82ORBIT, EYELIDS, AND OCULAR ADNEXA

Strabismus: never resect thyroid muscles; consider IR/MR recession with adjustable sutures.

Lid surgery: for upper lids, do either Mu¨ller recession/myotomy (internal) or levator recession/myotomy (external). For lower lids, recess retractors with spacer graft.

Skin excess: do blepharoplasty (conservative to avoid recurrent

retraction), excision of festoons, and CO2 skin resurfacing for postinflammation pigment changes.

Eyelid Surgery

GENERAL Local anesthetic standard eyelid mix is often 50:50 lidocaine 1% with epinephrine plus bupivacaine 0.75% with Wydase in a 10 cc syringe with a 26 gauge needle. Place a drop of tetracaine in each eye. Postoperative regimen for most patients includes ice packs 20 minutes every 2 hours for 48 hours, increased head of bed, antibiotic ointment 4 times per day for 4 days; consider oral antibiotic (e.g., Levaquin 500 mg PO every day for 7 days) for reoperations. Most patients are seen for a 1-week follow-up, but ptosis patients are often seen in 4 to 5 days in case surgical adjustment is needed.

BLEPHAROPLASTY Indicated for dermatochalasis with or without steatoblepharon.

Upper lid blepharoplasty: mark skin along lid crease, usually 8–10 mm from eyelid margin centrally and 5 mm nasally and temporally. Laterally follow the laugh crease, and medially make a downturn and go about 5 mm medial to the punctum to prevent webbing. Then mark the upper incision line according to the amount of skin to be removed: centrally always maintain at least 10 mm distance from the inferior eyebrow to the eyelid crease, or 15 mm if the patient has high arched brows. Incise skin with #15 blade, then excise the myocutaneous flap with blunt Westcott scissors. If the patient has significant steatoblepharon, bluntly dissect thru septum, isolate the central and nasal fat pads, and gently lift the fat pad with forceps (avoid excessive traction on the fat); use cautery for hemostasis. Close skin with 6.0 sutures. Usually no dressing is needed.

Lower lid blepharoplasty: skin incision along a line inferior to the lashes; may debulk fat pads. Excess skin is trimmed, and skin closed as above.

May injure the IO or cause lower lid retraction (from lower lid retractor or septal scarring or excessive skin removal if performed transcutaneously).

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Retroblepharoplasty: blepharoplasty and fat removal via transconjunctival approach in the lower lid to avoid visible scar but does not allow for skin removal. Can perform secondarily.

BROW PTOSIS Males have flat brow, women arched. Both sexes tend to have predominant temporal brow ptosis.

Direct brow lift: leaves a visible scar. Mark skin along the superior brow, then along a forehead crease according to the amount of skin removal desired. Incise with #15 blade, maintaining a cutting angle parallel to the eyebrow hair follicle orientation. Remove the myocutaneous flap with blunt Westcott scissors (stay superficial over the supraorbital neurovascular bundle). Close the deep layers with several 4.0 or 5.0 Vicryl interrupted sutures. Close the skin with 6.0 Prolene suture. Dress with Tefla pad.

Coronal forehead lift: best result, but do not use in patients with a high forehead or hairline.

Endoscopic lift: very good cosmetic result, as incisions are concealed in the hairline. Similar results as a coronal browlift, with excellent patient acceptance. Allows extirpation of procerus and corrugator muscles.

Hairline lift (pretrichial): useful for patients with a high hairline (>6 cm) to elevate the brow and advance the hairline.

ECTROPION Treated with horizontal tightening (wedge resection, Bick procedure, LTS), reattaching retractors, or reversing Quickert sutures. Also:

Medial spindle: excision of football-shaped area of medial palpebral conjunctiva that is closed with a vertical mattress suture that is externalized; useful for involutional ectropion of the medial eyelid associated with punctal eversion.

Two-snip procedure: useful for medial punctal ectropion; place one blade of Vannas scissors into punctum-ampula with other on conjunctiva, and cut a V shape to allow drainage into ampulla.

ENTROPION Lower lid tightening (LTS) plus:

Quickert sutures: plicate lower lid retractors to prevent orbicularis muscle override by forming a scar along several double-armed 4.0 Vicryl or silk suture tracts. Pass sutures 3–4 mm below lower tarsus, engage conjunctiva and lower lid retractors, turn superiorly, and exit skin 4–5 mm below lid margin. Pass second needle 3–4 mm lateral to first needle and tie tightly on bolsters, leaving for 3 to 4 weeks.

Wies procedure: full-thickness blepharotomy with marginal eyelid rotation to treat cicatricial entropion (often used in developing countries for trachoma-associated upper eyelid entropion).

‘‘Kurfing’’: cut grooves in tarsus to allow it to bend; used to treat cicatricial entropion.

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84 ORBIT, EYELIDS, AND OCULAR ADNEXA

Posterior tarsotomy: partial thickness cut across full tarsal length gives laxity to plate, and sutures are externalized and bolstered; used to treat cicatricial entropion.

EYELID LAXITY Most commonly results from involutional lateral canthal weakening. Treating lower lid laxity is a core component of entropion and ectropion repair.

Lateral tarsal strip (LTS) procedure: do a lateral canthotomy and inferior cantholysis. Divide the lateral eyelid into anterior and posterior lamellae with #15 blade or blunt Westcott scissors (cut along the gray line to dissect between orbicularis muscle and anterior tarsus). Prepare the tarsal strip by horizontally cutting conjunctiva and lower lid retractors from inferior tarsus, remove a thin strip of lid margin from superior border of tarsus, and scrape conjunctiva on posterior tarsus. Gauge necessary amount of shortening, then cut excess tarsus. Pass suture through the anterior face of the tarsal strip superiorly and inferiorly (best to use a double-armed 4.0 permanent or Vicryl suture on a P-2 tightly curved needle). After retracting lateral orbital rim soft tissue, pass the needles along the periosteum of the inner aspect of the lateral orbital rim, wanting a slight superior overcorrection. Assess amount of excess anterior lamella and excise, then close skin (e.g., with 6.0 chromic gut).

EYELID RECONSTRUCTION General principles: complete anesthesia, sustained hemostasis, protection of globe, closure of lid in layers (anterior lamella and posterior lamella), eversion of skin edges. Avoid vertical tension (make vertical incisions), and do not debride ‘‘necrotic’’ tissue, as it is often viable because of good facial skin vascularization.

Direct closure: if defect is less than one third of the total eyelid length in children or less than half in adults. May advance lid for greater amount of loss with lateral cantholysis (adds 3–5 mm), or use a semicircular flap (Tenzel). Use Vicryl for subcutaneous sutures and plain gut for skin closure.

Eyelid margin repair: pass suture in tarsus out gray line, then in opposite gray line out tarsus. Pass second suture through tarsal meibomian gland plane 2 mm from wound edge and 2 mm into tarsus, exiting into wound and equidistant into other tarsal segment and tie. Close tarsus with 6.0 Vicryl with knots on anterior surface. Place skin marginal sutures to align lashes with 6.0 silk, tie and leave long, and incorporate ends with skin sutures, which are removed in 7 days.

Full-thickness lid defect: bridge flap if >50% of lid margin lost (avoid in amblyopic age group).

Cutler-Beard flap: upper lid defect repaired with full-thickness tissue flap from lower lid. Requires a tarsal substitute.

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Hughes tarsoconjunctival flap: lower lid defect closed by bridge flap of tarsus and conjunctiva transposed into the lower lid defect with full-thickness skin graft or advancement flap to replace anterior lamella.

Partial-thickness lid defect: reconstruction is based on replacing anterior lamella (skin, muscle) or posterior lamella (tarsus or other tectonic support and conjunctiva or other mucous membrane).

Anterior lamella: may use a flap or a free graft.

Flaps for anterior lamellar reconstruction: advancement flap (can decrease tension with Burow’s triangle), rotation flap, or transposition flap.

Free skin graft: best source is the other eyelid; also may use retroauricular, preauricular, supraclavicular (can harvest up to 8 6 cm), and medial inner arm skin.

Eyelid skin graft: make a superficial incision (skin only, not muscle, as in blepharoplasty), then dissect down to dermal vessels and rete pegs between skin and muscle. Measure defect, then harvest graft 30% larger than defect, as shrinkage occurs.

Posterior lamella: mucous membrane grafts may be obtained from conjunctiva, buccal, or hard palate mucosa (the epithelium side glistens and tissue curls toward basement membrane side). Also, free tarsal grafts can be obtained (can take tarsus 5 mm wide12 mm long).

Lateral canthotomy and cantholysis: using local anesthetic, cut skin horizontally with Stevens or blunt Westcott scissors, separate conjunctiva and muscle, point scissors inferonasally and strum the inferior crus, then cut while pulling the eyelid margin outward with forceps (will feel a ‘‘give’’ when the crus is released).

LID RETRACTION

Gold weight: three-point fixation to superior tarsal plate with permanent suture. Cover implant with skin-muscle flap to lessen risk of extrusion.

PTOSIS SURGERY Always evaluate Herring’s effect on contralateral lid if unilateral ptosis.

Levator advancement: for good function (LF >8 mm), mild to moderate ptosis. For children, use the difference in levator height þ difference in levator function þ 4 mm. Drape so that both eyes are exposed. Mark skin crease and infiltrate with small amount (1.0–1.5 cc) of local anesthetic (postoperative adjustments can often be performed without local anesthetic until after the incision is teased open and the adjustments are made). Incise skin with #15 blade, then tent up wound

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86 ORBIT, EYELIDS, AND OCULAR ADNEXA

edges and snip down through orbicularis muscle. Gently dissect subcutaneous tissue with blunt Westcott scissors (point scissors toward brow, spread open, and bluntly dissect). Open septum, push fat back, and find levator aponeurosis (may have fatty infiltration). Trim a small amount of orbicularis muscle off the tarsal face to expose the superior tarsal margin. Place a central partial-thickness suture (e.g., 6.0 Prolene) while gently lifting tarsus with forceps (tell the patient he or she may experience some discomfort), then pick up the edge of the aponeurosis and pass the needle through the edge of the levator aponeurosis. Throw a temporary tie, and have the patient open his or her eyes to compare the eyelid positions for symmetry; adjust the suture or tie permanently. Repeat for a nasal limbus suture and possibly a temporal limbus suture. Overcorrect 1–2 mm because epinephrine stimulates the Mu¨ller’s muscle and lidocaine paralyzes the orbicularis muscle. Close skin to skin unless reforming eyelid crease, in which case incorporate some aponeurosis with every other suture pass. Postoperatively, if overor undercorrected or asymmetric contour, adjust within 5 to 7 days or wait a few months.

Posterior lamella resection: good function, minimal ptosis, no dry eye. May be tarsoconjunctival (Fasanella-Servat; removes a portion of normal tarsus) or conjunctival Mullerectomy (Putterman-Urist procedure). Preoperatively, use 2.5% phenylephrine to activate Mu¨ller’s muscle to estimate postoperative lid position.

Levator muscle resection, supra-Whitnall’s resection: unilateral fair to poor function (LF 5–7 mm), with adequate Bell’s phenomenon and tear function. Use difference in MRD þ difference in LF þ 5 (‘‘fudge’’ factor) ¼ amount of resection.

Frontalis suspension or sling: best for very poor or absent function (LF <4 mm). Used especially for complete CN III or congenital myogenic ptosis; contraindicated in good-fair function ptosis. Autogenous fascia lata has the best and most lasting results but may use donor fascia lata (lasts longer than silicone), temporalis fascia, Supramid (may have extrusion but less than silicone), silicone rods (higher extrusion rate), Gortex, or other donor materials (e.g., bovine pericardium, such as Perigard, or banked fascia lata).

TRICHIASIS All treatments may have depigmentation, scarring, herpetic viral activation, and recurrence.

Electrohyfrecation: local, focal trichiasis treated with radiofrequency unit needle placed into hair shaft; activate and see bubble form. Twenty to 50% recurrence.

Cryoablation: local anesthesia; double-cycle freeze-thaw to 20 C (compare with 30 C needed for cancer cell death and 40 C for normal cell death), then epilate in 1 week (cilia should pull out without resistance). Twenty to 40% recurrence.

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