palpebral conjunctiva is continuouswith the conjunctival fornices and merges withthe bulbar conjunctiva overlying the globe. Te

conjunctiva becomes freely mobile in the fornices.Te bulbar conjunctiva lines the sclera andterminates at the limbus.

Orbital SeptumTe orbital septum lies beneath the orbicularis

muscle and consists of a thin sheet of connectivetissue. It encircles the orbit as an extension of theperiosteum of the roof and the oor of the orbit.2Te orbital septum acts as a barrier of the orbitalcontents, and the orbital fat can be found posteriorto it. It extends from the arcus marginalis, wherethe periosteum and periorbita fuse, toward thetarsus.3 In the upper eyelid the septum inserts at thelevator, approximately 2 to 3 mm above the superioredge of the tarsus. In the lower eyelid, the septum

inserts to the inferior edge of the tarsus.19

Teseptum attaches medially to the lower end of theanterior lacrimal crest, called the lacrimal tubercle. Itcontinues from the lower to upper eyelid by passingunder the medial orbicularis muscle.3 Putterman19noted that the septum is dicult to trace laterallybecause it blends with the lateral canthal tendonand the lateral horn of the levator. Te septum alsotakes the shape of an arch under the supraorbitalnotch and around the supratrochlear andinfratrochlear nerves and vessels. Weakness in theorbital septum contributes to herniation of theorbital fat.

Reid et al.20 described a distinct brousanatomic layer, which extends from the orbitalseptum to cover the tarsus. Tey named the brousstructure the septal extension. Tey described thepreaponeurotic fat layer covered by the septalextension, which extends to cover the tarsus alongits anterior border to the ciliary margin. Te septalextension was found between the orbicularis

oculi and the levator aponeurosis, distinct fromthe levator tissue. Fibrous connections extendingfrom the levator aponeurosis penetrate the septalextension and the orbicularis muscle, connecting thelevator-dermal link to the septal extension. ensionplaced on the orbital septum leads to referredtension on the septal extension and secondarylagophthalmos. Te authors stated that the ndings

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might help avoid relapse and complicationsassociated with aesthetic and functional uppereyelid surgery.

Upper Eyelid Retractors and Mller MuscleTe upper and lower eyelids are analogous

structures with their main dierence being theirrespective retractors. In the upper eyelid, the levatorpalpebrae superioris and its aponeurosis comprise adistinct entity that evolved from the superior rectusmuscle.20 Te lower eyelid retractor is a fascialextension of the inferior rectus, which divides toencircle the inferior oblique muscle, called thecapsulopalpebral fascia.

Te levator muscle palpebrae originatesunder the lesser wing of the sphenoid just anteriorto the optic foramen.3 It extends anteriorly for40 to 45 mm and becomes tendinous in front ofWhitnall ligament (Fig. 4). Whitnall ligamentis a transverse band of brous condensation that

attaches superiorly to the widening levator. It isthe condensed fascial sheath of the levator muscleapproximately 18 to 20 mm above the superiorborder of the tarsus. Medially, it attaches to theconnective tissue around the trochlea and superioroblique tendon. Laterally, it attaches to the inneraspect of the lateral orbital wall, approximately10 mm superior to the lateral orbital tubercle. It

Figure 3. Lower eyelid anatomy. (Reprinted with permission from Kersten.13)

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functions to convert the anterior-posterior pullingforce of the levator to a superior-inferior direction,which raises and lowers the eyelid.2123 Te levatoraponeurosis joins the orbital septum above thesuperior border of the tarsus and sends brousstrands between the orbicularis oculi muscle septa

to the skin to make the lid crease.22 Te normalexcursion of the levator muscle is 15 mm.3

Mller muscle is a smooth, sympatheticallyinnervated muscle in the upper eyelid. It originatesfrom the undersurface of the levator muscle 8 to 10mm above the superior tarsal border and attachesto the superior edge of the tarsus.22 It functions toprovide 2 mm of lid retraction, and its interruptionin Horner syndrome causes mild ptosis.24

Kakizaki et al.25 found thatthe levator

aponeurosis has doubly stratied layers that includesmooth muscle. Te authors suggested that thelevator aponeurosis regulates tension in the anteriorlamella of the upper eyelid as the Mller muscleregulates the tension of the posterior lamella ofthe upper eyelid.26 Te structures lead to orderedmovement in the upper eyelid.

Lower Eyelid RetractorsIn the lower eyelid, the retractors originate fromthe capsulopalpebral head of the inferior rectusmuscle. Te capsulopalpebral fascia is analogous tothe levator in the lower eyelid. Te capsulopalpebralhead splits around the inferior oblique muscleand fuses again to form Lockwood ligament(similar to Whitnall ligament in the upper lid).Te inferior tarsal muscle is a sympatheticallyinnervated muscle analogous to Mller muscle ofthe upper lid. It originates on the posterior surfaceof capsulopalpebral fascia. Te inferior tarsal muscle,capsulopalpebral fascia, and orbital septum insert at

a fusion point into the anterior and inferior surfaceand base of the tarsus.22 Te capsulopalpebralfascia sends anterior projections that penetratethrough the orbicularis to the skin to create atransverse crease.3

Preaponeurotic FatTe preaponeurotic fat serves as an important

structure in eyelid anatomy. It is a crucial surgicallandmark. Te levator aponeurosis lies just posteriorto the preaponeurotic fat, and the septum liesjust anteriorly. In the upper eyelid, two fat padsare found: the nasal and middle fat pads (Fig. 5).Te nasal fat pad lies beneath the trochlea. Te

lower eyelid has three fat pads. Te nasal fat pad isseparated posteriorly from the central fat pad by theinferior oblique muscle. Te central and lateral fatpads are connected in deeper layers but anteriorlyare divided into two pads by a dense septalpartition.22 Te nasal fat pads are distinctly whiterin color in both the upper and lower eyelids whencompared with the yellow color of the more lateralfat pads.

Medial CanthusTe medial canthus provides a support point for theeyelids, helps provide its normal angular shape, andassists the lacrimal pump apparatus.27 It is rigidlyxed to the orbital wall.

McCord et al.22 illustrated the structure ofthe medial canthus and reported that medially, thepretarsal orbicularis produces two heads that passsupercial and deep to the canaliculi. Te anterior,more supercial, pretarsal orbicularis muscle formsthe anterior crus of the medial canthal tendon thatinserts into the frontal process of the maxillarybone. Te posterior, deeper, pretarsal orbicularisinserts into the posterior lacrimal crest. Te muscleis known as Horner muscle. Te deep pretarsalorbicularis inserts on the posterior lacrimal crestand the lacrimal fascia. Te deep preseptal bersinsert mainly on the lacrimal fascia, and this isknown asJones muscle. Te preseptal muscle formsthe horizontal raphe laterally, and medially, it insertsinto the anterior crus of the medial canthal tendon.

Lateral CanthusTe lateral canthal tendon resembles the medialcanthal tendon in that it supports the lids bysupplying a tendinous attachment of pretarsalorbicularis oculi muscle and ligamentousattachment of the tarsal plates to the periosteumof the lateral orbital tubercle. It also allows

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Figure 4. Anterior view o the levator palpebrae superioris shows the relationship to the tarsal plate and Whitnall ligament.

Figure 5. Fat compartments and lacrimal gland in the upper and lower eyelids.

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movement of the canthal angle by its posteriorbrous attachments to the check ligament of thelateral rectus muscle. In contrast to the medialcanthus, the lateral canthus is mobile, possessingup to 6 mm of vertical movement and 2 mm oflateral movement.28,29 Te lateral canthal tendon is

a brous structure that joins the upper and lowertarsal plates to Whitnall tubercle inside the orbitalrim, deep to the septum. Whitnall tubercle is anarea that is not easily found intraoperatively andmust be estimated clinically. It forms a prominenceapproximately 5 mm posterior to the lateral orbitalrim.30 Rosenstein et al.31 described the lateralcanthal tendon:

Superiorly, it is in continuitywith the lateral horn of the levator

aponeurosis. Inferiorly, it receivesbrous contributions from Lockwoodssuspensory ligament and then curvesposteriorly to attach to Whitnallstubercle. Anteriorly, the lateral extensionsof the preseptal and pretarsal orbicularisoculi muscles coalesce. Posteriorly,contributions from the check ligamentsof the lateral rectus muscle complete theformation of the lateral canthal tendon.

Te lateral canthus is located approximately 2 mmhigher than the medial canthus. Te measurementis the same for both sexes and does not change withincreasing age.28,32

Vascular Supply of the EyelidsTe eyelids receive their vascular supply from thefacial system, which is made from the branches othe internal and external carotid arteries. O of theinternal carotid artery comes the ophthalmic artery,which branches into the supraorbital, supratrochlear,

dorsal nasal, and lacrimal arteries. Te externalcarotid artery contributes the facial artery (angularartery) and supercial temporal artery (transversefacial artery, median temporal artery, and frontaland parietal branches). Te arterial network of theupper eyelid is composed of anastomoses betweenthe collateral branches of the ophthalmic artery(supraorbital artery, supratrochlear artery, and dorsal

nasal artery), a branch of the facial artery (angularartery), and the supercial temporal artery.33,34Te lateral region of the upper eyelid also receivesfurther blood supply from the branches of thesupercial temporal artery and the lacrimal artery.34

Erdogmus and Govsa33 described the

connection of the vascular supply and its location:Te dissection showed that the mainblood supplies of the upper and lowerlids were provided by the arterial arcades;the marginal, peripheral, supercial,and the deep ones. Te marginal andperipheral arcades consisted of theanastomosis of medial and lateralpalpebral arteries. Te marginal arcadecoursed just anterior to the lower

margin of the tarsal plate and gaveo small perforating branches thatascended tortuously on both sides of theorbicularis oculi muscle and the tarsalplate. Tese branches extend to the skin,the muscle and the tarsal plate. Teperforating branches running over theorbicularis oculi traversed obliquely, incontrast to the perforating vessels, with adescending diameter and became part ofthe vascular plexus and lower palpebraein all cases. Te peripheral arcade coursedalong the upper border of the tarsal plate.It was positioned along the surface ofthe Muller muscle at the superior borderof the tarsus. Te peripheral arcade gaveo perforating branches that descendedon both sides of the tarsal plate. Tedescending branches running over thetarsal plate connected with the ascendingbranches arising from the marginal

arcade, whereas the descending branchescoursing under the tarsal plate fannedout ne vessels and formed a vascularnetwork with the ascending branchesarising from the marginal arcade.

Te authors observed arterial arcades near theorbital rim and perforating vessels running on thesupercial and deep surfaces of the orbicularis oculi

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muscle, rather than intramuscular vessels, whichsuggests that the orbicularis oculi muscle. Teirobservation indicated that the orbicularis oculimuscle is not a tissue with a large vascularnetwork but is instead supplied by the surroundingvascular network.

Te venous system for the eyelids wasdescribed by McCord et al.,22 who reported thatthe anterior facial vein is the main supercialvenous structure. It follows approximately the samecourse as that of the facial artery but is supercialand more lateral to it. Te facial vein is calledthe angular vein near the medial canthus; it thenbecomes the supratrochlear vein and forms deepanastomosis superomedially in the orbit with thesuperior ophthalmic vein via the supraorbital vein.

Te angular vein lies temporal to the angular arteryover the insertion of the medial canthal tendon.Laterally, the supraorbital vein runs below theorbicularis oculi muscle on the frontalis muscleto communicate with the frontal branches of thesupercial temporal vein. Medially, the supraorbitalvein runs horizontally beneath the orbicularis anddoes not surface to join the frontal vein until itcommunicates with the superior ophthalmic vein ofthe orbit. A conuence of angular, supraorbital, andsupratrochlear veins forms the superior ophthalmicvein. Te superior ophthalmic vein acquiresvenous drainage from the globe and travels to thecavernous sinus. Because of the direct passage tothe cavernous sinus, infection of the facial areacan cause a supercial sepsis to spread to thecavernous sinus.

Lymphatics of EyelidsLymphatic vessels are found in the eyelids andparallel the course of the veins. Te medial

lymphatics drain to the submandibular lymphnodes. Te lateral lymph vessels drain into thepreauricular lymph nodes (Fig. 6).2

Lacrimal SystemUnder ordinary conditions, a tear lm iscontinuously produced. It protects the cornea andprovides some refractive power for the eye. Basic

or baseline secretion is produced by approximately50 small accessory glands of the Krause andWolfring glands, mucin-secreting goblet cells of theconjunctiva, and oil-secreting meibomian glandsand the glands of Zeiss at the eyelid margin. Temain lacrimal gland is actually a reex secretor and

acts in response to physical and emotional triggers(i.e., from emotional or foreign body stimulus).22,28,35

Te main lacrimal gland is divided into twoparts by the lateral horn of the levator aponeurosisand is found superotemporally in the orbit. Teupper or orbital lobe conforms to the space betweenthe orbital wall and the globe, extending from thelateral border of the levator aponeurosis on whichit rests, down to the frontozygomatic suture.22 Telower or palpebral lobe is located under the levator

aponeurosis in the subaponeurotic space. Tisinferior lobe is mobile and often can be prolapsedinto view in the conjunctival sac.35

Figure 6. Lymphatic drainage o the upper and lower

eyelids with drainage to the submandibular and

preauricular lymph nodes.

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Te vascular supply to the lacrimal gland isvia the lacrimal branch of the ophthalmic artery.It receives its innervation by way of cranial nervesV and VII and from sympathetics of the superiorcervical ganglion.22 Te secondary and accessorylacrimal glands are responsible for tearing under

ordinary circumstances, providing baseline tearsecretion.22,35

Te excretory system is made up of the upperand lower puncta, canaliculi, the tear sac, and thenasolacrimal duct. Tey work in conjunction withpretarsal orbicularis oculi, which drives the tearsfrom the tear meniscus in the conjunctival cul-de-sac down to the inferior meatus of the nose.

Jones35 described its structure. Te authorreported that the canaliculi are approximately 10

mm long, consisting of a vertical portion 2 mm longand a horizontal portion 8 mm long. Te verticalcomponent of each canaliculus begins with thepunctum, which lies in the apex of the lacrimalpapilla. It is approximately 0.3 mm in diameter andis surrounded by a ring of connective and elastictissue and a constrictor muscle. It is unique in thatit is the only part of the passages with walls rigidenough to produce capillary attraction. Te lumenwidens to form the ampulla, which is 2 to 3 mmat its longest diameter. Te ampulla, in turn, givesrise to the horizontal section, which is 0.5 mm indiameter. In 90% of cases, both canaliculi join toform a single common duct, which opens into thetear sac just posterior and superior to the center ofits lateral wall.

Jones35 noted that the tear sac andnasolacrimal duct are anatomically a singlestructure. Te upper end is the fundus, whichextends 3 to 5 mm above the level of the medialcommissure. Te combined length of the tear sac

and nasolacrimal duct is approximately 30 mm. Teupper 12 mm of the nasolacrimal duct lies in thenasolacrimal canal and is known as the interosseouspart. Te meatal portion of the duct usually opens5 mm below the vault of the anterior end of theinferior meatus.

Te lacrimal pump begins in the conjunctivalsac, where a tear strip is forced medially by

the movement of the lids during blinking.Te supercial and deep heads of the pretarsalorbicularis muscle close the ampullae and shortenthe canaliculi. Te preseptal orbicularis creates anegative pressure in the tear sac as the lacrimaldiaphragm produces alternating negative and

positive pressures to pull the tears into the sac andout of the nose.

EYELID RECONSTRUCTIONechniques for eyelid laceration repair or eyeliddefects after tumor removal range from allowingwounds to heal via secondary intention to the useof complex aps and grafts. Tose without loss oftissue should undergo minimal dbridement and beclosed primarily.3 When repairing eyelid lacerations

or defects, one must take great care to addressproper alignment of the lamellae. Structural repairof the anterior lamella aords a skin covering andblood supply to the eyelid. Te posterior lamellaprovides semirigid support to the eyelid and anonabrasive mucosal surface for normal blinking,which helps keep the ocular surface moist to protectthe cornea from drying. Functional restoration ofthe upper eyelid acts to protect the cornea, and thatof the lower eyelid allows it to oppose the globe andfurnish stability, aiding in the normal ow of tears.15In addition to proper alignment of the woundedges, the suture knots should be positioned awayfrom the globe to prevent corneal abrasions fromthe suture ends.

Granulation or healing via secondary intentionis an option in the repair of certain defects. Tedefects tend to be small and/or supercial and toinvolve such concave surfaces as the medial canthusor upper nasal side wall.3639

Full-thickness eyelid defects 25% of eyelid

length can be transformed into a pentagonalexcision and directly closed in younger patients withless eyelid laxity. In older patients with more eyelidlaxity, defects up to 40% of the length of the eyelidmargin can be closed directly in the same manner.One must ensure that the skin excision involved in apentagonal excision does not extend beyond the lidcrease, if possible. If necessary, the anterior lamella

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can be excised as a pentagon and the posteriorlamella can be excised as a rectangle to avoidextending the skin incision across the lid crease.15Te full-thickness defect is directly closed withthe use of the buried vertical mattress technique,as rst described by Burroughs et al.40 Te buried

vertical mattress technique uses a single 6-0 or 7-0polyglactin 910 suture pass, which is begun andcompleted in the tarsus with the knot tied deepwithin the eyelid tissue.

Ahmad et al.15 described the buried verticalmattress suture in detail:

Te buried vertical mattress suture isperformed using a 6-0 Vicryl sutureon an S-29 needle (Ethicon, Inc.,Somerville, NJ) in a far-far-near-near-

near-near-far-far pattern (Fig. 7).15

Tesuture is rst passed through the tarsusat one of the wound edges far from theeyelid margin and out of the tarsus at theeyelid margin far from the wound edge.Te suture is then passed back throughthe same tarsus at the eyelid margin nearthe wound edge and out of the tarsus atthe wound edge near the eyelid margin.Te suture is then passed through thetarsus of the opposite wound edge, near

the eyelid margin and out of the tarsus atthe eyelid margin near the wound edge.Te suture is then passed back throughthe same tarsus at the eyelid margin farfrom the wound edge and out of thetarsus at the wound edge far from the

eyelid margin. Te suture is then tiedand buried deep to the orbicularis oculimuscle everting the wound edges atthe eyelid margin. Simple interrupted6-0 Vicryl sutures are performed alongthe anterior aspect of the tarsus to

approximate the remainder of the tarsus.Another simple interrupted 6-0 Vicrylsuture is used to align the lash line. It iscrucial to align the lash line for a goodcosmetic outcome. Te skin is closedusing simple, interrupted 6-0 nylonsutures.

Te orbicularis muscle can be closed as a separatelayer. Te septum should not be closed becauseclosure of the septum can lead to eyelid retraction

and lagophthalmos, which can lead to signicantcorneal morbidity.Burroughs et al.40 reported that in 90 patients

undergoing the buried vertical mattress technique,no cases of wound dehiscence and only ve cases ofminimal notch formation occurred within follow-up ranging from 3 to 12 months.

Free Tissue GraftsFree tissue grafts should be coordinated to matchboth cosmetically and functionally. Tey should

have little or no shrinkage or absorption andbe associated with a minimal rate of infectionor rejection. ypically, autogenous tissue graftsare better at meeting the requirements than arehomologous tissue grafts or alloplastic materials.

Figure 7. Buried vertical mattress technique.A, Buried vertical mattress suture. B, Anterior tarsal sutures. C, Lash line

suture. (Reprinted with permission from Ahmad et al.15)

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SkinFull-thickness skin grafts contain both an epidermaland a dermal component. Preferred donor sitesfor full-thickness skin grafts used in eyelidreconstruction have traditionally included the uppereyelid, retroauricular or preauricular areas, and the

supraclavicular region, with the best match beingfrom the contralateral eyelid.22,41,42 Te inner armand groin are also possible donor sites, but theyshould not be considered rst because they do notprovide as suitable a match.22 For those patientswho have undergone previous facial surgery (i.e.,blepharoplasty or rhytidectomy) or for whomlarge skin grafts are needed, Custer and Harvey41described using the skin of the inner arm as analternative. A large amount of suitable skin might

be obtained from the arm for grafting purposes.In their study, 52 procedures were performed on42 patients. Partial graft necrosis occurred in twopatients, and mild asymptomatic graft contracturedeveloped in four. Steroid injections wereadministered to two patients with more markedgraft contracture. Chronic graft shrinkage occurredin three cases and involved the repair of ichthyosis-related cicatricial ectropion, and abnormal hairsappeared in four grafts.

A split-thickness skin graft is composed ofepidermis only, and the standard donor site is theanterior thigh. Te split-thickness grafts from thethigh generally have decient texture, color match,and a tendency to become pigmented. Te graft isobtained by a power-driven dermatome. Te mainapplication in ophthalmic plastic and reconstructivesurgery is for lining anophthalmic sockets andorbital cavities. Only in severe burn cases shouldthis method be a viable choice.22

ConjunctivaTe conjunctiva provides a smooth moist surface ofcontact for the cornea. A similar material is neededwhen replacing conjunctiva to prevent cornealirritation. Defects of the conjunctiva that cannot berepaired by advancement require a free graft.

Free conjunctival grafts from the same oropposite eye undergo signicant contraction and

are dicult to handle. One must take care toavoid compromising the donor fornix.3 Mucousmembrane grafts in an anophthalmic socketcontract rapidly. A conformer is therefore to bekept in the socket at all times for many weeks toprevent socket contracture. Skin cannot be used to

replace conjunctiva because the hairs on skin andthe squamous layer of epidermis are highly irritatingand potentially damaging to the cornea.3,43

Oral or buccal mucosa is the tissue of choicefor many plastic surgeons in need of a mucousmembrane graft. It is the most readily available ofmucous membranes that can be grafted in placeof posterior lamellae or eyelid margin resurfacing,but it tends to contract to approximately 50% ofpre-graft volume.3,43 It can be cut fairly thin and is

pliable. Te graft donor site typically is the innersurface of the lower lip, but additional grafts can betaken from the inner cheek or upper lip if needed.Because mucosal grafts tend to contract, they mustbe prepared slightly larger than the size of theproposed graft site. One must take care to avoid thevermillion margin of the lips, the gum, and Stensonduct inside the cheek when obtaining the graft.22Te harvesting site is outlined with methylene blueand subsequently incised with a number 15 Bard-Parker blade (BD, Franklin Lakes, NJ). Te graft isremoved with sharp and blunt scissor dissection andthen thinned with scissors. Te graft is then placedin an antibiotic solution until needed to replace theeyelid defect. Alternatively, a mucotome can be usedto harvest oral mucosa at preset thicknesses varyingbetween 0.2 and 0.5 mm.

Bowen Jones and Nunes44 followed patientswith oral mucosal grafts to the orbit for morethan 3.5 years. Fourteen of the study populationwere anophthalmic and suered from contracted

socket. Tree patients had eyes but were in needof additional conjunctiva. In those patients witheyes who were short of conjunctiva, the defect andfornices were covered with oral mucosa and a softcurved-shell conformer was tted to maintainthe depth of the fornices for 2 weeks. Satisfactoryfunctional results were obtained. Te authorsconcluded that the use of the soft shell to cover the

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globe and stretch the graft was essential to maintainthe full extent of the fornices for several weeks.Tey reported using palatal mucosa and nasalseptal mucosa for lining eyelids with less resultingcontraction, but less material was available forharvesting and the grafts were less pliable.

Ang and an45 described the use of autologousserum-free cultivated conjunctival sheets in a10-year-old patient with extensive recurrent viralpapillomata involving the superior and inferiortarsal, forniceal, and bulbar conjunctiva. Tepatient underwent surgical excision of all diseasedareas and double freeze-thaw cryotherapy. Teconjunctival equivalents were used to reconstructthe ocular surface and conjunctival fornices. Almostcomplete epithelialization was achieved by 5

days postoperatively. Te transplanted epitheliumremained intact, and good cosmetic and functionalresults were achieved. Despite the extensive surgery,no signicant cicatricial complications, such asforniceal shortening, symblepharon formation, orocular motility restriction, occurred. welve monthspostoperatively, the eye remained disease-free withno recurrence of the viral papilloma.

Te amniotic membrane is anatomicallythe innermost layer of the placenta and consists

of a thick basement membrane and an avascularstroma. It commonly is used to replace damagedmucosal surfaces and has been eectively andextensively used for reconstructing corneal4651 andconjunctival5255 surfaces damaged by a variety ofinsults and in dierent ocular surface disorders.51,56Solomon et al.51 showed that amniotic membranetransplant maintained a deep fornix and scar-freeenvironment with complete or partial success in 14of 17 eyes. In that study, preserved human amnioticmembrane was obtained from Bio-issue, Inc.

(Miami, FL). After thawing, the membrane wastrimmed to correspond with the conjunctival defect,including the bulbar surface of the fornix and thedeeper portion of the palpebral aspect of the fornix.Te membrane was then secured to the recessedconjunctival edge. Alternatively, the membranecan be stabilized with tissue glue such as isseeltissue sealant (Baxter Corp., Mississauga, ON). Te

authors noted that the reconstructed area can bevery large provided that the underlying bed is notischemic and the adjacent host conjunctiva remainsnormal. Amniotic membrane grafts have severaladvantages over oral mucosa. Tey are readilyavailable, can be trimmed to the required sizes,

and entail no donor site morbidity. Tey also havetherapeutic eects, such as promoting epithelialhealing and reducing inammation and pain.

Solomon et al.51 reported that the therapeuticeect of the amniotic membrane involvessynergistic actions that suppress brosis, reduceinammation, and promote epithelialization. Teamniotic membrane suppresses transforminggrowth factor- signaling and preventsdierentiation of normal human corneal and

limbal broblasts. It also suppresses the expressionof certain inammatory cytokines that originatefrom the ocular surface epithelia. Te inhibition ofinammation is a major factor in the preventionof further brovascular proliferation and scarformation in the conjunctiva. Additionally,amniotic membrane transplants maintain anormal conjunctival epithelium with goblet celldierentiation in vivo. In that regard, it issuperior to buccal or nasal mucous membranegrafts, the epithelia of which are dissimilar fromthat of the conjunctiva.

Tarsal PlateFor cases of eyelid reconstruction in which theposterior lamella has been lost, it is critical to usea material that simulates the tarsal-conjunctivalcomplex in thickness, surface quality, and resilience.A wide variety of materials have been used,including autogenous, homologous, and syntheticgrafts. Autogenous grafts that have been used

include hard palate, ear cartilage, temporalis fascia,fascia lata, nasal septal cartilage, tarsus, dermis,and periosteum.5762 Homologous donor scleraand synthetic polytetrauoroethylene grafts havealso been used.6365 Some materials do not lend apermanent solution, and late problems can arise.

Hard palate grafts and free tarsal grafts arecommonly used as posterior lamella alternatives in

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eyelid reconstruction. Tey each provide a mucosalsurface.6673A free tarsal graft is a suitable materialin that it provides exibility, rigidity, and shape.Ahard palate graft also provides rigidity, exibility,and thickness.Te hard palate graft is also readilyavailable and is not associated with any morbidity to

the contralateral eyelid.66 Te dense concentrationof collagen bers in the lamina propria of thehard palate provides this tissue with stability andrmness, but at the same time, it has enoughexibility to allow it to maintain its contour andact as replacement for the tarsus with excellenteyelid appearance and function, unlike ear or nasalcartilage.57 However, harvesting the hard palategraft requires a second surgical site that is notsterile and that must heal by secondary intention.

Donor site morbidity and patient discomfort bothdiscourage the use of hard palate grafts.74

Leibovitch et al.66 retrospectively evaluated15 patients who were treated with autogenoushard palate grafts and 16 who were treated withautogenous free tarsal grafts. Te authors describedthe free tarsus and hard palpate graft harvesting. Forfree tarsal graft harvesting, the authors describedthe following technique:

Local anesthetic was injected beneaththe pretarsal upper eyelid skin beforeeversion of the eyelid using a Desmarresretractor for subconjunctival injection ofadditional anesthetic above the superiortarsal margin. Te tarsus was incised 4to 5 mm above the lid margin, parallelto the eyelid margin, with the length ofthe horizontal incision up to 16 mm,depending on the available upper eyelidtarsus. Tis was followed by 2 verticalincisions at each end of the horizontal

incision, towards the upper border of thetarsus. Te graft was then dissected fromthe loosely attached levator aponeurosis,Mllers muscle, and conjunctiva.

In the study by Leibovitch et al.,66 hard palateharvesting involved local anesthetic injection intothe hard palate mucosa and mucoperiosteum,including the area around the greater palatine and

incisive foramina. After the required graft size wasmarked, two parallel incisions were made betweenthe median raphe and the gingival mucosa usinga number 15 Bard-Parker blade. An edge of thegraft was lifted, and dissection was continued in thesubmucosal plane. Hemostasis was achieved using

pressure, minimal cautery, or an absorbable gelatinsponge soaked in thrombin. A surgical stent wasused in some cases. Te harvested hard palate graftwas carefully thinned by removing fatty submucosawith scissors.

Leibovitch et al.66 explained that the hardpalate grafts were preferred in cases with insucientheight of the contralateral tarsal plate to enableharvesting of adequate free tarsal graft withpreservation of 4 mm of residual tarsus, to avoid

morbidity to the contralateral eye, and also per thepatients preference. Te complications for the hardpalate group included ocular irritation or discomfortin three patients, corneal edema or transientkeratopathy in two, partial graft dehiscence in two,upper lid retraction in two, and necrosis of theoverlying skin ap in one. Donor site complicationsincluded only one case of excessive bleeding fromthe hard palate site in the recovery room, whichrequired packing. No signicant complicationsoccurred in the patients treated with free tarsalplate grafts. Te donor upper lid complications weretwo cases of mild upper lid retraction and centralpeaking from a brous band.

Te presence of keratinized epithelium oftendiscourages the use of hard palate grafts in theupper lid because of the possible adverse eects onthe cornea. Te authors found this side eect to betemporary in all cases, resolving after several weeksto a non-keratinzed type, possibly in correlationwith the gradual metaplasia of the epithelium.

An ear cartilage graft furnishes rigid supportsimilar to that of the tarsus and has the ability toepithelialize over a period of weeks. Ear cartilageis also resistant to contraction and is thus an idealmaterial to act as a spacer.22 It lacks the malleabilityneeded to conform to the curved surface of the eyebut remains a valuable material for repairing tarsus.It can be thinned, rendering it more malleable when

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using a mucotome. McCord et al.75 described thetechnique for harvesting autogenous ear cartilage.Te authors described skin hooks used to exposethe posterior surface of the ear. Tey marked acurvilinear line parallel to the edge of the helix,keeping 4 mm from the edge of the helix. Tey

incised the skin and continued dissection downto the ear cartilage, which they then marked. Teauthors incised the cartilage with a scalpel and usedscissors to complete the full-thickness incision andto cut the graft o at its base.

Hashikawa et al.76 described the use of earcartilage as a support for the lower lid instead ofa spacer. Te authors reasoned that the long andwide plane of the auricular cartilage can enablethe lower lid to make contact naturally and closely

with the globe. Ear cartilage is generally sutured tothe eyelid remnants on either side of the defect, ifany, otherwise to the lateral orbital rim periosteum.Hashikawa et al. did not x the grafted cartilage tothe tarsal plate but to the medial canthal ligamentand lateral orbital rim without resting on the bonyrim. Te procedure was applied to various lowerlid deformities, including anophthalmic orbits,facial paralyses, reconstructed lids, and deformitiessecondary to trauma, maxillectomy, infection, burns,and neurobromatosis. Te authors described thetechnique used in the study:

Te auricular cartilage strip is harvestedfrom the anterior side of the ear. Froman incision made along the ridge ofthe antihelix and its superior crus, thesubcutaneous plane is dissected, theperichondrium is incised, and then a 4.5 1-cm strip of the auricular cartilage isharvested. Te donor site is subsequentlysimply closed layer by layer.

Small skin incisions are made at themedial and lateral canthal regions. Asubmuscular or a subcutaneous tunnel(depending on whether the orbicularisoculi muscle is lost at previous surgeryor trauma) is bluntly dissected from themedial canthal ligament to the lateralorbital rim and made wide enough

for the cartilage strip to go in, withits upper edge as close as possible tothe lid margin. Te auricular cartilagestrip is then inserted into the tunnel.Te tension of the lower lid is properlyadjusted, then one end of the strip is

xed to the medial canthal ligament withnonabsorbable suture and the other isxed to the periosteum at the level of theinsertion of the lateral canthal ligament,ascertaining that the lacrimal canaliculiis not ligated. Tere is no need to x thecartilage to the tarsus. Tus, the totallower lid is supported by the plane of thecartilage strip. Finally, the two incisionsmade at the medial and the lateral

canthal regions are simply closed.Because the procedure is simple and conducive

to restoring a stable and long-lasting lower lidsupport, the authors claimed that it is widelyapplicable to various deformities of the lower lid.Although the grafted cartilage was slightly visiblein some cases, none required removal.

wo of the 34 cases required secondaryoperations during the early postoperative periodbecause of detachment of the grafted cartilage from

the point of xation. Tis was considered the onlycomplication of the technique; otherwise, therewas good lid position during a follow-up periodof as long as 15 years. Warping of the cartilage didnot occur in any of the cases. A disadvantage ofthis procedure is that the lower lid becomes xedpostoperatively, and patients might experiencepartial disturbance in the visual eld at the extremedown-gaze. Terefore, the authors recommend theprocedure for patients with anophthalmic orbit or

severe deformity. Patients with poor vision in theeye undergoing eyelid repair might not be botheredby the possible complication of the down-gazedisturbance and might therefore also be suitablecandidates for the procedure.

Scuderi et al.77 published the results of their10-year experience with the nasal chondromucosalap for large upper eyelid full-thickness defects.

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for both reconstructive and aesthetic proceduresas a substitute for autogenous ear cartilage andfascia. In eight procedures, a spacer was placed inthe upper lid. One hundred four procedures wereperformed for spacers in the lower lid and 17 forlateral canthal reinforcement. In the upper eyelid,

Enduragen typically was used as a spacer graftbetween the levator-Mller muscle and tarsal platefor upper lid advancement procedures used to treatGraves lagophthalmos or overcorrected ptosisrepairs. All upper lid procedures were accomplishedusing an anterior transcutaneous approach. Afterrelease of the levator attachment to the tarsalplate, an Enduragen spacer graft, of varying heightdepending on needs (generally 35 mm), was thensecured to the superior edge of the tarsal plate

and the distal bers of the levator aponeurosisusing absorbable sutures. In the lower eyelid, theprocedures were performed either to insert spacermaterial in the lower lid in patients with prominenteyes or to counteract scarring in retracted lids.Either an anterior approach through a subciliaryincision or a posterior approach including acantholysis and transconjunctival incision wasused. Tirteen eyelid complications occurred in theseries presented by McCord et al., with a resultingcomplication rate of 10%. Nine cases requiredsurgical revision. Four cases of infection occurred,and all were successfully treated with oral andtopical antibiotics. Many of the cases that neededrevision were extreme cases that had undergonemultiple eyelid procedures before the operation inthe series by McCord et al. In those cases, extremescar contractures, previously placed grafts, and otherproblems were encountered. Te authors noted thatEnduragen is slightly more rigid than other tissueproducts; therefore, all edges and corners should

be trimmed and tapered before closure. Enduragenis described as having superior uniformity andpredictability of thickness, structural integrity, easeof use (it does not require soaking), andbetter durability.

Barbera et al.81 described using a venous wallgraft to reconstruct the posterior lamellae. Tewalls of propulsive veins were harvested from the

forearm in six patients and from the leg in onepatient to replace the tarsal-conjunctival complex.No complications occurred at any of the donor sitesor the eyelid area. No graft or ap suered vascularfailure. Cosmetic and functional results werejudged to be good to outstanding by both patients

and physicians. Te authors reported that thereconstructed eyelids had congruous thinness andthat the fornices were adequately deep. Te venouswall was found to be useful in that it is thin andpermits reconstruction of the entire height of theupper eyelid (approximately 15 mm) when using avein with a 5-mm diameter. Te elastic properties,smoothness, and concavity of the venous graftallow it to conform to the globe without inducinga chronic inammatory reaction on the bulbar

conjunctiva or on the cornea. Autogenous dermiscan also be used as a replacement for tarsus and isdiscussed below.

Composite GraftsComposite grafts provide multiple tissuerequirements for eyelid reconstruction in one stage.Composite grafting is a simple, safe, less invasive,and time-saving method for eyelid repair.

Korn et al.82 reported their experience withautologous dermis fat grafts as a posterior lamellarspacer graft in repair of eyelid malpositions. Te useof dermis fat as a composite graft in anophthalmicorbits has been well described.83,84 Te authorsargued that several features make autologousdermis fat a suitable spacer graft, including theability to supply both posterior lamella on thedermis face, volume replacement with fat, no riskof a transmissible agent, and low incidence oftissue rejection. Eleven patients with lower eyelidmalpositions from various causes were treated with

dermis fat grafting to the lower eyelid. Te source ofdermis fat was the hip, inferior and posterior to thesuperior iliac crest. After marking an ellipse of skin,the epithelium can be removed with either sharpdissection or with a diamond burr. Te dermis withthe needed fat is then excised, and the compositegraft is sutured into the eyelid defect with thedermis side toward the globe. Te donor site is then

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closed primarily. After 1 year of follow-up, all11 patients reported marked cosmeticimprovement and high satisfaction after thereconstructive surgery.

Te main concerns regarding the use of dermisfat grafting are surface keratinization and growth

of hairs leading to ocular surface irritation andcomplications.85 Korn et al.82 performed mechanicaldbridement of the epithelium and found thatstep necessary to prevent graft complications.With that approach, the authors did not note anypostoperative hair growth, surface keratinization, orany major complications. Furthermore, the authorsnoted that meticulous end-to-end approximationof the dermis side of the graft with the conjunctivaledge allows for uniform migration of the

conjunctival epithelial cells over the dermal graftsurface. Finally, the authors placed the graft deep inthe fornix, where corneal apposition is minimal.

Lee et al.86 treated 13 patients with sunkenand/or multiply folded upper eyelids using fascia-fatcomposite grafts from the mons pubis, temporal,and preauricular areas. Te technique was usedin patients who had undergone Oriental upperblepharoplasty, which often results in excessive fatremoval and can be associated with injury to theorbital septum. Adhesions of the skin to underlyingtissues down to the septum can develop. o remedysuch deformities, local tissue transfer can be usedto return a more desirable volume to the eyelidsand can solve the adhesion problem. Te authorsargue that dermis fat grafts might be too heavy,might aect upper eyelid motion, and might alsoproduce a visible mass. By contrast, the fascia-fatcomposite has a rich vascular fascial component;it is therefore expected to achieve vascularityearlier and to survive better than free fat alone. In

addition, it is lighter than the dermis-fat composite,provides a closer anatomic match to the damagedorbital fat and septum, and is abundant throughoutthe body. All 13 patients were satised with theappearance of the nal results. Deformities resultingfrom volume depletion and adhesion disappearedimmediately after the operation. Six-month resultswere maintained throughout the follow-up period

(average follow-up duration, 2.5 years after surgery)without development of any complications.

Yildirim et al.87 used composite sandwichgrafts containing skin-cartilage-skin for thereconstruction of full-thickness defects of the eyelidmargin. Composite grafts were removed from the

upper third of the auricular helix. Tirteen patientswere followed monthly for up to 6 months. Graftloss resulted in three patients who had marginalnecrosis of the outer skin layer of the compositegraft. All of the marginal losses were successfullytreated with daily dressings, without the need foradditional surgery. No corneal irritation or injuryfrom the use of helical skin for reconstruction ofconjunctiva at the eyelid margin was observed.Te authors stated that an advantage of using

this composite graft technique is that the helicalcartilage is thinner than that of the nasal septumand is therefore more similar to tarsus. Helicalcartilage also has a better curvature than does septalcartilage for the globe.

Reconstructive FlapsA wound or surgical defect that cannot be closedprimarily might require a ap for successfulreconstruction. A ap maintains its own bloodsupply from a pedicle or base attachment fromadjacent tissue, so it is useful for reconstructing siteswith poor vascularity that cannot sustain a skingraft.22 Tis feature also leads to less contractionand a more cosmetically appealing result than thoseachieved with grafts.

Upper EyelidDirect ClosureMost upper eyelid defects are caused by the removalof tumors, trauma, or congenital abnormalities. As

discussed earlier, direct closure of a full-thicknesseyelid defect that is 25% of the eyelid length canbe successfully accomplished with a pentagonalexcision approach in a younger patient with lesseyelid laxity. Older patients have increased lid laxity;thus, defects up to 40% of the length of the eyelidmargin can be closed directly. For direct closure, theburied vertical mattress technique15,40 is preferred to

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the classically taught three-suture technique.

Canthotomy and CantholysisIf direct eyelid closure causes excessive tensionon the eyelid, further mobilization of tissue isneeded and performing a lateral canthotomy and

cantholysis is a suitable solution. Te lateral canthalarea is injected with lidocaine with epinephrineto achieve both anesthesia and hemostasis. Anumber 15 Bard-Parker blade is used to make ahorizontal incision for 5 mm, starting at the lateralcanthus.75,88,89 Te incision is continued down to theorbital rim. Te superior ramus of the lateral canthaltendon should then be identied. Te superior andinferior rami are more easily palpated with scissortips than visualized.90 With Westcott scissors

pointed superoposteriorly toward the lateral orbitalrim, the superior arm of the lateral canthal tendoncan be detached from the orbital rim, causingsignicant mobilization of the upper eyelid.89

Holds and Anderson91 described the use ofcombined medial canthotomy and cantholysis asa single-stage reconstructive technique for use inthe reconstruction of the upper or lower eyelid.Tat technique sacrices one lacrimal canaliculusand can provide up to 20% of the horizontal eyelidlength for closure. Te authors recommended thatthe patient be under general anesthesia for thisprocedure. It involves transection of one lacrimalcanaliculus, lysis of one crus of the medial canthaltendon, and lateral advancement of the medialeyelid stump. Adequate reconstructive results wereachieved by using this technique to correct 29 eyeliddefects (21 upper eyelids and eight lower eyelids)during a 12-year period. Eleven of the patientsunderwent simultaneous lateral canthotomy andcantholysis. Complications included anterior

displacement of the medial portion of the eyelid,epiphora, notching of the medial portion of theeyelid, medial ectropion, and blepharoptosis.

Tenzel Rotational FlapCentral upper eyelid defects involvingapproximately 40% of the lid margin can be closedwith a semicircular ap, which is rotated into the

defect, as described by enzel.92,93 An inferiorarching semicircular line is marked from thelateral canthus extending temporally (Fig. 8). Tediameter of the ap is approximately 20 mm. Teap is incised with a number 15 Bard-Parker blade,and a Bovie cutting needle (Bovie Medical Corp.,

Clearwater, FL) can be used to incise throughmuscle and to achieve hemostasis.75 A lateralcanthotomy is made beneath the semicircular skinincision, and dissection is carried out to the lateralorbital rim. A superior cantholysis is performed asdescribed above, and the lateral portion of the upperlid is advanced medially to be attached to the lateralorbital rim. Te ap is then undermined and rotatedinward. Te edge of the ap should be sutured tothe medial edge of the defect with a buried vertical

mattress technique, as described above. Lateralxation is obtained by suturing the edge of the apto the periosteum at the lateral orbital rim withxation to the inferior ramus of the lateralcanthal tendon.75

Cutler-Beard Flap (Bridge Flap)Te Cutler-Beard ap is a lower eyelidadvancement ap that uses a full-thicknessrectangular segment from the lower eyelid torepair large or total defects of the upper eyelid.94It is a two-stage procedure used for reconstructionof defects involving more than one-half of theeyelid. Te defect of the upper lid is fashionedin a rectangular manner in preparation for arectangular ap from the lower eyelid.95 Te rststep involves marking the lower eyelid 1 to 2 mmbelow the inferior border of tarsal plate. A full-thickness horizontal incision is then made alongthe distal border of the lower tarsus. Verticalincisions are made next, completing a rectangular

ap (Fig. 9).Te ap is then advanced beneaththe remaining, undisturbed lower eyelid marginbridge and is inset into the upper eyelid defect.Te skin and orbicularis of the ap are split fromthe palpebral conjunctiva. Te conjunctiva is thensutured to the remaining upper eyelid conjunctiva.Te capsulopalpebral fascia just anterior to theconjunctiva is sutured to the remaining levator

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Figure 8. (Above) Tenzel ap or upper eyelid

reconstruction. An inerior arching semicircular line is

marked and incised rom the lateral canthus, extending

temporally. A lateral canthotomy is made, and a superior

cantholysis is perormed. The ap is rotated inward and

sutured to the medial edge o the deect.

Figure 9. (Left) Classic Cutler-Beard bridge ap technique.

A horizontal incision is made along the distal border o

the lower tarsus. A ull-thickness inerior eyelid ap is

created. The remaining lower lid margin orms a bridge.

Ater 4 to 8 weeks, the ap is cut. The pedicle slides back

and is sutured to the distal border o the bridge.

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complex.96 Te myocutaneous ap is advanced andsutured to the skin of the upper eyelid defect. Fourto 8 weeks later, the second stage occurs, duringwhich the ap is divided and the margin of theupper lid is reconstructed.97 Te pedicle slides backand is sutured to the distal border of the bridge.95

o gain more rigid support of the reconstructed lid,some authors98,99 recommend recreating the upperlid tarsus by using an inlay graft of ear cartilage,fascia lata, or eye bank sclera. Tis graft is suturedmedially and laterally to remaining tarsus andsuperiorly to the cut edge of thelevator aponeurosis.75

Hollomon and Carter96describedreplacement of upper eyelid tarsus with Achillestendon as part of the Cutler-Beard procedure.

Te Achilles tendon is composed of collagen brilbundles with supportive cells in a dense connectivetissue, similar to tarsus. It is readily available frommost tissue banks. Te technique was successfulin four patients. Te total follow-up ranged from6 months to 4 years. Of the four patients, noneexperienced infection, dehiscence, or necrosis.No cases of secondary ptosis, eyelid retraction, oreyelid malposition occurred, and no case requireda second procedure. Te authors explained thatthe main advantage of using this graft is itsunlimited quantity, providing sucient length forreconstructing large areas. An additional benetis that there is no second surgical site, reducingcomplications and healing time. Achilles tendonwas found to be more pliable and mobile thancartilage, yet it maintained its stability over time.Te disadvantages are cost, waste of excess unusedtissue, and rare possibility of disease transmissionpresent in all allografts.

Demir et al.97 reported a single-stage

procedure for reconstructing large full-thicknessupper eyelid defects using an orbicularis oculiadvancement ap. Te skin and muscle of thelimbs are totally mobilized, leaving the base of thepedicle intact with submuscular tissue attachments.A triangular V-Y advancement myocutaneousap is created, based on the submuscular plane.Te ap includes skin, muscle, and submuscular

tissue, but orbital septum is left intact. A hardpalate mucoperiosteal graft is harvested forposterior lamella reconstruction. Te hard palategraft is positioned in the defect and sutured tothe remaining tarsus or canthal tendon stumpsand conjunctiva. Te myocutaneous ap is then

advanced vertically to the defect and sutured to theinferior edge of the mucoperiosteal graft. Te eightpatients in the study by Demir et al. experiencedno major complications during follow-up periodsof 6 months to 4 years. Te ap was viable in everypatient, without total or partial necrosis, and nopatient required surgical revision. Te authorsfound that the technique allows for immediatevisual rehabilitation, provides functional orbicularismuscle to preserve blinking and eyelid closure, and

permits formation of natural eyelid surfacesand contours.

Irvine and McNab100 described a techniquefor large upper eyelid marginal defects with 3 to4 mm of residual upper lid tarsus. Te residualupper tarsus travels on a conjunctival pedicleafter releasing the levator aponeurosis and Mllermuscle. Te tarsus is moved to ll the posteriorlamella defect in a way similar to that of mobilizinga Hughes ap (Fig. 10). Lagophthalmos often waspresent to a minor degree of 1 to 2 mm, but patientswere asymptomatic. Te main late complicationoccurring in two patients was lanugo hairs fromthe anterior lamella causing corneal irritation andintermittent punctate epithelial keratopathy. Teconditions were successfully managed with topicallubricants. After the complication occurred in therst four patients, the technique was modied bysuturing the anterior lamella in a recessed positionof 1 to 2 mm to avoid the complication of lanugohairs causing corneal irritation. A full-thickness

skin graft can be used in the event of insucientanterior lamella.

Hsuan and Selva101 described a modiedCutler-Beard ap involving a free tarsal graft witha skin-only advancement ap from the lower eyelid,which is divided at 2 weeks. In four cases, the freetarsal graft was harvested from the contralateralupper eyelid. Te authors stated that using skin

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alone in the advancement ap spares dissectionof the orbicularis, resulting in less disruption to

the lower lid tissues. Tey suggested that the timerequired for the skin to stretch is less than that for acomparable myocutaneous ap, which is supportedby their results showing the ap was divided at 2weeks. Te skin-only ap carries a sucient bloodsupply, apparent during ap division at 2 weeks,which showed bleeding from the reconstructedtarsal margin and indicated good vascularity.Another advantage of this method is eye occlusionfor only 2 weeks compared with the traditional 4 to

8 weeks. Only one patient developed mild ectropionand was noted to be the youngest patient needingthe greatest vertical displacement to cover the upperlid defect.

Dutton and Fowler102 presented a modicationof the Cutler-Beard technique, which is valuable incases in which the upper eyelid margin is spared.Te technique is helpful for patients with cicatricialupper eyelid scarring and retraction of non-marginaltumor resection. A full-thickness horizontal incisionis cut just above the tarsus of the upper lid (in cases

of cicatricial retraction), or the non-marginal lesionis excised, conserving the upper lid margin. Teremainder of the surgery consists of the traditionalCutler-Beard technique. After 2 to 3 weeks, the apgains adequate blood supply from above. After 3 to4 weeks, the ap is divided. Te epithelium and scartissue along the inferior border of the lower eyelidbridge and along the superior border of the upper

eyelid bridge are trimmed to expose all lamellae.Te lateral and medial edges of the cheek incisions

are undermined, and, if necessary, a portion of thestretched ap ends is excised. Te conjunctiva andlower eyelid retractors are sutured to the inferiorborder of the lower tarsus with a running 6-0 fast-absorbing plain gut suture. Te authors describedperforming the procedure in only two patients whowere reported to have achieved excellent functionaland cosmetic results, although a follow-up durationwas not specied for the rst patient described. Tesecond patient subsequently underwent a frontalis

sling procedure to correct residual ptosis 8 monthspostoperatively.Another less common technique is a

pentagonal composite graft from the contralateralupper eyelid. Up to 30% of the contralateralupper eyelid can be harvested and transferred tothe aected eyelid. Te technique should be alast resort measure to avoid complications in thenormal eye. One should consider this method ifthe contralateral eye is blind or has poor visualpotential. A reconstructive ladder for upper eyelid

defects is shown (Fig. 11).13

Lower EyelidDirect ClosureLower eyelid defects involving 25% or less of theeyelid length in a young patient can be closed ina fashion similar to closure of the upper eyelid,with a direct end-to-end closure. In older patients

Figure 10. With an upper lid deect that includes 3 to 4 mm o residual tarsus, the upper tarsus is mobilized on a

conjunctival pedicle. Advancement o the tarsoconjunctival ap is shown. The tarsus is sutured in an advanced position,

orming a new posterior lamella lid margin.

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Figure 11. Reconstructive ladder or upper eyelid deect. A, Primary closure with or without lateral canthotomy

or superior cantholysis. B, Semicircular ap. C, Adjacent tarsoconjunctival ap and ull-thickness skin grat. D, Free

tarsoconjunctival grat and skin ap. E, Full-thickness lower eyelid advancement ap (Cutler-Beard ap). F, Lower

eyelid switch ap or median orehead ap. (Reproduced with permission from Kersten.13)

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with additional lid laxity, a defect consisting ofup to 40% of the lower eyelid margin can also beclosed directly. As revealed earlier; a pentagonalexcision closure with the buried vertical mattresstechnique15,40 is preferred over the classically taughtthree-suture technique.

Lateral Canthotomy and Inferior CantholysisIf direct closure causes excessive tension on thewound edges, a lateral canthotomy and inferiorcantholysis can notably mobilize the lateral portionof the defect. As described earlier, a number 15Bard-Parker blade is used to make an approximately5-mm horizontal incision in the skin at the lateralcanthus.75,88,89 Te incision is continued down to theorbital rim. Te inferior ramus of the lateral canthal

tendon should then be identied with scissor tips.Using Westcott scissors pointed toward the lateralorbital rim, the inferior arm of the lateral canthaltendon is cut from the orbital rim (Fig. 12). Telower lid should easily pull away from the lateralcanthus. Te lateral margin of the wound can thenbe mobilized nasally to close the lid margin defect.75

Tenzel Rotational FlapLower eyelid defects involving 40% to 60% of thelid margin can be closed with a lateral, semicircularminiap rotated into the lid defect.75,103 Similarto the technique used in creating a pentagonalconguration for direct closure of a lid defect, the

tissue inferior to the tarsal defect is excised in atriangular shape. A superior arching line is drawnon the skin beginning from the lateral canthusextending temporally to the lateral extension ofthe brow line (Fig. 13). Te diameter of the apdrawn is approximately 20 mm.75 Te outline isincised with a blade, and a lateral canthotomyincision is made below the ap with subsequentdissection down to the lateral orbital rim. Aninferior cantholysis is then performed. Te ap is

undermined and rotated nasally.Lateral lid support must be re-established

to prevent lateral drooping of the eyelid. Tis isaccomplished by suturing the dermis of the aptissue to the inner periosteum of the superior inneraspect of the lateral orbital rim.75

Te enzel ap can also be supplemented withperiosteum or ear cartilage for slightly larger defectsto create a support for the lateral eyelid. A periostealap is created by elevating a strip from the lateralorbital rim and keeping it hinged o the orbitalrim. Te ap is stretched across and attached to theinside of the advanced enzel ap. Alternatively, anear cartilage graft can be used to support the lateralportion decient of tarsus.75,103

Hughes FlapLarger defects that involve more than 50%(depending on lid laxity) of the lower lid marginare ideally closed with a Hughes ap.69 In 1937,Hughes104 presented a method for lower eyelid

reconstruction that makes use of the upper eyelidas the donor site. See also Hughes105 (1945) andRohrich and Zbar106 (1999). A tarsoconjunctivalap was created from the ipsilateral upper eyelid,and it was advanced inferiorly into the lower eyeliddefect to replace the absent posterior lamella.Hughes undermined cheek skin to elevate it,replacing absent lower lid skin without tension. Te

Figure 12.With the scissors pointed ineroposteriorly

toward the lateral orbital rim, the inerior arm o the lateral

canthal tendon is cut.

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undermined cheek skin was then brought upwardand sutured onto the anterior portion of the lowerhalf of the upper lid tarsal plate to rebuild theanterior lamella.

Macomber et al.107 later altered the Hughesap by using a full-thickness skin graft harvested

from either the postauricular, supraclavicular, orcontralateral upper lid skin as an alternative toelevating cheek skin. Te graft was sewn ontothe advanced tarsal plate. Te vascular supplyfor the graft came from the tarsoconjunctivalap. Macomber et al. also recommended eyelashtransplantation only in the young or aestheticallyminded patient after several weeks using a singlerow of hair follicles from the eyebrow. After 6weeks, the lid was divided.

Modied Hughes FlapYears after his original description104 was published,Hughes108 presented a modied Hughes ap inresponse to criticisms regarding postoperativeoutcomes. Cies and Bartlett109 reported methodsto avoid postoperative complications with the

Hughes ap. Tey argued to leave the inferiorportion of the upper eyelid tarsal plate in situ byplacing the incision above the lid margin, and theyrecommended removing Mller muscle from theap at the time of original dissection. Te authorsstated that the maneuvers preserved upper eyelidsupport and decreased postoperative upper eyelidretraction and entropion. Cies and Bartlett109and Pollock et al.110 additionally explained thatpreservation of at least 4 mm of tarsus vertically

from the eyelid margin is necessary to avoidpostoperative eyelid contour complications.

McCord et al.75 described the modiedHughes ap in detail. Per the authors, the lowerextent of the lower eyelid wound is fashioned intoa rectangular shape. Te horizontal length of thedefect is measured to determine the width of theupper lid ap. A three-sided advancement ap ismarked on the conjunctiva of the upper eyelid. Tehorizontal margin of the ap must be 4 mm awayfrom the lid margin. Te outlined ap is incisedthrough conjunctiva and tarsus to a level betweentarsus and levator aponeurosis. Te dissection iscontinued superiorly between Mller muscle andthe levator aponeurosis. Te medial and lateraledges of the tarsal ap are sutured to the edges ofthe lower lid tarsus. Te previous upper lid superiortarsal border becomes the lower lid tarsal margin. Incases in which lower lid tarsus at the lateral marginof the defect is not available, the tarsal ap fromthe upper lid can be anchored to the periosteum

using lateral canthal xation. Te inferior borderof the ap is sutured to the remaining conjunctiva.A full-thickness skin graft is placed over the tarso-conjunctival ap, and the superior edge of the skingraft is sutured 1 to 2 mm higher than the futurelower lid margin.

Various authors divided the Hughes ap after6 to 8 weeks109 or even after 2 to 4 weeks.75,111,112

Figure 13. Tenzel ap in lower eyelid reconstruction.

Ater a superior arching line is drawn and incised rom

the lateral canthus extending temporally, a lateral

canthotomy incision is created and inerior cantholysis

perormed. The ap is then undermined, rotated nasally,

and sutured.

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Additionally, successful division after 1 week wasreported.113 McNab et al.111 conducted a prospectiverandomized study comparing division of thepedicle of modied Hughes aps at 2 and 4 weeks.Statistical analyses showed no signicant dierencebetween the two groups for upper and lower eyelid

position at 3 months of follow-up or for othereyelid complications. In all cases, vascularization ofthe reconstructed lower eyelid was excellent in boththe 2- and 4-week groups.

Bartley and Messenger114,115 reported theresults of eight cases of premature traumaticdehiscence of a Hughes ap. Each case had beencaused by accidental trauma that occurred between1 and 11 days postoperatively in seven of the eightpatients. One patient was unable to identify the

exact day on which the ap separated. In fourpatients, the entire ap was involved. Te eyelidswere allowed to heal without immediate surgicalintervention. In four patients whose dehiscencedid not involve the entire pedicle, the residualtarsoconjunctival ap was divided after 16 to 36days. Final cosmetic and functional outcomes wereacceptable for the majority of the patients in theseries. Te ndings suggest that elective divisionof the conjunctival pedicle in routine cases canconceivably be performed sooner after primaryreconstructive procedures than previously thought.

Leibovitch and Selva113reported the outcomesof early division of 29 eyelids of 29 patients 1 weekafter undergoing lower eyelid reconstructive surgerywith a modied Hughes ap. Te follow-up periodranged from 6 to 23 months. No cases of apischemia, necrosis, or retraction of the lower eyelidoccurred. Lower eyelid complications occurred intwo patients with margin erythema. In one of thetwo patients, margin hypertrophy required excision

and cautery. Upper eyelid complications includedthree cases of lash ptosis. One patient had lateralupper eyelid retraction of 2 mm requiring ananterior approach levator recession 3 months aftersurgery. In two patients, biopsies were obtainedfrom the central and distal tarsal components of theap at the time of division. Te biopsies showedviable vascularized tissue with no evidence

of ischemia.Maloof et al.116 described use of the Hughes

ap combined with oblique medial and lateralperiosteal aps in eight patients. Te use of medialand lateral periosteal aps was noted to be the keyelement in the procedure, facilitating the use of the

Hughes tarsoconjunctival ap to correct maximaldefects of the lower eyelid in cases in which bothmedial and lateral canthal tendons were absent. Teauthors named the procedure the maximal Hughesprocedure. Here is their description of the creation ofthe aps:

Te periosteal aps were elevated fromthe inferomedial and inferolateral orbitalmargins with the base of the ap locatedat the desired position of the medial

and lateral canthal tendons. Te medialperiosteal ap was elevated from theanterior aspect of the inferomedial orbitalrim, overlying the frontal process of themaxilla and passing inferolaterally alongthe orbital rim. Care was taken to ensurethat the ap remained at least 4 mmwide along its entire length. Once abovethe level of the medial canthal tendon,the margins of the ap followed anangled path from the anterior aspect ofthe frontal process of the maxilla to therim of the orbit above the nasolacrimalsac, where the ap was reected into theorbital base. Te ap was constructedin this fashion to reduce the chance ofmedial ectropion of the lower eyelid. Teaverage length of this medial periostealap was long, approximating 20 mm, totake into account the curvature at theproximal end of the ap. o produce a

horizontal attachment, the periostealap was then folded on itself, giving atotal length of approximately 15 mm.Te lateral periosteal ap was createdin the same fashion, by elevating anoblique strip of periosteum from thelateral orbital rim over the zygoma andpassing inferomedially along the orbital

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rim. Te periosteum was elevated abovethe former site of the lateral canthaltendon and reected into the base of theorbit. Unlike the medial ap, the lateralap did not need to follow an angledcourse and was not folded on itself. In

all cases, the lateral periosteal ap wasthicker than the medial ap. Te tarsuswas anchored medially and laterally tothe periosteal aps using interrupted5-0 polyglactin sutures. Te conjunctivawas sutured to the inferior border of thetarsal plate and inferior margin of theperiosteal aps using a continuous 7-0polyglactin suture. Te anterior lamellaof the lower eyelid was then mobilized

and sutured to the upper border of thetarsoconjunctival ap. Cases in whichskin was decient, an orbicularis muscleadvancement ap was mobilized anda full-thickness skin graft was usedto replace the anterior lamella. Tetarsoconjunctival ap was not divided forat least 8 weeks.116

Te average follow-up duration in that study was 13months (range, 722 months). All aps and graftsremained viable, and no patient experienced cornealcomplications or lagophthalmos. All patients had acosmetically acceptable appearance with excellenteyelid contour. In two patients who underwent skinmuscle advancements, late lower eyelid retractiondeveloped. Medial ectropion developed in onepatient at 4 months postoperatively.

ei and Larsen117 illustrated the use of aHughes ap with a nasolabial ap to reconstruct thelower eyelid and to cover a large accompanying skindefect in one case. Te defect measured 38 mm in

width and 30 mm in height and was reconstructedwith the use of a subcutaneously based nasolabialap. Te tarsoconjunctival ap was divided 3 weekspostoperatively. Tree months postoperatively, thepatient had neither ectropion nor entropion. Tevascular supply for the ap was derived from theinfraorbital artery and the anastomoses between thelateral nasal artery and branches of the infraorbital

artery.118Te advantages with the use of nasolabialaps were the inconspicuous donor scar concealedin the nasolabial fold, the reliable vascularity of theap, and use of a non-hair-baring area.

Mustarde Rotational Cheek Flap

Te Mustarde ap is a full-thickness rotationalcheek ap that can be used for complete lowereyelid reconstruction in one operation.43,119,120 It ismost valuable for correcting vertically deep defects,particularly those in which the vertical dimensionis greater than the horizontal dimension, and themore nasal defects.22,75 A large, nasal, superiorlybased triangle is outlined with the medial edge onthe nasolabial fold (Fig. 14). A semicircular ap isthen made, beginning at the lateral canthus and

continuing laterally down to the area anterior to theauricular tragus. Te superior edge should extendat least to the height of the brow or above. Temedial triangle is excised, but its size will dependon the amount of tissue needed to rotate the ap.Te semicircular ap is then undermined. Beforethe undermined tissue is rotated, a chondromucosalgraft or autogenous ear cartilage graft is obtainedfor posterior lamellae reconstruction and is suturedinferiorly to the conjunctival mucosa in the inferiorfornix. Alternatively, a tarsoconjunctival graft, hardpalate graft, or synthetic material such as AlloDermcan be used. Te cheek ap is then rotated nasally toll the nasal triangular defect. Te medial canthusis recreated by placing a 5-0 Vicryl suture throughthe dermis of the cheek ap and anchoring it to theposterior ramus of the medial canthal tendon or tothe periosteum of the medial orbital rim. Te graftused for the posterior lamellae is then sutured tothe posterior margin of the cheek ap at the new lidmargin. Running 5-0 plain catgut suture is placed

at the mucosal-epithelial border. Te lateral canthusis replaced by suturing the dermis of the rotationalap to the superior, inner aspect of the lateralorbital rim with lateral canthal xation. Te skinis then closed. Te lateral edge of the ap can beclosed with a V-to-Y conguration or a triangularexcision of redundant skin. o end with, the eyelidsare sutured together with a tarsorrhaphy stitch that

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provides added upward tension on the ap andeverts the mucosa skin interface. Te tarsorrhaphyand skin sutures can be removed after 5 days.75

Tripier FlapIn 1889, ripier121 described the original ripier apfor cases in which the posterior lamella is preservedbut anterior lamellae lower eyelid restoration isrequired. It consisted of dissecting and elevatinga bipedicled ap from the upper eyelid that wasthen transposed inferiorly into a lateral lower

eyelid defect (Fig. 15).122 Te ap consists of uppereyelid skin and orbicularis muscle. ripier121 statedthat for a successful ap, the number of facialnerve branches severed needed to be minimizedand it was desirable to maintain the continuityof the orbicularis muscle bers.123 He wrote that

defects of one-half or even two-thirds of thelower eyelid could be reconstructed by using thistechnique. Adaptations of this ap have since beendescribed.123127

In his original manuscript, ripier121 alsodescribed a second variation of the ap that wasused to reconstruct upper eyelid defects with amyocutaneous ap based on prefrontal orbicularisoculi muscle bers positioned superior to theeyebrow. Tat technique is no longer commonly

used.121123

Elliot and Britto123 described a third variationof the ripier ap for reconstruction of marginaldefects of the upper eyelid. Te authors reportedthe design of a bucket-handle ap immediatelyinferior to the eyebrow on the upper preseptal bersof orbicularis oculi. Te ap is designed identicallyto the ap used by ripier to reconstruct the lowereyelid but uses the tissues more superior and closerto the lower margin of the eyebrow.

Bickle and Bennett122 presented a fourth

ripier ap variation for reconstruction of a medialdefect on the lower eyelid. A medially basedmyocutaneous ap (including supercial bers ofthe orbicularis oculi muscle) was designed fromthe medial upper eyelid. Te ap was intentionallymade longer than necessary because, on rotation,it loses length. Te lower planned incision line wasplaced over the pretarsal crease. An incision wasmade from the defect on the lower eyelid extendingacross the medial canthus and onto the uppereyelid; the incision was then continued laterallyalong the pretarsal crease and curved upward andthen medially to complete the ap. Te ap waselevated and transposed into the defect on themedial aspect of the lower eyelid and then suturedinto place. A standing cone (dog ear) occurred atthe ap base in the medial canthus, but it could notbe excised at the time of ap placement because

Figure 14. Mustarde rotational cheek ap. Top, Shaded area

shows inerior eyelid deect. Middle, Nasal chondromucosal

grat is secured to the lateral orbital rim. The rotated ap is

anchored to the external lateral orbital rim. Bottom, Deect

is closed.

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doing so would compromise the vascular supplyto the ap. At 5 months follow-up, the lacrimalsystem was functional, and no eyelid malpositionhad occurred. Te authors stated that the residualdog ear would probably resolve on its own, althoughin some cases, if excessive, the dog ear might needto be injected with tr

vol 11 r2 eyelid

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