Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Region III
Region III defects will often include parotidectomy or a lateral temporal bone resection in addition to
removal of a portion of the posterior cranial fossa. Larger, bulky flaps, such as the ALT or RAM, are
frequently required; if an oral cavity defect is anticipated, then two skin paddles may be needed. If a
lateral temporal bone resection and/or mastoidectomy is performed, well-vascularized muscle is helpful
to obliterate the middle ear and seal off any exposed dura and/or exposed mastoid air cells 25,26 (Figure
38.9). If resection of the middle ear is anticipated, upfront BAHA placement should be considered. If the
external ear is resected, reconstruction is best addressed separately in a delayed manner. Prosthetic
rehabilitation is the mainstay for oncologic auricular reconstruction; these prostheses can be secured with
an adhesive or through the use of osseointegrated implants, provided adequate bone stock remains
available to stabilize the implants.
FIGURE 38.9 A. Zone III skull base defect following a right lateral temporal bone resection including division of the facial
nerve. The defect is reconstructed with an anterolateral thigh myocutaneous free flap, with muscle placed into the deepest
portion of the defect and obliterates the Eustachian tube orifice. Several cable nerve grafts were performed in conjunction with
static facial reanimation to restore facial nerve function. B,C. Postoperative result. Note return of motor nerve function following
cable nerve grafting, approximately 12 months after the reconstruction.
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Postoperative Care and Management of Complications
The principal goal of reconstruction of the resected skull base is to separate the aerodigestive tract from
the brain and intracranial contents. Consequently, meticulous isolation of the dura and brain by well-
vascularized soft tissue flaps is necessary to prevent meningitis, cerebritis, brain abscesses, neurologic
injury, and death. Postoperatively, the patient should be maintained on prophylactic intravenous
antibiotics with empiric coverage of normal sinonasal flora. If the dura has been resected, consideration
should be given for antibiotics that can penetrate the blood-brain barrier. In addition to flap monitoring,
frequent neurologic examinations should be conducted. Postoperative computed tomography (CT) or
magnetic resonance imaging scans are obtained according to the recommendations of a neurosurgeon.
Although it is not uncommon to see intracranial air on imaging in the early postoperative period,
increasing pneumocephalus or any change in the clinical neurologic examination should trigger a prompt
return to the operating room. Such findings could suggest a number of complications, including infection,
flap dehiscence, hematoma, or intracranial bleed. Any concern for a CSF leak should be evaluated and
confirmed with a beta-2 transferrin test. Most minor CSF leaks can be effectively treated conservatively
with antibiotic prophylaxis and bed rest. Lumbar drains, externalized ventricular drains, or dural repair
are more invasive options for recalcitrant leaks. If a portion of the orbit has been reconstructed, visual
acuity and extraocular muscle function should be frequently examined postoperatively. Any concern for
decreased visual acuity should prompt an ophthalmologic examination and imaging. Impingement of the
optic nerve or entrapment of an extraocular muscle by the reconstruction usually requires a return to the
operating room.
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Reconstruction After Maxillectomy
Management of the maxillectomy defect is a particularly complicated and controversial field within head
and neck oncologic reconstruction. Options include the use of prosthetic obturators, soft tissue free flaps,
osseous free flaps, alloplastic implants, and autologous grafts. Reconstructive algorithms can be complex
and must take into account a variety of considerations. Multiple approaches have been described and
differ based on the prioritization of defect characteristics and reconstructive techniques. 27–31
One of the fundamental problems with reconstructing the midface is that the defects created by oncologic
resection are highly variable. Such defects usually involve not only the maxillary bones but may also
include a number of adjacent facial and cranial bones, as well as soft tissues of the face, palate, and orbit.
Several classification systems have been introduced and can be helpful in guiding reconstruction. 27–29
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Anatomy and Nomenclature
The maxilla contributes to forming the boundaries for three cavities: the roof of the mouth, the floor and
lateral nasal walls, and the floor and medial orbital walls. Each maxilla articulates with the zygomatic,
frontal, ethmoid, nasal, lacrimal, palatine, and vomer bones. Many maxillary tumors extend into or arise
from the orbit. Therefore, a maxillectomy may be combined with an orbital floor resection or an orbital
exenteration. The orbital roof consists of the frontal bone and separates the intracranial contents from the
orbit; the floor is made up of the maxilla, palatine, and zygomatic bones; the medial wall consists of the
frontal, lacrimal, and ethmoid bones; the lateral wall includes the zygomatic and sphenoid bones.
Spiro and colleagues categorized maxillectomies according to the number of walls resected, dividing
them into limited, subtotal, and total subtypes. 30 Unfortunately, this algorithm is relatively simplistic and
does not help to guide the reconstruction. Although several other classification systems have been
described, we prefer a classification system that provides for an anatomic description of the defect 27–29
(Table 38.3). Orbital exenteration, which includes removal of the globe as well as the other orbital
contents in contrast to enucleation which refers to globe removal only, may be included with the
maxillary resection.
TABLE 38.3
Maxillectomy Classification Systems and Reconstructive Techniques
Hanasono
Cordeiro
Brown
Resection Description
Resection Depiction
Reconstruction
Suprastructure
I
I
Any part of maxilla
not including the
palate or alveolus
No treatment versus soft tissue
flap if skin resected
(ALT/RAM/RFF)
Premaxillary
–
–
Central alveolus
between canines ±
primary palate
Obturator versus osteocutaneous
flap (RFOC/FOC)
Unilateral posterior
Palatomaxillectomy
IIa
IIb
Alveolus distad to
canine, palate, and one
or more walls of the
maxilla
Obturator versus ALT/RAM/RFF
Unilateral
hemipalatomaxillectomy
IIa
IIb
Entire hemipalate and
maxilla
ALT/RAM versus FOC
Bilateral
IIb
IId
Bilateral palate and
FOC
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palatomaxillectomy
maxilla
Maxillectomy with
orbital floor resection
IIIa
IIIb
Any
maxillectomy + orbital
floor resection
Choice of flap based on
maxillectomy defect; orbital floor
reconstructed with alloplastic
implant versus autologous bone
graft (iliac crest versus split
calvarial)
Orbitomaxillectomy
IV
V
Any
maxillectomy + orbital
exenteration
ALT/RAM versus
ALT/RAM + FOC versus
chimeric scapula
osteomyocutaneous flap
ALT, anterolateral thigh; RAM, rectus abdominis myocutaneous.
Medial maxillectomy involves resection of the medial wall of the maxilla and inferior turbinate. This
surgery is usually indicated for tumors arising from the lateral nasal wall or lacrimal system. This
resection may be performed through a lateral rhinotomy incision or, more recently, endoscopically.
Reconstruction is only necessary if the skin of the medial canthal area or lateral nasal sidewall has been
removed with the maxilla (Figure 38.10). In this situation, a paramedian forehead flap or radial forearm
free flap can be used to resurface the medial canthus skin; a portion of the flap can be de-epithelialized
and buried deep to the lateral rhinotomy incision to prevent fistula formation.
FIGURE 38.10 Medial maxillectomy via lateral rhinotomy incision. A. Defect involves resection of skin overlying the medial
canthus and superior lateral nasal sidewall as well as medial maxillary wall. B. Reconstructed with paramedical forehead flap;
distal aspect of flap de-epithelialized and buried to reinforce the inferior aspect of the incision. C. Postoperative result after
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pedicle transection and radiation therapy.
Suprastructure maxillectomies involve the orbital floor but do not involve the palate. In these cases, the
orbital floor is reconstructed with an alloplast such as titanium mesh or bone graft from the calvarium or
ilium. The nonvascularized orbital floor reconstruction and cheek are supported by a bulky soft tissue
free flap with a de-epithelialized skin paddle, such as the ALT or RAM free flaps, or a pedicled
temporalis muscle flap if the reach and volume appear to be adequate for the defect. If facial skin is also
resected, cheek reconstruction becomes necessary and is usually best accomplished using a
myocutaneous free flap, such as the ALT or RAM.
For maxillectomies that involve removal of some or all of the palate, the amount of hard and soft palate
resected, as well as the plan for dental restoration, will dictate whether a prosthetic obturator is indicated
or if a flap should be performed. Okay and colleagues provide a set of guidelines based on what defects
are compatible with a prosthetic obturator. 32 In general, palatoalveolar defects that spare both canine
teeth can be successfully treated with an obturator (Table 38.3). In these cases, cantilever forces resulting
in unstable prosthetic retention are minimized because of the favorable root morphology of the canine
adjacent to the obturator and the generous arch length provided by the remaining alveolus. Obturators
are inappropriate for maxillectomy defects that include a concurrent resection of the skull base, orbital
floor, orbital contents, or facial skin, regardless of the remaining dentition and alveolar arch.
Additionally, some patients may not like certain features of an obturator, such as the fact that it must be
removed and cleaned regularly and periodically adjusted or replaced for fit, wear and tear, and/or fungal
colonization.
When an obturator cannot be used either because of defect geometry or patient preference, a soft tissue
free flap can be used to replace the missing palate and support the soft tissues of the face for
palatoalveolar defects posterior to the canine tooth. The ALT or RAM free flaps are well suited for this
indication. In obese patients, the radial forearm fasciocutaneous flap can be used. In any palatal defect
reconstructed with a flap, meticulous surgical technique must be practiced when insetting the flap to the
remaining palate. We recommend resecting additional palatal mucosa so that the flap-palate seam is
positioned over bone, thus minimizing the chance of an oronasal fistula should an incisional dehiscence
occur.
When reconstructing any variety of midface defect with a free flap, achieving adequate pedicle length can
be challenging. In general, either the ST vessels or any branch from the external carotid artery in the neck
will serve as an adequate recipient. The vein corresponding to the selected recipient artery, or an end-to-
side anastomosis to the internal jugular vein, will suffice for drainage. If a neck recipient is used, the
pedicle will need to be tunneled from the midface, where the flap is inset, into the neck. This is typically
done through a subcutaneous tunnel within the cheek and over the mandible into the neck. This should
prevent injury to the distal branches of the facial nerve; care should be taken to avoid Stensen duct when
creating the tunnel. When designing the flap, every effort should be made to design the skin paddle as
distal as possible from the pedicle to maximize length. If the pedicle cannot reach the chosen recipient,
then an interposition vein graft should be used to lengthen the pedicle.
It is difficult to use an obturator when the palatal-alveolar defect extends mesial to the ipsilateral canine
tooth. In this geometry, there are greater cantilever forces acting on the prosthesis, which must also rely
on less dentition for retention. There are a variety of flap options for reconstruction following
hemipalatomaxillectomy, which results in a defect that extends to the midline. Soft tissue free flaps, such
as the ALT or RAM, will provide adequate bulk to obliterate the maxillary sinus, support the cheek, and
provide skin for reconstruction of the palatal defect (Figure 38.11). Unfortunately, they do not provide a
rigid skeletal framework. Over time, this may contribute to loss of anterior maxillary projection on the
side of the flap. Although surgery is usually more technically challenging, osteocutaneous free flaps can
provide skeletal support and also facilitate dental rehabilitation via osseointegrated implants; we prefer
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this reconstructive technique for hemipalatomaxillectomy defects in highly functional, compliant patients
with good oncologic prognosis (Figure 38.12). One caveat is that we have found that placement of
osseointegrated implants in an irradiated bone flap is prohibitively dangerous, associated with a high rate
of infection, osteoradionecrosis, and loss of the reconstruction. Therefore, if an osteocutaneous free flap is
used for reconstruction and the patient receives postoperative radiation therapy, then one of the main
purposes for using a bony reconstruction is obviated. In such cases, temporary placement of an obturator
or soft tissue flap followed by delayed conversion to an osseous flap after radiation therapy is an option.
FIGURE 38.11 A. Posterior palatomaxillectomy defect. B. Anterolateral thigh perforator flap harvest. C. Closure of the
palatomaxillary defect. D. Postoperative result showing good facial symmetry.
FIGURE 38.12 A. Left hemipalatomaxillectomy defect. B. A fibula osteocutaneous free flap was chosen so that
osseointegrated implants could later be placed for dental restoration. C. Postoperative result, showing fibula skin paddle used
to close the palatal defect.
Premaxillary defects usually arise from resection of lip or nasal pathologies. Most defects are relatively
small and amenable to obturation alone. However, if the patient does not prefer an obturator,
reconstruction must be performed to support the upper lip and nasal tip, replace the nasal floor and
primary hard palate, and serve as a site for future dental implantation. Although the bony defect is
relatively small, it can be challenging to reconstruct. An osteocutaneous free radial forearm or fibula flap
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can be used to replace the missing alveolus, serve as a rigid skeletal framework to support the lip and
nose, and replace the resected palate. A premaxillary maxillectomy is one of the rare circumstances in
which an osteocutaneous radial forearm flap can be considered a first-line option. Ahmad and colleagues
provide an excellent description of their experience and surgical technique for using this flap for this
particular defect. 33
A prosthetic obturator is not an option for bilateral palatomaxillectomy defects because of lack of support,
and soft tissue flaps lack the rigidity to prevent midfacial collapse. 31,32 These defects require bony
reconstruction to maintain midface height, width, and projection, as well as to house dental implants. A
bilateral palatomaxillectomy requires a long length of bone, typically 14 to 16 cm, making the fibula the
most appropriate choice.
The leg that is ipsilateral to the side of the planned microvascular anastomosis is selected for fibula
harvest. When the bony defect extends more laterally or posteriorly on one side than another, that side is
usually preferred for the anastomosis because of the closer proximity to the neck. Alternatively, the side
of the neck with better recipient blood vessels, if any, is used. In any bilateral palatomaxillectomy
reconstruction, there is a strong possibility of requiring vein grafts to reach the recipient vasculature; this
should be anticipated and planned appropriately. Typically, the fibula flap is shaped similarly to the
Greek letter omega in the transverse plane (Figure 38.13). This configuration approximates the width and
projection of the native maxilla. The lateral portions of the fibula replace the anterior wall of the maxillary
sinus and malar eminence, if resected. The width of the fibula bone replaces the midfacial height. The
middle portion of the flap restores the anterior projection and alveolus. A portion of soleus or flexor
hallucis longus muscle is included with the fibula flap to fill the maxillary sinus. The skin paddle is
designed to reconstruct the palatal defect.
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FIGURE 38.13 A. Computer modeling of a fibula reconstruction for a bilateral palatomaxillectomy defect. B. Fibula free flap
after osteotomies for reconstruction of a bilateral palatomaxillectomy defect. C. The fibula can accommodate osseointegrated
implants for dental restoration.
There are a number of CAD/CAM systems available to assist with osseous flap planning, such as that
required for maxillectomy reconstruction (see Figure 38.13). 34 For these highly complex, challenging
surgeries, CAD/CAM and the advent of virtual surgical planning can improve accuracy of the
reconstruction and reduce operative time. Using preoperative CT scans of the facial skeleton combined
with a CT angiogram of the lower extremity, the exact location and angles of the osteotomies can be
preplanned and designed according to the location of the patient’s fibula perforators. These data are then
translated to three-dimensionally printed cutting guides for both the fibula and the maxilla for an
accurate and precise fit. Recently, using this same CT data, technology has been developed to create a
milled titanium plate, corresponding to the exact shape of the reconstruction. CAD/CAM can increase the
accuracy of the reconstruction, better approximating the patient’s premorbid occlusion and craniofacial
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dimensions, translating to a better functional and cosmetic result.
Dental restoration with osseointegrated implants is performed 3 to 6 months after flap reconstruction. In
patients with significant subcutaneous adipose tissue in the flap skin paddle, thinning of the flap is
usually performed concurrently with implant placement. Removal of a portion of the plate or screws may
be necessary for the fibula to accommodate the implants; therefore, bony union of the fibula at all
osteotomy sites and to the native facial skeleton must be confirmed preoperatively.
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Maxillectomy With Orbital Floor Defect
The orbital floor can be successfully reconstructed with a variety of alloplastic materials as well as
autologous bone grafts, most commonly harvested from either the iliac crest or outer table of the
calvarium. Many surgeons believe that bone grafts are more resistant to radiation-induced complications;
however, our own experience does not support their use over alloplasts. 24,28 Kirby and colleagues found
that bone grafts were more likely to be complicated by orbital dystopia and enophthalmos compared
with alloplastic materials. 35 Indeed, shaping an autologous graft is more challenging than shaping
titanium mesh; this feature likely contributed to the adverse outcomes discussed in this paper. When
using a fibula osteocutaneous free flap to reconstruct a hemipalatomaxillectomy or bilateral
palatomaxillectomy with an orbital floor defect, we will include soleus or flexor hallucis longus muscle to
support the alloplast or bone graft. We believe it is imperative that the reconstructed orbital floor be in
direct continuity with well-vascularized tissue to minimize complications.
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Maxillectomy With Orbital Exenteration
When an orbital exenteration is performed in isolation and no aspects of the maxilla or skull base are
removed, and there is no history of radiation or no anticipation of radiation, the reconstruction can be
very simple. In this situation, the goal is to provide a deep, concave orbit lined with durable skin able to
accept a prosthesis. A split-thickness skin graft lining the orbital cavity fulfills these criteria well. It may
be helpful to allow for a period of secondary intention healing and dressing changes to build granulation
tissue, prior to placing the skin graft. Other options include a local flap such as a temporalis muscle or
temporoparietal fascia flap with a skin graft or a thin fasciocutaneous free flap such as a radial forearm
flap. The temporalis muscle flap is thin enough to permit a secure prosthesis fit but results in a depression
at the donor site. Such a depression can be easily corrected with either fat grafting or placement of a
high-
 density porous polyethylene implant. 36 Rotation of either of these flaps may require removal of the
lateral orbital wall to achieve the length needed to reach the medial aspect of the orbit; this also creates a
significant contour deformity.
The complexity of the reconstruction increases significantly when the inferior, medial, or superior walls
of the orbit have been removed. In this more complicated scenario, the primary goals of reconstruction
are to line the orbital cavity with durable tissue, to exclude the nasal or sinus cavities, and to protect the
brain when the orbital roof has been removed. If the bony resection is limited, the radial forearm free flap
may still be a reliable option; this thin flap will accommodate an orbital prosthesis without revision
surgery. In cases when the bony resection is more extensive, such as an orbitomaxillectomy, a bulky flap
is preferred. The ALT or RAM flaps are good options in this scenario. Either flap can be designed with
both a muscle component and fasciocutaneous segment; the muscle is used to fill the sinuses, thus
preventing infection with sinonasal flora or fistula formation, and the skin portion is used to resurface the
orbit. The added flap bulk is also required to restore midfacial volume and cheek contour. The orbital
contour is usually convex in these cases, and the reconstruction will require a revision at a later date if an
orbital prosthesis is desired.
Defects involving both an orbital exenteration and a palatomaxillectomy are best reconstructed with flaps
with multiple skin paddles to close these three defects (orbit, cheek/sinuses, and palate). Both the RAM
and ALT are good choices. In cases where the perforator anatomy is not compatible with multiple
separate skin paddles, a portion of the flap can be de-epithelialized for reconstruction of multiple
surfaces. It is the authors’ preference to leave a noncutaneous flap surface facing the nasal cavity to
spontaneously mucosalize around a soft silicone nasopharyngeal trumpet; this process takes 2 to 3 weeks.
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Questions
1. A 57-year-old man presents with a 6 cm ameloblastoma of the hard palate. He undergoes bilateral
maxillectomy, including total removal of his hard palate and alveolar ridge. What is the most
appropriate reconstructive technique?
a. Prosthetic obturator
b. Temporalis muscle pedicled flap
c. Iliac crest bone graft
d. ALT free flap
e. Fibula osteocutaneous free flap
2. A 92-year-old man is diagnosed with diffuse squamous cell carcinoma of the scalp, metastatic to
the cervical lymph nodes. He is healthy other than the fact that he has a BMI of 35 and requires
corrective lenses in order to achieve normal vision. A 20-cm diameter excision, including the
pericranium, of the scalp and cervical lymphadenectomy is planned. What is the most appropriate
method of reconstruction?
a. Latissimus dorsi myocutaneous flap with anastomosis to the ST vessels
b. Vascularized composite tissue allograft of the scalp with anastomosis to the bilateral terminal
external carotid arteries and end-to-side anastomosis to the internal jugular veins
c. Latissimus dorsi muscle flap and skin graft with anastomosis to the ST vessels
d. ALT fasciocutaneous flap to facial vessels
e. Vastus lateralis muscle flap and skin graft with anastomosis to the ST vessels
3. A 37-year-old woman is diagnosed with osteosarcoma of the skull. The lesion has eroded through
the scalp and the patient has been treated preoperatively with radiation. A 7 cm2 diameter
craniectomy and scalp resection is planned. The neurosurgeon tells you he is very worried about
recurrence. What is the most appropriate material for the reconstruction of the calvarium?
a. PEEK
b. Titanium mesh
c. No calvarial reconstruction necessary
d. Bone allograft with bone morphogenic protein
e. Calcium phosphate
4. A 42-year-old man undergoes resection of the anterior skull base to remove an
esthesioneuroblastoma. He has a history of a significant laceration to the left preauricular area. The
skull base surgeon reconstructs the missing anterior cranial fossa with a pedicled pericranium flap.
Postoperatively, the patient develops CSF rhinorrhea. He is placed on prophylactic antibiotics with
his head of bed elevated, but the leak persists even after 5 days. The neurosurgeons place a lumbar
drain, but clear fluid continues to drain through the patient’s nose. The plastic surgeon is consulted
for recommendations. What is the most reasonable treatment option?
a. Continue conservative management
b. Return to the operating room for exploration, dural repair by neurosurgery, and re-inset of the
pericranial flap
c. Return to the operating room for exploration, dural repair by neurosurgery, and resurfacing
the resected skull base with a buried vastus lateralis muscle flap.
d. Return to the operating room for exploration, dural repair by neurosurgery, and resurfacing
the resected skull base with a pedicled left temporalis major muscle flap
e. Return to the operating room for exploration, dural repair by neurosurgery, and resurfacing
the resected skull base with a free buried omentum flap
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5. A 67-year-old man with an HbA1c of 11 mg/dL, dialysis-depended end-stage renal disease, and an
ejection fraction of 20% is diagnosed with a squamous cell carcinoma eroding through the hard
palate. An infrastructure palatomaxillectomy is planned with resection of the hard palate and left
maxillary alveolus. The ipsilateral canine tooth and all teeth mesial to it will be spared. What is the
most appropriate method of reconstruction?
a. Free fibula osteocutaneous flap
b. Radial forearm osteocutaneous flap
c. Radial forearm fasciocutaneous flap
d. Prosthetic obturator
e. ALT flap
1. Answer: e. Several techniques are used in palatomaxillary reconstruction. Palatal obturators are
acceptable for small defects. However, prosthetic retention can be difficult or impossible in sizable
defects, particularly when there are few teeth to stabilize the prosthesis. The temporalis muscle flap
can be rotated into the oral cavity and is useful for closing isolated defects of the midpalate.
However, this flap would not provide the structural support necessary to maintain the shape of the
midface. Iliac crest bone grafts stabilized with titanium hardware can be used for some posttraumatic
defects but are prone to infection, extrusion, and nonunion in radiated patients, particularly when
the defect is as extensive as this one. The ALT free flap can close the palatal defect and restore shape
to the cheek in patients with a unilateral maxillectomy. However, in anterior and bilateral defects,
such as this one, a myocutaneous free flap, like the temporalis muscle flap, would not restore the
height, width, and projection of the anterior midface. The fibula osteocutaneous free flap and other
vascularized bone flaps can be shaped to restore the skeletal support of the midface in extensive,
bilateral maxillary defects. The skin paddle of the flap can be used to close the palatal defect to
restore speech and swallowing function. Also, the fibula osteocutaneous free flap can accept
osseointegrated implants for dental restoration because of the good quality of bone stock associated
with this flap.
2. Answer: c. The extent of the planned resection will require a free tissue transfer because of lack of
available locoregional options. A skin graft alone would be inappropriate considering the anticipated
resection will include the pericranium. Using a latissimus myocutaneous flap for a 20-cm wide defect
is possible, but the donor site would not be able to close primarily, requiring a skin graft.
Additionally, with a BMI of 35, the thickness of the skin paddle would likely require multiple
revisionary procedures to achieve an acceptable appearance; it is best to avoid procedures that will
necessitate revision in the elderly. An ALT fasciocutaneous flap or vastus lateralis muscle flap will
not be large enough to fully reconstruct the defect. The ST vessels are the recipient vessels of choice
in any scalp reconstruction. Any patient that wears glasses should be instructed to not wear them
postoperatively to avoid inadvertent pedicle compression. The facial vessels will likely be exposed,
considering the need for a neck dissection in this patient. However, a vein graft is likely necessary to
achieve the required pedicle length to reach the neck; if the ST vessels are adequate and available,
they are preferred.
3. Answer: a. Titanium mesh is an effective material for craniectomy reconstruction; however, it is
associated with significant imaging artifact, marking radiologic surveillance of disease recurrence
challenging. Any calvarial defect greater than 6 cm2 should be reconstructed. PEEK implants are
radiolucent and can be customized to the patient, based on the planned resection and preoperative
imaging data. In this scenario, given the other available answer choices, a PEEK reconstruction is
most appropriate. Bone morphogenic protein is a morphogen and should be avoided in cases of
malignancy. Calcium phosphate is useful for smaller calvarial defects; however, it carries a high late
infection risk; therefore, it should be avoided in this patient with a history of preoperative radiation.
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4. Answer: c. The CSF leak is unlikely to resolve with continued conservative management at this
point. Re-inset of the pericranial flap is unwise considering it failed in initially preventing the leak.
Although a temporalis muscle flap may reach the anterior skull base, the patient’s prior left
preauricular injury may be damaging the muscle’s blood supply, obviating its use as a flap. The
vastus lateralis muscle flap is a good option in this scenario; it is well vascularized and conforms to
the shape of the skull base, easily sealing off the intracranial space from the sinonasal cavity. The
muscle can be buried and monitored with an implantable Doppler probe. The omentum could be
used; however, few plastic surgeons would consider it a first-line option given the need for a
laparotomy to harvest it.
5. Answer: d. This patient with multiple medical comorbidities is not a good candidate for a free
tissue transfer. An obturator is an excellent option for reconstruction of limited palatal defects. The
extent of the remaining alveolar dentition is sufficient to counteract the substantial cantilever forces
that will be imparted to the obturator.
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References
Raposio, E, Santi, P, Nordström, RE. Effects of galeotomies on scalp flaps. Ann Plast Surg. 1998;41:17-21.
Orticochea, M. Four flap scalp reconstruction technique. Br J Plast Surg. 1967;20:159-171.
Muresan, C, Hui-Chou, HG, Dorafshar, AH, et al. Forehead reconstruction with microvascular flaps: utility of aesthetic subunits. J Reconstr
Microsurg. 2012;28:319-326.
Menick, FJ. A 10-year experience in nasal reconstruction with the three-stage forehead flap. Plast Reconstr Surg. 2002;109:1839-1855.
Kane, WJ, McCaffrey, TV, Wang, TD, Koval, TM. The effect of tissue expansion on previously irradiated skin. Arch Otolaryngol Head Neck
Surg. 1992;118:419-426.
Hansen, SL, Foster, RD, Dosanjh, AS, Mathes, SJ, Hoffman, WY, Leon, P. Superficial temporal artery and vein as recipient vessels for facial
and scalp microsurgical reconstruction. Plast Reconstr Surg. 2007;120:1879-1884.The superficial temporal artery and vein have historically not
been considered adequate for microsurgical reconstruction and have rarely been described as recipient vessels. The authors demonstrate that the
superficial temporal artery and vein for scalp and face reconstruction are reliable and safe and state that they should be considered as primary recipient
vessels in microsurgical reconstruction of the upper two-thirds of the face and/or scalp.
Hussussian, CJ, Reece, GP. Microsurgical scalp reconstruction in the patient with cancer. Plast Reconstr Surg. 2002;109:1828-1834.
Sosin, M, De la Cruz, C, Bojovic, B, et al. Microsurgical reconstruction of complex scalp defects: an appraisal of flap selection and the timing
of complications. 
 J Craniofac Surg. 2015;26:1186-1191.
Sosin, M, Schultz, BD, De La Cruz, C, et al. Microsurgical scalp reconstruction in the elderly: a systematic review and pooled analysis of the
current data. Plast Reconstr Surg. 2015;135:856-866.
Simunovic, F, Eisenhardt, SU, Penna, V, et al. Microsurgical reconstruction of oncological scalp defects in the elderly. J Plast Reconstr Aesthet
Surg. 2016;69:912-919.
Chao, AH, Yu, P, Skoracki, RJ, et al. Microsurgical reconstruction of composite scalp and calvarial defects in patients with cancer: a 10-year
experience. Head Neck. 2012;34:1759-1764.
Lee, EI, Chao, AH, Skoracki, RJ, Yu, P, DeMonte, F, Hanasono, MM. Outcomes of calvarial reconstruction in cancer patients. Plast Reconstr
Surg. 2014;133:675-682.Retrospective review of 289 calvarial reconstructions in cancer patients. The authors demonstrate a similar complication
profile in a variety of alloplasts with the exception of calcium phosphate, which was found to have a high infection rate.
Rubin, JP, Yaremchuk, MJ. Complications and toxicities of implantable biomaterials used in facial reconstructive and aesthetic surgery: a
comprehensive review of the literature. Plast Reconstr Surg. 1997;100:1336-1353.
Hanasono, MM, Goel, N, DeMonte, F. Calvarial reconstruction with polyetheretherketone implants. Ann Plast Surg. 2009;62:653-655.
Kumar, AR, Bradley, JP, Harshbarger, R, et al. Warfare-related craniectomy defect reconstruction: early success using custom alloplast
implants. Plast Reconstr Surg. 2011;127:1279-1287.
Moreira-Gonzalez, A, Jackson, IT, Miyawaki, T, et al. Clinical outcome in cranioplasty: critical review in long-term follow-up. J Craniofac
Surg. 2003;14:144-153.
Netscher, D, Alford, EL, Wigoda, P, Cohen, V. Free composite myo-osseous flap with serratus anterior and rib: indications in head and neck
reconstruction. Head Neck. 1998;20:106-112.
Sinno, S, Rodriguez, ED. Definitive management of persistent frontal sinus infections and mucocele with a vascularized free fibula flap. Plast
Reconstr Surg. 2017;139:170-175.
Lee, JW, Hsueh, YY, Lee, JS. Composite skull and dura defect reconstruction using combined latissimus dorsi musculocutaneous and
serratus anterior muscle-rib free flap coupled with vascularized galea transfer: a case report. Microsurgery. 2010;30:632-635.
Hasan, Z, Gore, SM, Ch’ng, S, et al. Options for configuring the scapular free flap in maxillary, mandibular, and calvarial reconstruction.
Plast Reconstr Surg. 2013;132:645-655.
Selber, JC, Chang, EI, Clemens, MW, et al. Simultaneous scalp, skull, kidney, and pancreas transplant from a single donor. Plast Reconstr
Surg. 2016;137:1851-1861.The first report of a simultaneous scalp, skull, kidney, and pancreas transplant from a single donor. The case was successful
and established vascularized composite tissue allograft reconstruction of the scalp and skull as a potential option in the appropriate clinical scenario.
Sosin, M, Ceradini, DJ, Levine, JP, et al. Total face, eyelids, ears, scalp, and skeletal subunit transplant: a reconstructive solution for the full
face and total scalp burn. Plast Reconstr Surg. 2016;138:205-219.
Irish, J, Gullane, PJ, Gentili, F, et al. Tumors of the skull base: outcome and survival analysis of 77 cases. Head Neck. 1994;16:3-10.This seminal
article introduces the classification schema commonly used when describing skull base resections and reconstructions.
Hanasono, MM, Lee, JC, Yang, JS, et al. An algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital
exenteration. Plast Reconstr Surg. 2009;123:98-105.
Rosenthal, EL, King, K, McGrew, BM, et al. Evolution of a paradigm for free tissue transfer reconstruction of lateral temporal bone defects.
Head Neck. 2008;30:589-594.
Hanasono, MM, Silva, AK, Yu, P, Skoracki, RJ, Sturgis, EM, Gidley, PW. Comprehensive management of temporal bone defects after
oncologic resection. Laryngoscope. 2012;122:2663-2669.
Brown, JS, Shaw, RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol. 2010;11:1001-1008.Seminal
article introducing a widely accepted maxillectomy classification system.
Hanasono, MM, Silva, AK, Yu, P, Skoracki, RJ. A comprehensive algorithm for oncologic maxillary reconstruction. Plast Reconstr Surg.
2013;131:47-60.Seminal article describing an anatomic description and classification system for maxillectomy defects, as well as reconstructive options
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organized by defect classification.
Cordeiro, PG, Santamaria, E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr
Surg. 2000;105:2331-2346.Seminal article describing an important classification system for maxillectomy defects. It establishes that free tissue transfer
provides the most effective and reliable form of immediate reconstruction for complex maxillectomy defects.
Spiro, RH, Strong, EW, Shah, JP. Maxillectomy and its classification. Head Neck. 1997;19(4):309-314.
Moreno, MA, Skoracki, RJ, Hanna, EY, Hanasono, MM. Microvascular free flap reconstruction versus palatal obturation for maxillectomy
defects. Head Neck. 2010;32:860-868.
Okay, DJ, Genden, E, Buchbinder, D, Urken, M. Prosthodontic guideline for surgical reconstruction of the maxilla: a classification system of
defects. J Prosthet Dent. 2001;86:352-363.
Ahmad, FI, Means, C, Labby, AB, et al. Osteocutaneous radial forearm free flap in nonmandible head and neck reconstruction. Head Neck.
2017;39:1888-1893.
Chang, EI, Hanasono, MM. State-of-the-art reconstruction of midface and facial deformities. J Surg Oncol. 2016;113:962-970.
Kirby, EJ, Turner, JB, Davenport, DL, Vasconez, HC. Orbital floor fractures: outcomes of reconstruction. Ann Plast Surg. 2011;66:508-512.
Mericli, AF, Gampper, TJ. Treatment of postsurgical temporal hollowing with high-density porous polyethylene. J Craniofac Surg.
2014;25:563-567.
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C H A P T E R 3 9
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Reconstruction of the Eyelids, Correction of Ptosis,
and Canthoplasty
Benjamin P. Erickson and Derrick C. Wan
Key Points
Comprehensive understanding of eyelid anatomy, coupled with careful assessment of individual
patient factors, guides diagnosis, and selection of appropriate procedures.
Divide upper and lower eyelid defects into anterior lamellar (partial-thickness and full-thickness
defects), then by size to select reconstructive options.
Full-thickness defects are reconstructed in layers, restoring a mucosalized posterior lining, structural
support layer, and anterior skin/muscle layer. At least one lamella must have an intact blood supply.
Avoid undue vertical tension while appropriately correcting horizontal laxity to minimize the risk of
postoperative eyelid malposition. When necessary, use a wedge excision with the apex pointing
away from the lid margin to approximate a pentagon to avoid dog-ears and notching.
Repair of eyelid ptosis requires an understanding of the possible etiologies and full preoperative
evaluation, including assessment of lid position and levator function.
Lower eyelid malposition and lid laxity can be treated with a lateral canthoplasty (division of the
canthus and repositioning) or canthopexy (redirection of intact canthal tendon). Procedures to
shorten and provide lower eyelid support depend on the severity of lid laxity.
The eyelids are complex lamellar structures that function to protect the anterior globe from injury and
maintain ocular surface integrity. They also aid in regulating light exposure to the eye and distribute the
tear film over the cornea during blinking. Primary goals of any surgical procedure to reconstruct or
modify the eyelids must focus on establishing or preserving a stable structure with adequate height and
functional closure, and on maintaining a nonkeratinized mucosal posterior surface to avoid abrasion to
the underlying cornea. Restoration of symmetry and appearance remain secondary goals. Understanding
the anatomic architecture of the upper and lower eyelid is critical to achieving satisfactory functional and
cosmetic outcomes.
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Eyelid Anatomy
Lamellar Structure and Surface Anatomy
The upper and lower eyelids are composed of the skin, minimal subcutaneous tissue, orbicularis oculi
muscle, submuscular areolar tissue, a fibrous layer consisting of orbital septum and tarsal plate,
retroseptal fat pads, lid retractors, and conjunctiva (Figure 39.1). For conceptual purposes, however, these
structures are divided into anterior and posterior lamellae, with the tarsofascial layer in between. The
upper eyelid extends from the lid margin inferiorly to the eyebrow superiorly, which demarcates it from
the forehead. The natural curvature of the lid is generated by the shape of the tarsal plate as well as
coaptation to the curvature of the globe beneath. In the upper lid, a skin crease can be found
approximately 8 to 9 mm superior to the eyelid margin in men and 9 to 11 mm in women, though in the
Asians this lid crease can be found significantly lower. The inferior eyelid extends from the lid margin
superiorly to the malar fold below, which runs from the medial canthal region inferomedially to the
nasojugal fold and serves to delimit the lower lid from the cheek. A lower eyelid fold, particularly in
children, can also be found approximately 3 to 5 mm from the lid margin.
FIGURE 39.1 Cross-sectional schematic of upper (A) and lower (B) eyelid anatomy.
With the eye open, the palpebral fissure measures 28 to 30 mm in length and approximately 9 mm in
height. The highest point of the upper lid is typically found just medial to the center of the pupil, with the
lid margin resting 1 to 2 mm below the superior limbus in adults. The lowest point of the lower eyelid can
be found lateral to the center of the pupil, with the margin at the inferior limbus. Finally, in Caucasians,
the lateral canthus is positioned 2 mm higher than the medial canthus, whereas in Asians this can be
found 3 mm higher.
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Eyelid Skin
The skin of the upper and lower eyelids is among the thinnest in the body, measuring less than 1 mm
thick. A greater number of sebaceous glands can be found in the nasal portion of the lids, making these
regions smoother and oilier than temporal eyelid skin. There is relatively minimal subcutaneous fat in the
eyelids, which can mostly be found beneath preorbital and preseptal skin. Beneath pretarsal skin, as well
as laterally over the medial and lateral canthal ligaments, the underlying fat is absent. This anatomic
relationship facilitates motility, but also contributes to disproportionate redundancy with aging. Of note,
descent of the brow fat pad into the lateral upper lid is common, and it should not be confused with
retroseptal fat.
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Eyelid Muscles
Muscles of the eyelids can be divided into protractors, which close the eyes, and retractors, which open
them. The orbicularis oculi muscle is the primary protractor and is divided into orbital, preseptal, and
pretarsal portions. Fibers of the orbital portion originate from the medial orbital margin and medial
canthal tendon and sweep around the orbit in horseshoe fashion to insert back on the medial canthus. The
preseptal and pretarsal subunits originate from the medial canthal tendon and insert on the lateral
horizontal raphe. The orbital subunit functions in forced closure, whereas the preseptal and pretarsal
subunits are employed for blinking and voluntary winking. Temporal, zygomatic, and buccal branches of
the facial nerve innervate the muscle from the undersurface.
Eyelid retractors consist of the levator palpebrae superioris and Müller muscle in the upper lid, and
capsulopalpebral fascia in the lower lid. The levator palpebrae superioris arises from the orbital apex and
terminates in an aponeurosis, which fuses with the orbital septum anteriorly prior to attaching to the
superior tarsal plate posteriorly. It is innervated by the oculomotor nerve and serves as the principal
upper lid retractor. An anterior extension from the levator can be found inserting into the pretarsal
orbicularis oculi muscle and skin, forming a skin crease in the upper eyelid. Dehiscence of the levator
muscle from the tarsal plate with age or trauma results in blepharoptosis and elevation of the lid crease.
In concert with the levator palpebrae superioris, the sympathetically innervated Müller muscle
contributes an additional 2 to 3 mm lid elevation. It originates from the undersurface of the levator
muscle and inserts on the superior margin of the tarsal plate. With decreased sympathetic tone, as in
Horner syndrome, loss of this muscle function results in mild ptosis.
In the lower eyelid, fascial extensions of the inferior rectus muscle continue anterosuperiorly to form the
capsulopalpebral fascia. This primarily inserts on the inferior border of the lower tarsal plate, though
minor fibers also insert on the conjunctiva of the inferior fornix, facilitating lower lid descent with
downward gaze. Analogous to the upper eyelid, sympathetically innervated fibers are intimately
involved with the posterior surface of the capsulopalpebral fascia, although they are typically not
identifiable as a distinct anatomical layer. The orbital septum in the lower eyelid also fuses with the
capsulopalpebral fascia in similar fashion to the upper lid.
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Orbital Septum
The orbital septum is a thin layer of connective tissue that separates the eyelid from the anterior orbit. It is
continuous with the periosteum along the orbital rim (arcus marginalis) and attaches to the tarsal plates
through fusion with the levator palpebrae superioris in the upper lid and capsulopalpebral fascia in the
lower lid. Variable indistinct fusion, however, can result in more prominent orbital fat projection in
different ethnicities, and with age, thinning of the septum can also lead to more noticeable fat descent.
The orbital septum has considerable laxity, but scarring of the septum from trauma or surgical
intervention can precipitate lid retraction.
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Fat Pads
Adipose tissue in the upper eyelid is divided into two components, the central (preaponeurotic) fat pad
and the medial fat pad. The central fat pad is broad and yellow secondary to higher levels of carotenoids
and is found in between the orbital septum and levator aponeurosis. The medial fat pad, which is more
pale yellow or white in color, is located in the same plane and is separated from the central fat pad by the
trochlea of the superior oblique muscle. Finally, the lacrimal gland occupies the lateral compartment in
the upper eyelid. It is firmer to palpation, pink in color, and may become more prominent on upper lid
examination with age due to prolapse.
The lower eyelid contains three retroseptal fat compartments known as the lateral, central, and nasal fat
pads. The inferior oblique muscle separates the medial and central fat pads, whereas the arcuate
expansion extending from the capsulopalpebral fascia separates the medial and lateral fat pads. As the fat
pads reside behind the septum, insertion of this fascial layer outside the orbital rim laterally creates the
recess of Eisner into which a portion of the lateral fat pad sits. Because of the intimate association of the
inferior oblique muscle with lower lid fat, injury to this muscle during surgical dissection can result in
torsional diplopia.
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Tarsoligamentous Sling
The tarsal plates comprise the fibrous skeleton of the upper and lower eyelids and provide structural
integrity. The superior tarsal plate is typically 10 to 12 mm in height centrally, narrowing medially, and
laterally to assume a crescentic shape. The inferior tarsal plate is more rectangular and measures
approximately 4 mm in height centrally. The maximum thickness is 1 mm and each tarsus is
approximately 30 mm long. Within the upper and lower eyelid, tarsus can be found 25 to 40 sebaceous
meibomian glands. These empty at the lid margin posterior to the gray line and are responsible for the
oily layer of the tear film.
Each tarsus tapers medially and laterally, joining to form canthal tendons. Together with the tarsal plates,
they form the tarsoligamentous sling, which maintains lid-globe apposition. The medial canthal tendon is
intricately related to the orbicularis oculi muscle and splits to form anterior and posterior limbs that insert
into the anterior and posterior lacrimal crest, respectively. The lateral canthal tendon passes deep to the
orbital septum and inserts 2 mm posterior to the lateral orbital rim on a bony prominence known as
Whitnall tubercle. Proper attachment of canthal tendons both medially and laterally is responsible for
preserving sharp canthal angles and maintaining lid-globe apposition.
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Conjunctiva
The conjunctiva is a smooth, translucent, nonkeratinized mucous membrane that can be divided into
palpebral, forniceal, and bulbar components. The palpebral conjunctiva lines the posterior surface of the
upper and lower eyelid and is firmly adherent to the tarsal plates. This continues into the upper and
lower fornices where there is redundant tissue to facilitate free motility of the eye. Beyond the forniceal
conjunctiva, reflection anteriorly forms the bulbar conjunctiva which coats the surface of the globe. Goblet
cells within the conjunctiva produce mucin, whereas accessory lacrimal glands are responsible for basal
secretion of aqueous tears. Conjunctival tissue loss can result in lid malposition and limitation in ocular
motility, and decreased mucin or tear production can increase risk for ocular surface injury.
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Lacrimal System
The lacrimal glands are situated in the superolateral region of each orbit and are responsible for reflex
secretion of the aqueous layer of the tear film. Two lobes can be found, separated by the levator
aponeurosis, with the orbital lobe residing within the lacrimal fossa and the smaller palpebral portion
close to the eye along the inner surface of the eyelid. Aqueous tears drain into the superolateral fornix via
ductules and the wiper-blade action of the orbicularis oculi and tarsal plates pushes tears medially.
In the normal setting, tears pass over the surface of the globe to reach lacrimal puncta at the inner corner
of eyelids. These then pass tears through lacrimal canaliculi and ducts into the lacrimal sac, which turns
into the nasolacrimal duct to provide drainage into the inferior nasal meatus. The lacrimal sac sits within
the lacrimal fossa which is enveloped by the orbicularis oculi and medial canthal tendon. Contraction of
the orbicularis muscle during blinking drives the pumping mechanism of the lacrimal sac, which draw
tears into the puncta and propels them through the nasolacrimal duct. Decreased tear production can
lead to keratoconjunctivitis sicca, with persistent dryness and burning of the eyes, whereas excess tear
production with disruption of the lacrimal drainage system at any level may result in epiphora, or
overflow of tears onto the face.
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Blood Supply and Lymphatics
The eyelids contain a rich anastomotic blood supply derived from both the internal and external carotid
arteries. The internal carotid arterial supply arises from terminal branches of the ophthalmic artery,
which supply the medial palpebral vessel directly and the lateral palpebral vessel via the lacrimal artery.
In the upper eyelid, a marginal arcade can be found on the anterior tarsal surface, approximately 2 to
4 mm above the lid margin. A second peripheral arcade can be found above the tarsal plate on the
anterior surface of the Müller muscle, which can be susceptible to injury during eyelid surgery. In the
lower eyelid, only one, more rudimentary arcade can be found approximately 2 mm below the inferior
tarsal margin. External carotid artery supply arises from anastomotic branches of the angular artery, the
superficial temporal artery, and the maxillary artery. Rich lymphatic drainage can be found for the
eyelids and the conjunctiva. The lateral two-thirds of the upper lid and lateral half of the lower lid drain
primarily through the preauricular lymph nodes, whereas the medial portion of the upper and lower lid
drain through the submandibular lymph nodes. Persistent lymphedema of the eyelids can be functionally
and cosmetically debilitating, with high rates of recurrence after surgical revision, but is fortunately a rare
complication.
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Preoperative and Postoperative Considerations
Defects of the upper or lower eyelids can result from congenital anomalies, trauma, or tumor resection.
Irrespective of etiology, however, structures of the eyelid, including skin, muscle, tarsoligamentous sling,
and conjunctiva must be fully evaluated and, if deficient, must be addressed in operative planning.
Evaluation with respect to location and extent of tissue involvement (partial- or full-thickness) may also
help to guide reconstructive planning. For congenital defects, such as with colobomas seen in paramedian
clefts, Treacher Collins syndrome, or Goldenhar syndrome, a full evaluation for other associated
anomalies must be performed. For postoncologic resection defects, knowledge of the histologic diagnosis
and resection margin status should be obtained prior to proceeding with reconstruction. Along with these
concerns, a full ophthalmologic history and examination should be performed. Prior ocular injuries,
surgery, or history of inflammation may alter anatomic relationships and need to be recognized prior to
surgery to reduce risk of postoperative complications.
Malposition of the eyelid can be seen with entropion, ectropion, or lid retraction. A snap-back test is
crucial for evaluation of laxity in the setting of eyelid malposition. The lower eyelid is pulled down and
away from the globe to determine how long it takes to return to the original position without blinking. In
the normal lower eyelid (Grade 0), it should spring back immediately to the original position, whereas a
delay is observed with lid laxity. Grade I laxity is observed with 2 to 3 second delay, Grade II laxity with
4 to 5 seconds delay, and Grade III laxity with >5 seconds delay and return to position with blinking.
Finally, with Grade IV laxity, frank ectropion is maintained without return to the original position.
Importantly, though lid laxity must be addressed in successful periocular Mohs reconstruction,
preoperative laxity may be beneficial and should therefore be treated conservatively until after definitive
excision and repair is planned.
The patient must also be evaluated prior to surgery for signs and symptoms of dry eye or blepharitis, as
these may be exacerbated postoperatively. Adequate tear film production can be assessed with a
Schirmer’s test, in which a filter paper strip is inserted into the lower sulcus for 5 minutes to measure
moisture. Tear production is considered to be diminished with less than 15 mm in the absence of a topical
anesthetic and with 5 to 10 mm when a topical anesthetic is given. Alternatively, tear production can also
be evaluated by administering fluorescein eye drops to determine whether there is interpalpebral staining
of the cornea.
For patients with excess tear accumulation or epiphora, a dye disappearance test or dilation and irrigation
can be performed. While under sedation and anesthetic, a No. 00 Bowman probe can also be passed
through the lacrimal drainage system to determine the precise locus of obstruction. Typical distances in
an adult are 8 to 10 mm to the common canaliculus, 10 to 12 mm to the lacrimal sac, and 24 mm to the
proximal end of the nasolacrimal duct.
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Upper Eyelid Reconstruction
Defects of the upper eyelid may arise from various causes, but tissue loss following tumor resection is the
most common indication for reconstruction. Mohs micrographic surgery is frequently employed in the
periorbital region, and this technique provides increased certainty of negative margins prior to
reconstruction. Less frequently, substantial tissue deficit arising from developmental anomalies or trauma
may need to be addressed. As the upper eyelid covers a greater portion of the cornea, it serves a more
important role in globe protection than the lower eyelid. Consequently, eyelid reconstruction is indicated
in all but a few instances, such as when small defects <5 mm that do not involve the lid margin or canthus
may be left to heal. 1 The type of reconstruction strategy employed depends on recognition of anatomic
deficits, including vertical and horizontal dimensions, as well as depth. Careful assessment of regional
and distant tissue availability is also critical. To approach upper lid reconstruction in an organized
manner, eyelid defects are divided into anterior lamellar (partial-thickness) and full-thickness defects
according to size.
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Anterior Lamellar and Partial-Thickness Defects
The anterior lamella includes the skin and orbicularis oculi muscle of the eyelid, and small defects <5 mm
involving only these structures can heal well by secondary intention. 1 Larger defects may result in
contracture and lid deformity, necessitating further surgery to address lid retraction or ectropion. For
partial-thickness defects involving less than 50% of the upper eyelid, primary closure is ideal, particularly
when there is redundant skin adjacent to the defect. When more tissue recruitment is necessary,
undermining of the skin and orbicularis muscle with advancement of local myocutaneous flaps are
preferred, as they provide optimal color and texture match. Incisions should be concealed in relaxed skin
tension lines when this does not result in significant vertical shortening of the anterior lamella, which can
produce postoperative eyelid malposition. Vertical scars generally heal well when confined to the eyelid
proper and are sometimes necessary to ensure that tension is distributed horizontally rather than
vertically within the eyelids.
Primary closure is not typically feasible for larger partial-thickness defects involving greater than 50% of
the upper eyelid. In this setting, skin grafts offer adequate replacement of eyelid skin. Full-thickness skin
grafts are preferable to split-thickness skin grafts due to less contracture postoperatively. The optimal
skin graft donor site for upper eyelid defects is the contralateral upper lid, as this provides skin with thin
dermis, minimal hair, and excellent color/texture match. The skin graft can be harvested through a
standard blepharoplasty incision, employing nontoothed forceps to pinch excess skin and determine the
amount that can be removed safely. Incisions are made with a #15 blade, and Westcott scissors are used to
elevate the skin off the orbicularis muscle. After hemostasis is obtained, the donor site is closed with
running monofilament sutures and the skin graft is thinned to the rete ridges. Fenestrations or quilting
sutures can be placed to prevent accumulation of serosanguinous fluid. The skin graft is secured with
interrupted 6-0 or 7-0 absorbable sutures and a skin graft bolster dressing is kept in place for several days.
Importantly, grafts may be oversized by approximately 30%, particularly over the preseptal lid to allow
for contracture. 2 When there is insufficient contralateral upper eyelid skin, other secondary sites for skin
harvest include the preauricular or postauricular region, supraclavicular region, and upper inner arm.
Although color and texture match may be less ideal with some of these alternative donor sites,
satisfactory results have been reported in up to 95% of patients with only mild complications reported,
including hypertrophic scarring in 23% and hypopigmentation in 6%, particularly with supraclavicular
and inner arm donor sites. 3
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Full-Thickness Defects
Depending on laxity, full-thickness defects of the upper lid up to 25% of the horizontal length may be
closed primarily, though in older patients defects up to 1/3 may be treated in this fashion. Assessment
includes pulling the edges together to confirm adequate closure under minimal tension, and if present,
consideration can be made to include a lateral canthotomy and cantholysis. Prior to closure, defect
margins should be trimmed to create sharp, perpendicular tarsal borders. A wedge can be resected
superiorly to create a pentagonal defect with its apex pointing away from the lid margin to allow ends to
meet appropriately without lid notching. 4 The lid margin is approximated with 5-0 or 6-0 silk vertical
mattress suture placed through the meibomian gland orifices in a far-far, near-near fashion to help evert
the wound edges. Three or four partial thickness 5-0 polyglactin sutures are then used to approximate the
tarsus. Finally, the skin is closed over the repaired tarsus to complete the layered reconstruction.
Larger full-thickness defects of the upper lid involving 25% to 75% of the lid are typically not amenable to
direct closure and are frequently reconstructed with a modified Hughes advancement/sliding
tarsoconjunctival flap with skin graft or composite graft covered by a myocutaneous advancement flap.
Key to any of these approaches is the re-establishment of a posterior mucosal layer, a structural support
layer, and a well-vascularized covering anteriorly. Importantly, 4 mm of tarsus is necessary to maintain
stability at the lid margin. If there is sufficient superior tarsus remaining above the defect, an
advancement tarsoconjunctival flap may be used to reconstruct the upper lid. To accomplish this, the
upper eyelid is everted, and relaxing incisions are made in the conjunctiva on either side of the defect. A
tarsoconjunctival flap is then created by dissecting off the anterior orbicularis muscle, levator
aponeurosis, and Müller muscle up to the superior fornix, leaving only the conjunctiva attached to the
tarsus posteriorly. The flap is advanced inferiorly into the wound on a conjunctival pedicle and the edges
are sutured to the marginal tarsus with 5-0 polyglactin sutures. A sliding tarsoconjunctival flap can also
be elevated from either the medial or lateral eyelid remnant and swung into an adjacent defect using
similar elevation of anterior tissue off the tarsus along with a horizontal relaxing incision in the
conjunctiva. With either tarsoconjunctival flap technique, a full-thickness skin graft or a local
myocutaneous flap is used for anterior coverage.
Alternatively, composite grafts combined with local myocutaneous advancement flaps can be utilized to
address larger full-thickness upper eyelid defects. 5 A free tarsal graft with conjunctiva from the
contralateral upper lid is preferred, as both nasal septal cartilage-mucosa and hard palate mucosa grafts
are keratinized, potentially placing the cornea at risk of abrasion and damage until metaplasia has
occurred. The donor area can be left to heal by secondary intention. Care must be taken, however, to
preserve sufficient tarsus inferiorly, as well as to avoid damage to the upper eyelid retractors, as a donor-
site complication in the contralateral normal lid could be devastating.
Once the composite graft is inset into the defect and anchored in lamellar fashion to the tarsal remnants
and eyelid retractors, a vascularized myocutaneous advancement flap is used to address the anterior
lamella. Commonly employed flaps include a sub-brow bipedicled skin-orbicularis oculi muscle flap,
paramedian forehead flap, and modified Tenzel flap. The sub-brow myocutaneous orbicularis oculi flap
yields excellent postoperative eyelid contour with the benefit of replacing deficient tissue with
physiologically similar skin and muscle. It is also a single-staged procedure that maintains adequate
eyelid closure due to preserved orbicularis oculi muscle function. 6 The resulting sub-brow defect at the
donor site can be managed with a free skin graft obtained from the contralateral upper eyelid.
An inverted, modified Tenzel (semicircular) flap is another valuable single-stage myocutaneous
advancement flap that is frequently utilized to close defects encompassing up to two-thirds of the upper
eyelid. Extra skin is rotated from the lateral temple and the donor site is closed primarily. An incision is
marked in a semicircular manner from the lateral canthus and extends inferiorly; the larger the diameter,
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the greater the advancement is possible. A skin-muscle flap is undermined in the preseptal plane and
kept superficial beyond the orbital rim to avoid injury to the temporal branch of the facial nerve. After
flap rotation, the primary defect is closed after removing a Burow triangle, as needed. Given the success
of these procedures in reconstructing full-thickness defects of the upper lid, other historical techniques,
including the Cutler-Beard flap, have fallen out of favor.
Full-thickness defects involving greater than 75% of the upper eyelid are among some of the most
challenging problems to treat given limited donor options. Total or near-total upper eyelid reconstruction
can often be approached using a mucosalized tarsal graft and overlying myocutaneous orbicularis oculi
flap, as previously discussed, but the graft typically has insufficient horizontal length and needs to be
combined with hinged periosteal flaps or other adjunctive techniques. This technique has been shown to
result in excellent outcomes, with only occasional need for minor revision surgery necessary. 7
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Outcomes and Prognosis
Outcomes following reconstruction of the upper eyelid can be measured by both function and aesthetics.
Asymmetric marginal position, though not a usually serious complication, can nonetheless be frustrating
for both the patient and surgeon, and may require further procedures to correct. In most instances, ptosis
following eyelid surgery should be monitored for 6 months for spontaneous recovery of function before
considering additional revision surgery. The most frequent late complication in patients undergoing
upper eyelid surgery is exposure keratopathy, which can be seen in 20%. 8 Other complications following
upper eyelid reconstruction include lagophthalmos, lid ectropion, orbital hematoma, corneal injury, and
conjunctival scarring/symblepharon. Although greater initial tissue deficits are generally associated with
poorer outcomes, the above described techniques routinely yield satisfactory results, even with larger
defects, if there is meticulous attention to detail.
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Lower Eyelid Reconstruction
Reconstruction of the lower eyelid follows many of the same principles elaborated above for the upper
eyelid. However, although there are many structural similarities between the upper and lower eyelid,
special considerations arise specific to the lower lid. Anatomically, the lower eyelid is shorter in height
and less mobile, and from a functional standpoint, it contributes minimally to closure. Nonetheless, the
lower eyelid is critical for passive corneal coverage, and reconstruction must focus on appropriate lid
position and tone. Surgical tension in the lower eyelid should also be directed horizontally in a
superolateral direction. Vertical tension can result in entropion, ectropion, or retraction of the lower
eyelid, all of which can be difficult to surgically correct secondarily. Finally, in the lower eyelid, attention
must be paid to appropriate medial and lateral canthal fixation, which are essential for maintenance of
position and contour and the nasolacrimal drainage system, which may need to be addressed in medial
defects involving the lower eyelid. Much like the upper eyelid, defects can be considered based on the
depth and size, both of which guide selection of the appropriate reconstructive strategy.
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Anterior Lamella and Partial-Thickness Defects
Small partial-thickness defects involving the lower eyelid can generally be repaired primarily, although
careful attention to the resulting vector forces is required to prevent postoperative eyelid malposition.
Local tissue advancement with undermining of the skin and orbicularis muscle is helpful for tissue
draping but does not reduce wound tension. Vertical closures should be avoided when possible, as
previously discussed.
Larger partial-thickness defects involving greater than 50% of the lower eyelid cannot be closed primarily
and require either skin grafting or a local myocutaneous flap. Similar to the upper eyelid, full-thickness
skin grafting from the contralateral upper eyelid is preferred, as it contracts less than split-thickness skin
grafts and provides for an excellent color and texture match. Alternative donor sites for skin graft harvest
include pre- or postauricular and supraclavicular regions when the upper lid is not available. A Frost
suspension suture can reduce downward pull on the lower eyelid during the early postoperative period.
Local myocutaneous transposition flaps are also useful to reconstruct larger anterior lamellar defects of
the lower eyelid, and temporally hinged monopedicle or bipedicle (Tripier) flaps from the ipsilateral
upper lid are two of the most commonly employed (Figure 39.2). The pedicle is kept as wide as possible
laterally and should be at least 1:4 in base to length dimensions to preserve vascularity. For more
extensive anterior lamellar defects, the myocutaneous transposition flap can be raised in a bipedicle
fashion as a bucket-handle (Tripier flap). 9 For both techniques, good color match is achieved, donor sites
can frequently be closed primarily, reconstruction can proceed without visual field obstruction, and
second stage procedures are only occasionally needed.
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FIGURE 39.2 Schematic of bipedicled Tripier flap elevation from ipsilateral upper eyelid (top) and inset into lower eyelid
(bottom).
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Full-Thickness Defects
When faced with a full-thickness defect of the lower eyelid, replacement of the anterior and posterior
lamella is required, just as in the upper eyelid, to restore adequate function. Lower lid defects in this
category can be divided into small deficits involving less than 30% of the lower lid, moderate defects
involving 30% to 50% of the lower lid, and large defects greater than 50% of the lower lid. Importantly,
adjustments to these guidelines are often required based on the age and tissue characteristics of the
individual.
With defects less than 30% of the eyelid width, primary closure can often be performed, though
meticulous reapproximation of the lid margin is key to a satisfactory repair without lid notching. A
pentagonal wedge resection with the apex directed inferiorly can be included to avoid a dog-ear
deformity. Alternatively, a Burow triangle can be excised after posterior lamellar closure. Primary suture
repair of the lower lid can be performed using analogous techniques and materials described for the
upper eyelid. When excess tension is encountered, a lateral canthotomy and inferior cantholysis can be
considered. The lateral canthotomy should initially be performed with relatively minimal external skin
incision in the event that conversion to a Tenzel flap is required. The inferior crus of the split tendon can
then be strummed with closed scissors and cut to release the lateral eyelid from the globe and complete
the inferior cantholysis. Following the advancement of the lower eyelid, the canthal incision is closed
with interrupted 7-0 sutures to reform the lateral canthal angle and prevent rounding of the palpebral
fissure.
A Tenzel semicircular rotation flap is typically used to repair lower eyelid defects of moderate size. It
involves rotation of a semicircular musculocutaneous tissue beginning at the lateral canthus and
extending upward in a semicircular fashion (Figure 39.3). Extensive lateral undermining of the flap with
canthotomy and inferior cantholysis is also performed to facilitate the advancement of the eyelid and
reapproximation of the tarsal defect with minimal tension. The canthal angle is then reformed by passing
4-0 Vicryl through the remaining superior canthal tendon/periosteum of the orbital rim and the
orbicularis muscle on the deep margin of the flap. Other options for the closure include local
myocutaneous transposition flaps, in concert with previously described composite grafts or a Hughes
sliding tarsoconjunctival flap, although the latter may not be well suited for patients sighted only in the
involved eye or in younger patients of amblyogenic age. 10,11
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FIGURE 39.3 Photograph of patient following lower eyelid reconstruction with a Tenzel semicircular myocutaneous rotation
flap.
The largest full-thickness defects of the lower eyelid, particularly those involving the entire lid or with a
vertical dimension greater than the horizontal one, are best reconstructed using a Mustarde cheek
rotation flap in conjunction with a composite graft or Hughes flap (Figure 39.4). This technique involves
rotation of a large skin and muscle flap from the cheek, beginning at the lateral canthal angle and
extending upward into the temple region. Marking the flap well above the level of the lateral canthus
before extending to the periauricular skin is critical to correctly position the lateral canthal angle. When a
Hughes flap is not used for posterior lamellar reconstruction, a temporary tarsorrhaphy is often useful
during the initial phase of healing to combat the mechanical effect of edema. Posterior extension proceeds
in the subcutaneous plane just anterior to the ear and then inferiorly across the mandible, as needed. A
Burow triangle of the skin may need to be excised below the defect to facilitate the inset of the flap.
Dermal anchorage of the Mustarde cheek flap to the lateral orbital rim periosteum is also key to
minimizing vertical tension on the reconstructed lid.
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FIGURE 39.4 Lower eyelid Mohs defect (A) reconstructed with a Mustarde cheek rotation flap (B).
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Outcomes and Prognosis
Complications specific to lower eyelid reconstruction include lower lid laxity and lateral canthal dystopia,
marginal ectropion, and lid retraction. These may all arise from inappropriate restoration of lid length or
inadequate fixation. Lower lid laxity and lateral tissue sag may develop from overcorrection of horizontal
length, as well as poor fixation at the lateral canthus. A lateral tarsal strip procedure or canthoplasty may
be necessary to tighten the lower lid in these situations. With ectropion and lid retraction, vertical
deficiency may be worsened by gravity and altered lid mobility. Early postoperative swelling can also
contribute to mechanical ectropion. A Frost-style traction suture can be placed for 1 week to provide early
postoperative lid support. Finally, with excessive scarring after reconstruction, cicatricial ectropion may
be noted. This complication has been noted in 5% of patients undergoing lower eyelid reconstruction. 12
In general, scars should be allowed to mature and should not be surgically revised until 6 months or
more postoperatively.
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Canthal Reconstruction
Medial Canthal Reconstruction
Reconstruction of the medial canthal region is complex due to structures that may be involved and
contours that are difficult to recreate. In addition, defects in this region are associated with a high
incidence of lacrimal system injury, which may need to be repaired primarily or addressed in delayed
fashion. For small defects limited to the anterior lamella, healing by secondary intention can be
considered, though full-thickness skin grafting facilitates more expeditious healing. With larger defects,
or those lacking sufficient vascularized tissue for skin grafting, a local medially based myocutaneous
transposition flap from the upper eyelid can be performed. Alternatively, a glabellar rotation
advancement flap may be employed (Figure 39.5). 13 Importantly, thicker flaps result in excess tissue bulk
in the normally thin medial canthal region, and occasionally require thinning during a secondary
procedure. When the medial canthal tendon is disrupted, fixation of the remaining portion is necessary to
restore alignment and lower eyelid support. However, anterior fixation alone may not be adequate to
restore lid-globe apposition. Suture fixation to posterior lacrimal crest, miniplate anchoring, or transnasal
wiring may also be employed when there is more extensive disruption. Concomitant lacrimal probing or
stent placement should be considered in select cases to reduce the risk of kinking the canaliculi and
inhibiting lacrimal drainage.
FIGURE 39.5 A. Medial canthal defect with glabellar flap marked. B. Elevation and inset of glabellar rotation flap into medial
canthal defect.
Defects involving the lacrimal system should be fixed in concert with medial canthal reconstruction when
possible with minimally invasive techniques. When a dacryocystorhinostomy with or without Jones tube
is required, however, repair should be deferred until careful postoperative observation has ensured an
acceptably low risk of tumor recurrence has diminished. Partial interruptions of the canaliculus can be
repaired over a monocanalicular or bicanalicular silicone stent, which is generally left in place for
3 months before removal. When primary reconstruction is deferred, follow-up evaluation is necessary to
determine whether the patient develops epiphora.
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Lateral Canthal Reconstruction
Defects in the lateral canthal region may include loss of skin and muscle as well as injury to the lateral
canthal tendon. For tissue deficits limited to this region, the quantity of tissue that must be reconstructed
is often minimal and may be addressed with full-thickness skin grafts or local advancement flaps. Color
and texture match for full-thickness skin grafts can best be achieved by harvesting nearby tissue, and the
postauricular donor site is frequently employed with minimal donor-site morbidity. A cheek flap, similar
to that described above for lower eyelid defects, is also frequently employed, as are laterally based
orbicularis oculi myocutaneous flaps from the upper eyelid region. Restoration of the lateral canthal
tendon, if disrupted, is critical. Failure to adequately repair the lateral canthal tendon can result in
rounding of the lateral canthus, shortening of the palpebral fissure, lower lid retraction, ectropion,
lagophthalmos, and poor lacrimal pump function. 14 Simple disruptions may be primarily repaired with
4-0 polypropylene suture; however, larger defects in the lateral canthal tendon where the proximal end is
lost may require suturing the periosteum at the level of Whitnall tubercle or through small drill holes in
the lateral orbital rim.
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Correction of Eyelid Ptosis
At rest, the normal upper eyelid position lies in between the pupillary aperture and the superior limbus.
Ptosis describes an abnormally low upper eyelid margin in the relaxation, greater than 2 mm below the
corneoscleral junction. This can arise from dysfunction of the levator complex (true ptosis) or
abnormalities in surrounding anatomy (pseudoptosis), as can be seen in enophthalmos, brow ptosis, or
hypertropia. True ptosis can be classified as congenital or acquired, and by etiology including
aponeurotic, myogenic/neurogenic, or mechanical. For patients with congenital ptosis, fibrofatty
dysgenesis of the levator complex is observed, and ptosis remains relatively constant throughout life until
surgery is performed. Poor levator function and lagophthalmos is typically seen on examination of these
patients. Various forms of acquired ptosis exist, with levator dehiscence the most common. Classically,
ptosis seen from a dehisced levator aponeurosis is associated with a lid crease that is higher and an upper
sulcus that is deeper than the uninvolved side. Aponeurotic dehiscence can also be seen following mild
trauma or after cataract surgery. Myogenic/neurogenic causes of ptosis are associated with conditions
such as myasthenia gravis, oculopharyngeal muscular dystrophy, and idiopathic late-onset familial
ptosis. These etiologies are particularly difficult to treat as defects are progressive and ocular surface
protective mechanisms function poorly, rendering these patients at heightened risk of corneal
complications. Finally, for mechanical causes of ptosis, tumors of the upper eyelid or orbit may present
with ptosis, and a careful evaluation of the entire orbit is thus necessary when examining the patient who
presents for ptosis correction.
One situation that warrants individual consideration is ptosis seen with the Marcus Gunn jaw-winking
phenomenon, which accounts for 2% to 13% of congenital ptosis. 15 Patients with this syndrome
demonstrate both a variable degree of ptosis at rest and winking associated with jaw movement, sucking,
or swallowing. These findings are as a result of aberrant connections between motor branches of CN V
and the superior division of CN III. Both ptosis and winking can be disconcerting for the patient, and
surgical approach is highly dependent on which component is responsible for the greater cosmetic defect.
Although procedures that shorten the levator aponeurosis can improve the ptosis, patients must also be
informed that concomitant increase in wink excursion may be noted. In contrast, severing the levator
tendon can reduce winking, but requires placement of a frontalis sling, which will create other significant
asymmetries that the patient must be prepared to accept.
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Preoperative Evaluation
Examination of the patient who presents with ptosis should begin with a gross evaluation observing lid
contour, eyelashes, and skin quality. Particular attention should be paid to the presence and position of
the lid fold, as blunting can suggest poor lavatory function, whereas a deep, elevated fold suggests
levator dehiscence. Inspection of the brow is also important, given that redundancy of tissue in this
region may contribute to ptosis and that elevation can partially mask eyelid ptosis. Pupillary asymmetry
(anisocoria) or deficiencies in extraocular muscle function may raise the suspicion of Horner syndrome or
CN III palsy as a cause for ptosis. Possible myogenic causes should be pursued in patients with variable
or fatigable ptosis. Palpation of the lid may reveal an orbital process, and computed tomography
scanning should be considered in appropriate patients as part of a preoperative evaluation. An age-
appropriate visual acuity and visual field test should be performed in all patients with ptosis who are
able to cooperate. Additional evaluation should include testing orbicularis oculi function, corneal
sensation, strength of Bell phenomenon, and in adults with dry eye symptoms, a Schirmer test for tear
function. Though not an absolute contraindication to surgery, patients with poor orbicularis function, Bell
phenomenon, or tear production may be at increased risk for keratitis following ptosis surgery as any
lagophthalmos or corneal exposure may be worsened.
Accurate quantification of lid ptosis and levator function is critical for selecting the correct surgical
approach for ptosis repair. This begins with a measurement of the upper eyelid position in primary
position with the brow relaxed (Figure 39.6). The adult cornea typically measures 11 mm in height, with
the corneal light reflex serving as a useful reference midpoint. A normal upper eyelid margin rests 1 to
2 mm below the superior limbus, and a patient with 3.5 mm of ptosis would therefore be noted to have a
resting lid margin at or just above the corneal light reflex. Severity of ptosis is classified as mild (1–2 mm),
moderate (2–3 mm), or severe (≥4 mm). Levator function is next evaluated by stabilizing the patient’s
brow with the examiner’s thumb. A ruler is then used to measure maximal excursion of the lid margin
from extreme upgaze to extreme downgaze (see Figure 39.6). Normal excursion is usually greater than
12 mm. Levator function in the patient with ptosis is classified as good (≥8 mm), fair (5–7 mm), and poor
(≤4 mm). Finally, evaluation of the sympathetically innervated Müller muscle function can be performed
by instilling 2.5% phenylephrine eye drops and evaluating changes to marginal reflex distance after
10 minutes. 16 For patients with mild to moderate ptosis and good levator function, this test has been
thought to accurately predict final eyelid position with a Müller muscle–conjunctiva resection.
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FIGURE 39.6 A. Upper eyelid ptosis evaluation with lid position noted first at rest. B. Using a ruler, levator excursion is then
determined by measuring change in lid position between extreme upgaze (B) and extreme downgaze (C).
The goals of surgical correction for ptosis are to elevate the lid position and restore the upper eyelid fold.
Inherent anatomic defects, such as those seen in congenital ptosis, may limit the ability to achieve these
goals, and an understanding of these constraints is necessary before proceeding with surgery. In children,
general anesthesia is typically required, but in adults, local anesthesia may be preferred as it allows for
patient cooperation in adjusting the lid height. Several procedures are routinely performed for correction
of ptosis, including a Müller muscle–conjunctiva resection, levator advancement, and frontalis sling. The
degree of eyelid ptosis and levator excursion measured preoperatively help to guide selection of proper
surgical approach.
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Müller Muscle–Conjunctiva Resection
Patients who demonstrate mild ptosis (2–3 mm), good levator excursion, and an appropriate
phenylephrine test are good candidates for Müller muscle–conjunctiva resection. Posterior ptosis surgery
was initially described by Fasanella and Servat, but subsequent modifications by Putterman have resulted
in improved predictability and minimized anatomic disruption. In brief, the anesthetized eyelid is
everted over a retractor, a graded quantity of conjunctiva and underlying Müller muscle are tented up
and purchased with a Putterman clamp. 17 The edges are then sutured and the excess tissue excised.
Importantly, although this technique offers a rapid approach to ptosis correction without need to
significant dissection, there is little room for intraoperative adjustment and violation of the conjunctival
surface may increase risk for postoperative corneal irritation. Consequently, proper patient selection for a
modified Müller muscle–conjunctiva resection is critical.
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Levator Advancement and Levator Repair
The levator advancement is a versatile procedure that can appropriately address patients with mild to
moderate ptosis and fair to good levator excursion (≥5 mm). This approach is widely applicable to
patients with senescent/involutional ptosis, traumatic ptosis, and even some with congenital ptosis who
have some preserved levator function. A similar anterior approach is taken following placement of
anesthetic eyedrops and injection of local anesthesia. The orbital septum is opened and the underlying
preaponeurotic fat pad gently dissected from the underlying levator musculoaponeurotic complex.
The levator is then advanced and secured to the tarsal plate using interrupted lamellar mattress sutures.
These are temporally tied and cooperative patient’s lid height and contour can then be evaluated in a
seated position with the operating room lights dimmed. If epinephrine is used in the local anesthetic, an
additional 1 to 1.5 mm of overcorrection may be necessary to account for Müller muscle stimulation. Once
the lid position is set, the sutures are tied permanently. Restoration of the upper eyelid crease can be
achieved through reattachment of the orbicularis muscle to the levator aponeurosis. Though this
technique is quite versatile for treating many causes of ptosis, with overall success rates of 76% to 85%
reported. 18,19 Both under- and overcorrection have been observed, with preoperative levator function, one
of the most significant predictors of surgical outcome. Considerable dissection and consequent edema can
also make intraoperative adjustments difficult. Of note, predictability for bilateral levator advancement is
diminished due to Herring phenomenon, and postoperative surprises are more common.
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Frontalis Sling
In patients with variable degrees of ptosis and poor levator excursion (≤4 mm), as can be seen in patients
with congenital ptosis, elevation of the upper eyelid can best be accomplished through suspension to the
frontalis muscle. Elevation of the lid is therefore coupled to elevation of the brow. A variety of materials
can be used, with silicone, autologous fascia lata, and palmaris longus tendon among the more common
choices.
Many different techniques have been described to create the frontalis sling, but the double rhomboid
design remains the most often used (Figure 39.7). Three incisions are made in the brow in line with the
lateral canthus, the center of the lid, and the medial canthus. Although analogous stab incisions may be
made above the ciliary margin in young children, an open lid crease technique with tarsal dissection and
sling fixation is typically performed in older patients. A Wright fascia needle is then passed starting from
the brow incisions in a preperiosteal plane, exiting the lid incisions in the postorbicularis fascia plane.
Care should be taken to avoid excessively superficial or deep passage.
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