Atlas Phẫu Thuật Mí Mắt Và Hốc Mắt – Jonathan Dutton (2012)

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

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ibrary of Congress Cataloging-in- ublication ata
Dutton, Jonathan J.
Atlas o oculoplastic and orbital surgery / Jonathan J. Dutton ; T omas G. Waldrop, illustrator. — 1st ed.
p. ; cm.
Includes bibliographical re erences and index.
ISBN 978-1-4511-4312-6
I. itle.
[DNLM: 1. Eyelids—surgery—Atlases. 2. Orbit—surgery—Atlases. 3. Lacrimal Apparatus—surgery—
Atlases. 4. Ophthalmologic Surgical Procedures—methods—Atlases. 5. Reconstructive Surgical Proce-
dures—methods—Atlases. WW 17]
617.7'71—dc23
2012011414
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iii
About t he Illust rat or
THOMAS G. WALDROP, M.S.M.I., received his
Master o Science degree in medical illustration rom the
Medical College o Georgia in 1978. He directed the oph-
thalmic photography and ultrasound section o the Retina
Institute in St. Louis be ore establishing his medical illus-
tration service in Hillsborough, North Carolina, in 1980.
Since then, he has worked closely with Dr. Dutton on our
atlases and editions on ophthalmic surgery and anatomy.
Mr. Waldrop is an active pro essional member o the
Association o Medical Illustrators.
About t he Aut hor
JONATHAN J. DUTTON, M.D., Ph.D., is pro essor
and vice chair in the Department o Ophthalmology at
the University o North Carolina at Chapel Hill. He com-
pleted his master’s and doctorate degrees in zoology and
vertebrate biology, respectively, at Harvard University in
1970. He joined the aculty o Princeton University rom
1970 to 1973 as Sinclair Pro essor o Vertebrate Paleon-
tology and Evolutionary Biology. Between 1965 and 1973,
Dr. Dutton led 10 eld expeditions to East A rica and
published widely on vertebrate morphology and mam-
malian evolution. A ter receiving his M.D. degree in 1978
and going on to residency training in ophthalmology at
Washington University Medical School, he completed
a ellowship in oculoplastic and orbital surgery at the
University o Iowa. Dr. Dutton joined the aculty at the
Duke University Eye Center rom 1983 to 1999. He served
as CEO o the Atlantic Eye and Face Center in Cary North
Carolina rom 1999 to 2002 and then joined the aculty at
the University o North Carolina in 2002. He serves on the
editorial board o several ophthalmology journals, and is
Editor-in-Chief of Ophthalmic Plastic and Reconstructive
Surgery. Dr. Dutton specializes in oculoplastic reconstruc-
tive and orbital surgery and periorbital and ocular oncol-
ogy. He has published eight books on ophthalmic surgery,
anatomy, radiology, eyelid, and orbital disease, and has con-
tributed more than 150 peer reviewed articles in scienti c
journals.

iv
Preface
T
his atlas is an updated version o a book originally pub-
lished in 1992 as part o a our-volume set on ophthalmic
surgery. T at version has been out o print or several years.
In the present version we have updated many procedures,
eliminated some that are no longer in general use, and added
12 new procedures that have gained popularity during the
past decade. As in the original version, this book presents a
visual guide to ophthalmic plastic and reconstructive surgery.
We present basic oculoplastic eyelid, lacrimal, and orbital
procedures in a manner that will provide a quick and read-
ily comprehensible re erence. T ere is no attempt at exhaus-
tive compilation o procedures, many hundreds o which have
been described. Instead, or each group o disease processes
or anatomical conditions we have selected those operations
that have withstood the tests o time and numbers and that
most oculoplastic surgeons have ound particularly use ul.
We do not intend this book primarily or the trained
oculoplastic specialist who is amiliar with a variety o sur-
gical procedures. Rather, we direct it at the less experienced
surgeon in oculoplastic procedures, in particular residents
in training, as well as those who may per orm these opera-
tions in requently, such as the general ophthalmologist,
otolaryngologist, dermatologist, and some general plastic
surgeons.
T e atlas is organized into three major sections: eye-
lid surgery, lacrimal system surgery, and orbital surgery.
Most o the eyelid procedures are grouped according to
the disease processes they correct, such as blepharoptosis
or ectropion. Lacrimal drainage operations are grouped
according to the anatomic location o the blockage; or
example punctal, canalicular, and nasolacrimal duct. Deep
orbital operations are arranged mainly by the route o
access into the most important surgical spaces, not by spe-
ci c pathologic processes.
Each major section or part begins with a discussion o
relevant surgical anatomy, illustrated with sequentially lay-
ered gures through the relevant structures. It is dif cult to
per orm any surgery optimally without a solid understand-
ing o local anatomic and physiologic relationships. T ese
anatomical chapters provide oundations or understand-
ing the surgical descriptions that ollow.
For each group o related procedures, there is a discus-
sion o etiologic pathology and techniques o preoperative
evaluation that are indispensable or planning any surgi-
cal approach. T e proper selection o a speci c operation
or any given disease or malposition o ten means the di -
erence between success and ailure. T ere ore, the text
includes key points that will help the reader plan the most
appropriate operation and minimize unnecessary com-
plications. We conclude each section with a short list o
selected re erences or those interested in urther readings.
Following the general discussion o the disease or condi-
tion, we detail our approach to the operative techniques in
stepwise ashion, with captioned text on the le t-hand page
and matching illustrations on the right-hand page. In the
original version o this book, we introduced the concept
o inverting the gures. Again, here, we depart rom the
standard approach o illustrating oculoplastic procedures
acing the patient in the upright position. Rather, we draw
illustrations rom the view as seen by the operating sur-
geon, which in most cases is standing at the patient’s head.
T e image is thereby seen “upside-down,” but best approxi-
mates the view seen by the surgeon. For some operations,
such as dacryocystorhinostomy or lateral orbitotomy, the
view is rom the side, again approximating the surgeon’s
perspective. We believe that this eases the transition rom
the printed page to the operating table.
In a ew cases, certain eponyms are so intrinsic to the
literature that deleting them would be con using. For the
most part, however, eponyms are nondescriptive and con-
vey little use ul in ormation. T ere ore, we have elected to
replace most o them with more anatomically meaning ul
descriptive terms. For each operation, we also include a
brie list o the most appropriate indications and, in some
cases, contraindications. Following a description o the
technique, we indicate appropriate postoperative care. In
addition, we list the most common potential complica-
tions, along with a brie discussion o how to avoid and
correct them.
T e number o individuals who have contributed inno-
vative approaches to the eld o oculoplastic and recon-
structive surgery is legion, and use ul modi cations o
older procedures requently appear in the literature. Few
operations described in this book are new, and in most
cases, we have merely compiled the cumulative experi-
ences o our colleagues. We are indebted to their vision
and dedication.
Jonathan J. Dutton, M.D., Ph.D., and
T omas G. Waldrop, M.S.M.I.

23. External Levator Aponeurosis Advancement 88
24. Supra-Whitnall’s Ligament Levator
Muscle Resection 92
25. Harvesting Autogenous Fascia Lata 96
26. Frontalis Muscle Suspension with Autogenous
Fascia Lata 98
27. Frontalis Muscle Suspension with Silicone
Rod 102
H. E pi 104
28. Lateral Tarsorrhaphy 106
29. Eyelid Shortening by Lateral Tarsal Strip
Fixation 108
30. Medial Spindle Tarsoconjunctival
Resection 110
31. Full-thickness Marginal Wedge Resection 112
32. Modi ed Lazy-T Procedure 114
33. Medial Canthal Ligament Plication 116
34. Temporal Fascia Lower Eyelid Suspension 118
35. Anterior Lamellar Eyelid Lengthening
with Skin Graft 120
. E pi 123
36. Full-thickness Eyelid Sutures
(Quickert-Rathbun) 126
37. Modi ed Full-thickness Eyelid Sutures
for Epiblepharon Repair 128
38. Lower Eyelid Crease Reformation for Epiblepharon
Correction 130
39. Lower Eyelid Retractor Reinsertion 132
40. Retractor Reinsertion with Horizontal
Eyelid Shortening 134
41. Retractor Reinsertion with Lateral Tarsal Strip
Fixation 136
42. Anterior Lamellar Shortening with Epitarsal
Muscle Fixation 138
43. Marginal Eyelid Rotation by Anterior
Horizontal Tarsal Groove Resection 140
44. Horizontal Blepharotomy with Marginal Eyelid
Rotation (Wies Procedure) 142
45. Posterior Lamellar Eyelid Lengthening with
Free Tarsoconjunctival, Scleral, or Cartilage
Graft 144
46. Posterior Eyelid Lengthening with Mucous
Membrane Graft 146
J. i Ey id R i 148
47. Levator Aponeurosis Recession with Müller’s
Muscle Extirpation 150
Cont ent s
About the Author/About the Illustrator iii
Preface iv
PART I Eyelid Surgery 1
. i 3
1. Anesthesia in Ophthalmic Plastic Surgery 4
B. S gi my Ey id 6
2. Eyelid Anatomy 7
. H d m d zi 25
3. Chalazion Incision and Drainage, Transcutaneous
Approach 26
4. Chalazion Incision and Drainage, Transconjunctival
Approach 28
D. T i i i d Di i i i 30
5. Cryosurgery for Trichiasis 32
6. Radiosurgery for Trichiasis 34
7. Internal Eyelash Bulb Resection 36
E. m i B p p y 38
8. Etiology and Associated Deformities 40
9. Upper Eyelid Blepharoplasty with Fat Excision 42
10. Asian Upper Eyelid Blepharoplasty 46
11. Re xation of Lacrimal Gland Prolapse 48
12. Reformation of the Upper Eyelid Crease 50
13. Lower Eyelid Blepharoplasty with Fat Excision 52
14. Lower Eyelid Blepharoplasty with Fat
Redraping 56
15. Lower Eyelid Blepharoplasty with Eyelid
Shortening 60
16. Lower Eyelid Blepharoplasty with Lateral
Canthopexy 64
17. Transconjunctival Excision of Lower Eyelid
Herniated Orbital Fat 68
F. B w i 70
18. Direct Brow Elevation 72
19. Transblepharoplasty Endotine Brow Fixation 74
20. Endoscopic Forehead Elevation 76
G. B p p i 80
21. Posterior Tarsoconjunctival Resection
(Fasanella-Servat) 84
22. Posterior Müller’s Muscle–Conjunctival
Resection 86
v

B. S g y L im d
i i 220
73. Two-snip Punctoplasty 222
74. Repair of Canalicular Lacerations 224
75. Canalicular Reconstruction 228
. S g y L im S d
D 230
76. Nasolacrimal System Probing, with Infracturing
of the Inferior Turbinate 232
77. Nasolacrimal System Probing with Silicone
Intubation Stents 234
78. Nasolacrimal System Balloon Dacryoplasty 236
79. Dacryocystorhinostomy 238
80. Canaliculodacryocystorhinostomy 242
81. Conjunctivodacryocystorhinostomy 244
PART III Orbital Surgery 247
. S gi my O i 250
82. Surgical Anatomy of the Orbit 252
B. O i my d 270
83. Transcutaneous, Transseptal Anterior
Orbitotomy 272
84. Transcutaneous, Transperiosteal Anterior
Orbitotomy 274
85. Lateral Orbitotomy 276
. S g y O i W 281
86. Orbital Decompression, Inferior
and Medial Walls 284
87. Orbital Decompression, Transcaruncular Medial
Wall 290
88. Orbital Decompression, Transconjunctival
Inferior Wall 292
89. Orbital Decompression, Lateral Wall 294
90. Repair of Orbital Floor Fracture 296
91. Miniplate Fixation for Orbital Rim Fracture 298
92. Subperiosteal Orbital Volume
Augmentation 300
D. E i , Evi i ,
d Ex i 302
93. Enucleation with Primary Acrylic or Silicone
Implant 306
94. Enucleation with Biointegrated Porous Ocular
Implant 310
95. Dermis-fat Orbital Implant Graft 312
96. Repair of the Exposed Ocular Implant 314
97. Evisceration 316
98. Orbital Exenteration 318

d x 321
48. Lower Eyelid Retractor Disinsertion with Scleral
Graft 154
49. SMAS Midface Elevation and Fixation 156
K. R p i S p N -m gi
Ey id 158
50. Simple Direct Closure of an Elliptical Skin
Defect 160
51. Myocutaneous Advancement Flap 162
52. Myocutaneous Rotation Flap 164
53. Myocutaneous Transposition Flap 166
54. Rhombic Flap 168
55. Z-plasty Transposition Flap 170
L. Upp Ey id R i 172
56. Direct Layered Closure of Marginal Eyelid
Defects 174
57. Lateral Semicircular Rotation Flap (Tenzel) 176
58. Horizontal Tarsoconjunctival Transposition
Flap 178
59. Free Tarsoconjunctival Graft 180
60. Lower Eyelid Single Bridged Advancement Flap
(Cutler-Beard) 182
61. Lower Eyelid Double Bridged Advancement
Flap 184
M. L w Ey id R i 186
62. Lateral Semicircular Rotation Flap with Periosteal
Fixation 188
63. Free Tarsoconjunctival Graft and Myocutaneous
Advancement Flap 190
64. Upper-to-lower Eyelid Tarsoconjunctival
Advancement Flap (Hughes Procedure) 192
N. M di d L
R i 196
65. Reduction of Epicanthal Folds
with Y to V Advancement Flap 198
66. Reduction of Epicanthal Fold
by Four- ap Technique 200
67. Lateral Augmentation Canthoplasty 202
68. Lateral Reduction Canthoplasty 204
69. Correction of Vertical Canthal Angle
Dystopia 206
70. Glabellar Rotation Flap 208
71. Median Forehead Transposition Flap 210
PART II Lacrimal Drainage System
Surgery 213
. S gi my L im D i g
Sy m 215
72. Surgical Anatomy of the Lacrimal Drainage
System 216
Contents
vi

P

A

R

T
I
Eyelid
Surgery

HE EYELIDS ARE COMPLEX ANA OMIC S RUC URES HA PERFORM A VI AL
unction o ocular protection. T ey provide a mechanical barrier against sun-
light and oreign material. T e eyelids also contribute to the physiologic main-
tenance o the corneal sur ace and precorneal tear lm. Adequate unction o the
eyelids requires the integrity o numerous structural components, proper alignment
with the globe, and the coordination o several dif erent neuromuscular groups.
Many congenital and acquired de ormities can af ect the eyelids. Some result rom
normal aging phenomena such as canthal ligament laxity, involutional ptosis, prolapse
o orbital at, or redundancy o eyelid skin. Others may ollow traumatic injury or be
associated with periocular mani estations o systemic diseases, such as thyroid orbi-
topathy. When mild, as with minimal ptosis, or dermatochalasis, these de ormities may
be o cosmetic concern only. When severe, however, they may signi cantly inter ere
with vision. In some cases, eyelid malpositions or de ormities may cause corneal injury
and permanent loss o vision. It is important to remember that some eyelid abnormali-
ties result rom deeper orbital pathologic processes. T us, subtle proptosis can mimic
eyelid retraction, and enophthalmos may initially be con used with ptosis.
Complete evaluation o the eyelid and the orbit is essential be ore consideration o
any oculoplastic operation. As with all ophthalmic procedures, a best-corrected visual
acuity must be recorded be ore proceeding urther with any examination. A complete
medical and ophthalmic history is taken, and a current list o medications is noted.
T ere is some disagreement in the literature regarding the need to stop anticoagulation
therapy prior to oculoplastic surgery. T ese days as many as 60% o individuals may be
on such medications, most o them or nonmedical reasons. Most o ten, this may be
a low-dose aspirin or prophylactic purposes. In such cases, it is reasonable to ask the
patient to discontinue aspirin use 7 to 10 days prior to surgery. However, i the patient
is on anticoagulation or medical reasons, such as recently placed arterial stents, pul-
monary embolism, recent stroke, or deep venous thrombosis, then the risks o bleeding
must be weighed against the risk o a thromboembolic event. For procedures with a
low risk o bleeding and negligible consequences such as ptosis or blepharoplasty, and
a higher risk o thromboembolism, it is usually best not to discontinue anticoagulation.
T is approach has been documented extensively in the surgical literature. On the other
hand, or cases at higher risk o bleeding or those with a greater consequence rom
bleeding, such as deep orbital surgery or procedures on vascular tumors, i the risk o
thromboembolism is low to moderate, it may be possible to stop anticoagulation with
or without bridge therapy, with the consultation o the patient’s cardiologist or primary

2
care physician. In cases at high risk or both bleeding and a thromboembolic event, it
may be better to postpone the surgery until the patient can more sa ely be taken of
these medications.
T e eyelids are examined in the primary position and in all other positions o gaze.
T e height, contour, tone, and orientation o the eyelid margins are noted. Levator
muscle unction, associated dystonic movements, and synkinetic contractions with
ocular motility or acial movements are care ully documented. Unsuspected anterior
orbital pathologic processes may be revealed by palpation and eversion o the eye-
lids. A slit lamp examination is essential to determine either ocular sur ace or anterior
segment disease that may result in secondary eyelid dys unction, or to establish the
extent o corneal injury rom eyelid malpositions. A Schirmer’s test or baseline tear
production is important in estimating the potential ef ect o eyelid repair, especially in
elderly patients. Specialized tests must be employed or certain disease states, such as
the Jones’ tests in lacrimal drainage disorders and orbital radiology or echography or
suspected orbital extension o eyelid lesions.
For most cases where oculoplastic surgery may be indicated, preoperative photo-
graphs should be taken or documentation and are usually required or third-party
reimbursement. In cases o eyelid and brow ptosis, visual eld testing is important or
documentation and is usually done with the brows in normal position and elevated.
In cases o traumatic loss or surgical injury rom excision o tumors, the size and
location o the de ect are recorded, as is any involvement o associated structures, such
as the levator aponeurosis, canthal ligaments, or the lacrimal drainage system. T e
visual status o the opposite eye and the condition o adjacent tissues, including laxity
or the presence o any pathologic process, must be noted because these may af ect the
choice o operative technique.
In all cases o eyelid reconstruction, choosing the appropriate surgical procedure is
critical to success ul treatment. Numerous etiologies may be responsible or any ana-
tomic disorder, and each may require a dif erent approach to therapy. In some cases,
medical management may be more appropriate than surgical intervention. T ere ore,
in the sections below, we discuss the speci c causes o each condition and attempt to
provide some rationale or determining the most suitable operation. Where appropri-
ate or each disorder, there is urther discussion o preoperative evaluation and speci c
diagnostic tests. ▼

A
3
Anesthesia
SECTION

1
4
1
rior orbitotomy, placement o a secondary ocular implant,
and most eyelid reconstructions.
A small amount o local anesthetic with epinephrine
injected into the operative site will acilitate hemostasis
and make the surgery considerably easier. T is is recom-
mended even on general cases. Local inf ltrative or retro-
bulbar anesthetic with epinephrine is administered 5 to
10 minutes be ore surgery. With orbital procedures, such
as enucleation, this will allow a nearly bloodless dissection
and will reduce the risk o vagal-induced bradycardia dur-
ing traction on the extraocular muscles. We avoid the use
o epinephrine on other orbital cases so that we can moni-
tor pupillary reaction during the case.
Regional and local anesthetic agents work by blocking
sodium conduction and inhibiting membrane excitation
in peripheral nerves. With the exception o cocaine, these
agents cause vasodilatation and are there ore usually mixed
with epinephrine in a concentration o 1:100,000 or less or
local hemostasis. T e surgeon must be aware o the poten-
tial systemic e ects and toxic doses o local anesthetics,
especially in major reconstructive procedures where larger
amounts must be used. oxicity is generally mani est by
cardiac dys unction and cortical inhibitory neuron block-
ade with central nervous system excitation. T e patient may
experience syncope and become agitated and uncoopera-
tive. Sel -limited ocal seizures may ollow. At higher toxic
levels, depression o autonomic centers may lead to apnea
and hypotension requiring ull cardiopulmonary support.
T e maximum sa e limit or initial injection o 2% lidocaine
is about 15 mL (4 mg/kg). In the presence o epinephrine,
this can be increased to 20 mL. I additional anesthetic
is required during the case, no more than 5 to 10 mL/h
should be administered. For 1% lidocaine, these values can
be doubled. Allergic reactions to local anesthetic agents are
rare and mani est as rashes, hives, edema, dyspnea, tachy-
cardia, and hypotension. In most cases, these are managed
with corticosteroids and antihistamines.
Epinephrine is usually added to the local anesthetic
because o its vasoconstrictive properties. T is not only
provides hemostasis but also helps to slow the absorption o
the inf ltrative agent, thus prolonging its duration o action.
T e typical dilution in most anesthetic agents is 1:100,000
to 1:200,000. T is can be associated with potential systemic
complications including apprehension, tremor, tachycardia,
and extra systoles as possible sequelae. Elevation o blood
pressure may lead to excessive bleeding. T e use o epineph-
rine should be limited or omitted in patients with signif -
cant hypertension or a known history o cardiac arrhythmia.
Dilution to 1:400,000 will reduce systemic complications
without signif cantly reducing its local hemostatic e ect.
T
he general principles o surgical anesthesia apply in
ophthalmic plastic procedures as in any other surgery.
Presurgical evaluation, including a detailed medical history
and current medications list, is mandatory or determining
patient risk. Patients with hypertension, diabetes, and other
systemic illnesses should be under adequate control be ore any
elective operations. T e patient's age, level o apprehension,
and ability to cooperate and the nature and potential length o
the operative procedure will in uence the type o anesthesia
selected. For all local monitored and general anesthetic cases,
the anesthesiologist should participate ully in the preopera-
tive evaluation and in the intraoperative care o the patient.
Success ul surgery depends on not only surgical skill and
technique but also patient com ort and cooperation and
on minimizing intraoperative and postoperative bleeding.
T is is especially important in oculoplastic surgery where
the majority o procedures are per ormed under local anes-
thesia with monitored anesthesia care. Premedication or
both local and general anesthesia will relax the patient
and allay inevitable anxiety. T is is usually managed by
the anesthesiologist in all general and local standby cases
per ormed in a hospital or surgicenter setting. For o ce
procedures, a mild sedative such as 5 or 10 mg o valium
given by mouth 60 minutes be ore surgery may be used i
desired.
opical anesthesia can minimize the discom ort asso-
ciated with local injection o anesthetic agents. EMLA
(topical lidocaine 2.5% and prilocaine 2.5%) applied 30
to 60 minutes be ore the procedure or ice compresses or
10 minutes can reduce the pain o local needle injection.
General anesthesia is necessary or young children
and pre erred or adults undergoing lengthy procedures
or deeper orbital surgery. It is also use ul when surgery is
planned on multiple sites, as with harvesting oral mucosa or
large skin gra ts. Although certain procedures such as enu-
cleation are easily per ormed with local or regional anes-
thetic, the emotional trauma o losing an eye o ten makes
general anesthesia pre erable in most cases. T e choice o
any general anesthetic agent is usually le t to the discre-
tion o the anesthesiologist. T is will be determined by the
patient's age, general medical condition, and prior anes-
thetic history. T e anesthesiologist should be requested
to maintain systemic blood pressure within the normal
to low-normal range during surgery. For more extensive
dissections or or orbital procedures, blood pressures in
the hypotensive range may be benef cial, especially when
anticipating vascular lesions. However, many procedures
traditionally per ormed under general anesthetic can be
per ormed equally as well with local inf ltration or regional
nerve blocks. T ese include dacryocystorhinostomy, ante-
Anesthesia in Ophthalmic Plastic Surgery

5
CHAP ER 1 ▼ Anesthesia in Ophthalmic Plastic Surgery
whose ull unction may be needed during the operation. I
desired, orbital nerve blocks should be given at their oram-
inal exit points around the bony orbital rims rather than
deeper in the orbit.
Inhalation anesthesia with nitrous oxide or other agents
is use ul or short procedures in children and in adults
where inf ltrative or ull general anesthesia is not desirable.
It may also be used prior to local anesthetic inf ltration to
avoid the use o narcotics and sedatives in elderly patients
or in those with cardiovascular diseases.
SUGGESTED FURTHER READING
Bramhall J. Regional anesthesia or aesthetic surgery. Semin Cutan Med
Surg. 2002;21:3–26.
Cohen AJ. Oculoplastic and orbital surgery. Ophthalmol Clin N Am.
2006;19:257–267.
Covino BG. Pharmacology o local anesthetic agents. Ration Drug T er
1987;21:1–9.
Deleuze A, Gentili ME, Bonnet F. Regional anesthesia or head and neck
surgery. Ann Fr Anesth Reanim. 2009;28:818–823.
Ehlert K, Arnold DE. Local anesthetic agents. Br J Anesth. 1990;23:
831–844.
Harmatz A. Local anesthetics: uses and toxicities. Surg Clin N Am.
2009;89:587–598.
Kaweski S. opical anesthetic creams. Plast Reconstr Surg. 2008;121:
2161–2165.
Mustoe A, Buck DW II, Lalonde DH. T e sa e management o anes-
thesia, sedation, and pain in plastic surgery. Plast Reconstr Surg.
2010;126:165e–176e.
Quaba O, Huntley JS, Bahia H, McKeown DW. A users guide or reduc-
ing the pain o local anesthetic administration. Emerg Med J. 2005;
22:188–189.
Ramos-Zabala A, Perez-Mencia M , Fernandez-Garcia R, et al. Anesthesia
techniques or outpatient laser resur acing. Lasers Surg Med. 2004;
34:269–272.
Sar akioglu N, Sar akioglu E. Evaluating the e ects o ice application
on the pain elt during botulinum toxin type-a injections: a pro-
spective randomized, single-blind controlled trial. Ann Plast Surg.
2004;53:543–546.
Shapiro FE. Anesthesia or outpatient cosmetic surgery. Curr Opin
Anaesthesiol. 2008;21:704–710.
Suresh S, Voronov P. Head and neck blocks in children: an anatomical and
procedural review. Paediatr Anaesth 2006;16:910–918.
T orne AC. Local anesthetics. In: Aston SJ, Beasley RW, T orne CHM,
eds. Grabb and Smith's Plastic Surgery. Philadelphia, PA: Lippincott-
Raven; 1997:99–103.
Local anesthesia is appropriate or most ophthalmic
plastic procedures and may be used in cooperative chil-
dren as young as 6 years o age. Agents are usually o the
amino amide class with a rapid onset o action and dura-
tion o action o 1 to 4 hours. We pre er to use lidocaine 2%
with 1:100,000 epinephrine mixed 50:50 with bupivacaine
0.75%. T is gives anesthesia or 4 to 8 hours with minimal
epinephrine side e ects. Adequate topical anesthetic to the
corneal sur ace should be used throughout local surgery
with topical proparacaine or tetracaine.
T e major site o local anesthesia used in oculoplastic
eyelid surgery is the pretarsal subcutaneous block. It pro-
vides excellent anesthesia to the anterior lamella, including
the skin, orbicularis muscle, and orbital septum, and also
the anterior tarsal sur ace. T e posterior tarsal sur ace and
conjunctiva usually remain sensitive. It is important to use
as little anesthetic agent as possible to avoid tissue distor-
tion. In general, 0.5 to 1.0 mL is su cient or most unilateral
eyelid procedures such as correction o ptosis, entropion
repair, or blepharoplasty. Massage o the area immediately
ollowing injection will help disperse the bolus and prevent
hematoma. T e use o hyaluronidase in the local anesthetic
will urther disperse the bolus and restore the eyelid to
near-normal anatomy prior to incision.
When anesthesia is needed or surgery on the palpe-
bral conjunctiva or posterior tarsal sur ace, a retrotarsal
block is indicated. In this procedure, the local anesthetic
is injected subconjunctivally along the proximal tarsal bor-
der or subconjunctivally in the ornix. T is block does not
anesthetize the skin or orbicularis muscle so that or ull-
thickness eyelid procedures the retrotarsal block must be
combined with subcutaneous inf ltration. With injection
into Müller's muscle, bleeding is more common and digital
pressure over the injection site should be maintained or
several minutes.
Orbital nerve blocks, such as rontal, supratrochlear,
or in raorbital, provide excellent regional anesthesia
without distortion o tissues but do not allow or local
epinephrine-induced hemostasis. When placed into the
anterior orbit, they also carry the risk o orbital hemorrhage
and paralysis o orbital muscles, such as the levator muscle,

6
SECTIONB
Surgical Anatomy of the
Eyelids

7
Horner's muscle. Reconstruction in the canthal areas must
take these relationships into consideration. Normal tone in
the orbicularis muscle is essential, not only or proper eye-
lid closure and apposition to the cornea but also or unc-
tioning o the lacrimal pump mechanism. T is is especially
true or the lower eyelid, where gravitational ef ects act-
ing upon even minimal eyelid laxity or orbicularis muscle
weakening may result in symptomatic ectropion.
T e postorbicular ascial plane is an avascular, loose
areolar tissue layer between the orbicularis muscle and
the orbital septum–levator aponeurosis ascial complex.
It anatomically separates the eyelid into an anterior skin–
muscle lamella and a posterior tarsoconjunctival lamella.
It is an important surgical re erence plane during eye-
lid surgery, and it allows nearly bloodless dissection and
identi cation o the underlying orbital septum. T is plane
extends to the eyelid margin where it is represented as the
gray line. Occasionally, the subbrow at pad may extend
into the upper eyelid within this plane where it overlies the
orbital septum. In such cases, it may be misidenti ed as
the preaponeurotic at pockets that are situated posterior
to the septum. When this happens, the septum might be
thought to be the aponeurosis, which could have disastrous
consequences in some surgical procedures.
T e orbital septum is a thin, connective tissue mem-
brane that separates the eyelid proper rom the orbit.
It originates around the bony orbital rim where it arises
rom a dense brous adhesion ring, the arcus marginalis.
T e latter is the point o con uence o the acial perios-
teum, orbital periorbita, the galea aponeurotica rom the
orehead and scalp, and the orbital septum. Superiorly, the
septum passes into the upper eyelid, where it inserts onto
the levator aponeurosis 3 to 5 mm above the upper tarsal
border in Caucasians, and lower in Asians. In the lower
eyelid, the septum usually inserts directly onto the in erior
edge o the tarsus, where it uses with the capsulopalpebral
ascia, although it may insert onto the latter prior to join-
ing the tarsal plate. T ese relationships are important to
note because advancement o the aponeurosis or capsulo-
palpebral ascia without rst separating the septum could
cause a tethering o the lid to the orbital rim with resultant
lagophthalmos. At the canthal angles, the septum divides
into two layers. T e anterior layer inserts onto the brous
canthal ligament, and the posterior layer passes back in
company with the deep heads o the orbicularis muscle to
insert onto the posterior lacrimal crest medially and the
orbital tubercle laterally.
T e preaponeurotic at pockets in the upper eyelid and
the precapsulopalpebral at pockets in the lower eyelid
are anterior extensions o extraconal orbital at. T ey are
S
urgery on the eyelids and periorbital tissues requires a
thorough knowledge o normal anatomic structural and
unctional relationships. Numerous anatomic systems are
tightly juxtaposed within a very small space, and even under
ideal circumstances normal anatomy may be di cult to inter-
pret. Success ul surgery demands correction o pathologic
states while preserving or reconstructing normal structures
whenever possible.
T e interpalpebral ssure measures 9 to 12 mm in
vertical height and 28 to 30 mm in horizontal extent. In
primary position o gaze, the normal upper eyelid margin
lies at the superior corneal limbus in children and 1.5 to
2 mm below it in the adult. T e marginal contour reaches
its highest point just nasal to the midpupil. T e lower eye-
lid margin normally rests at the in erior corneal limbus.
T ese relationships must be kept in mind during repair or
reconstruction o eyelid malpositions.
T e upper eyelid crease is a horizontal old in the skin
caused by attachments o super cial levator aponeurotic
bers to orbicularis intermuscular septa. Normally the
crease lies 8 to 10 mm above the eyelid margin. In non-
Asian eyelids, this crease should be re ormed during pto-
sis or blepharoplasty surgery to maintain normal cosmetic
appearance and to prevent overhang o eyelid skin. In the
Asian eyelid, this crease is either lower in position or absent,
because o the more distal insertion o the orbital septum
and the in erior extension o extraconal orbital at. A less
well-de ned crease is present in the medial two-thirds
o the lower eyelid. T ese creases are important in eyelid
unction, as they maintain a union o the anterior and pos-
terior eyelid lamellae. T is prevents overhang o skin and
mechanical entropion or secondary epiblepharon. During
any procedure on the eyelids in which the skin–muscle
lamella is elevated rom underlying tissues, re ormation o
this crease is important to avoid these complications.
T e orbicularis oculi is a complex, striated muscle
sheet lying just beneath the eyelid skin. It is innervated by
the temporal and zygomatic branches o the acial nerve,
with some variable contribution rom the buccal branch.
T e muscle is divided anatomically into an orbital portion
overlying the bony orbital rims and a palpebral portion
within the mobile portion o the eyelid. T e latter is ur-
ther somewhat arbitrarily subdivided into a preseptal por-
tion overlying the orbital septum and a pretarsal portion
overlying the tarsus. T e pretarsal portion ends medially
and laterally in slips that pass posterior to the main inser-
tions o the preseptal bers. T ese slips orm components
o the posterior crura o the canthal ligaments and tighten
the eyelids against the globe. T e medial slip is especially
well developed and orms a distinct structure known as
2
Eyelid Anatomy

SEC ION B ▲ Surgical Anatomy of the Eyelids
8
surgically important landmarks because they help identi y
a plane immediately anterior to the major eyelid retractors.
In the upper eyelid, these at pockets lie just in ront o the
levator aponeurosis, thus creating a relationship that is
essential to remember during eyelid surgery under general
anesthesia, or in cases o eyelid trauma where other normal
anatomic relationships may be distorted. With weakening
and redundancy o the orbital septum, these at pockets
bulge orward, producing the puf y and baggy eyelids seen
commonly in the elderly and as a amilial trait in some
younger individuals.
In the upper eyelid, the levator palpebrae superioris
muscle arises rom the lesser sphenoid wing and passes
orward in close approximation to the superior rectus
muscle. Just behind the superior orbital rim, the leva-
tor muscle widens, and a variably thickened condensa-
tion is seen in the muscle sheath. T is structure runs
horizontally across the superior orbit both anterior and
posterior to the levator muscle. It attaches medially to
the ascia around the trochlea and to the surrounding
orbital bone. Laterally it inserts onto the capsule o the
lacrimal gland and to the periosteum o the rontal bone.
T is structure orms the superior transverse orbital liga-
ment o Whitnall and provides support or the eyelid and
levator aponeurosis and or the anterior portion o the
extensive superior orbital ascial system. Except in some
older levator resection procedures, this ligament should
never be cut.
At Whitnall's ligament, the levator muscle passes into
its brous aponeurosis, which continues downward some
14 to 20 mm to the tarsus. Near the upper tarsal border,
the aponeurosis sends slips orward to insert onto the
intermuscular septa o the pretarsal orbicularis muscle.
As mentioned earlier, on retraction o the lid, these slips
pull on the muscle and skin to orm the eyelid crease. T e
aponeurosis inserts into the tarsus along the lower two-
thirds o its anterior sur ace, but most signi cantly along
the lower one-third. Distally, the aponeurosis broadens
into the medial and lateral “horns,” which insert behind
the canthal ligaments. T ese are usually cut during levator
muscle resection surgery and with large advancements o
the aponeurosis, and they must not be con used with the
more superior attachments o Whitnall's ligament.
In the lower eyelid, the capsulopalpebral ascia is a
brous, sheet-like extension rom Lockwood's in erior
orbital suspensory ligament and is the analogue o the leva-
tor aponeurosis. Lockwood's ligament is a condensation o
the coapted sheaths around the in erior rectus and in erior
oblique muscles and their pulley systems and traverses the
in erior orbit. T e capsulopalpebral ascia passes upward
to insert onto the lower border o the tarsus along with
the in erior orbital septum. Fine, brous slips pass rom
this ascial sheet to the orbicularis intermuscular septa,
thus orming the lower eyelid crease. Medially and later-
ally broad extensions contribute to the posterior crura o
the canthal ligaments, as do slips rom the superior septum
and the horns o the aponeurosis in the upper eyelid.
Immediately posterior to the levator aponeurosis in the
upper eyelid and the capsulopalpebral ascia in the lower
eyelid is the sympathetic smooth muscle o Müller. T is
is an accessory retractor o the eyelid and is responsible
or the minimal upper eyelid ptosis and lower lid elevation
seen in patients with Horner's syndrome. In the upper eye-
lid, Müller's muscle is a thin, highly vascular sheet arising
rom Whitnall's ligament and the distal-most bers o the
levator muscle. It extends to the upper border o the tarsal
plate. A ne membrane extends downward rom Müller's
muscle anterior to the tarsus and may be considered as
its tendon. In the lower eyelid, Müller's muscle is less well
developed and may be di cult to identi y intraoperatively.
T e tarsal plates consist o dense, brous tissue that
gives structural integrity to the eyelids. A replacement
or this structure is important in reconstructive proce-
dures, especially in the lower eyelid. T e vertical height o
the plate is 8 to 10 mm in the upper eyelid and 3 to 4 mm
in the lower. Medially and laterally the tarsus passes into
brous strands that, with the super cial and deep heads
o the orbicularis muscle, orm the canthal ligaments. T e
lateral canthal ligament is especially imsy and with age
requently becomes redundant, thus causing laxity o the
lower eyelid. Reestablishment o lateral canthal support is
essential in reconstruction o the lower eyelid and in cor-
rection o involutional laxity to success ully counter the
ef ects o gravity.
T e conjunctiva is a mucous membrane that covers the
posterior sur ace o the eyelids. T e palpebral portions lie
immediately posterior to the tarsal plates and the sympa-
thetic muscles o Müller and continue into the ornices,
where they join the bulbar conjunctiva. At the superior
ornix is a suspensory ligament, which consists o ascial
strands and smooth muscle cells arising rom the con-
joined sheaths o the levator and superior rectus muscles.
T e in erior ornix suspensory ligament arises rom Lock-
wood's ligament. T ese suspensory structures must be
reconstructed during certain procedures to prevent con-
junctival prolapse.
Vascular supply to the eyelids is extensive. T e posterior
eyelid lamellae receive blood primarily via the lacrimal and
nasal branches o the ophthalmic artery, with anastomotic
connections rom the anterior ciliary arteries through the
conjunctiva. In the upper eyelid, two arterial arcades are
present: the marginal arcade along the lid margin and the
peripheral arcade along the upper border o the tarsus. In
the lower eyelid, usually only a marginal arcade is present,
and a peripheral arcade may be seen as a variant. In each
eyelid, the arcades are ed by the medial and lateral pal-
pebral arteries. Whenever possible, at least one o these
eeding vessels should be preserved during eyelid recon-
structive procedures, although vascular compromise is
rarely seen even when both eeding vessels are sacri ced.
T e anterior eyelid lamellae also receive blood rom the
super cial carotid system through the transverse acial,
super cial temporal, and angular arteries, which anasto-
mose with the deep orbital system near the medial and

9
CHAP ER 2 ▼ Eyelid Anatomy
rom the superior division o the oculomotor nerve, and
Müller's muscle receives dif use sympathetic branches pri-
marily via the internal carotid system along various orbital
nerves and arteries.
Lymphatic vessels are present in the eyelids and con-
junctiva. Drainage is in erior and lateral into the deep and
super cial cervical node systems. T e lateral two-thirds o
the upper eyelid and the lateral one-third o the lower eye-
lid drain laterally into the super cial parotid preauricular
nodes. T e medial one-third o the upper eyelid and medial
two-thirds o the lower eyelid drain in eriorly to the sub-
mandibular nodes. However, recent studies suggest a more
dif use drainage pattern where almost all regions around
the eye may drain into the preauricular nodes. Extensive
excision o subcutaneous eyelid tissues or deep incisions in
the in erolateral eyelid area may result in persistent lymph-
edema due to disruption o these vessels.
T e lacrimal drainage system establishes a complex rela-
tionship with the medial canthal ligament, thus complicat-
ing surgery in this region. T e puncta are situated on the
eyelid margins 6 to 8 mm lateral to the medial canthal angle.
T ey pass into the canaliculi, which run immediately in
ront o the anterior brous crura o the canthal ligament,
and are surrounded by a band o short, muscular bers
known as the muscles o Riolan. Anatomically the latter are
part o the pretarsal orbicularis muscle. T e lacrimal sac lies
in a bony ossa separated rom the nose by the thin lacrimal
bone. Slips o the orbicularis muscle insert onto and around
the sac and, together with the muscles o Riolan and Horn-
er's muscle, contribute to the lacrimal pump mechanism.
lateral origins o the arcades. T e venous system rom the
eyelids is more dif use and drains into both the anterior
acial vessels and the deep orbital system via the superior
ophthalmic vein.
T e sensory nerve supply rom the eyelids passes to
the gasserian ganglion via the ophthalmic and maxillary
divisions o the trigeminal nerve. Sensory in ormation
rom the central upper eyelid is carried in the supraor-
bital nerve and rom the medial upper eyelid in the supra-
trochlear and in ratrochlear nerves. All three nerves
pass backward to join the ophthalmic division. ermi-
nal branches o the lacrimal nerve receive sensory input
rom the lateral portion o the upper lid. wo additional
branches, the zygomaticotemporal and zygomatico acial
nerves, carry sensory in ormation rom the temple and
lateral canthal regions, respectively. T ese nerves pen-
etrate the lateral orbital wall through small oramina to
join the zygomatic nerve within the orbit, and the lat-
ter passes backward to unite with the in raorbital nerve.
Sensory innervation rom the lower eyelid stems mainly
rom the maxillary division o the trigeminal nerve via
the in raorbital nerve, with some contributions rom the
in ratrochlear nerve medially.
T e motor supply to the orbicularis muscle comes rom
the acial nerve via its temporal and zygomatic branches
and requently also contains anastomotic connections
rom the buccal branch. T ese anastomotic connections
orm an arborizing pattern laterally, where they may be
injured during lateral canthal and eyelid reconstructive
procedures. T e levator muscle receives motor innervation

SEC ION B ▲ Surgical Anatomy of the Eyelids
10
FIG. 2.1. External anatomy of eyelids and periorbital structures. 1, Superior sulcus
(eyelid crease). 2, Superior marginal cilia. 3, Lateral canthal angle. 4, Lacrimal puncta.
5, Malar fold (zygomatic furrow). 6, Inferior eyelid crease. 7, Plica semilunaris. 8, Medial
canthal angle. 9, Caruncle. 10, Nasojugal fold.
FIG. 2.2. Super cial facial and orbicularis oculi muscles. 1, Frontalis muscle.
2, Procerus muscle. 3, Corrugator supercilii muscle. 4–9: Orbicularis muscle. 4, Superior
orbital portion. 5, Superior preseptal portion. 6, Superior pretarsal portion. 7, Inferior
pretarsal portion. 8, Inferior preseptal portion. 9, Inferior orbital portion. 10, Medial
canthal ligament.
FIG. 2.3. Details of medial canthal insertions of the orbicularis oculi muscle
in the lower eyelid. 1, Muscle of Riolan. 2, Horner's muscle (deep head of pretarsal
portion). 3, Lacrimal sac. 4, Superior head of pretarsal portion. 5, Super cial head of
preseptal portion. 6, Super cial head of orbital portion.

11
CHAP ER 2 ▼ Eyelid Anatomy
1
2
3
4
5
6
7
8
9
10
FIG. 2.1
1
2
3
4
5
6
7
8
9
10
FIG. 2.2
1
2
3
4
5
6
FIG. 2.3

SEC ION B ▲ Surgical Anatomy of the Eyelids
12
FIG. 2.4. Orbital septum and preaponeurotic fat pads. T e orbicularis muscle is
removed, and the orbital septum is opened to reveal the preaponeurotic fat.
1, Cut edge of the superior orbital septum. 2, Lacrimal gland. 3, Superior tarsal plate.
4, Inferior tarsal plate. 5, Cut edge of the inferior orbital septum. 6, Superior central fat
pad. 7, Superior medial fat pad. 8, Levator aponeurosis. 9, Capsulopalpebral fascia.
10, Inferior medial fat pad. 11, Inferior central fat pad. 12, Inferior lateral fat pad.
FIG. 2.5. Major retractors of the upper and lower eyelids. 1, Superior tarsal plate.
2, Lateral horn of levator aponeurosis. 3, Inferior tarsal plate. 4, Lockwood's suspensory
ligament. 5, Whitnall's suspensory ligament. 6, Levator aponeurosis. 7, Medial horn of
levator aponeurosis. 8, Capsulopalpebral fascia.

13
CHAP ER 2 ▼ Eyelid Anatomy
1
2
3
4
5
6
7
8
9
10
11
12
FIG. 2.4
1
2
3
4
5
6
7
8
FIG. 2.5

SEC ION B ▲ Surgical Anatomy of the Eyelids
14
FIG. 2.6. Arterial supply to the eyelids. 1, Lacrimal artery. 2, Superior peripheral
arcade. 3, Superior lateral palpebral artery. 4, Superior marginal arcade. 5, Inferior
lateral palpebral artery. 6, Inferior palpebral branches. 7, Zygomaticofacial artery.
8, ransverse facial artery. 9, Supraorbital artery. 10, Supratrochlear artery. 11, Dorsal
nasal artery. 12, Superior medial palpebral artery. 13, Inferior medial palpebral artery.
14, Inferior marginal arcade. 15, Angular artery. 16, Facial artery. 17, Infraorbital artery.
FIG. 2.7. Venous supply from the eyelids. 1, Supraorbital vein. 2, Super cial tempo-
ral vein. 3, ransverse facial vein. 4, Frontal vein. 5, Supratrochlear vein. 6, Nasofrontal
vein. 7, Angular vein. 8, Anterior facial vein.

15
CHAP ER 2 ▼ Eyelid Anatomy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
FIG. 2.6
1
2
3
4
5
6
7
8
FIG. 2.7

SEC ION B ▲ Surgical Anatomy of the Eyelids
16
FIG. 2.8. Sensory nerves from the eyelids via trigeminal nerve branches.
1, Lacrimal nerve. 2, Zygomaticotemporal nerve. 3, Zygomaticofacial nerve.
4, Supraorbital nerve. 5, Supratrochlear nerve. 6, Infratrochlear nerve. 7, Infraorbital
nerve.
FIG. 2.9. Motor innervation to the eyelid protractors. 1, emporal branch of the
facial nerve (N. VII). 2, Zygomatic branch of the facial nerve. 3, Buccal branch of the
facial nerve. 4, Frontalis muscle. 5, Orbicularis muscle.

17
CHAP ER 2 ▼ Eyelid Anatomy
1
2
3
4
5
6
7
FIG. 2.8
1
4
5
2
3
FIG. 2.9

SEC ION B ▲ Surgical Anatomy of the Eyelids
18
FIG. 2.10. Lymphatic drainage from the eyelids. 1, Super cial and deep parotid
(preauricular) nodes. 2, Submandibular nodes. 3, Super cial and deep cervical nodes.
FIG. 2.11. Horizontal cross section through the upper eyelid and orbit at the
level of the canthal ligaments. 1, Preseptal portion of orbicularis muscle. 2, Anterior
crus of medial canthal ligament. 3, Posterior crus of medial canthal ligament.
4, Anterior lacrimal crest. 5, Lacrimal sac. 6, Posterior lacrimal crest. 7, Horner's muscle.
8, Medial check ligament. 9, Superior tarsal plate. 10, Superior pretarsal orbicularis
muscle. 11, Lateral horizontal raphe. 12, Lateral orbital septum. 13, Lateral canthal liga-
ment. 14, Lateral check ligament. 15, Orbital portion of orbicularis muscle.
16, Lacrimal gland (lower pole). 17, emporalis muscle.

19
CHAP ER 2 ▼ Eyelid Anatomy
1
2
3
FIG. 2.10
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
FIG. 2.11

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

21
CHAP ER 2 ▼ Eyelid Anatomy
FIG. 2.12
1
2
3
4
5
6
7
8
9
10
12
11
13
14
15
16
19
18
17
20

SEC ION B ▲ Surgical Anatomy of the Eyelids
22
FIG. 2.13. Layered sagittal cross section through the eyelids showing the orbital
septum and insertions of the levator aponeurosis. 1, Preaponeurotic fat pad.
2, Müller's muscle. 3, Inferior sympathetic muscle of Müller. 4, Precapsulopalpebral
orbital fat pad. 5, Arcus marginalis. 6, Superior orbital septum. 7, Levator aponeurosis.
8, Superior pretarsal orbicularis muscle. 9, Inferior pretarsal orbicularis muscle.
10, Inferior orbital septum.
FIG. 2.14. Layered sagittal cross section through the eyelids showing tarsus and
Müller's muscle. 1, Whitnall's ligament. 2, Cut edge of the levator aponeurosis.
3, Müller's sympathetic muscle. 4, Superior peripheral arterial arcade. 5, Superior
tarsal plate. 6, Inferior tarsal plate. 7, Inferior peripheral arterial arcade. 8, Inferior
sympathetic muscle of Müller. 9, Cut edge of the capsulopalpebral fascia.
FIG. 2.15. Layered sagittal cross section through the eyelids showing the bulbar
and palpebral conjunctiva. 1, Superior rectus muscle. 2, Superior fornix suspensory
ligament. 3, Bulbar conjunctiva. 4, Palpebral conjunctiva. 5, Superior tarsal plate.
6, Inferior tarsal plate. 7, Inferior fornix suspensory ligament. 8, Inferior rectus muscle.
1
5
6
7
8
9
10
2
3
4
FIG. 2.13

23
CHAP ER 2 ▼ Eyelid Anatomy
1
2
3
4
5
6
7
8
9
FIG. 2.14
1
2
3
4
5
6
7
8
FIG. 2.15

SEC ION B ▲ Surgical Anatomy of the Eyelids
24
SUGGESTED FURTHER READING
Bilyk JR. Periocular and orbital anatomy. Curr Opin Ophthalmol.
1995;6:53–58.
Burkat CN, Lemke BN. Anatomy o the orbit and its related structures.
Otolaryngol Clin North Am. 2005;38:825–856.
Doxanas M , Anderson RL. Clinical Orbital Anatomy. Baltimore, MD:
Williams & Wilkins; 1984:57–89.
Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. 2nd ed.
London, UK: Elsevier; 2011:129–164.
Kakizaki H, Malhotra R, Madge SN, Selva D. Lower eyelid anatomy: an
update. Ann Plast Surg. 2009;63:344–351.
Kakizaki H, Malhotra R, Selva D. Upper eyelid anatomy: an update. Ann
Plast Surg. 2009;63:336–343.
Kleinjes WG. Forehead anatomy: arterial variations and venous link o the
midline orehead ap. J Plast Reconstr Aesthet Surg. 2007;60:593–606.
Most SP, Mobley SR, Larrabee WF Jr. Anatomy o the eyelids. Facial Plast
Surg Clin North Am. 2005;13:487–492.
Oh SR, Priel A, Korn BS, Kikkawa DO. Applied anatomy or the aesthetic
surgeon. Curr Opin Ophthalmol. 2010;21:404–410.
Ridgway JM, Larrabee WF. Anatomy or blepharoplasty and brow li t.
Facial Plast Surg. 2010;26:177–185.
Seif SR, Seif BD. Anatomy o the Asian eyelid. Facial Plast Surg Clin
North Am. 2007;15:309–314.
Stewart JM, Carter SR. Anatomy and examination o the eyelids. Int Oph-
thalmol Clin. 2002;42:1–13.
Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York, NY: Raven
press; 1985:21–32.

25
SECTIONC
A
hordeolum is an acute in ectious abscess o an eyelid
gland characterized by localized swelling, erythema, and
tenderness. T e external hordeolum, or stye, is a superf cial
in ection o a Zeis or Moll gland in the anterior eyelid lamella.
A stye usually orms on the marginal eyelid skin in the region
o the lash ollicles. Medical management consists o warm
compresses and topical antibiotics, and spontaneous resolu-
tion is common. Surgical drainage is indicated only when the
lesion ails to respond to conservative treatment and when the
lesion points on the sur ace.
An internal hordeolum is an acute, usually staphylococ-
cal, in ection o a meibomian gland within the tarsal plate.
T ese may point toward the conjunctiva or the skin, and
purulent material can requently be expressed rom the
inspissated meibomian ductule on the lid margin. reat-
ment consists o warm compresses and topical antibiotics
and may require systemic antibiotics or control.
A chalazion is a nonin ectious sterile accumulation o
lipid material that is almost always secondary to obstruc-
tion o a meibomian gland ductule. It may cause signif cant
in ammation and pressure necrosis o the tarsus in addi-
tion to thickening rom granuloma ormation. A chalazion
rarely resolves spontaneously. Medical therapy includes
injection o corticosteroids, 0.1 or 0.2 mL, o triamcino-
lone acetonide, 40 mg/mL, directly into the lesion. reat-
ment may have to be repeated a ter several weeks. Surgery
may be necessary or curettage o the thick caseous con-
tents or or excision o any persistent granulomatous mass.
Recurrent chalazia in the same location require histologic
examination to rule out sebaceous cell carcinoma.
For drainage o external hordeola, a local inf ltrative
anesthetic is injected around the base o the lesion rather
than directly into it. For internal hordeola or chalazia in
the tarsus, inf ltrative anesthesia should be given both
subcutaneously and subconjunctivally along the proximal
border o the tarsal plate. A regional block may also be
given at the appropriate branches o the trigeminal nerve.
For the transcutaneous approach, the incision is horizontal
and is thereby parallel to skin tension lines to avoid scar
contraction. When posterior drainage on the conjunctival
sur ace is necessary, a vertical incision is used to minimize
injury to adjacent meibomian glands.
SUGGESTED FURTHER READING
Ahmad S, Baig MA, Khan MA, et al. Intralesional corticosteroid injection
vs surgical treatment o chalazia in pigmented patients. J Coll Physi-
cians Surg Pak. 2006;16:42–44.
Ben Simon GJ, Rosen N, Rosner M, Spierer A. Intralesional triamcinolone
acetonide injection versus incision and curettage or primary chalazia:
a prospective, randomized study. Am J Ophthalmol. 2011;151:
714–718.
Carrim ZI, Shields L. A simplif ed technique or incision and curettage o
chalazia. Orbit. 2008;27:401–402.
Dhaliwal U, Bhatia A. A rationale or therapeutic decision-making in cha-
lazia. Orbit. 2005;24:227–230.
Dua HDD, Nilawar DV. Nonsurgical treatment o chalazia. Am J Ophthal-
mol. 1982;94:424 (letter).
Duarte AF, Moreira E, Nogueira A, et al. Chalazion surgery: advantages
o a subconjunctival approach. J Cosmet Laser T er. 2009;11:154–156.
Lederman C, Miller M. Hordeola and chalazia. Pediatr Rev. 1999;20:
283–284.
Mansour AM. Injections or chalazia? Ophthalmology. 2006;113:353–354.
Ozdal PC, Codère F, Callejo S, et al. Accuracy o the clinical diagnosis o
chalazion. Eye. 2004;18:135–138.
Pizzarello LD, Jakobiec FA, Ho eldt JD, et al. Intralesional corticosteroid
therapy o chalazia. Am J Ophthalmol. 1978;85:818–821.
Sandramouli S, Gonglore BC. riamcinolone or chalazia. Ophthalmol-
ogy. 2006;113:889.
Starr MB. In ections and hypersensitivities o the eyelids. In: Smith BC,
Delia Rocca RC, Nesi FA, Lisman RD, eds. Ophthalmic Surgery. Vol 1.
St. Louis, MO: Mosby-Year Book; 1987.
Unal M. Chalazion treatment. Orbit. 2008;27:397–398.
Hordeolum and
Chalazion

26
3
FIG. 3.3. With chronic chalazia, excise the entire granulo-
matous capsule with scissors. Avoid excessive excision within
2 mm of lid margin to prevent lid notching and injury to the
cilia.
FIG. 3.4. Gently hyfrecate the base of the cavity with
bipolar cautery to achieve hemostasis. Remove the chalazion
clamp and close the skin wound with 6-0 fast-absorbing plain
gut sutures. If the lesion was very large, a small amount of
redundant skin may be excised before closure.
FIG. 3.1. Place a chalazion clamp over the eyelid margin
with the solid backing plate on the conjunctival surface.
Center the oval, open ring plate over the pointing lesion on the
skin surface, and tighten the clamp. Cut the skin with a scalpel
blade, making a horizontal incision at least 3 mm from the
eyelid margin to avoid injury to the lash follicles. Deepen the
incision until the cyst contents extrude into the wound.
FIG. 3.2. Using a chalazion curette, remove the contents
of the lesion completely. Scrape the walls of the entire inner
surface. Carefully explore the interior for loculated pockets.
Open these and curette the cavities to the level of normal tarsus.
INDICATIONS: Chronic chalazion granuloma with the major portion pointing anterior to the tarsus and acute internal
hordeola pointing toward the skin and not responding to medical therapy.
Chalazion Incision and Drainage,
Transcutaneous Approach
POSTOPERATIVE CARE: Apply antibiotic ointment to
the suture line twice daily or 1 week or until the sutures
are dissolved.
POTENTIAL COMPLICATIONS:
Hypertrophic scar formation—T is is rarely seen, mainly
in patients with a known history o orming keloids. Ste-
roid injection into the scar or massage with topical ste-
roids or Mederma may help reduce the scar. It may also
be excised a ter it is matured.
Loss of cilia—T is may occur i the dissection is carried
too ar toward the lid margin. ake care not to injure the
lash bulbs, which lie about 2 mm rom the mucocutane-
ous eyelid border.
Eyelid notching—Occasionally, the ull-thickness tarsus is
necrotic. I the excision bed is large and is carried closer
than 2 mm rom the eyelid margin, a buckling or notch-
ing may result. I cosmetically objectionable, this is
corrected with a secondary eyelid wedge resection and
primary repair.
Recurrence of chalazion or hordeolum—Recurrence
may ollow incomplete excision o the abscess cavity lin-
ing or ailure to curette all loculated chambers.

27
CHAPTER 3 ▼ Chalazion Incision and Drainage, Transcutaneous Approach
FIG. 3.1
FIG. 3.2
FIG. 3.3
FIG. 3.4

28
FIG. 4.4. Remove the cyst contents completely with a cha-
lazion curette. Explore for loculated pockets toward the eyelid
margin, being careful not to injure eyelash follicles. Excise the
residual brous cyst capsule with scissors. Lightly hyfrecate
the cavity walls, if necessary, to promote hemostasis. Remove
the clamp and leave the wound open for continued drainage.
FIG. 4.1. Tighten a chalazion clamp over the eyelid margin
with the open plate centered over the pointing lesion on
the conjunctival surface. Evert the eyelid to expose the lesion.
FIG. 4.2. Make a vertical incision through the conjunctiva
and the posterior tarsal abscess wall. If possible, the incision
should not extend closer than 2 to 3 mm to the eyelid margin.
FIG. 4.3. Grasp one edge of the wound and cut a small,
triangular ap of the tarsus and conjunctiva from one side
of the posterior cyst wall to allow for drainage.
INDICATIONS: Acute internal hordeolum or chronic chalazion pointing on the conjunctival sur ace.
4
Chalazion Incision and Drainage,
Transconjunctival Approach
POSTOPERATIVE CARE: I mild bleeding continues a ter
the clamp is removed, place a f rm dressing over the eyelids
or 6 to 12 hours. Apply warm compresses and antibiotic
ointment on the eye twice daily or 5 to 7 days.
POTENTIAL COMPLICATIONS:
Loss of cilia—T is may occur when incisions, cautery, or
excessive curettage is used within 2 to 3 mm o the eye-
lid margin.
Marginal eyelid notch—Notching can result rom exces-
sive excision o the stabilizing tarsus too close to the
lid margin. It is important to leave at least 2 to 3 mm
o intact tarsus along the margin i possible, especially
when ull-thickness tarsal necrosis is present around
the lesion.
Chronic obstruction of meibomian glands—T is may
ollow the conjunctival approach when large, horizontal
incisions cut across many ductules. Except or the small,
triangular ap excision suggested or drainage, keep all
transconjunctival incisions vertical.

29
CHAPTER 4 ▼ Chalazion Incision and Drainage, Transconjunctival Approach
FIG. 4.1
FIG. 4.4
FIG. 4.3
FIG. 4.2

30
SECTIOND
Trichiasis and Distichiasis
T
richiasis is a disorder in which eyelid cilia are misdi-
rected toward the globe, thus resulting in corneal and
conjunctival abrasion and chronic ocular sur ace pain.
richiasis may be primary or secondary. In primary tri-
chiasis, the lash ollicles are distorted and misaligned in an
otherwise normally positioned eyelid margin. It may result
rom chronic inf ammatory disorders such as severe bleph-
aritis or recurrent chalazia. Primary trichiasis may also ol-
low as a result o mechanical or chemical eyelid trauma or
previous eyelid surgery. In secondary trichiasis, the lash
ollicles are normally aligned in the lid, but the eyelid mar-
gin is rotated inward and the lashes touch the cornea. T is
condition may be caused by any severe entropion associ-
ated with horizontal eyelid laxity, retractor disinsertion,
or posterior lamellar contraction. Posterior lamellar con-
traction may be seen with conjunctival cicatricial inf am-
matory diseases, such as cicatricial ocular pemphigoid or
Stevens-Johnson syndrome, in trachoma, or with chemical
burns. In congenital or acquired epiblepharon, the anterior
skin–muscle lamella rides up over the lower eyelid tarsus
and mechanically rotates the lashes inward against the
globe, especially in downward gaze.
Distichiasis is a congenital or acquired development o
one or more extra rows o cilia located within the tarsus
and situated behind the normal row o lashes. Even though
growth is usually undistorted, because o their abnormal
position, these cilia requently result in corneal touch. In
both primary trichiasis and distichiasis, the aberrant cilia
must be removed or com ort and to prevent urther cor-
neal damage.
Medical management o trichiasis consists o liberal
ocular lubrication and requent mechanical epilation o
the o ending cilia. T e results are usually unsatis actory
and surgical intervention eventually will be necessary in
most cases. However, many surgical approaches yield less
than ideal results, usually because o recurrence and less
commonly because o undesirable unctional or cosmetic
sequelae.
When associated with eyelid malpositions such as
entropion or eyelid margin de ormity, the management
o secondary trichiasis must be directed toward marginal
reconstruction. T is is discussed later under the appropri-
ate sections. T e treatment o trichitic or distichitic cilia in
an otherwise normal eyelid can be achieved by a number o
procedures with varying success rates.
T e technique o cryodestruction is use ul in the man-
agement o large areas o trichiasis and when care ully per-
ormed is associated with minimal risk to normal eyelid
tissues. Its success depends upon adequate degree o reez-
ing at the site o the lash ollicle and requires the use o a
thermocouple probe. A rapid rate o reeze induces intra-
cellular crystallization, which is necessary or cell destruc-
tion. Slow thaw is associated with recrystallization, which
urther enhances intracellular membrane disruption. T e
use o epinephrine in the local anesthetic reduces heat
trans er through adjacent tissues and improves the e ec-
tiveness o treatment. In addition, the rate o thermal con-
ductivity is signi cantly enhanced with repeat reezing,
and a double reeze–thaw cycle yields greater destructive
results. Caution should be used in applying cryotherapy to
dark-skinned individuals since this can result is signi cant
depigmentation.
Electrohy recation and radiosurgery are more suited to
eradication o one or a ew cilia. However, because o the
very small area o destruction and the uncertainty o local-
izing the needle tip at individual ollicles, results are less
predictable and recurrences more requent than with cryo-
surgery. In this procedure, injury to normal tissues is also
more common, especially when large numbers o lashes
are treated simultaneously.
When the entire eyelid margin is involved, surgical
excision may be more appropriate, especially i cryode-
struction has ailed. Excision may be accomplished by an
internal resection o the lash ollicles beneath a small myo-
cutaneous f ap. Eyelid splitting procedures, either with or
without mucous membrane gra ting, are more di cult,
may require harvesting o oral mucosa, and usually lead to
poorer unctional and cosmetic results.
SUGGESTED FURTHER READING
Alemayehu W, Kello AB. richiasis surgery: a patient-based approach.
Community Eye Health. 2010;23:58–59.
Bartley GB, Lowry JC. Argon laser treatment o trichiasis. Am J Ophthal-
mol. 1992;113:71–74.
Başar E, Ozdemir H, Ozkan S, et al. reatment o trichiasis with argon
laser. Eur J Ophthalmol. 2000;10:273–275.
Chi MJ, Park MS, Nam DH, et al. Eyelid splitting with ollicular extir-
pation using a monopolar cautery or the treatment o trichiasis and
distichiasis. Graefes Arch Clin Exp Ophthalmol. 2007;245:637–640.
Choo PN. Distichiasis, trichiasis, and entropion: advances in manage-
ment. Int Ophthalmol Clin. 2002;42:75–87.
Dutton JJ, aw k HA, DeBacker CM, Lipham WJ. Direct internal eye-
lash bulb extirpation or trichiasis. Ophthal Plast Reconstr Surg.
2000;16:142–145.
Gower EW, Merbs SL, Munoz BE, et al. Rates and risk actors or un avor-
able outcomes 6 weeks a ter trichiasis surgery. Invest Ophthalmol Vis
Sci. 2011;52:2704–2711.
Kersten RC, Leiner FP, Kulwin DR. arsotomy or the treatment o cica-
tricial entropion with trichiasis. Arch Ophthalmol. 1992;110:714–717.

Kezirian GM. reatment o localized trichiasis with radiosurgery. Ophthal
Plast Reconstr Surg. 1993;9:260–266.
McCracken MS, Kikkawa DO, Vasani SN. reatment o trichiasis and
distichiasis by eyelash trephination. Ophthal Plast Reconstr Surg.
2006;22:349–351.
Moosavi AH, Mollan SP, Berry-Brincat A, et al. Simple surgery or severe
trichiasis. Ophthal Plast Reconstr Surg. 2007;23:296–297.
Pham R , Biesman BS, Silkiss RZ. reatment o trichiasis using an
810-nm diode laser: an e cacy study. Ophthal Plast Reconstr Surg.
2006;22:445–447.
Rosner M, Bourla N, Rosen N. Eyelid splitting and extirpation o hair ol-
licles using a radiosurgical technique or treatment o trichiasis. Oph-
thalmic Surg Lasers Imaging. 2004;35:116–122.
Sodhi PK, Verma L. Surgery or trichiasis. Ophthalmology. 2004;111:
2147–2148.
Vaughn GL, Dortzbach RK, Sires BS, Lemke BN. Eyelid splitting with
excision or microhy recation or distichiasis. Arch Ophthalmol.
1997;115:282–284.
Wojno H. Lid splitting with lash resection or cicatricial entropion and
trichiasis. Ophthal Plast Reconstr Surg. 1992;8:287–289.
Wu AY, T akker MM, Wladis EJ, Weinberg DA. Eyelash resection proce-
dure or severe, recurrent, or segmental cicatricial entropion. Ophthal
Plast Reconstr Surg. 2010;26:112–116.
Yeung YM, Hon CY, Ho CK. A simple surgical treatment or upper lid
trichiasis. Ophthalmic Surg Lasers 1997;28:74–76.
31
SEC ION D ▼ richiasis and Distichiasis

32
FIG. 5.3. Place the cryoprobe tip on the conjunctival sur-
face 2 to 3 mm from the eyelid margin and adjacent to the
aberrant cilia near the thermocouple needle. Apply a reeze
cycle to −20°C. A white area o rost should orm on the lid.
Allow the lid to thaw slowly and completely, ollowed by a
second reeze cycle to −20°C.
FIG. 5.4. Five to seven days after treatment, mechanically
remove the cilia with epilation forceps. T ere should be no
resistance. I treatment ails to eradicate all of ending lashes,
repeat the procedure a ter 2 to 3 months.
FIG. 5.1. Position a scleral shell over the globe for protec-
tion. Inject local anesthetic with 1:100,000 epinephrine 3 to
4 mm rom the lid margin and subconjunctivally along
the proximal tarsal border. ake care to avoid injury to the
marginal vascular arcade. Allow 10 minutes or maximum
vasoconstriction.
FIG. 5.2. Insert a 23-gauge microthermocouple needle
probe into the postorbicular fascial plane 3 mm from
and parallel to the eyelid margin. T e probe tip must
be positioned adjacent to the eyelash bulbs or accurate
temperature recording.
INDICATIONS: Misdirected eyelid cilia o any number.
CONTRAINDICATIONS: Additional caution should be used with dark-skinned individuals because this technique may
cause depigmentation. Patients with active cicatricial inf ammatory diseases should be on adequate systemic immuno-
suppression or several months prior to any cryodestructive procedure to minimize risk o exacerbation.
5
Cryosurgery for Trichiasis
POSTOPERATIVE CARE: Apply a topical steroid and
antibiotic ointment to the eyelid margin three to our
times daily or 5 days. A mild analgesic may be needed or
the rst 1 to 2 days.
POTENTIAL COMPLICATIONS:
Eyelid edema—T is may be signi cant or 12 to 72 hours
a ter treatment and is proportional to the size o the
area treated. It typically resolves without sequelae.
Eyelid necrosis—T e risk o necrosis is greater with tem-
peratures below −30°C. Epidermal necrosis is more
common with cryoprobe application to the skin sur ace.
I excessive tissue breakdown is noted early, hyperbaric
oxygen may be considered.
Depigmentation—T is is more common in darkly pig-
mented skin, and an alternative treatment modality
should be considered in such individuals.
Treatment failure—Partial recurrence is common and
may be seen more requently with inadequate reeze
temperature or misplacement o the thermocouple
needle probe. reatment may be repeated a ter 2 to
3 months. I a large area o ailure is involved, inter-
nal surgical excision o lash bulbs would be more
appropriate.

33
CHAP ER 5 ▼ Cryosurgery or richiasis
FIG. 5.2
FIG. 5.1
FIG. 5.3
FIG. 5.4

34
FIG. 6.2. Apply the radio frequency (RF) pulse for 5 to
10 seconds until small bubbles appear at the lid margin
surface. If more immediate destruction or contraction of tissue
is seen, reduce the power setting. Manually epilate the cilium
with epilation forceps. T ere should be no resistance and the lash
bulb should be attached to the cilium to indicate adequate abla-
tion. If the lash does not pull out easily, repeat the treatment.
FIG. 6.1. In ltrate local anesthetic subcutaneously along
the lid margin adjacent to the area to be treated. Pull the
eyelid margin away from the globe or use a scleral protector.
Insert an insulated radiosurgery wire needle into the lash
follicle to the bulb, parallel to the cilium shaft.
INDICATIONS: One to a ew trichitic or distichitic cilia.
6
Radiosurgery for Trichiasis
POSTOPERATIVE CARE: Apply a steroid and antibiotic
ointment three to our times daily or 4 to 5 days. Mild
analgesics may be needed or the f rst 1 to 2 days.
POTENTIAL COMPLICATIONS:
Lid margin distortion—T is may result rom excessive
tissue destruction and thermal contraction o the tarsus.
Apply only the minimal RF power necessary to cause
very mild bubbling. Avoid simultaneous treatment over
large areas o the eyelid.
Treatment failure—T is usually ollows poor placement
o the needle tip so that the lash bulb remains untreated.
T is is especially true with distichiasis because the lash
ollicles may be curved and not located directly below
the external cilium. reatment ailure also results rom
applying too low a power setting. Radiosurgery or cryo-
surgery may be per ormed again a ter 2 to 3 months.

35
CHAP ER 6 ▼ Radiosurgery for richiasis
FIG. 6.1
FIG. 6.2

36
used to destroy the lash bulbs. ake care not to cut through the
skin. If distichitic cilia are noted arising from within the tarsus,
follow their shafts with small, vertical cuts into the tarsus until the
bulb is found. T ese are then excised or destroyed with cautery.
FIG. 7.4. Mechanically epilate the cilia from along the
treated area. T ere should be no resistance, and the cilia
should come out lacking their bulbs. Any residual bulbs may be
destroyed individually with additional light cautery.
FIG. 7.5. Reform the eyelid crease by xing the orbicularis
muscle to epitarsus or to the orbital septum with three or
four 7-0 chromic sutures.
FIG. 7.6. Close the skin with 6-0 fast-absorbing plain gut
sutures.
FIG. 7.1. Mark an incision line in an existing eyelid crease.
In ltrate local anesthetic into the postorbicular fascial plane
along the marked line. Cut through the skin with a scalpel
blade and open the orbicularis muscle with Westcott scissors.
FIG. 7.2. Carry the dissection in the postorbicular fascial
plane along the anterior face of the tarsus toward the eyelid
margin. In the upper eyelid, take care not to injure the levator
aponeurosis or the marginal vascular arcade. About 2 mm from
the lid margin, identify the lash bulbs as small, rounded, dark
objects lying in a row within a small horizontal gap between
the orbicularis muscle and the muscle of Riolan.
FIG. 7.3. Using ne micro-Westcott scissors, excise the cilia
bulbs and a strip of orbicularis muscle from along the entire
area of trichiasis. Alternatively, low-level bipolar cautery can be
INDICATIONS: richiasis with more than one-quarter lid margin involvement; ailure o other treatment modalities.
7
Internal Eyelash Bulb Resection
POSTOPERATIVE CARE: Apply iced compresses inter-
mittently or 24 hours while awake. Place antibiotic oint-
ment on the suture line three to our times daily or 5 to 7
days or until the sutures are dissolved.
POTENTIAL COMPLICATIONS:
Treatment failure—T is is caused by inadequate exci-
sion o all of ending lash bulbs in the af ected area. I
a ew cilia remain, treat these with spot cryosurgery or
radiosurgery a ter 4 to 6 weeks. With distichiasis, cilia
typically originate within the tarsal plate and are more
di cult to remove by this technique.
Eyelid margin scarring—T is is a result o excessive
removal o the marginal orbicularis muscle and button-
holing o the skin. Limit the dissection to the lash bulbs
and a thin strip o muscle.

37
CHAP ER 7 ▼ Internal Eyelash Bulb Resection
FIG. 7.1
FIG. 7.4
FIG. 7.2
FIG. 7.5
FIG. 7.3
FIG. 7.6

38
SECTIONE
Cosmetic Blepharoplasty
is repositioned to avoid postoperative ullness in the lateral
eyelid.
T e presence o any in erior scleral show should be noted
and care taken not to exacerbate this by overly aggressive
vertical removal o lower eyelid skin. In some cases, eleva-
tion o the lid margin may be needed or cosmetic improve-
ment. Any blunting o the lateral canthal angle resulting
rom laxity o the lateral canthal ligament should also be
recorded and may be corrected by lateral tarsal strip f xa-
tion at the time o surgery. Greater degrees o generalized
eyelid laxity and even rank ectropion may require urther
eyelid shortening. During preoperative evaluation, it is
particularly important to recognize the presence o brow
ptosis. Failure to correct signif cant brow droop will result
in little improvement rom blepharoplasty alone. Brow
ptosis correction must be per ormed either through direct or
through endoscopic li t, or with a brow pexy, be ore excision
o upper eyelid skin. T e existence, position, and symme-
try o the eyelid creases must be measured and appropri-
ate crease re ormation per ormed i necessary. All o these
actors, when present, will alter the surgical approach some-
what and may signif cantly a ect the outcome.
T e ordering o steps in blepharoplasty is essential or
a success ul result. Marking o excess eyelid skin is done
be ore administration o local anesthetic, since the latter
might distend and distort the tissues, thus making accurate
marking more di cult. I signif cant upper eyelid at is to
be removed, or i the levator aponeurosis is to be shortened,
the upper incision line is not cut until the orbital work has
been completed. At this point, the upper skin–muscle ap
is draped over the in erior wound edge and excess ap is
resected.
In most blepharoplasty procedures designed or reduc-
tion o excess eyelid skin, excision o a skin ap that
includes orbicularis muscle is pre erred because redun-
dancy o muscle almost always accompanies redundancy o
overlying skin. T e exceptions occur when lymphedema-
tous and thickened subcutaneous tissues produce baggy
lids and estoons anterior to the underlying muscle. In such
cases, skin and subcutaneous tissue may be removed with
preservation o most o the muscle layer. Removal o skin
with preservation o muscle may result in less postopera-
tive edema, but the long-term results are the same as with
skin and muscle resection.
Fixation o the upper eyelid crease will signif cantly
enhance the cosmetic e ect, unless an Asian lid is to be
maintained. In general, the crease is placed 10 to 12 mm
above the lid margin and f xed to the levator aponeurosis.
B
lepharoplasty is a procedure or the removal o lax eyelid
skin and/or reduction o prolapsed eyelid at. It can be
per ormed or unctional purposes to improve visual f eld, or
it can be done or purely aesthetic concerns. Cosmetic sur-
gery per ormed by the ophthalmologist is usually conf ned
to the upper and lower eyelids and brows. Many patients
desiring aesthetic reconstruction, however, may also ben-
ef t rom surgery on adjacent acial structures such as the
orehead, nose, temple, and cheeks. Preoperative examina-
tion must take note o these associated abnormalities, and
in some cases, a more inclusive acial surgery might be more
appropriate.
During evaluation o the patient or cosmetic surgery, it
is essential to discuss the patient’s expectations, the results
that realistically can be achieved, and any potential compli-
cations. T e patient must understand that although excess
eyelid skin and herniating orbital at can be removed,
small lateral eyelid urrows, sagging malar cheek pads,
and dark circles beneath the lower lids typically will not be
improved with standard blepharoplasty procedures alone.
Such abnormalities should be pointed out be ore surgery in
order to avoid disappointment.
Preoperative evaluation should record in detail the
presence o associated eyelid de ormities, so modif ca-
tions in the surgical approach can be planned in advance.
T e amount o excess eyelid skin is estimated while the
patient is in the upright position, because it appears con-
siderably less when the patient is supine. Location and
degree o protruding at pockets are recorded, also while
the patient is upright. Hypertrophy o the pretarsal orbi-
cularis muscle appears as a horizontal thickening o the
lower eyelid immediately beneath the lid margin. It is
more prominent when the patient is smiling and is re-
quently con used with prolapse o orbital at. T e pres-
ence o lateral upper eyelid hooding will require some
modif cation with regard to the extent and shape o the
incision line. T e same is true or signif cant medial upper
eyelid pouching. Ptosis o the upper eyelid is measured
and i necessary is repaired at the time o blepharoplasty.
Shortening o the levator aponeurosis will a ect the
amount o skin excised, so the ptosis correction precedes
removal o excess skin.
Prolapse o the lacrimal gland is common and must not
be con used with protrusion o orbital at. T ere is no ante-
rior at pocket in the temporal upper eyelid. T e lacrimal
gland is f rmer to palpation than orbital at and can easily
be displaced beneath the orbital rim. At surgery, it is pinker
in color than at. When present, a prolapsed lacrimal gland

Smith BC, Bosniak SI. Reconstructing the supratarsal crease. In: Bosniak
SL, Smith BC, eds. Advances in Ophthalmic Plastic and Reconstructive
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Lower Eyelid Blepharoplasty with Fat Excision
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orbital at, and hypertrophied orbicularis: a skin ap approach. In:
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SUGGESTED FURTHER READING
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1981;8:635–641.
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39
SECTION E ▼ Cosmetic Blepharoplasty

40
FIG. 8.5. Temporal hooding of eyelid skin may hang over the
lateral palpebral ssure and canthal angle. It requires more
extensive lateral skin resection over the orbital rim.
FIG. 8.6. Medial pouching results from bulging of the
medial fat pocket, with or without associated redundant
skin. When extensive, an M-plasty modi cation of the medial
excision bed may be required.
FIG. 8.7. Prolapse of the lacrimal gland results in lateral
fullness of the upper eyelid, which super cially resembles
bulging fat. On palpation, the gland is rm with rounded
contour and can easily be displaced upward beneath the
orbital rim.
FIG. 8.8. Lower eyelid laxity is frequently associated with
dermatochalasis and results from stretching of the lateral
canthal ligament or the tarsus. It may cause inferior scleral
show, ectropion, and epiphora.
FIG. 8.1. Dermatochalasis of the upper eyelid without fat
prolapse results in marked overhang of redundant skin,
frequently obscuring the eyelid margin and sometimes
producing a pseudoptosis. In the lower eyelid, dermatocha-
lasis produces at folds of excess skin draping over the malar
eminence.
FIG. 8.2. When associated with prolapse of extraconal
orbital fat, dermatochalasis results in fullness of the eyelids,
which becomes more pronounced in the upright position
and with pressure on the globe.
FIG. 8.3. When true eyelid ptosis complicates dermato-
chalasis, the upper eyelid margin to the pupillary re ex
distance (MRD1) is reduced to <2 mm and does not correct
with mechanical elevation of the redundant skin.
FIG. 8.4. Brow ptosis can markedly accentuate the
apparent degree of upper eyelid dermatochalasis, resulting
in broad folding of upper eyelid skin. It is frequently more
pronounced temporally.
8
Etiology and Associated Deformities

41
CHAPTER 8 ▼ Etiology and Associated Deformities
FIG. 8.1
FIG. 8.2
FIG. 8.3
FIG. 8.4
FIG. 8.5
FIG. 8.6
FIG. 8.7
FIG. 8.8

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