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Park recommended removing all the skin from the
amputated segment except for the helical rim. The cartilage
was then sandwiched between two flaps: a skin flap
anteriorly and a fascial flap posteriorly, both based on the
mastoid region. The skin on the helical rim later necrosed
but was salvaged with additional operations.
MICROVASCULAR REPLANTATION
Microvascular replantation provides a more naturalappearing reconstructed ear and is preferred to other forms
of delayed reconstruction.
It is a technically demanding operation due to the small caliber
of the vessels, and often venous outflow is a problem.
Microvascular anastomosis is performed to either the posterior
auricular artery or the superficial temporal artery. Both can
restore the blood supply to the entire amputated segment given
the numerous interconnections that are present between these
two arterial networks.
If no vein can be found, or the veins are small, have a low
threshold for starting leeches postoperatively.
PEARLS
1. Ears are usually operated on between the ages of 6 and 7 when
ear growth is nearly complete.
2. For the burned ear, mafenide acetate is preferred due to its
superior cartilage penetration. Complications of mafenide use
include pain and beware of hyperchloremic metabolic acidosis
from carbonic anhydrase inhibition.
3. Microvascular replantation may sacrifice the superficial temporal
artery, which would impair the use of the temporoparietal fascial
flap in the future.
4. Costal cartilage is often stiffer and more calcified in adults
compared to children; thus, the cartilaginous ear framework
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1.
2.
3.
4.
used for total ear reconstruction in adults is usually carved en
bloc.
QUESTIONS YOU WILL BE ASKED
1. What is the most common reason ear replantations fail?
Poor venous outflow.
2. Why is it more difficult to use autogenous cartilage in the elderly
for total ear reconstruction?
Calcification of the rib cartilage.
Recommended Readings
Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal
defect of the ear. Plast Reconstr Surg. 1967;39(5):472‐477.
Baker SR. Local Flaps in Facial Reconstruction. Elsevier; 2022.
Brent B. The acquired auricular deformity. A systematic approach to its analysis
and reconstruction. Plast Reconstr Surg. 1977;59(4):475‐485.
Pribaz JJ, Crespo LD, Orgill DP, Pousti TJ, Bartlett RA. Ear replantation
without microsurgery. Plast Reconstr Surg. 1997;99(7):1868‐1872.
*
Denotes common in-service examination topics.
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23
Eyelid Reconstruction
Jane S. Kim and Peter M. Kally
OVERVIEW
EYELID ANATOMY AND PHYSIOLOGY
(FIG. 23-1)
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Figure 23-1 Cross section of the upper and
lower eyelids. (From Shahzad F, Mehrara
BJ, Fay A. Lower eyelid reconstruction with
palatal grafts. In: Chung KC, Disa JJ, Gosain
A, et al., eds. Operative Techniques in Plastic
Surgery. Wolters Kluwer; 2020:1094-1098.
Figure 3.23.1A.)
The primary function of the eyelids is to protect the globe and to
maintain adequate lubrication of the ocular surface.
The movement of the upper eyelid is dynamic, whereas the
lower eyelid acts as a static sling.
The eyelid is composed of three lamellae (see Fig. 23-2, Table
23-1)
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Figure 23-2 Periorbital musculature.
(From Thorne CH, ed. Grabb and Smith’s
Plastic Surgery. 7th ed. Lippincott Williams
& Wilkins; 2014. Figure 46.3A.)
TABLE 23-1 Structures of the Eyelid
Anterior lamella: well-vascularized external coverage
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Figure 23-3 A. Fat compartments of
the eyelids. B.Ligamentous support of
the eyelids.
(From Thorne CH, ed. Grabb and
Smith’s Plastic Surgery. 7th ed.
Lippincott Williams & Wilkins; 2014.
Figures 46.6 and 46.5.)
Middle lamella: central structural support
Posterior lamella: deep structural support with a mucosal
lining
Ligamentous Structures of the Eyelid (Fig. 23-3)
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Figure 23-4 Vascular supply (A) and
sensory innervation (B) of the eyelids.
(From Nguyen J, Fay A. Tenzel
semicircular rotational flap. In: Chung KC,
Disa JJ, Gosain A, et al., eds. Operative
Techniques in Plastic Surgery. Wolters
Kluwer; 2020:1084-1088. Figure
3.21.1CD.)
Medial canthal tendon (MCT)
Originates at the medial margin of the superior and
inferior tarsal plates
Crura fuse as a tripartite common tendon prior to
insertion on the medial orbital wall
Anterior limb: passes anterior to the lacrimal sac
Inserts onto the frontal process of the
maxillary bone (anterior lacrimal crest)
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Provides majority of MCT strength and
contributes to punctal position
Posterior limb: passes posterior to the lacrimal sac
Inserts onto the posterior lacrimal crest
Thinner and weaker than the anterior limb but
contributes to lid-globe apposition
Superior limb: forms the roof of the lacrimal sac
Inserts onto the orbital process of the frontal
bone
Functions in the lacrimal pump mechanism
and provides greater contribution to lid-globe
apposition
Function: provides support for the eyelids, particularly
with punctal position and lid-globe apposition
Lateral canthal tendon (LCT)
Originates at the lateral margin of the superior and
inferior tarsal plates
Upper and lower crura fuse as a Y-shaped common
tendon that inserts onto Whitnall tubercle
Function: provides support for the eyelids
Transected in lateral canthotomy/cantholysis procedure
to relieve orbital compartment syndrome (ie,
retrobulbar hemorrhage)
Whitnall (superior transverse) ligament
Formed by condensation of fibrous tissues surrounding
the levator palpebrae superioris
Medially anchored to connective tissues surrounding
the trochlea and laterally to the lacrimal gland and
lateral orbital rim (10 mm above Whitnall tubercle)
Function: provides support for the upper eyelid,
lacrimal gland, and surrounding tissues. Acts as a
fulcrum for the levator palpebrae superioris
Lockwood (suspensory) ligament
Formed by fusion of the sheath of the inferior rectus
muscle, the inferior tarsal muscle, and the check
ligaments of the medial and lateral rectus muscles
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Medially anchored to the MCT and laterally to Whitnall
tubercle
Function: provides support for the globe and the
anteroinferior orbit (like a hammock)
Orbicularis-retaining (orbitomalar) ligament
Arises from the arcus marginalis of the inferior orbital
rim and inserts onto the dermis of lower eyelid skin,
forming the nasojugal fold
Laterally becomes lateral orbital thickening, which
should be released when elevating the lateral brow
Transected in fat transposition technique for lower
eyelid blepharoplasty
Periocular Fat
Retro-orbicularis oculi fat (ROOF): sub-brow fat and
superior preseptal fat that lie deep to the orbicularis oculi
muscle and superior to the orbital (postseptal) fat
Suborbicularis oculi fat (SOOF): inferior supraperiosteal
fat that lies deep to the orbicularis oculi muscle and the
superficial malar fat pad
Vascular Supply of the Eyelid (Fig. 23-4)
Dual blood supply from both external (ECA) and internal
carotid arteries (ICA)
Upper eyelid: primarily supplied by branches of the
ophthalmic artery (ICA)
The peripheral arterial arcade is located between the
levator palpebrae superioris and Müller muscle just
above the superior tarsal border.
The marginal arterial arcade is located 2-3 mm from
the lid margin.
Lower eyelid: primarily supplied by branches of the facial
artery (ECA)
The marginal arterial arcade is located 2-3 mm from
the lid margin.
Sensory Innervation of the Eyelid (Fig. 23-4)
Upper eyelid: ophthalmic division (V1) of CN V
Lower eyelid: maxillary division (V2) of CN V
Motor Innervation of the Eyelid
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