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

294
89
FIG. 89.5. Continue elevating periorbita toward the
superior orbital ssure. Here periorbita is more rmly
attached to bone.
FIG. 89.6. Retract the orbital contents medially with a
broad malleable retractor, and grind down the lateral wall
with a drill and diamond burr. Irrigate with water during
drilling to cool the bone. Remove bone to the level of marrow,
leaving the cranial table intact. If bleeding occurs, press some
bone wax onto the surface of the burred bone.
FIG. 89.7. Remove the bone from the entire greater
sphenoid wing upward to the lacrimal gland fossa.
FIG. 89.8. Replace orbital tissues against the lateral wall
and close periosteum with interrupted 5 0 Vicryl sutures.
Close orbicularis muscle with interrupted stitches of 6-0 Vicryl
and the skin with interrupted and a running suture of 6-0
fast-absorbing gut.
FIG. 89.1. Mark an incision line in the upper eyelid crease
and extend it laterally within a lateral rhytid for a distance
of about 1 cm.
FIG. 89.2. Incise the skin and orbicularis muscle with
scissors and cauterize any bleeding points.
FIG. 89.3. Follow the orbital septum laterally to the orbital
rim, and expose the rim superiorly and inferiorly from the
frontozygomatic suture to the maxillozygomatic suture.
Incise the periosteum along the orbital rim just outside the
orbital septum with a scalpel blade and dissect periorbita from
the zygomatic bone with a Freer elevator.
FIG. 89.4. Using a malleable retractor and a dissector,
elevate periorbita along the lateral orbital wall onto the
greater wing of the sphenoid bone for a distance of about
35 to 40 mm.
INDICATIONS: Expansion of the bony orbital contour, primarily in thyroid orbitopathy for cosmetic reduction of
proptosis or optic nerve compression, when extraocular muscles are enlarged.
Orbital Decompression, Lateral Wall
POSTOPERATIVE CARE AND POTENTIAL COMPLI-
CATIONS: See care and complications as for Orbital
Decompression, Inferior and Medial Walls, p. 346.

295
CHAPTER 89 ▼ Orbital Decompression, Lateral Wall
FIG. 89.1
FIG. 89.2
FIG. 89.3
FIG. 89.4
FIG. 89.5
FIG. 89.6
FIG. 89.7
FIG. 89.8

296
90
FIG. 90.4. If a full oor implant is used, drill a small hole
through the orbital rim and the front of the implant and
secure it into position with a 4-0 prolene suture to prevent
forward displacement.
FIG. 90.5. If a smaller implant is used, cut a ap on the
anterior edge and place the implant with the ap tongue
pushed into the defect to prevent anterior migration.
Repeat the forced traction test to be certain soft tissues have
not been trapped beneath the implant posteriorly.
FIG. 90.6. Close periosteum over the orbital rim with
interrupted 4-0 Vicryl sutures. Reform the lower eyelid
crease if necessary by xing orbicularis muscle to the orbital
septum with several 7-0 chromic stitches 4 mm below the
incision line. T e skin wound is repaired with a running stitch
of 6-0 fast-absorbing plain gut.
FIG. 90.1. Perform a forced traction test to determine
the degree of muscle entrapment. Proceed as for Orbital
Decompression Fig. 88.1 through 88.4 (pp. 350 to 351) to
expose the orbital oor. Visualize the anterior edge of the
fracture site and note the extent of incarceration of periorbita
and fascial tissues.
FIG. 90.2. If orbital tissues are incarcerated within bony
fragments, gently depress or elevate fragments of bone
while teasing periorbita and fat lobules free with a
periosteal elevator and microdissectors. Carefully separate
orbital tissues from the infraorbital nerve and vessels. Expose
the entire fracture site to its posterior limit if possible. Repeat
the forced traction test to con rm freedom of ocular motility.
FIG. 90.3. Cut a piece of Supramyd, Te on, Medpor, or other
implant material so it is large enough to overlap the defect
by at least 5 mm on all sides.
INDICATIONS: Repair o any size blow-out ractures o the orbital f oor associated with in erior rectus muscle entrapment
or signi cant enophthalmos; large f oor ractures without entrapment or enophthalmos.
Repair of Orbital Floor Fracture
POSTOPERATIVE CARE: Place a light pressure dress-
ing or 24 hours and apply iced compresses to the eyelids
intermittently or 24 hours a ter the dressing is removed.
Antibiotic ointment is applied to the suture line three to
our times daily or 7 days. Systemic antibiotics are pre-
scribed or 1 week.
POTENTIAL COMPLICATIONS:
Visual loss—T is is exceedingly rare unless the f oor
exploration is carried too ar to the orbital apex. Care
must be used in upward retraction o the globe and
pressure must be released intermittently. T e implant
should not exceed 3.5 cm in anteroposterior depth
because longer implants may compress the optic nerve
posteriorly.
Motility restriction—T is may be caused by trapping o
orbital tissues beneath the implant posteriorly. Mallea-
ble retractors should be used to con rm tissue reedom
rom around the implant, and the orced traction test
must be repeated a ter the implant has been positioned.
Entropion o the lower eyelid—Occasionally the preseptal
orbicularis ails to brose to the underlying orbital septum
and eyelid retractors. T is results in upward migration over
tarsus, producing an induced epiblepharon. Re xation o
preseptal orbicularis to deeper tissues will prevent this.
Migration o the f oor implant—When it displaces, the
implant usually migrates anteriorly and appears as a
bulge in the lower eyelid. T is complication is mini-
mized with proper xation, either with a suture through
the rim or with f aps cut into the implant.

297
CHAP ER 90 ▼ Repair of Orbital Floor Fracture
FIG. 90.1
FIG. 90.2
FIG. 90.3
FIG. 90.4
FIG. 90.5
FIG. 90.6

298
91
FIG. 91.5. Continue the dissection as necessary to expose
the entire limit o the ractured bone pieces.
FIG. 91.6. Realign the ractured segments so that the
ractured margins are repositioned. Place an appropriately
sized and shaped miniplate across the fracture, drill pilot holes
as needed, and tighten screws into the holes. Place at least two
screws on either side of the fracture.
FIG. 91.7. Reapproximate the periosteum over the plate and
close it with interrupted sutures o 4-0 Vicryl.
FIG. 91.8. Close the skin incision with a running stitch o 6-0
ast-absorbing gut.
FIG. 91.1. Mark an incision line 2 mm below the lower eyelid
margin beginning 1 mm temporal to the in erior punctum
and extending laterally to the lateral canthal angle.
FIG. 91.2. Cut through the orbicularis muscle with scissors
to enter the postorbicular ascial plane.
FIG. 91.3. Separate the in erior orbicularis retaining
ligament rom the orbital rim to elevate the orbicularis
muscle and super cial musculoaponeurotic system (SMAS)
of o the upper check or a distance o about 1 to 2 cm,
depending upon the extent o the racture. Carefully identify
the infraorbital foramen and neurovascular bundle to avoid
injury to these structures.
FIG. 91.4. Incise periosteum just anterior to the arcus
marginalis and elevate the periosteum rom the underlying
bone anteriorly and posteriorly to expose the rim.
INDICATIONS: Realignment of displaced orbital rim or other bony fragments following fracture.
Miniplate Fixation or Orbital Rim
Fracture

299
CHAPTER 91 ▼ Miniplate Fixation for Orbital Rim Fracture
FIG. 91.1
FIG. 91.2
FIG. 91.3
FIG. 91.4
FIG. 91.5
FIG. 91.6
FIG. 91.7
FIG. 91.8

300
92
FIG. 92.5. I correcting enophthalmos in an orbit with
a seeing eye, use one or two 2-mm thick silastic or
polyethylene sheets, or strips o cancellous bone gra t.
FIG. 92.6. I possible, close periorbita to periosteum over
the rim with interrupted 4-0 Vicryl sutures. Reform the
lower eyelid crease by xing orbicularis muscle to the orbital
septum or retractors with several interrupted 7-0 chromic
sutures 4 mm below the incision line. Reapproximate the skin
edges with interrupted stitches of 6-0 fast-absorbing plain gut.
FIG. 92.1. Proceed as or Orbital Decompression Fig. 88.1
through 88.4 (pp. 350 to 351) to expose the orbital oor.
FIG. 92.2. Elevate periorbita of the orbital oor rom the
in erior orbital ssure laterally to the maxillary–ethmoid
suture medially, and posteriorly or a distance o about
3.5 to 4 cm.
FIG. 92.3. Insert an orbital alloplastic implant or polyeth-
ylene sheets along the oor so its anterior edge sits behind
the orbital rim.
FIG. 92.4. T e implant may be stabilized by drilling a hole
through the orbital rim and implant, and securing it with a
4-0 prolene suture.
INDICA IONS: Correction o enophthalmos in the anophthalmic socket. With modif cation, the procedure may be used
in the presence o a seeing eye, but with extreme caution.
Subperiosteal Orbital Volume
Augmentation
POS OPERA IVE CARE: Place a pressure dressing over
the orbit or 24 hours. Apply antibiotic ointment to the
suture line three to our times daily or 7 days.
PO EN IAL COMPLICA IONS:
Extrusion of the implant—Alloplastic subperiosteal
implants tend to displace anteriorly unless f rmly
anchored into position. It is unwise to rely upon peri-
osteal closure alone to secure the implant. I minimal
displacement does occur, it may not require repair.
However, protrusion into the lower eyelid will necessi-
tate repositioning and ref xation.
Muscle imbalance—When volume augmentation is per-
ormed on a socket with a seeing eye, displacement o
the in erior oblique and rectus muscles may result in
postoperative diplopia and hyperophthalmia. T is usu-
ally resolves a ter several months. I it does not, the
implant may have to be removed or strabismus surgery
per ormed.

301
CHAPTER 92 ▼ Subperiosteal Orbital Volume Augmentation
FIG. 92.1
FIG. 92.3
FIG. 92.6
FIG. 92.4
FIG. 92.2
FIG. 92.5

302
D
SEC ION
R
emoval o the eye may be indicated or extensive trauma,
or intraocular malignancy, or uncontrolled pain in an
eye with no vision, or or a cosmetically disf gured blind globe.
Enucleation is usually per ormed under general anesthesia
because o the psychologic stress involved in the loss o an eye.
However, it can be done under local retrobulbar anesthesia
without di culty. Even when per ormed under general anes-
thesia, retrobulbar anesthetic injection containing epineph-
rine signif cantly reduces bleeding during the procedure and
reduces the incidence o the oculocardiac re ex. In all cases,
the pathologic process should be conf rmed visually be ore
surgery. For intraocular lesions, such as malignant melanoma,
the pupil must be dilated and the lesion observed be ore sur-
gery to avoid the catastrophic consequences o removing the
wrong eye.
In enucleation or intraocular malignancy, the risk
o intraoperative dissemination o tumor cells remains
unknown. Nevertheless, a minimal-touch technique has
been advocated and should be used or all eyes that contain
malignancies. In this modif cation, the extraocular mus-
cles are gently cut ree at their insertions without hooking
because the latter step is associated with excessive eleva-
tion o intraocular pressure. I the check ligaments are not
stripped, the muscles will not retract but remain attached
to anterior enon’s capsule. T e muscles can easily be
retrieved a ter removal o the globe, sutured to enon’s,
or attached to an ocular implant. T e optic nerve is not
clamped be ore cutting. I minimal extrascleral extension
is noted, a posterior tenonectomy is per ormed.
In most cases, a primary ocular implant is placed into
the enucleated socket. T is procedure is necessary to
restore orbital volume. Acrylic or silicone spheres have
given consistent results with ew complications. How-
ever, over the past several decades, the biointegrated
porous implants have gained in popularity and represent
the major implant types in use today. We pre er to place the
ocular implant within enon’s capsule in the same anatomic
space occupied by the globe. It is rarely necessary to place
the implant behind posterior enon’s capsule as a primary
procedure. With care ul wound closure and absence o ten-
sion, implant extrusion is uncommon. An implant should
not be inserted in the presence o orbital in ection or
trauma with oreign matter contamination. In such cases,
enon’s and conjunctiva should be closed primarily, and a
secondary implant placed at a later date.
Early exposure o the ocular implant is associated with
poor wound closure and the use o an oversized implant,
causing wound tension. In ection and hematoma also
Enucleation, Evisceration,
and Exenteration
contribute to exposure. Implant migration resulting in
poor prosthetic f t results in erosion o conjunctiva and
enon’s, with eventual exposure. Except in cases o in ec-
tion or tumor recurrence in the orbit, an exposed implant
should be replaced with a secondary implant o smaller
size. T e smaller implant may be covered with donor sclera
or autogenous ascia and placed behind posterior enon’s
or added support.
Although the nonporous spheres are associated with
a low complication rate, they provide only limited pros-
thetic motility in most patients. Several types o integrated
implants have been introduced since 1985 to increase
motility, including coralline hydroxyapatite, porous poly-
ethylene, and aluminum oxide. Extraocular muscles are
attached, and a peg can be placed some months a ter
surgery that couples with the overlying prosthesis. T is
arrangement gives superior prosthetic motility. However,
peg-related complications have been reported in 20% to
60% o cases, so that ewer than 8% o porous implants are
currently being pegged in the United States and the United
Kingdom. Studies have shown that prosthetic motility o
unpegged porous implants is not any better than or non-
porous implants. T is has led some authors to question the
value o using porous implants, given their greater cost and
the increased preparation time.
T e use o a dermis- at gra t as a primary implant ol-
lowing enucleation is advocated by some. Loss o gra t
volume is less a ter primary than a ter secondary implan-
tation; nevertheless, at atrophy over time is common. In
children, however, orbital at gra ts may show growth over
time. T is procedure requires a separate incision or har-
vesting the gra t. Dermis- at implantation f nds its greatest
value where there is insu cient conjunctiva and enon’s
capsule to allow complete closure over a standard implant.
It should not be used in any orbit with compromised vas-
cular supply, such as a ter severe trauma, or irradiation,
because the risk o gra t atrophy and loss is signif cantly
increased.
T e f tting o a custom-molded ocular prosthesis ollow-
ing enucleation is a procedure equal in importance to the
surgery itsel . T e surgeon must develop a close working
relationship with an ocularist, and both must remain active
in the continuing care o the patient. Six weeks are gen-
erally allowed or healing and resolution o edema be ore
prosthetic f tting.
Evisceration o the globe di ers rom enucleation in that
the patient’s scleral shell and attached extraocular muscles
are le t intact, but the intraocular contents are removed.

Although the cornea may be le t in place, its preserva-
tion may be associated with chronic ocular sur ace pain.
We pre er removal o the cornea, which also allows more
room or a deeper prosthesis and more natural-appearing
anterior chamber depth. Evisceration has the advantage o
giving good cosmetic results and excellent motility. T e
risk o postoperative enophthalmos is less because there is
little trauma to orbital at. Larger implants can be placed
or restoration o volume i the posterior sclera is opened
with several ull-thickness slits to allow it to gape.
T e signif cant disadvantage o evisceration is the
largely theoretic consideration o sympathetic ophthal-
mia induced in the contralateral eye. In numerous stud-
ies, the incidence o sympathetic ophthalmia ollowing
the modern technique o evisceration is not signif cantly
higher than with enucleation. Nevertheless, the patient
must be in ormed o the possible risk o sympathetic with
this operation. Some cases o unsuspected intraocular
malignancy ollowing evisceration have been reported.
In most cases, these predated the availability o ophthal-
mic ultrasound, and or later cases, most patients were
either not imaged or the surgeon disregarded intraocu-
lar abnormalities suggestive o tumor. Nevertheless, this
risk, although very small, must be kept in mind. Eviscera-
tion should not be considered in a patient with opaque
media without adequate imaging. In most cases, eviscer-
ation is an appropriate alternative to enucleation. It has
been considered the procedure o choice in the presence
o endophthalmitis to prevent orbital contamination and
bacterial access to the subarachnoid space with potential
or meningitis.
Exenteration is a radical procedure in which part or all
o the orbital so t tissues are removed. It is used primar-
ily or li e-threatening disease processes not treatable by
more conservative methods, such as primary malignant
tumors o the conjunctiva and eyelids that involve deeper
orbital tissues. Some orbital tumors previously treated
with exenteration, such as rhabdomyosarcoma, are more
success ully managed with chemotherapy and radiother-
apy. Nonmalignant diseases, such as orbital mucormyco-
sis, can be managed medically in selected cases but may
also require exenteration when di use or associated with
extensive orbital necrosis. Patients who have severe pro-
ptosis and orbital pain rom di use lymphangiomas or
other benign tumors may also benef t rom exenteration
or control o symptoms.
In standard exenteration techniques, the eyelids and all
orbital so t tissues are removed as a unit, leaving the bare
bony socket. In some cases, such as adenoid cystic carci-
noma o the lacrimal gland, resection o adjacent bone may
be necessary or complete excision o the tumor. Limited
orms o exenteration also have been utilized. In some
cases, this is no more than an extended enucleation with
removal o conjunctiva, some orbital at and portions o
extraocular muscles. T is procedure is particularly use ul
or anterior or ocular sur ace malignancies. T e cosmetic
results are less devastating than with the radical procedure,
and the recovery time is shortened signif cantly. Other pro-
cedures attempt to salvage the eyelids while removing all
other orbital tissues. T is type o approach adds little to the
f nal cosmetic result. However, preservation o upper and
lower eyelid skin, i not involved in the pathologic process,
is use ul to help cover the orbital de ect and aid in more
rapid healing.
Attempts to f ll the exenterated socket with alloplas-
tic implants or transposed temporalis muscle have been
proposed but may only mask deep recurrences o tumor.
It is best to cover the bony socket with a split-thickness
skin gra t, which allows rapid healing yet is thin enough so
any recurrent tumor may be seen early. Alternatively, the
socket may be allowed to spontaneously granulate and epi-
thelialize over several months. An oculo acial prosthesis
may be f tted a ter healing is complete.
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implants utilizing aps rom the implant capsule. Ophthalmology.
2005;112:516–523.
Wang JK, Liao SL, Lai PC, Lin LL. Prevention o exposure o porous orbital
implants ollowing enucleation. Am J Ophthalmol. 2007;143:61–67.
Wu AY, Vagef MR, Georgescu D, et al. Enduragen patch gra ts or exposed
orbital implants. Orbit. 2011;30:92–95.
304 SEC ION D ▲ Enucleation, Evisceration, and Exenteration

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306
93
FIG. 93.6. Identify and expose the insertions of the rectus
muscles but do not strip the intermuscular septum or
check ligaments for more than 3 to 4 mm.
FIG. 93.7. Place a muscle hook beneath the insertion of the
medial rectus muscle. Weave the needle of a double-armed
6-0 Vicryl suture through the muscle tendon 4 mm from its
insertion, and tighten with a locking stitch on each side. Cut
the muscle from the globe, leaving 3 mm of tendinous stump
attached to sclera for traction. Place the muscle hook beneath
the insertion of the lateral rectus muscle and pass a suture
through the tendon near the sclera. Cut the muscle from sclera
close to its insertion.
FIG. 93.8. Pass the two arms of the lateral rectus muscle
suture through anterior enon’s capsule 5 mm from the
lateral canthal angle and tie the ends on the conjunctival
surface. In similar fashion, suture the medial rectus muscle to
enon’s capsule.
FIG. 93.1. Place an eyelid speculum beneath the lids to
expose the globe. ent up the conjunctiva with forceps and
make a small cut with scissors near the corneal limbus.
FIG. 93.2. Insert the closed scissors into the subconjunctival
space parallel to the limbus and gently spread the blades to
bluntly dissect conjunctiva from sclera.
FIG. 93.3. Remove the scissors and reinsert one blade
beneath conjunctiva. Make a cut to separate conjunctiva
from its limbal attachments.
FIG. 93.4. Continue to bluntly separate conjunctiva from
sclera, and then cut it from around the limbus for 360
degrees.
FIG. 93.5. Insert the closed blades of the scissors along the
sclera in each of the four quadrants between the rectus
muscles and bluntly separate conjunctiva and enon’s from
sclera with a spreading motion to the equator of the globe.
INDICA IONS: Removal o the eye or chronic pain, traumatic disruption, endophthalmitis, intraocular malignancy, or
cosmetic improvement o a blind, disf gured eye.
Enucleation with Primary Acrylic or
Silicone Implant

307
CHAP ER 93 ▼ Enucleation with Primary Acrylic or Silicone Implant
FIG. 93.1
FIG. 93.2
FIG. 93.3
FIG. 93.4
FIG. 93.5
FIG. 93.6
FIG. 93.7
FIG. 93.8

SEC ION D ▲ Enucleation, Evisceration, and Exenteration
308
FIG. 93.9. T e superior and inferior rectus muscles can be sutured in similar fashion or
cut from the globe without a xation suture. If enucleation is performed for an intraocular
tumor, do not hook any of the muscles. Gently grasp each of the four muscles with a forceps
one at a time without applying excessive traction and cut them from sclera with scissors.
FIG. 93.10. Grasp the medial rectus muscle stump with sturdy toothed forceps.
Pull the globe upward and rotate it laterally. Pass an enucleation or Metzenbaum
scissors behind the globe on the medial side and swing the scissors’ tip back and forth
to identify the optic nerve. T e nerve is felt as a tense cord that extends back from the
posterior surface of the globe 180 degrees from the central cornea.
FIG. 93.11. As the tip of the scissors passes over the optic nerve, open the blades
enough to pass around the nerve, but not so much to include orbital fat and
other structures. Push the tips of the scissors toward the lateral orbit to ensure a
complete cut and then slide it backward toward the apex so the nerve is transected
at least 4 to 5 mm behind the globe. Maintain forward traction on the globe and
cut through the optic nerve with one stroke. If the eye contains a retinoblastoma or
perioptic melanoma, cut the nerve at least 10-15 mm behind the globe.
FIG. 93.12. As the nerve is being severed, the globe will lift partially out of the
orbit. Cut the superior and inferior oblique muscles from sclera at their attachments
and remove the globe.
FIG. 93.13. Quickly pack the orbit with cottonoid strips soaked in local anesthetic
with epinephrine and apply digital pressure for several minutes. Slowly remove
the packs and directly cauterize any residual bleeding points. Several malleable
retractors will facilitate exposure.
FIG. 93.14. Place an 18- to 22-mm acrylic or silicone sphere into the orbital
cavity. Placement of the ocular implant is facilitated with an introducer. It is not
necessary to open the posterior enon’s capsule.
FIG. 93.15. Close anterior enon’s capsule with interrupted 5-0 Vicryl sutures. Do
not leave any visible gaps. T ere should not be any tension across the wound.
FIG. 93.16. Grasp the edges of conjunctiva at the medial and lateral extents of
the wound and gently pull the edges outward to de ne the conjunctival margins.
Close conjunctiva with a running stitch of 6-0 plain gut.
POS OPERA IVE CARE: Place a medium-size plastic
con ormer, coated on its inside sur ace with antibiotic
ointment, under the eyelids. Apply a f rm dressing over
the orbit or 48 hours. Apply antibiotic ointment to the
in erior ornix three to our times daily a ter the dressing
is removed and continue or two weeks. A custom-made
prosthesis may be f tted a ter 6 weeks.
PO EN IAL COMPLICA IONS:
Orbital hemorrhage—Postoperative orbital bleeding may
be rom the central retinal artery, the cut extraocular
muscles, or vessels within the orbital at. A retrobulbar
hemorrhage usually reabsorbs a ter several weeks.
Displacement or extrusion of ocular implant—Minor
displacement o the implant usually requires no treat-
ment except or modi ication o the prosthesis. Early
extrusion is most commonly caused by too large an
implant with tension on enon’s or conjunctiva, or by
poor wound closure. I extrusion does occur, allow
the socket to heal and place a secondary implant
later.
Ptosis—Upper eyelid ptosis is typical ollowing enucle-
ation or orbital surgery. It usually resolves over several
weeks. I persistent a ter 3 months, it can be repaired by
levator aponeurosis advancement.
Shallow fornices—T is may result rom too tight an
imbrication o enon’s during closure or rom loss o
ornix f xation. It may be repaired by placement o dou-
ble-armed 4-0 chromic ornix sutures through conjunc-
tiva, periosteum o the orbital rim, and out through the
eyelid skin to re orm the in erior ornix.
Enophthalmos—Loss o orbital at rom trauma, previ-
ous orbital surgery, or progressive atrophy may result
in postoperative enophthalmos. I minimal, this is cor-
rected by enlarging the prosthesis. I signif cant, how-
ever, orbital volume augmentation is needed.

309
CHAP ER 93 ▼ Enucleation with Primary Acrylic or Silicone Implant
FIG. 93.9
FIG. 93.10
FIG. 93.11
FIG. 93.12
FIG. 93.13
FIG. 93.14
FIG. 93.15
FIG. 93.16

310
94
windows with the rectus muscles. Attach each muscle to the
anterior lip of its respective window, using the previously
placed 6-0 Vicryl suture. With porous polyethylene spheres
pass the sutures through the pre-existing tunnels.
FIG. 94.5. Close Tenon’s capsule with interrupted 5-0 Vicryl
stitches and the conjunctiva with a running suture of 6-0
plain gut.
FIG. 94.6. If the implant is to be pegged, allow 6 to
12 months for complete vascularization. Mark the center
of the implant in primary position and inject 0.1 mL of local
anesthetic beneath conjunctiva at this point. Excise a small
window of conjunctiva and enon’s 2 to 3 mm in diameter to
expose the implant.
FIG. 94.7. Stabilize the implant with forceps. Using a 4-mm
cutting burr on a rotary drill or graded 18- to 14-gauge needles,
cut a radially aligned hole 9 mm deep to the center of the
implant.
FIG. 94.8. Screw a titanium peg provided with the implant
into the hole. T e prosthesis will have to be modi ed with a
matching posterior depression to accept the peg.
FIG. 94.1. Proceed as for standard enucleation, Fig. 93.1
through 93.13 (pp. 366 to 369), except place a double-armed
6-0 Vicryl suture through all four rectus muscles. If the
enucleation is performed for intraocular tumor, gently cut the
muscles from the slcera without hooking and place sutures after
the eye is removed.
FIG. 94.2. If the implant is to be covered with sclera, pre-
pare an enucleated donor scleral shell by making two
relaxing incisions 180 degrees apart. Place a 20-mm porous
implant into the shell and close the incisions with a running
5-0 Vicryl suture. Newer implants, such as hydroxyapatite and
aluminum oxide, can be purchased prewrapped. Porous poly-
ethylene implants do not have to be wrapped.
FIG. 94.3. With the optic nerve stump facing forward, cut
four 2 by 3 mm windows in the scleral shell. Place these
windows 90 degrees apart and 4 to 6 mm from the center
of the optic nerve stump. Optionally, drill a 1-mm diameter
hole to the center of the implant at each window and at the
posterior corneal defect for vascularization.
FIG. 94.4. Using an introducer, place the implant into
the enucleated socket. urn the implant to align the scleral
INDICATIONS: As a primary ocular implant ollowing enucleation or evisceration, or as a secondary implant when
improved prosthetic mobility is desired. Also, ollowing multiple extrusions where stabilization o the implant is necessary.
Enucleation with Biointegrated Porous
Ocular Implant
POSTOPERATIVE CARE: Place antibiotic ointment into
the socket and f t a medium- to large-size con ormer
beneath the eyelids. Place a f rm dressing or 48 hours.
A ter the dressing is removed, apply antibiotic ointment to
the socket three to our times daily or 2 weeks. A custom
prosthesis is f tted a ter 6 weeks.
POTENTIAL COMPLICATIONS: All the complications
seen with standard enucleation may also be seen in this
procedure. In addition:
Granulation tissue in the motility peg hole—T is occurs
with excessive irritation around the peg. It may be
removed by excision or a CO2 laser. Application o topi-
cal steroid ointment may retard regrowth.
Poor motility—T is is seen mostly in secondary implants,
where the rectus muscles are contracted or scarred.
Final motility is limited by the status o the extraocular
muscles and is usually better in the horizontal direction.

311
CHAP ER 94 ▼ Enucleation with Biointegrated Porous Ocular Implant
FIG. 94.1
FIG. 94.2
FIG. 94.3
FIG. 94.4
FIG. 94.5
FIG. 94.6
FIG. 94.7
FIG. 94.8

312
95
FIG. 95.5. Cut around the exposed dermis with a scalpel and
extend the cut through the underlying fat to the level of the
muscular fascia.
FIG. 95.6. Transfer the graft to the recipient orbit. Pass both
arms of the preplaced 6-0 Vicryl suture on the medial rectus
muscle through one edge of the dermis plug and tie it down.
Suture the conjunctiva and Tenon’s adjacent to the muscle to
the dermis graft with interrupted stitches of 6-0 Vicryl.
FIG. 95.7. Continue placing sutures around the graft
perimeter inferiorly and superiorly, gently pushing the fat
into the orbit as you go. As each rectus muscle is approached,
suture it to the dermis plug. If muscle were not retrieved, just
suture the graft to Tenon’s. Before closing the lateral quadrant,
if the graft volume appears too large, excise some of the fat.
FIG. 95.8. Close the donor site by cutting the marked
triangular segments from the edges to form an ellipse.
Undermine along the deep fascia and close subcutaneous
tissues with interrupted 4-0 Vicryl stitches. Reapproximate the
dermis with interrupted 4-0 Vicryl sutures and close the skin
with vertical mattress sutures of 4-0 prolene.
FIG. 95.1. For a primary implant, proceed as for standard
enucleation, as described in Fig. 93.1 through 93.13
(pp. 366 to 369), except place 6-0 Vicryl xation sutures
through the tendons of all four rectus muscles before
enucleating the globe. Open posterior Tenon’s capsule widely
to expose the intraconal fat compartment.
FIG. 95.2. For a secondary implant, proceed with removal
of the exposed sphere. If possible, identify the four rectus
muscles and pass a 6-0 Vicryl suture through the tendon of
each. Do not risk injury to the muscles if not easily done; their
brotic attachment to Tenon’s will provide motility.
FIG. 95.3. Mark the donor site on the posterior hip or
abdomen. Draw a circle 20 mm in diameter and extend it into
an ellipse for easier closure.
FIG. 95.4. With a scalpel blade, incise the skin along the
marked line. Dissect the epidermis from underlining dermis
with a scalpel blade or scissors.
INDICATIONS: As a primary ocular implant ollowing enucleation especially in children, or as a secondary implant a ter
implant exposure with partial loss o conjunctiva and Tenon’s capsule.
Dermis-fat Orbital Implant Graft
POSTOPERATIVE CARE: Place antibiotic ointment and
a con ormer on the conjunctiva, and tape a dressing over
the orbit or 48 hours. A ter removal o the dressing, apply
antibiotic ointment to the gra t three to our times daily
until completely epithelialized. Systemic antibiotics are
administered or 10 days. Remove the donor site skin
sutures a ter 14 days.
POTENTIAL COMPLICATIONS:
Graft failure—Total gra t ailure is uncommon but
may be seen where vascular supply is compromised
such as a ter irradiation or in cases o severe socket
contracture.
Volume loss—Gra t shrinkage rom at atrophy is usual
but is increased with traumatic manipulation during
surgery or rom poor vascular supply in the host bed.
Atrophy is a more signif cant problem in secondary
implants than in primary procedures.
Hair growth and conjunctival irritation—Growth o hair
rom the dermis gra t may remain subconjunctival or
extend through it, causing chronic socket irritation. Electro-
epilation may be needed or elimination o o ending hairs.
Prosthetic revision—Because o progressive at atrophy,
repeated modif cation o the prosthesis may be required
in some cases.

313
CHAPTER 95 ▼ Dermis-fat Orbital Implant Graft
FIG. 95.1
FIG. 95.2
FIG. 95.3
FIG. 95.4
FIG. 95.5
FIG. 95.6
FIG. 95.7
FIG. 95.8

314
96
FIG. 96.5. Place a new implant into the orbit behind
posterior Tenon’s capsule. I the previous implant has been
exposed or a while, irrigate the socket with 10 cc o antibiotic
solution. In the presence o rank orbital in ection, do not place
a secondary implant or at least several months a ter resolution
o the problem.
FIG. 96.6. Close posterior Tenon’s capsule with interrupted
5-0 Vicryl stitches.
FIG. 96.7. Approximate the edges o anterior Tenon’s
capsule with 5-0 Vicryl sutures. I Tenon’s is thinned or
absent, a gra t o autogenous temporalis ascia or epicranium
can be placed over the implant to serve as a buf er between
the implant and conjunctiva.
FIG. 96.8. Close conjunctiva with a running suture o 6-0
plain gut.
FIG. 96.1. Place a speculum beneath the eyelids to expose
the conjunctiva and exposed implant. With scissors, make
a cut medially and laterally through conjunctiva and Tenon’s
capsule into the cavity holding the implant.
FIG. 96.2. Hold the edges o Tenon’s capsule apart with
orceps and remove the implant with orceps.
FIG. 96.3. Because it may be dif cult to identi y
epithelialization that may have occurred around the
extruding implant, completely excise the brous capsule
lining the implant cavity. Create a resh edge around the
opening o conjunctiva and Tenon’s capsule by excising a
narrow strip o tissue.
FIG. 96.4. Open posterior Tenon’s with scissors, using a
spreading motion to expose the intraconal orbital at. I
Tenon’s capsule is inadequate to cover the new implant, use a
smaller implant or convert to a dermis- at gra t implantation.
INDICATIONS: Exposure o an ocular implant a ter enucleation or evisceration without signif cant loss o Tenon’s
capsule or conjunctiva.
Repair o the Exposed Ocular Implant
POSTOPERATIVE CARE: Place a con ormer beneath the
eyelids. Apply a f rm dressing or 24 hours. Place antibi-
otic ointment under the lids three to our times daily or 7
days. A new prosthesis will need to be f tted a ter 6 weeks.
POTENTIAL COMPLICATIONS:
Orbital hemorrhage—Dissection into the intraconal
space carries the risk o injury to deep orbital vessels. As
with enucleation, hemostasis and a f rm postoperative
dressing are important.
Shallow fornices—Necrosis and loss o Tenon’s capsule
and conjunctiva over the central part o the extruding
implant may make closure di cult without shorten-
ing the ornices. In such cases, a dermis- at gra t is a
more appropriate procedure. I inadequate ornices are
noted postoperatively, a mucous membrane gra t may
be placed at a later date.

315
CHAPTER 96 ▼ Repair o the Exposed Ocular Implant
FIG. 96.1
FIG. 96.2
FIG. 96.3
FIG. 96.4
FIG. 96.5
FIG. 96.6
FIG. 96.7
FIG. 96.8

316
97
FIG. 97.5. Cauterize the central retinal artery and the vortex
veins. Use a suction catheter for visualization.
FIG. 97.6. Scrub the inside of the scleral shell with
cotton-tipped applicators soaked in 100% alcohol to
remove all traces of uvea. Irrigate the shell copiously several
times with saline solution.
FIG. 97.7. Make a cut through the sclera superonasally and
inferotemporally for a distance of about 1 cm. Insert a 14- to
16-mm diameter nonporous sphere into the shell. T ere should
be no tension on the scleral edges on attempted closure.
A larger implant of 18-20 mm can be used if the posterior
sclera is incised around the optic nerve and several relaxing
incisions are made to gape the scleral shell.
FIG. 97.8. Close the scleral wound with interrupted 5-0
Vicryl sutures. rim any dog-ears at the extremities of the
scleral incisions. Close enon’s with 5-0 Vicryl stitches and
conjunctiva with a running stitch of 6-0 plain gut.
FIG. 97.1. Place a speculum beneath the eyelids to expose
the globe. Perform a 360-degree peritomy of conjunctiva and
enon’s capsule with scissors, using blunt and sharp dissection.
Bluntly undermine enon’s capsule from the underlying sclera
to the level of the rectus muscle insertions.
FIG. 97.2. With a scalpel blade, make an incision into sclera
2-3 mm behind the corneal limbus. Extend the incision
around 360 degrees, cutting to the level of the suprachoroidal
space. ake care not to enter the anterior chamber or to cut
through the choroid.
FIG. 97.3. Separate the choroid from sclera with an evisceration
spoon and continue the dissection back to the optic nerve.
Mild bleeding will be encountered from the vortex veins.
FIG. 97.4. With the evisceration spoon, transect the uvea
from the optic nerve head as close as possible to the
sclera and remove the intraocular contents, including the
attached cornea, in one piece.
INDICATIONS: For removal o a blind pain ul, or cosmetically undesirable eye rom trauma, end-stage disease, or
endophthalmitis.
CONTRAINDICATIONS: T e presence o any intraocular malignancy.
Evisceration
POSTOPERATIVE CARE: Place a con ormer beneath the
lids. Apply a pressure bandage over the orbit or 24 hours.
Apply an antibiotic ointment three to our times daily or 7
days. A custom prosthesis is f tted a ter 6 weeks.
POTENTIAL COMPLICATIONS:
Wound dehiscence—As with enucleation, this results
most commonly rom poor wound closure or the
placement o too large an implant. Early dehiscence
is repaired immediately, replacing the implant with a
smaller size i necessary.
Chronic pain—T is may be seen a ter evisceration with
retention o the cornea. When intractable, the cornea
can be resected or the eviscerated shell can be enucle-
ated and a secondary ocular implant placed.
Sympathetic ophthalmia—T e true incidence o this
disease with modern evisceration techniques remains
unknown but is exceedingly rare and may not be much
higher than with enucleation. However, evisceration
should be undertaken only with in ormed consent a ter
penetrating injuries with uveal prolapse. reatment o
sympathetic ophthalmia is medical, with use o systemic
steroids.

317
CHAP ER 97 ▼ Evisceration
FIG. 97.1
FIG. 97.2
FIG. 97.3
FIG. 97.4
FIG. 97.5
FIG. 97.6
FIG. 97.7
FIG. 97.8

318
98
FIG. 98.5. Pack the orbit with gauze sponges soaked with
epinephrine and apply pressure for 10 minutes. Remove the
sponges and cauterize any residual bleeding vessels. Perforating
vessels through the orbital bones are controlled with bone wax.
FIG. 98.6. Harvest a split-thickness skin graft from the
upper, outer quadrant of the thigh with a dermatome. Place
the graft in the orbit and trim excess skin from the wound
margins. If the graft was not meshed, excise the dog-ear aps
that develop when the graft is folded into the orbital concavity.
FIG. 98.7. Suture the graft to skin at the orbital rim with
interrupted and running 6-0 Vicryl stiches.
FIG. 98.8. Lay multiple 2-inch strips of Telfa or nonadherent
gauze to cover the graft and overlap the orbital rim. Pack
the orbit rmly with cotton balls soaked to dripping in saline
solution that contains gentamicin. Press the cotton into the
cavity to mould it into the crevices, while removing all excess
saline solution with suction. Cover the wound with a rm
dressing.
FIG. 98.1. Mark an incision line around the orbit just inside
the orbital rim. If necessary because of tumor extension in the
skin, mark the line outside this limit to allow at least 5 mm of
normal tissue beyond the tumor edges. Cut through the skin
and muscle with a scalpel blade or cautery needle.
FIG. 98.2. Dissect beneath the orbicularis muscle to the
orbital rim. Incise periosteum along the rim. At the medial
and lateral rims, disinsert the canthal ligaments from their
attachments to bone.
FIG. 98.3. Separate periorbita from the orbital walls with a
Freer elevator. Firm attachments will be encountered at the
trochlea and along the superior and inferior orbital ssures.
Transect the lacrimal duct as it enters the lacrimal canal just
inside the inferomedial orbital rim. If the tumor involves the
lacrimal sac and duct, remove the anterior wall of the canal
with rongeurs and transect the duct at its entrance into the
nose.
FIG. 98.4. Pass enucleation scissors medially around the
orbital tissues to the apex. Transect the tissues and remove
the specimen. Alternatively, a wire snare allows clean separa-
tion of the orbital contents closer to the apex.
INDICATIONS: Removal o the orbital contents or control o ocular and adnexal malignancies, or eradication o uncon-
trolled Mucor orbital cellulitis, or severe orbital contracture, or pain ul inf ltrative benign orbital lesions, or or congeni-
tal de ormities.
Orbital Exenteration
POSTOPERATIVE CARE: Cover the donor site with f ne
mesh gauze or a commercially available gra t dressing. A ter
5-7 days, the anterior hal o the orbital packing can be
removed. T e remainder is removed a ter 10-14 days. T e
orbital cavity is irrigated daily with a dilute solution o
hydrogen peroxide, and crusts are débrided with a orceps.
An oculo acial prosthesis may be f tted a ter 8 weeks or
the patient can wear a black eye patch.
POTENTIAL COMPLICATIONS:
Graft failure or delayed healing—T is results rom bleed-
ing beneath the gra t caused by inadequate hemostasis,
low-grade in ection, or poor approximation o the gra t
to the orbital walls. I small areas o the gra t become
necrotic, these areas are débrided. I the gra t does not
survive, it can be removed and the socket irrigated daily
with 50% hydrogen peroxide and antibiotic ointment
until it heals by spontaneous granulation.
Facial numbness—Numbness o the orehead is inevi-
table because the rontal and supratrochlear nerves are
excised with the orbital contents.
Sinus–orbital fistula—Openings in the lamina papy-
racea o the ethmoid bone may be present rom
tumor involvement or rom spontaneous dehiscence,
or rom iatrogenic per oration during surgery. I
the sinus mucosa is breached or has been biopsied,
it may grow into the orbit beneath the skin gra t,
resulting in ailure. A gra t should not be placed over
the opening. he istula can be closed later by mar-
supialization.

319
CHAPTER 98 ▼ Orbital Exenteration
FIG. 98.1
FIG. 98.2
FIG. 98.3
FIG. 98.4
FIG. 98.5
FIG. 98.6
FIG. 98.7
FIG. 98.8

(Trang không có chữ)

321
Index
A
Abducens nerve, 254, 264–267, 265, 267
Abrasion, corneal (see Corneal abrasion)
Abscesses, orbital, 248
Acquired entropion, 123
Advancement
levator aponeurotic or ptosis, 81, 88–91, 89, 91
myocutaneous, ree tarsoconjunctival gra t or
lower eyelid reconstruction, 190, 191
myocutaneous or superf cial non-marginal
eyelid de ects, 158
single bridged, o lower eyelid, or upper
eyelid reconstruction, 182, 183
tarsoconjunctival, upper to lower eyelid,
192–195, 193, 195
Y to V, or reduction o epicanthal olds, 198, 199
Advancement ap, 162, 163
double bridged, o lower eyelid, or upper
eyelid reconstruction, 184, 185
Adynamic brow, as complication o direct brow
li t, 72
A- rame Müller’s muscle aponeurectomy, 81
Agger nasi cells, 216
Alloplastic ocular implant, in enucleation, 303,
306–309, 307, 309
Alopecia, as complication o endoscopic ore-
head li t, 78
Ampulla, 216, 218–219, 218
Anesthesia
or brow elevation, 72, 73
or enucleation, 72, 73, 302
orehead, as complication o transblepharo-
plasty endotine brow f xation, 74
in raorbital nerve, as complication o orbital
decompression, 288
inhalation, 5
in ophthalmic plastic surgery, 4–5
retrobulbar, 4
scalp
as complication o endoscopic orehead
li t, 78
as complication o transblepharoplasty
endotine brow f xation, 74
supraorbital as complication o direct brow
li t, 72
Anesthetic agent, choice o , 4
Angle, canthal (see Canthal angle)
Angular artery, 8, 14, 15
Angular vein, 14, 15, 264, 265
Annulus o Zinn, 254, 260, 261
Antibiotics or hordeolum, 25
Aponeurosis, levator, 260, 261
horn o , 12, 13
recession o , with Müller’s muscle extirpa-
tion, 150–153, 151, 153
Aponeurotic advancement/levator, or ptosis,
81, 88–91, 89, 91
Aponeurotic ptosis, 80
Arcus marginalis, 7
Arterial arcades, 9
Artery(ies)
angular, 8, 14, 15
carotid, 268, 269
internal, 262, 263
ciliary, 262, 263, 268, 269
ethmoidal, 262, 263, 268, 269
acial, 9, 14, 15
in raorbital, 14, 15, 262, 263
in ratrochlear, 262, 263
lacrimal, 14, 15, 254, 262, 263, 266–269,
267, 269
maxillary, 262, 263
nasal, 262, 263, 268, 269
naso rontal, 262, 263, 268, 269
ophthalmic, 8, 254, 262–265, 263, 265
palpebral, 14, 15, 217, 262, 263, 268, 269
retinal, central, 254, 262, 263
supraorbital, 262, 263, 266–269, 267, 269
supratrochlear, 14, 15
temporal superf cial, 9
zygomatico acial, 14, 15, 260, 261, 268, 269
zygomaticotemporal, 254
Asian upper eyelid blepharoplasty, 46, 47
Aspirin, use be ore ophthalmic surgery, 1
Asymmetry
as complication o direct brow li t, 72
as complication o transconjunctival excision
o herniated orbital at, 68
eyelid crease
as complication o aponeurotic advance-
ment, 90
as complication o Asian upper eyelid
blepharoplasty, 46
as complication o upper eyelid blepharo-
plasty with at excision, 44
Augmentation canthoplasty, lateral, 202, 203
Augmentation o orbital volume subperiosteal,
300, 301
Autogenous ascia lata
rontalis muscle suspension with, 98–101,
99, 101
harvesting, 96, 97
B
Balloon dacryoplasty, nasolacrimal system,
236, 237
Biointegrated porous ocular implant, with
enucleation, 310, 311
Bleeding, nasal
as complication o dacryocystorhinostomy, 240
as complication o nasolacrimal system
probing, 232
as complication o orbital decompression, 288
Blepharoplasty
cosmetic, 38–69
etiology and associated de ormities, 40, 41
lower eyelid
with canthopexy, 52–55, 53, 55
with eyelid shortening, 60–63, 61, 63
with at excision, 52–55, 53, 55
with at redraping, 56–59, 57, 59
upper eyelid
Asian upper eyelid, 46, 47
with at excision, 42–45, 43, 45
ref xation o prolapsed lacrimal gland, 48, 49
Blepharoptosis, 80–103
external levator aponeurosis advancement,
88–91, 89, 91
rontalis muscle suspension with autogenous
ascia lata, 98–101, 99, 101
rontalis muscle suspension with silicone rod,
102, 103
harvesting autogenous ascia late, 96, 97
posterior Müller’s muscle-conjunctival resec-
tion, 86, 87
posterior tarsoconjunctival resection, 84, 85
Supra-Whitnall’s ligament levator muscle
resection, 92–95, 93, 95
Blepharotomy, horizontal, with marginal rota-
tion, 142, 143
Blindness (see Vision, loss o )
Block(s)
nerve, orbital, or ophthalmic surgery, 5
retrotarsal, or ophthalmic surgery, 5
subcutaneous, pretarsal or ophthalmic
surgery, 5
Blow-out ractures o orbit, 306
Bone
ethmoid, 253, 256–259, 257, 259
rontal, 218, 219, 253, 256–259, 257, 259
lacrimal, 218, 219, 253, 256, 257
maxillary, 218, 219, 252, 253, 256–259,
257, 259
nasal, 218, 219, 256, 257
palatine, 252
sphenoid, 256, 257
temporal, 256, 257
zygomatic, 252, 256–259, 257, 259
Bony orbit, 252
Bridged advancement ap
double bridged, o lower eyelid, or upper
eyelid reconstruction, 184, 185
lower eyelid single, or upper eyelid recon-
struction, 182, 183
Brow
adynamic, as complication o direct brow
li t, 72
contour de ects, as complication o posterior
tarsoconjunctival resection, 84
Brow contour, poor, as complication o direct
brow li t, 72
Note: Page numbers in Italics denote f gures

Index
322
Brow elevation
direct, 70, 72, 73
endoscopic orehead elevation, 76–79, 77, 79
transblepharoplasty endotine f xation, 74, 75
Brow f xation, endotine, 74, 75
Brow ptosis, 70–79 see also Brow elevation and
Brow f xation
causes o , 70
correction o , 70
Buccal branch o the acial nerve, 16, 17
Bulbar conjunctiva, 22, 23
Bulging o medial at pocket, 40, 41
C
Canalicular injury
as complication o medial spindle tarsocon-
junctival resection, 110
as complication o modif ed “Lazy- ” proce-
dure, 114
Canalicular occlusion as complication o medial
canthal ligament plication, 116
Canalicular slitting, as complication o cana-
licular reconstruction, 228
Canaliculodacryocystorhinostomy, 220, 242, 243
Canaliculus
common, 216, 218, 219
lacerations, repair o , 224–227, 225, 227
lacrimal puncta and surgery on, 220–229
obstruction o , 220
reconstruction o , 228, 229
slitting o
as complication o nasolacrimal system
balloon dacryoplasty, 236
as complication o nasolacrimal system prob-
ing with silicone intubation stents, 234
erosion o lacrimal puncta as complication
o canalicular repair, 226
stenosis o , 220
as complication o canalicular reconstruc-
tion, 228
at laceration site as complication o
repair, 226
superior, 218, 219
Canthal angle
lateral, dystopia o
as complication o lateral tarsal strip
f xation, 108
as complication o SMAS mid ace
elevation and f xation, 156
as complication o temporal ascia lower
eyelid suspension, 118
lateral, ectropion o
as complication o retractor reinsertion and
lateral tarsal strip eyelid f xation, 136
as complication o temporal ascia lower
eyelid suspension, 118
elevation o , as complication o retractor
reinsertion with lateral tarsal strip
eyelid f xation, 136
rounded, as complication o lower eyelid
blepharoplasty, 54
medial, 10, 11
rounded, as complication o retractor rein-
sertion with lateral tarsal strip eyelid
f xation, 136
vertical dystopia correction o , 206, 207
Canthal angle dystopia, 66
Canthal ligament
lateral, 202
medial
crus o , 218, 219
plication, 116, 117
Canthoplasty
augmentation, lateral, 202, 203
reduction, lateral, 204, 205
Canthus
lateral
reconstruction, 196–211
trichiasis at, as complication o lateral
tarsal strip f xation, 108
medial, reconstruction, 196–211
Capsulopalpebral ascia, 7–8, 253
Carotid artery, internal, 262, 263, 268, 269
Cartilage gra t, posterior lamellar lengthening
with, 144, 145
Caruncle, 10, 11
Cavernous sinus, 260, 261, 264, 265
Cells
agger nasi, 216
ethmoid sinus, 258, 259
Central orbital space, 270
Central retinal artery, 254, 262, 263
Central retinal vein, 264, 265, 268, 269
Cerebrospinal uid leak, as complication o
orbital decompression, 288
Cerebrum, 258, 259
Cervical nodes, 18, 19
Chalazion, 25
hordeolum and, 25–29
incision and drainage o
transconjunctival approach to, 28, 29
transcutaneous approach to, 26–27
recurrence o ollowing incision and drainage
procedures, 26
Check ligaments, 253
Chronic pain, as complication o evisceration,
316
Cicatricial ectropion, 104 (see also Ectropion)
as complication o Z-plasty transpositional
aps, 170
Cilia
loss o , complicating incision and drainage o
chalazion, 26, 28
marginal, superior, 10, 11
Ciliary artery, 262, 263, 268, 269
Ciliary ganglion, 262, 263, 266, 267
Ciliary nerve, 262, 263, 266, 267
Closure
direct o elliptical de ect, simple, 160, 161
layered, direct, o marginal de ects o upper
eyelid, 174, 175
o so t-tissue opening as complication o lost
Jones tube, 244
Cocaine, use o , 220
Common canaliculus, 216, 218, 219
Computerized tomography o orbit, 246
Congenital ectropion syndrome, 204
Congenital nasolacrimal duct obstruction, 230
Conjunctiva, 8
bulbar, 22, 23
lymphatic vessels, 9
palpebral, 22, 23
prolapse o , as complication o supra-Whit-
nall’s levator muscle resection, 94
Conjunctival ornix, 20, 21
Conjunctival hypertrophy o eyelid margin as
complication o tarsoconjunctival
advancement ap, 194
Conjunctival irritation as complication o
dermis- at orbital gra t, 312
Conjunctival resection, posterior Müller’s
muscle, 81, 86, 87
Conjunctivodacryocystorhinostomy, 220, 244, 245
Connective tissue septa o periorbita, 253
Contour de ects, as complication o posterior
tarsoconjunctival resection, 84
Coralline hydroxyapatite ocular implant, 302
Corneal abrasion
as complication o ree tarsoconjunctival
gra t, 180
as complication o ull-thickness marginal
wedge resection, 112
as complication o horizontal blepharotomy,
with marginal rotation, 142
as complication o lower eyelid single bridged
advancement ap, 182
as complication o nasolacrimal system surgery
balloon dacryoplasty, 236
probing with silicone intubation stents, 234
as complication o posterior lamellar length-
ening
with ree tarsoconjunctival gra t, 144
with mucous membrane gra t, 146
as complication o posterior tarsoconjuncti-
val resection, 84
as complication o retractor reinsertion with
horizontal eyelid shortening, 134
Corneal discom ort
as complication o balloon dacryoplasty, 236
as complication o nasolacrimal system prob-
ing with silicone stents, 234
Corneal injury as complication o marginal
rotation by anterior horizontal tarsal
groove resection, 140
Corneal irritation as complication o canalicular
reconstruction, 228
Corneal staining as complication o posterior
Müller’s muscle-conjunctival resec-
tion, 10
Corrugator supercilii muscle, 10, 11
Corticosteroids, or chalazion, 25
Cosmetic blepharoplasty, 38–69
Cryodestuction or trichiasis, 30
Cryosurgery or trichiasis, 32, 33
Cutler-Beard procedure or upper eyelid recon-
struction, 182, 183
D
Dacryocystorhinostomy, 230, 238–241, 239,
241
Dacryoliths, 230
Decompression, orbital
inadequate, as complication o orbital
decompression, 288
in erior and medial walls, 284–288, 285, 287
Dehiscence, wound
as complication o evisceration, 316
as complication o lateral semicircular rota-
tional ap, 176
as complication o retractor reinsertion with
eyelid shortening, 134
Delayed healing, as complication o orbital
exenteration, 318
Depigmentation as complication o cryosur-
gery, 32
Dermatochalasis o upper eyelid, 40, 41
Dermis- at orbital implant gra t, 312, 313

323
Index
Diplopia
as complication o orbital decompression,
288
as complication o anterior orbitotomy, 272
Direct brow li t, 70, 72, 73
Direct closure o elliptical de ect, simple,
160, 161
Direct layered closure o marginal de ects o
upper eyelid, 174, 175
Disc, optic, 258, 259
Disinsertion o lower eyelid retractor, with
scleral gra t, 154, 155
Displacement o implant as complication o
enucleation with primary alloplastic
implant, 308
Distichiasis, 30
electrohy recation or, 30
trichiasis and, 30–37
Donor eyelid
retraction o , as complication o posterior
lamellar lengthening with ree tarso-
conjunctival, 144
upper, lagophthalmos o , as complication o
anterior lamellar lengthening with
skin gra t, 120
Donor site, granulation over growth as compli-
cation o posterior lamellar lengthen-
ing with ree tarsoconjunctival, 144
Double bridged advancement ap, lower eyelid,
or upper eyelid reconstruction, 184,
185
Drainage, incision and, o chalazion
transconjunctival approach to, 28, 29
transcutaneous approach to, 26–27
Duct, lacrimal
membranous, 217, 218, 219
surgery on, 213–245
Dye disappearance test, 213
Dystopia, canthal angle
lateral
as complication o lateral tarsal strip f xa-
tion, 108
as complication o temporal ascia lower
eyelid suspension, 118
vertical correction o , 206, 207
E
Echography o orbit, 247, 248
Ectropion, 104–121
causes o , 104
cicatricial, 104
as complication o Z-plasty transpositional
aps, 170
as complication o ree tarsoconjunctival
gra t and myocutaneous advancement
ap, 190
as complication o rontalis muscle suspen-
sion
with autogenous ascia lata, 102
with silicone rod, 102
as complication o temporal ascia lower
eyelid suspension, 118
congenital, 204
involutional, 104
lateral canthal angle
as complication o retractor reinsertion with
lateral tarsal strip eyelid f xation, 136
as complication o temporal ascia lower
eyelid suspension, 118
mechanical, 104
paralytic, 104
persistent or recurrent, as complication o
anterior lamellar lengthening with
skin gra t, 120
residual lower eyelid, as complication o
SMAS mid ace elevation, 156
Edema
eyelid
as complication o cryosugery or trichia-
sis, 32
as complication o transcutaneous trans-
periosteal anterior orbitotomy, 274
persistent, as complication o lower eyelid
double bridged advancement ap, 184
single bridged advancement ap, 182
Electrohy recation or trichiasis and distichia-
sis, 30
Elevation o lateral canthal angle as complica-
tion o retractor reinsertion with
lateral tarsal strip eyelid f xation, 136
Elliptical de ect, simple direct closure o , 160, 161
Endoscopic orehead elevation, 76–79, 77, 79
Endotine
brow f xation, 74, 75
palpable
as complication o endoscopic orehead
li t, 78
as complication o transblepharoplasty
endotine brow f xation, 74
Enophthalmos
as complication o enucleation, 308
and subperiosteal orbital volume augmenta-
tion, 300, 301
Entropion, 123–147
acquired, 123
cicatricial, 124
classif cation o , 123
congenital, 123
involutional, 123
marginal, as complication o horizontal tar-
soconjunctival transposition ap, 178
mechanical, 123
overcorrection o
as complication o anterior lamellar short-
ening with epitarsal f xation, 138
as complication o ull-thickness eyelid
sutures, 126
as complication o horizontal blepharot-
omy with marginal rotation, 142
recurrence o
as complication o ull-thickness eyelid
sutures, 126
as complication o lower eyelid retractor
reinsertion, 132
spastic chronic, 123
undercorrection o
as complication o anterior lamellar short-
ening with epitarsal f xation, 138
as complication o marginal rotation by
anterior horizontal tarsal groove
resection, 140
Enucleation, 302–319
with biointegrated porous ocular implant,
310, 311
with dermis- at gra t, 312, 313
with primary acrylic or silicone implant,
306–309, 307, 309
Epiblepharon
acquired, 123
as complication o lower eyelid retractor
reinsertion, 132
correction o , lower eyelid crease re ormation
or, 130, 131
induced, 7
lower eyelid, as complication o anterior
orbitotomy, 272
repair o , modif ed ull-thickness eyelid
sutures or, 128, 129
Epicanthal olds, reduction o , 198, 199, 200, 201
Epinephrine
lidocaine with, or ophthalmic surgery, 5
systemic e ects o , 5
Epiphora
persistent, as complication o dacryocysto-
rhinostomy, 240
recurrent, as complication o nasolacrimal
system probing, 232
surgery to correct, 220
Epitarsal f xation, anterior lamellar shortening
with epitarsal f xation, 138, 139
Erosion, o lacrimal puncta
and canaliculus slitting as complication o
canalicular repair, 226
as complication o nasolacrimal system
balloon dacryoplasty, punctal, 236
probing with silicone intubation stents, 234
Ethmoid bone, 252, 256, 257, 258, 259
Ethmoid oramina, 252, 256, 257
Ethmoid sinus cells, 258, 259
Ethmoidal artery, 262, 263, 268, 269
Ethmoidal nerve, 262, 263, 266, 267
Ethmoidal vein, 264, 265, 268, 269
Euryblepharon, interpalpebral f ssure, 204
Evisceration, 316, 317
enucleation and exenteration, 302–319
Excision
o excess eyelid skin, 38
o at
lower eyelid blepharoplasty, 52–55, 53, 55
upper eyelid blepharoplasty, 42–45, 43, 45
o lash bulbs, internal, 32
transconjunctival, o herniated lower eyelid
orbital at, 68, 69
Exenteration
enucleation and evisceration, 302–319
orbital, 318, 319
Exposed ocular implant, repair o , 314, 315
External tarsoaponeurectomy, 81
Extirpation, Müller’s muscle, levator aponeuro-
sis recession with, 150–153, 151, 153
Extraconal orbital at, 258, 259
Extraconal space, 270
Extraocular muscle(s), 253, 254, 270
anatomy, 258–265, 259, 261, 263, 265
congenital f brosis, 80
paresis o , as complication o anterior orbi-
totomy, 274
Extrusion o ocular implant
as complication o enucleation with primary
acrylic or silicone implant, 308
as complication o subperiosteal orbital vol-
ume augmentation contents, 300
Eyebrow (see Brow)
Eyelash bulb
internal resection, 36, 37
internal excision o , 32

Index
324
Eyelid
anatomy, 7–24, 11, 13, 15, 17, 19, 21–23
arterial supply to, 8–9, 14, 15
contour o , poor
as complication o rontalis muscle suspen-
sion with autogenous ascia lata, 100
as complication o lateral semicircular
rotational ap, 176
as complication o levator aponeurosis
recession with Müller’s muscle extir-
pation, 152
as complication o levator aponeurotic
advancement, 90
as complication o supra-Whitnall’s, leva-
tor muscle resection, 94
de ects o , non marginal superf cial, repair o ,
158–171
donor
retraction o , as complication o posterior
lamellar lengthening with gra t, 144
edema o
as complication o cryosurgery or trichia-
sis, 32
as complication o transcutaneous trans-
periosteal anterior orbitotomy, 274
excess skin o , excision o , 108
f xation o , lateral tarsal strip, retractor rein-
sertion with, 136, 137
lamellae o , vascular supply, 8
lateral skin redundancy o , as complication o
eyelid shortening by lateral tarsal strip
f xation, 108
laxity
as complication o ree tarsoconjunctival
gra t, 190
overcorrection o , as complication o
lateral tarsal strip f xation, 108
persistent as complication o lateral tarsal
strip f xation, 108, 109
lower (see Lower eyelid)
lymphatic vessels, 9, 18, 19
margin o
conjunctival hypertrophy, as complication
o upper to lower eyelid tarsoconjunc-
tival advancement ap, 194
distortion o , as complication o electrohy-
recation or trichiasis, 30
notching o , as complication o lower
eyelid blepharoplasty combined with
eyelid shortening, 62
necrosis o , as complication o cryosugery or
trichiasis, 32
normal position o , 7
notching o
as complication o direct layered closure o
marginal de ects, 174
as complication o incision and drainage o
chalazion, 26, 28
overcorrection o
as complication o levator aponeurosis
recession with Müller’s muscle extir-
pation, 152
as complication o lower eyelid retractor
disinsertion with scleral gra t, 154
periorbital structures, external anatomy, 10, 11
persistent eyelid ullness, as complication o
ref xation o lacrimal gland prolapse, 48
ptosis o , as complication o anterior orbi-
totomy, 274
retraction o
as complication o ree tarsoconjunctival
gra t, 180
as complication o horizontal tarsoconjunc-
tival transposition ap, 178
as complication o lower eyelid double
bridged advancement ap, 184
as complication o lower eyelid retractor
reinsertion, 132
as complication o lower eyelid single
bridged advancement ap, 182
correction o , 148–157
lower eyelid recession with Müller’s
muscle extirpation, 150–153, 151,
153
lower eyelid retractor disinsertion with
scleral gra t, 154, 155
SMAS mid ace elevation, 156, 157
shortening o
horizontal ull-thickness, retractor reinser-
tion with, 134, 135
by lateral tarsal strip f xation, 108, 109
lower eyelid blepharoplasty with cantho-
pexy, 64–67, 65, 67
lower eyelid blepharoplasty with, 60–63,
61, 63
skin o
residual redundant, as complication o
upper eyelid blepharoplasty with at
excision, 44
undercorrection o
as complication o anterior lamellar short-
ening with epitarsal f xation, 138
as complication o levator aponeurosis
recession with Mueller’s muscle extir-
pation, 152
as complication o lower eyelid retractor
disinsertion with scleral gra t, 154
vascular supply to, 8–9, 14, 15
venous supply to, 9, 14, 15
Eyelid crease, 10, 11
asymmetric
as complication o Asian upper eyelid
blepharoplasty, 46
as complication o upper eyelid blepharo-
plasty with at excision, 44
f xation o , a ter cosmetic blepharoplasty,
38
in erior, 10, 11
irregular
as complication o anterior lamellar short-
ening with epitarsal f xation, 138
as complication o Asian upper eyelid
blepharoplasty, 44
lower, re ormation o , or epiblepharon cor-
rection, 130, 131
poor, as complication o supra- Whitnall’s,
levator muscle resection, 94
upper, 7
re ormation o , 50, 51
Eyelid margin notch
as complication o ull-thickness marginal
wedge resection, 112
as complication o modif ed “Lazy- ” proce-
dure, 114
Eyelid margin scarring, 36
Eyelid sutures, ull-thickness, 126, 127
modif ed, or epiblepharon repair,
128, 129
F
Face, numbness o , as complication o orbital
exenteration, 318
Facial and orbicularis oculi muscles, superf cial,
10, 11
Facial artery, 14, 15
Facial nerve, 7
branches o , 16, 17
Facial vein, 14, 15
Fascia, capsulopalpebral, 7–8, 12, 13, 253
Fascia lata, autogenous
rontalis muscle suspension with, 98–103,
99, 101
harvesting, 122–124, 123
Fascia lower eyelid suspension, temporal, 96,
97, 119
Fascial plane, postorbicular, 7
Fascial suspension procedure or ectropion,
105, 118, 119
Fat excision
lower eyelid blepharoplasty, 52–55, 53, 55
upper eyelid blepharoplasty, 42–45, 43, 45
Fat, orbital
extraconal, 258, 259
lower eyelid, herniated, transconjunctival
excision o , 68, 69
Fat pad
in erior, 12, 13
orbital, precapsulopalpebral, 22, 23
preaponeurotic, 7,
orbital septum and, 12, 13
precapsulopalpebral, 7, 22, 23
superior, 12, 13
Fat pocket, medial, bulging o , 40, 41
Fat redraping, lower eyelid blepharoplasty with,
52–55, 53, 55
Fissure(s)
in erior orbital, 252–255, 257
interpalpebral, 7, 204
palpebral, dislocation o tubing into, as com-
plication o nasolacrimal system
balloon dacryoplasty, 236
probing with silicone intubation stents, 234
superior orbital, 252–255, 257
Fistula, sinus-orbital, as complication o orbital
exenteration, 318
Fixation
epitarsal, anterior lamellar shortening with,
138, 139
eyelid, lateral tarsal strip, retractor reinser-
tion with, 136, 137
rontalis muscle, with autogenous ascia lata,
98–100, 99, 101
lateral tarsal strip, eyelid shortening, 108, 109
orbital rim racture, miniplate o , 298, 299
periosteal, lateral semicircular rotation ap,
188, 189
Flap
advancement (see Advancement ap)
rhombic, 168, 169
rotational
lateral semicircular, or upper eyelid recon-
struction, 176, 177
myocutaneous, 164, 165
skin, or repair o superf cial non-marginal
eyelid de ects, 158–171
transposition
horizontal tarsoconjunctival, or upper
eyelid reconstruction, 178, 179

325
Index
median orehead, necrosis, 210, 211
myocutaneous, 166, 167
Z-plasty, 170, 171
Fold(s)
epicanthal, reduction o , 198, 199, 201
malar, 10, 11
nasojugal, 10, 11
Foramen(ina)
ethmoidal, 252, 256, 257
in raorbital, 256, 257
pterygopalatine, 256, 257
rotundum, 256, 257
Forehead li t
endoscopic, 76–78, 77, 79
temporal, 70
Forehead transposition ap, median, 210, 211
necrosis o , 210
Fornix(ces)
conjunctival, 20, 21, 174, 175
in erior, suspensory ligament o , 7, 22, 23
lacrimal, 216
lacrimal sac, 256, 257
shallow
as complication o enucleation with pri-
mary acrylic or silicone implant, 308
as complication o repair o exposed ocular
implant, 314
superior, suspensory ligament o , 8, 20–23,
21, 23
Four- ap technique or reduction o epicanthal
olds, 200, 201
Fractures
miniplate f xation or orbital rim, 298, 299
orbital, 281
blow-out, 252
repair o , orbital oor, 296, 297
Free tarsoconjunctival gra t
and myocutaneous advancement ap or
lower eyelid reconstruction, 190, 191
or posterior lamellar lengthening with, 144,
145
or upper eyelid reconstruction, 180,181
Frontal bone, 218, 219, 252, 256, 257, 258, 259
Frontal nerve, 266, 267
Frontal nerve block or ophthalmic surgery, 5
Frontal vein, 14, 15
Frontalis muscle
suspension o , with autogenous ascia lata,
98–101, 99, 101
suspension with, silicone rod, 102, 103
Frontoethmoid suture, 252
Frontozygomatic suture, 252, 256, 257
Full-thickness eyelid shortening with retractor
reinsertion with, 134, 135
Full-thickness eyelid sutures
overcorrection o , 126
modif ed, or epiblepharon repair, 128, 129
G
Ganglion
ciliary, 2, 263, 266, 267
semilunar, 260, 261, 264, 265
trigeminal, 260, 261, 264, 265
General anesthesia
or brow elevation, 72, 73
or ophthalmic surgery, 4
Glabellar, rotation ap, 208, 209
Gland
lacrimal (see Lacrimal gland)
meibomian, chronic obstruction
complicating incision and drainage o
chalazion, 28
Gra t
dermis- at, as orbital implant gra t, 312, 313
ailure, 312
mucous membrane, posterior lamellar
lengthening with, 144, 145, 146,147
scleral, lower eyelid retractor disinsertion
with, 154, 155
tarsoconjunctival, ree
myocutaneous advancement ap or lower
eyelid reconstruction, 190, 191
scleral or cartilage, posterior lamellar
lengthening with, 144, 145
or upper eyelid reconstruction, 180, 181
Gra t ailure
as complication o anterior lamellar length-
ening with skin gra t, 120
as complication o orbital exenteration, 318
as complication o posterior lamellar length-
ening with mucous membrane gra t,
144, 146
Granulation overgrowth o donor site as com-
plication o tarsoconjunctival gra t,
144
Granulation tissue in central hole as complica-
tion o porous ocular implant, 310
Granuloma(s), as complication o conjunctivod-
acryocystorhinostomy, 244
Graves’ orbitopathy, 270, 282
proptosis with, 148, 249, 281
Growth o hair, as complication o dermis- at
orbital implant gra t, 312
H
Hair growth as complication o dermis- at
orbital implant gra t, 312
Harvesting autogenous ascia lata, 96, 97
Hasner, valve o , 217, 218, 219
Healing, delayed, as complication o orbital
exenteration, 318
Hematoma
as complication o endoscopic orehead li t, 78
as complication o transblepharoplasty endo-
tine brow f xation, 74
as complication o upper eyelid blepharo-
plasty with at excision, 44
Hemorrhage, orbital
as complication o anterior orbitotomy, 274
as complication o enucleation with primary
acrylic or silicone implant, 308
as complication o horizontal blepharotomy
with marginal rotation, 142
as complication o lateral orbitotomy, 280
as complication o lower eyelid blepharo-
plasty with at excision, 54
as complication o repair o exposed ocular
implant, 314
Herniated lower eyelid orbital at, transcon-
junctival excision o , 68, 69
Hooding o eyelid skin, temporal, 40, 41
Hordeolum, 25
and chalazion, 25–29
drainage o , 25
external treatment, 25
internal treatment, 25
Horizontal blepharotomy, with marginal rota-
tion, 142, 143
Horizontal ull-thickness eyelid shortening,
retractor reinsertion with, 134, 135
Horizontal tarsal groove resection, anterior
marginal rotation by, 140, 141
Horizontal tarsoconjunctival transposition ap or
upper eyelid reconstruction, 178, 179
Horner’s muscle, 7, 10, 11
Horner’s syndrome, 8
Horns o levator aponeurosis, 253
Hypertrophic scar(s)
a complication o our- ap technique or
epicanthal old, 200
as complication o incision and drainage o
chalazion, 26
I
Imaging, magnetic resonance, o orbit, 281
Implant, ocular (see Ocular implant)
Incision and drainage o chalazion
transconjunctival approach, 28, 29
transcutaneous approach, 26, 27
In ection
as complication o harvesting autogenous
ascia lata, 96
wound, as complication o dacryocystorhi-
nostomy, 240
In raorbital artery, 14, 15, 262, 263
In raorbital canal, 252
In raorbital oramen, 256, 257
In raorbital groove, 252, 256, 257
In raorbital nerve, 9, 260, 261
anesthesia o , as complication o orbital
decompression, 288
In raorbital neuralgia as complication o orbital
decompression, 288
In raorbital neurovascular bundle, 258, 259
In raorbital sulcus, 256, 257
In raorbital vein, 264, 265
In ratrochlear artery, 262, 263
In ratrochlear nerve, 9, 16, 17, 254, 262–265,
263, 265
In ratrochlear vein, 266–269, 267, 269
Inhalation anesthesia, 5
Injury
canalicular
as complication o medial spindle tarso-
conjunctival resection, 110
as complication o modif ed “Lazy- ”
procedure, 114
corneal, as complication o marginal rotation
by anterior horizontal tarsal groove
resection, 140
lacrimal gland, as complication o anterior
orbitotomy, 272
to orbit, traumatic, 248
Internal carotid artery, 262, 263
Internal resection o lash bulbs or trichiasis,
36, 37
Interpalpebral f ssure, 7
euryblepharon, 204
Intraconal space, 270
Intubation stents, silicone, nasolacrimal system
probing with, 234, 235
Involutional ectropion, 104
Irregular eyelid crease(s)
as complication o anterior lamellar shorten-
ing with epitarsal f xation, 138
as complication o Asian upper eyelid blepha-
roplasty, 44

Index
326
Irregular eyelid crease(s) (Continued)
as complication o re ormation o the upper
eyelid crease, 50
as complication o upper eyelid blepharo-
plasty with at excision, 44
Irritation
conjunctival, as complication o dermis- at
orbital implant gra t, 312
corneal, as complication o canalicular recon-
struction, 228
Ischemia o Z-plasty transpositional aps, 170
J
Jones I test, 213
Jones II test, 213
Jones pyrex tube
in conjunctivodacryocystorhinostomy, 244, 245
L
Lacerations, canalicular, repair o , 224–227,
225, 227
Lacrimal artery, 14, 15, 254, 262, 263, 266–269,
267, 269
Lacrimal bone, 218, 219, 252, 256, 257
Lacrimal drainage system, 9
anatomy o , 216–219, 219
surgery on, 213–245
Lacrimal duct
membranous, 217–219, 219
surgery on, 213, 220–229
Lacrimal ossa, 216
Lacrimal gland, 12, 13, 258–269, 259, 261, 263,
265, 267, 269,
injury to, as complication o anterior orbi-
totomy, 272
prolapse o , 38
ref xation, 48, 49
Lacrimal nerve, 9, 16, 17, 260, 261, 266, 267
Lacrimal papillae, 216, 218, 219
Lacrimal puncta, 9, 216, 218, 219
and canaliculi, surgery on, 220–229
erosion o
and canalicular slitting as complication o
canalicular repair, 234
as complication o nasolacrimal system
probing with silicone stents, 234
recurrent obstruction o , as complication o
dacryocystorhinostomy, 240
Lacrimal ridge, 216
Lacrimal sac, 9, 10, 11, 216–219, 219
surgery on, 213–245
Lacrimal sac ossa, 256, 257, 262, 263
Lacrimal vein, 266–269, 267, 269
Lagophthalmos
as complication o Asian upper eyelid blepha-
roplasty, 46
as complication o rontalis muscle suspension
with autogenous ascia lata, 100
with silicone rod, 102
as complication o levator aponeurotic
advancement, 90
as complication o anterior orbitotomy, 272
o donor upper eyelid as complication o
anterior lamellar lengthening with
skin gra t, 120
Lamellar lengthening
anterior, with skin gra t, 120, 121
posterior
with ree tarsoconjunctival, 144, 145
with mucous membrane gra t, 146, 147
Lamellar shortening, anterior, with epitarsal
f xation, 138, 139
Lamina papyracea, 252
Lateral augmentation canthoplasty, 202, 203
Lateral canthal ligament, 18, 19, 202
Lateral canthopexy, lower eyelid blepharoplasty,
64–67, 65, 67
Lateral reduction canthoplasty, 204, 205
Lateral wall, orbital decompression, 294, 295
Laxity, eyelid (see Eyelid, laxity o )
Layered closure o marginal de ects o upper
eyelid, direct, 174, 175
Leak, cerebrospinal uid, as complication o
orbital decompression, 288
Levator aponeurosis, 8, 12, 13, 260, 261
advancement or repair o , or ptosis, 81
horn o , 12, 13
recession o , with, Müller’s muscle extirpa-
tion, 150–153, 151, 153
Levator muscle, 253–255
or ptosis, 81
Supra-Whitnall’s ligament levator muscle
resection, 92–95, 93, 95
Levator palpebrae superioris muscle, 253,
258–261, 259, 261, 264, 265
Lid margin distortion, 34
Lidocaine with epinephrine or ophthalmic
surgery, 4
Li t
direct brow, 70, 72, 73
orehead
mid orehead, 70
temporal, 70
Ligament
check, 306, 307
Lockwood’s, 8, 12, 13, 253
suspensory
o in erior ornix, 8, 22, 23, 253
o superior ornix, 8, 20, 21, 22, 23
Whitnall’s, 8, 12, 13, 253
Local anesthesia
or brow elevation, 72, 73
or ophthalmic surgery, 4, 5
Lockwood’s ligament, 8, 12, 13, 253
Lower eyelid
blepharoplasty o
with eyelid shortening, 60–63, 61, 63
with at excision, 52–55, 53, 55
with at redraping, 56–59, 57, 59
crease, re ormation o , or epiblepharon cor-
rection, 130, 131
double bridged advancement ap o , or
upper eyelid reconstruction, 184, 185
ectropion o as complication o
repair o orbital oor ractures, 296
transcutaneous transseptal anterior orbi-
totomy, 272
epiblepharon, as complication o transcuta-
neous transseptal anterior orbitotomy,
272
major retractors o , 12, 13
margin o , 7
orbital at o , herniated, transconjunctival
excision o , 68, 69
reconstruction o , 186–195
retraction o
as complication o lower eyelid blepharo-
plasty with at excision, 54
as complication o transconjunctival exci-
sion o herniated lower eyelid orbital
at, 68
retractor o
disinsertion with scleral gra t, 154, 155
reinsertion, 132, 133
single bridged advancement ap o , or upper
eyelid reconstruction, 182, 183
temporal ascia, suspension o , 118, 119
Lower lacrimal papilla, 216, 218, 219
Lymphatic drainage rom eyelids, 18, 19
Lymphatic vessels o eyelids and conjunctiva, 9
Lymphedema rom disruption o lymphatic
vessels, 9
M
Maier, sinus o , 216
Malar old(s), 10, 11
Marginal arterial arcades, 9, 14, 15
Marginal cilia, superf cial, 10, 11
Marginal de ects o upper eyelid, direct layered
closure o , 174, 175
Marginal entropion as complication o hori-
zontal tarsoconjunctival transposition
ap, 178
Marginal rotation
by anterior horizontal tarsal groove resec-
tion, 140, 141
horizontal blepharotomy with, 142, 143
Marginal wedge resection, ull-thickness,
112, 113
Maxillary artery, 262, 263
Maxillary bone, 218, 219, 252, 256–259,
257, 259
Maxillary division o the trigeminal nerve, 9
Maxillary sinus, 256–259, 257, 259
Meatus, nasal, in erior, 218, 219
Mechanical ectropion, 104 (see also Ectropion)
Mechanical ptosis, 81
Medial canthal ligament plication, 116, 117
Median orehead transposition ap, 210, 211
Meibomian gland, chronic obstruction com-
plicating incision and drainage o
chalazion, 28
Membrane, mucous, gra t o , posterior lamellar
lengthening with, 146, 147
Membranous lacrimal duct, 217–219, 219
Middle turbinate, 218, 219
Mid ace elevation and f xation o SMAS, 156, 157
Mid orehead li t, 70
Migration o oor implant as complication o
orbital oor ractures repair, 296
Modif ed ull-thickness eyelid sutures or epi-
blepharon repair, 128, 129
Modif ed “Lazy- ” procedure or ectropion,
114, 115
Motility, ocular, restriction o , as complication
o repair o orbital oor ractures, 296
Motor innervation to the eyelid protractors,
16, 17
Mucous membrane gra t, posterior lamellar
lengthening with, 146, 147
Müller’s muscle, 8, 21–23
aponeurectomy, A- rame, 81
conjunctival resection, 81, 86, 87
extirpation o , levator aponeurosis recession
with, 150–153, 151, 153
Muscle(s)
corrugator supercilii, 10, 11

327
Index
extraocular, 253, 254, 270
paresis o , as complication o anterior
orbitotomy, 274
acial and orbicularis oculi, superf cial, 10, 11
rontalis, 10, 11, 16, 17
suspension o , with autogenous ascia lata,
98–101, 99, 101
suspension with, silicone rod, 102, 103
Horner’s, 7, 10, 11
lamella, 205
levator palpebrae superioris, 8, 253–255,
258–261, 259, 261, 264, 265
resection or ptosis, 81–82
Müller’s, 8, 22–23
Müller’s, extirpation o , levator aponeurosis
recession with, 150–153, 151, 153
oblique, 253–255, 258–265, 259, 261, 263,
265
orbicularis, 9, 16, 17, 204, 205
orbicularis oculi, medial canthal insertions
o , 10, 11
procerus, 10, 11
rectus (see Rectus muscle(s)
o Riolan, 9, 10, 11
sympathetic smooth, muscle o Müller, 8, 22,
22–23, 150–153, 151, 153
Muscle sheath o levator palpebrae superioris
muscle, 8
Myocutaneous advancement ap, 162, 163
and ree tarsoconjunctival gra t, 190, 191
Myocutaneous rotational ap, 164, 165
Myocutaneous transposition ap, 166, 167
Myogenic ptosis, 80
N
Nasal artery, 262, 263, 268, 269
Nasal bleeding
as complication o dacryocystorhinostomy,
240
as complication o nasolacrimal system prob-
ing, 232
as complication o orbital decompression,
288
Nasal bone, 218, 219, 256, 257
Nasal meatus, in erior, 218, 219
Nasociliary nerve, 253, 254, 262, 263, 266, 267
Naso rontal artery, 262, 263, 268, 269
Naso rontal vein, 14, 15
Nasolacrimal drainage system
anatomy, 216–219, 219
balloon dacryoplasty, 236, 237
canalicular reconstruction, 228, 229
canaliculodacryocystorhinostomy, 242, 243
conjunctivodacryocystorhinostomy, 244, 245
dacryocystorhinostomy, 238–241, 239, 241
obstruction o , 230
probing o , 232, 233
punctoplasty, 222, 233
Necrosis o Z-plasty transpositional aps, 170
Nerve(s)
abducens, 254, 264–267, 265, 266
ciliary, 262, 263, 266, 267
ethmoidal, 262, 263, 266, 267
acial, 7
rontal, 266, 267
in raorbital, 9, 16, 17, 260, 261
in ratrochlear, 9, 254, 262, 263, 266, 267
lacrimal, 9, 16, 17. 260, 261, 266, 267
maxillary division o the trigeminal nerve, 9
nasociliary, 253, 254, 262, 263, 266, 267
oculomotor, 253, 260–267, 261, 263, 264, 267
optic, 254, 260, 261, 264, 265
superf cial parotid nerve, 9
supraorbital, 9, 16, 17, 266, 267
supratrochlear, 9, 16, 17, 266, 267
temporal nerve, superf cial, 9
trigeminal, 9, 252, 254, 260, 261, 264, 265
trochlear, 254, 262–267, 263, 265, 267
zygomatic, 260, 261
zygomatico acial, 9, 260, 261
zygomaticotemporal, 9, 16, 17
Nerve blocks, orbital, or ophthalmic
surgery, 5
Neurogenic ptosis, 80
Neurovascular bundle, 258, 259
Nitrous oxide or ophthalmic surgery, 5
Nodes
cervical, 18, 19
parotid, 9, 18, 19
submandibular, 9, 18, 19
Nonmarginal eyelid de ects, superf cial, repair
o , 158–171
Notch, supraorbital, 256, 257
Notching o eyelid margin
as complication o direct layered closure o
marginal de ects, 174
as complication o ull-thickness marginal
wedge resection, 112
as complication o lower eyelid blepharo-
plasty combined with eyelid shorten-
ing, 62
as complication o modif ed “Lazy- ” proce-
dure, 114
Numbness, acial, as complication o orbital
exenteration, 318
O
Oblique muscle(s), 253–255, 258–265, 259, 261,
263, 265
Obstruction
canaliculi, 220
o lacrimal puncta, recurrent, as complica-
tion o dacryocystorhinostomy, 240
nasolacrimal system, 230
Occlusion, canalicular, as complication o
medial canthal ligament plication, 116
Ocular implant(s)
displacement o , as complication o enucle-
ation 308
enucleation with biointegrated porous, 310,
311
extrusion o
as complication o subperiosteal orbital
volume augmentation, 300
oor, migration o implant in, as complication
o orbital oor ractures repair, 296
primary acrylic or silicone, enucleation with,
306–309, 307, 309
repair o exposed, 314, 315
Ocular motility
poor, as complication o porous ocular
implant, 310
restriction o , as complication o orbital oor
ractures repair, 296
Oculomotor nerve, 253–254, 260–267, 261,
263, 265, 267
Ophthalmia, sympathetic, as complication o
evisceration, 316
Ophthalmic artery, 8, 254, 262–265, 263, 265,
268, 269
Ophthalmic division o the trigeminal nerve, 9
Ophthalmic plastic surgery, anesthesia in, 4–5
Ophthalmic vein(s), 254, 255, 264, 265, 268, 269
Optic canal, 256, 257
Optic disc, 258, 259
Optic nerve, 253, 254, 260, 261, 264, 265
Orbicularis muscle, 7, 10–13, 11, 13, 18–23, 17,
19, 21, 23, 204
and acial muscles, superf cial, 10, 11
medial canthal insertions, in lower eyelid, 10, 11
motor supply, 9, 16, 17
pretarsal, 9, 10, 11
Orbit
anatomy, 252–269, 257, 259, 261, 263, 265,
267, 269
arterial system o , 262, 263, 268, 269
blow-out ractures o , 252
bones, 252–253, 256, 257
extraocular muscles, 253, 258–263, 259, 261,
263
oor o , migration o implant in, as complica-
tion o orbital oor ractures repair,
296, 297
neurovascular anatomy o , 266, 267
sensory and motor nerves o , 262, 263
surgery, 247–319
venous system o , 264, 265, 268, 269
walls o , 252, 253
surgery on, 281–301
Orbit f ssures, 252, 256, 257
Orbital decompression
in erior and medial walls, 284–288,
285, 287
lateral wall, 294, 295
transconjunctival in erior wall, 292, 293
transcaruncular medial wall, 290, 291
Orbital exenteration, 318, 319
Orbital at
extraconal, 258, 259
lower eyelid herniated, transconjunctival
excision o , 68–69
Orbital ractures, 296–299, 297, 299
Orbital hemorrhage
as complication o lateral orbitotomy, 280
as complication o lower eyelid blepharo-
plasty, 54
as complication o repair o exposed ocular
implant, 314
as complication o anterior orbitotomy, 274
Orbital implant gra t, dermis- at, 312, 313
Orbital ligament o Whitnall, 8, 12, 13, 20–23,
21, 23, 253
Orbital nerve blocks or ophthalmic surgery, 5
Orbital portion o orbicularis muscle,
7, 10, 11
Orbital rim, miniplate f xation, 298, 299
Orbital septum, 8, 12, 13
in erior, 20, 21
and preaponeurotic at pads, 12, 13
superior, 20, 21
Orbital space, 253, 270
Orbitotomy, 372, 273
lateral, 276–280, 277, 279
transcutaneous, transperiosteal anterior,
274, 275
transcutaneous, transseptal anterior,
272, 273

Index
328
Overcorrection
as complication o lateral tarsal strip f xation,
108
as complication o rontalis muscle suspen-
sion with silicone rod, 102
o entropion
as complication o anterior lamellar short-
ening with epitarsal f xation, 138
as complication o ull-thickness eyelid
sutures, 126
as complication o horizontal blepharot-
omy with marginal rotation, 142
o eyelid retraction
as complication o levator aponeurosis
recession with Müller’s muscle extir-
pation, 152
o ptosis
as complication o rontalis muscle suspen-
sion, 100
as complication o levator aponeurotic
advancement, 90
as complication o posterior tarsoconjunc-
tival resection, 84
as complication o supra-Whitnall’s levator
muscle resection, 94
Overgrowth, granulation, o donor site as
complication o posterior lamellar
lengthening with ree tarsoconjuncti-
val gra t, 144
P
Pain
chronic, as complication o evisceration, 316
at endotine site, 74
leg, as complication o harvesting autogenous
ascia lata, 96
Palatine bone, 252
Palpable endotine
as complication o endoscopic orehead li t, 78
as complication o transblepharoplasty endo-
tine brow f xation, 74
Palpebral artery(ies), 14, 15, 217, 262, 263, 268,
269
Palpebral f ssure, 7
dislocation o silicone tubing into
balloon dacryoplasty, 236
probing with silicone intubation stents, 236
Palpebral portion o orbicularis oculi, 7, 10, 11
Papillae, lacrimal, 266, 218, 219
Paralysis, pupillary, as complication o lateral
orbitotomy, 280
Paresis
extraocular muscle o , as complication o
anterior orbitotomy, 274
lateral rectus muscle, as complication o
lateral orbitotomy, 280
Parotid (preauricular) nodes, 9, 18, 19
Periorbita, 253, 258, 259
Periosteal f xation, with lateral semicircular
rotation ap with, or lower eyelid
reconstruction, 188, 189
Peripheral arterial arcade, 9, 15, 16
Peripheral orbital space, 270
Persistent eyelid ullness, and lacrimal gland
prolapse, 48
Persistent eyelid laxity, as complication lateral
tarsal strip f xation, 108
Pinch test or eyelid redundancy, 104
Plastic surgery, ophthalmic, anesthesia, 4–5
Plication, medial canthal ligament, 116, 117
Poor motility, as complication o porous ocular
implant, 310
Postorbicular ascial plane, 7
Preaponeurotic at pads, 8, 12, 13
Preauricular nodes, 9, 18, 19
Premedication or local and general anesthesia, 4
Preoperative evaluation o patient, 4
Primary acrylic or silicone implant, enucleation
with, 306–309, 307, 309
Probing, nasolacrimal system
with in racturing o in erior turbinate, 232, 233
with silicone intubation stents, 234, 235
Prolapse
o conjunctiva, as complication o supra-
Whitnall’s levator muscle resection, 94
o lacrimal gland, 48, 49
Prosthetic revision as complication o dermis-
at orbital implant gra t, 312
Pseudoptosis, 81
Pterygopalatine oramen, 256, 257
Ptosis
aponeurotic, 80–81
brow, 70–78
cause o , determination o , 80
classif cation o , 80
as complication o direct layered closure o
marginal de ects, 108
as complication o enucleation with primary
acrylic or silicone implant, 308
as complication o ree tarsoconjunctival
gra t, 180
as complication o lateral semicircular rota-
tional ap, 176
as complication o anterior orbitotomy, 274
mechanical, 81
myogenic, 80
neurogenic, 80
overcorrection o
as complication o rontalis suspension
with autogenous ascia lata, 100
as complication o levator aponeurotic
advancement, 102
as complication o posterior tarsoconjunc-
tival resection, 84
as complication o supra-Whitnall’s levator
muscle resection, 94
patient evaluation, 81–82
pseudoptosis, 81
surgery or
external levator aponeurosis advancement,
88–91, 89, 91
rontalis muscle suspension with autog-
enous ascia lata, 98–101, 99, 101
rontalis muscle suspension with silicone
rod, 102, 103
harvesting autogenous ascia late, 96, 97
posterior Müller’s muscle-conjunctival
resection, 86, 87
posterior tarsoconjunctival resection, 84, 85
supra-Whitnall’s ligament levator muscle
resection, 92–95, 93, 95
undercorrection o
as complication o rontalis suspension
with autogenous ascia lata, 100
as complication o levator aponeurotic
advancement, 90
as complication o posterior Müller’s
muscle–conjunctival resection, 86
as complication o posterior tarsoconjunc-
tival resection, 84
as complication o supra-Whitnall’s levator
muscle resection, 94
upper eyelid
as complication o lateral orbitotomy, 280
as complication o lower eyelid double
bridged advancement ap, 184
as complication o lower eyelid single
bridged advancement ap, 182
Puncta, lacrimal, 10, 216, 218, 219
erosion o
as complication o nasolacrimal system
probing with silicone stents, 234
as complication o nasolacrimal system
balloon dacryoplasty, 234
surgery o , 220–229
Punctate corneal staining, as complication o
posterior Müller’s muscle-conjuncti-
val resection, 10
Punctoplasty, 222, 223
Pupillary paralysis, as complication o lateral
orbitotomy, 280
R
Radiosurgery or trichiasis, 34, 35
Recession, levator aponeurosis, with Müller’s
muscle extirpation, 150–153, 151, 153
Reconstruction
lower eyelid, 186–195
o medial and lateral canthi, 196–211
upper eyelid, 172–177
Reconstruction o canthal de ect, 202–211
Rectus muscle(s), 253–255, 258–319, 259, 261,
263, 265
imbalance o , as complication o subperios-
teal orbital volume augmentation, 300
paresis, as complication o lateral orbitotomy,
280
Reduction canthoplasty, lateral, 204, 205
Reduction o epicanthal olds, 198–201, 199, 201
Ref xation o lacrimal gland prolapse, 48, 49
Reinsertion
lower eyelid retractor, 132, 133
retractor
with horizontal ull-thickness eyelid short-
ening, 134, 135
with lateral tarsal strip f xation, 136, 137
Repair o exposed ocular implant, 314, 315
Resection
eyelash bulb, internal, 36, 37
levator muscle
or ptosis, 81–82
Supra-Whitnall, 92–95, 93, 95
medial spindle, 110, 111
posterior Müller’s muscle-conjunctival, 81,
86, 87
tarsal groove, anterior horizontal, marginal
rotation, 140, 141
tarsoconjunctival gra t, 190, 191
transconjunctival or ptosis, Fasanella-Servat,
84, 85
wedge, marginal, ull-thickness, 112, 113
Residual redundant eyelid skin
as complication o Asian upper eyelid blepha-
roplasty, 46
as complication o upper eyelid blepharo-
plasty with at excision, 44
Retinal artery, central, 254

329
Index
Retinal vein, central, 264, 265, 268, 269
Retraction
donor eyelid, as complication o ree tarso-
conjunctival, 144
eyelid (see Eyelid, retraction o )
Retractor(s)
o eyelid, 12, 13
lower eyelid
disinsertion o , with scleral gra t, 154, 155
reinsertion o , 132, 133
reinsertion o
with horizontal ull-thickness eyelid short-
ening, 134, 135
with lateral tarsal strip eyelid f xation, 136, 137
Retrobulbar anesthesia, 4
Rhombic ap, 168, 169
Riolan muscles o , 9
Rosenmüller, valve o , 216
Rotation ap
glabellar, 208, 209
lateral semicircular
with periosteal f xation, or lower eyelid
reconstruction, 188, 189
or upper eyelid reconstruction, 176, 177
myocutaneous, 164, 165
Rotation, marginal
by anterior horizontal tarsal groove resec-
tion, 140, 141
horizontal blepharotomy with, 142, 143
Rounded canthal angle as complication o
retractor reinsertion with lateral tarsal
strip eyelid f xation, 136
Rounded lateral canthal angle as complication
o lower eyelid blepharoplasty with at
excision, 54, 62
Rounded lateral eyelid contour as complication o
lateral semicircular rotational ap, 176
S
Sac, lacrimal (see Lacrimal sac)
Scalp anesthesia
as complication o endoscopic orehead li t, 78
as complication o transblepharoplasty endo-
tine brow f xation, 74
Scar ormation
hypertrophic
as complication o incision and drainage o
chalazion, 26
as complication o our- ap technique or
reduction o epicanthal old, 200
poor, as complication o harvesting autog-
enous ascia lata, 96
Scarring
eyelid margin, as complication o internal
eyelash bulb resection, 36
visible, as complication o direct brow li t, 72
Sclera, 258, 259
Scleral gra t
ree posterior lamellar lengthening with, 120,
121
lower eyelid retractor disinsertion with, 154,
155
Scleral show, as complication o transconjuncti-
val excision o lower eyelid herniated
orbital at, 68
Semicircular rotation ap, lateral
with periosteal f xation, or lower eyelid
reconstruction, 188, 189
or upper eyelid reconstruction, 176, 177
Semilunar ganglion, 260, 261, 264, 265
Septum, orbital
in erior, 12, 13
lateral, 18, 19
and preaponeurotic at pads, 12, 13
superior, 12, 13
Shallow ornices, as complication o repair o
exposed ocular implant, 314
Shortening
eyelid
horizontal ull-thickness, retractor reinser-
tion with, 134, 135
by lateral tarsal strip f xation, 108, 109
lamellar, anterior, with epitarsal f xation,
108, 109
lower eyelid blepharoplasty combined with,
64–67, 65, 67
Silicone intubation stents, nasolacrimal system
probing, 234, 235
Silicone rod, rontalis muscle suspension with,
102, 103
Simple direct closure o elliptical de ect, 160, 161
Single bridged advancement ap, lower eye-
lid, or upper eyelid reconstruction,
182, 183
Sinus
cavernous, 260, 261, 264, 265
ethmoid, cells o , 258, 259
o maier, 216
maxillary, 256–259, 257, 259
Sinusitis, as complication o orbital decompres-
sion, 288
Sinus-orbital f stula, as complication o orbital
exenteration, 318
Skin, eyelid
excess o , excision o , 108
lateral redundancy o , as complication o
lateral tarsal strip f xation, 108
residual redundant, as complication o
upper eyelid blepharoplasty, 44
Slitting, canalicular
as complication o nasolacrimal system
balloon dacryoplasty, 236
probing with silicone intubation stents, 234
erosion o lacrimal puncta and, as complica-
tion o canalicular repair, 226
SMAS mid ace elevation and f xation, 156, 157
So t-tissue opening, closure o , as complication o
conjunctivodacryocystorhinostomy, 244
Sphenoid bone, 256, 257
Sphenozygomatic suture, 256, 257
Split-level tarsectomy–tarsoaponeurectomy, 81
Squamous portion o temporal bone, 256, 257
Staining, corneal punctate as complication o
Müller’s muscle-conjunctival, resec-
tion, 86
Stenosis, canalicular, 220
as complication o canalicular reconstruc-
tion, 228
at laceration site as complication o repair, 226
Stents, silicone intubation, nasolacrimal system
probing with, 234, 235
Stye, treatment o , 25
Subcutaneous block, pretarsal, or ophthalmic
surgery, 5
Submandibular nodes, 9, 18, 19
Subperiosteal compartment, 270
Subperiosteal orbital volume augmentation o
orbit, 300, 301
Sulcus
in raorbital, 256, 257
superior, 10, 11
Sunken hollow appearance as complication o
transconjunctival excision o herni-
ated lower eyelid orbital at, 68
Superf cial acial and orbicularis oculi muscles,
10, 11
Superf cial nonmarginal eyelid de ects, repair
o , 158–170
Superf cial parotid nerve, 9
Superf cial temporal artery, 9
Superf cial temporal vein, 14, 15
Supraorbital anesthesia as complication o
direct brow li t, 72
Supraorbital artery, 262, 263, 266–269, 267, 269
Supraorbital nerve, 9, 16, 17
Supraorbital notch, 256, 257
Supraorbital vein, 266–269, 267, 269
Supratrochlear artery, 14, 15
Supratrochlear nerve, 9, 16, 17, 266, 267
Supratrochlear nerve block or ophthalmic
surgery, 5
Supratrochlear vein, 266–269, 267, 269
Supra-Whitnall levator muscle resection,
92–95, 93, 95
Surgery
eyelid, 1–211
lacrimal drainage system, 213–245
on lacrimal puncta and canaliculi, 220–229
on lacrimal sac and duct, 230–245
orbital, 247–319
on orbital walls, 281–301
plastic, ophthalmic, anesthesia, 4–5
Surgical anatomy
o eyelid, 6–23
o lacrimal drainage system, 216–219, 219
o orbit, 252–269
Suspension, temporal ascia lower eyelid, 118, 119
Suspensory ligament
Lockwood’s, 8, 12, 13, 253
Whitnall’s, 8, 12, 13, 20, 21, 23, 253
Suture(s)
eyelid, ull-thickness, 126, 127
modif ed, or epiblepharon repair, 128, 129
rontoethmoid, 252
rontozygomatic, 252, 256, 257
sphenozygomatic, 256, 257
zygomaticosphenoid, 252
Sympathetic muscle, Müller, 8, 22–23, 150–153,
151, 153
Sympathetic ophthalmia as complication o
evisceration, 316
Syndrome
congenital ectropion, 204
Horner’s, 8
T
ransconjunctival in erior wall, orbital decom-
pression, 292, 293
arsal groove resection, anterior horizontal,
marginal rotation by, 140, 141
arsal plate(s), 8, 11, 12, 18–22, 19, 21, 23
arsal strip eyelid f xation, lateral
eyelid shortening by, 108, 109
retractor reinsertion with, 136, 137
arsectomy–tarsoaponeurectomy, split-level, 81
arsoaponeurectomy, external, 81

Index
330
arsoconjunctival advancement ap, upper to
lower eyelid, 192–195, 193, 195
arsoconjunctival gra t, ree
and myocutaneous advancement ap or
lower eyelid reconstruction, 190, 191
posterior lamellar lengthening with, 144, 145
or upper eyelid reconstruction, 180, 181
arsoconjunctival resection, 81
medial spindle, 110, 111
posterior, 84, 85
arsoconjunctival transposition ap, or upper
eyelid reconstruction, 178, 179
arsorrhaphy, lateral, 106, 107
ear out ow, test o , 213
ears, drainage, obstruction, 213
emporal artery superf cial, 78, 79, 254
emporal bone, 256, 257
emporal branch o acial nerve, 16, 17, 70
emporal ascia lower eyelid suspension, 118, 119
emporal orehead li t, 70
emporal hooding o eyelid skin, 40, 41
emporal nerve, superf cial, 9
emporal vein, superf cial, 14, 15
emporalis muscle, 118, 119, 188, 189
endon, canthal
medial
crus o , 218, 219
plication o , 116, 117
est
dye disappearance, 213
Jones I, 213
Jones II, 213
pinch, or eyelid redundancy, 104
T ickening o Z-plasty transpositional aps, 170
issue, granulation in central hole as complica-
tion o porous ocular implant, 310
omography, computerized, o orbit, 281
ransblepharoplasty Endotine brow f xation, 74, 75
ranscaruncular medial wall, orbital decom-
pression, 284, 285
ransconjunctival approach to incision and
drainage o chalazion, 28, 29
ransconjunctival excision o lower eyelid
herniated orbital at, 68, 69
ransconjunctival resection or ptosis, 84, 85
ranscutaneous approach to incision and drain-
age o chalazion, 26–27, 27
ranscutaneous, transperiosteal anterior orbi-
totomy, 274, 275
ranscutaneous, transseptal anterior orbitot-
omy, 272, 273
ransperiosteal anterior orbitotomy, 274, 275
ransposition ap
horizontal tarsoconjunctival, or upper eyelid
reconstruction, 178, 179
median orehead, 210, 211
necrosis, 210
myocutaneous, 166, 167
Z-plasty, 170, 171
ransseptal anterior orbitotomy, 272, 273
ransverse acial artery, 9, 14, 15
ransverse acial vein, 14, 15
ransverse ligament o Whitnall, 8, 12, 13, 20,
21, 23, 253
arsoconjunctival advancement ap, upper to
lower eyelid, 192–195, 193, 195
riamcinolone acetonide or chalazion, 25
richiasis, 30
cryodestruction or, 30
cryosugery or, 32, 33
and distichiasis, 30–37
electrohy recation or, 30
eyelash bulb, internal resection, 36, 37
at lateral canthus as complication o by lateral
tarsal strip f xation, 108
medical management o , 30
primary, 30
radiosurgery or, 34, 35
recurrence o
ollowing cryosurgical treatment, 30
ollowing electohy recation, 30
secondary, 30
surgical management o , 30
rigeminal ganglion, 260, 261, 264, 265
rigeminal nerve, 252, 254, 260, 261
ophthalmic division, 260, 261, 264, 265
branches o sensory nerves rom eyelids, 16, 17
rochela, 264, 265
rochlear nerve, 254, 262–267, 263, 265, 267
umors, orbital, 148, 303
urbinates, 258, 259
wo-snip punctoplasty, 222, 223
U
Undercorrection
as complication o rontalis muscle suspen-
sion with silicone rod, 102
o entropion
as complication o anterior lamellar short-
ening with epitarsal f xation, 138
as complication o marginal rotation by
anterior horizontal tarsal groove
resection, 140
o eyelid retraction
as complication o levator aponeurosis
recession with Müller’s muscle extir-
pation, 152
as complication o lower eyelid retractor
disinsertion with scleral gra t, 154
o ptosis
as complication o rontalis muscle suspen-
sion with autogenous ascia lata, 100
as complication o levator aponeurotic
advancement, 90
as complication o posterior Müller’s
muscle–conjunctival resection, 86
as complication o posterior tarsoconjunc-
tival resection, 84
as complication o supra-Whitnall’s levator
muscle resection, 94
Upper eyelid
blepharoplasty, with at excision, 42–45, 43, 45
donor, lagophthalmos o , as complication o
anterior lamellar lengthening with
skin gra t, 120
major retractors o , 12, 13
margin o , 7
marginal de ects o , direct layered closure o ,
174, 175
ptosis o
as complication o lateral orbitotomy, 280
as complication o lower eyelid bridged
advancement ap, 182
as complication o anterior orbitotomy, 272
reconstruction o , 172–185
Upper eyelid crease, 7
re ormation o , 50, 51
Upper lacrimal papilla, 216, 218, 219
Upper to lower eyelid tarsoconjunctival
advancement ap, 192–195, 193, 195
V
Valve
o Hasner, 217
o Rosenmüller, 216
Vein(s)
angular, 14, 15, 264, 265
central retinal, 264, 265, 268, 269
ethmoidal, 264, 265, 268, 269
acial, 14, 15
rontal, 14, 15
in raorbital, 264, 265
in ratrochlear, 266–269, 267, 269
lacrimal, 266–269, 267, 269
naso rontal, 14, 15
ophthalmic, 254, 255, 264, 265, 268, 269
superf cial temporal, 14, 15
supraorbital, 14, 15, 266–269, 267, 269
supratrochlear, 266–269, 267, 269
temporal, superf cial, 14, 15
vortex, 264, 265, 268, 269
Vertical canthal angle dystopia, correction o ,
206, 207
Visible scar as complication o direct brow
li t, 72
Vision, loss o
as complication o lower eyelid blepharo-
plasty with at excision, 54
as complication o orbital decompression, 288
as complication o repair o orbital oor
ractures, 296
as complication o upper eyelid
blepharoplasty with at excision, 44
Volume orbital, loss as complication o dermis-
at orbital gra t, 312
Vortex vein, 264, 265, 268, 269
W
Wedge resection, marginal, ull-thickness, 112,
113
Whitnall’s ligament, 8, 12, 13, 20, 21, 23, 253
Wies procedure or entropion, 142, 143
Wound dehiscence
as complication o evisceration, 316
as complication o lateral semicircular rota-
tional ap, 176
as complication o retractor reinsertion with
horizontal eyelid shortening, 134
Wound in ection as complication o dacryocys-
torhinostomy, 240
Y
Y to V advancement ap or reduction o epi-
canthal olds, 198–201, 199, 201
Z
Zinn, annulus o , 253, 260, 261
Z-plasty or repair o superf cial nonmarginal
eyelid de ects, 158
Z-plasty transpositional aps, 170, 171
Zygomatic arch o temporal bone, 256, 257
Zygomatic bone, 252, 256–259, 257, 259
Zygomatic branch o acial nerve, 7, 9, 16, 17
Zygomatic urrow, 10, 11
Zygomatic nerve, 260, 261
Zygomatico acial artery, 260, 261, 268, 269
Zygomatico acial nerve, 9, 16, 17, 260, 261
Zygomaticosphenoid suture, 252
Zygomaticotemporal artery, 254
Zygomaticotemporal nerve, 9, 16, 17