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Orbicularis oculi: CN VII
Levator palpebrae superioris: superior division of CN III
Müller (superior tarsal) muscle and inferior tarsal muscle:
sympathetic
PREOPERATIVE ASSESSMENT
Goal: to restore form and function of the eyelids and periocular
structures including the medial and LCTs as well as the tear
ducts
Examination
Assess visual acuity for both eyes.
Perform a basic slit lamp exam.
Dry eyes
Add 2% fluorescein dye to the eye and observe if
there is any staining.
Tear film break-up time
Add 2% fluorescein dye to the eye and observe
how quickly the tear film breaks up or evaporates.
The longer the time it takes to evaporate, the more
stable the tear film.
Normal: >10 seconds
Abnormal: <5 seconds
*Assess tear production.
Schirmer test
Place paper strip in inferior fornix for 5 minutes.
Topical anesthetic can prevent reflexive
tearing (false positive).
The more wet the paper strip, the less dry the eye.
Normal: >10 mm
Abnormal: <10 mm
Assess lid laxity.
Snap-back test
Pull the lower eyelid away from the globe. Upon
release, it should immediately return to its normal
position without blinking.
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If this takes longer than 1 second, then significant
laxity is present.
Assess laxity, ptosis, and overall structural support of
surrounding tissues.
Mobility of tissues adjacent to defect
Presence of midface ptosis
Vector
Refers to the position of the anterior surface of the
globe in relation to the most anterior point of the
inferior orbital rim on lateral view.
Neutral vector: vertical line (no inclination)
from the cornea to the rim
Negative vector: posteriorly inclined line from
the cornea to the rim (increased risk of
postoperative lower lid retraction and
ectropion)
RECONSTRUCTION OF EYELID AND
CANTHAL DEFECTS
PARTIAL-THICKNESS EYELID
DEFECTS (FIG. 23-5)
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Figure 23-5 Eyelid reconstruction. FT, full
thickness; PT, partial thickness. (Adapted from
Spinelli HM, Jelks GW. Periocular
reconstruction: a systematic approach. Plast
Reconstr Surg. 1993;91(6):1017-1024;
Thorne CH, ed. Grabb and Smith’s Plastic
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Surgery. 7th ed. Lippincott Williams & Wilkins;
2014. Figure 32.2.)
Anterior Lamellar Defects
Adjacent tissue transfer (preferred) or full-thickness skin
graft (preferred site for FTSG: contralateral upper eyelid)
Consider frost sutures and/or lateral canthopexy or
canthoplasty to reduce risk of postoperative lid retraction
Posterior Lamellar Defects
If involves conjunctiva only
Primary repair by 1-3 widely spaced, buried,
interrupted 7-0 or 8-0 Vicryl sutures for smaller defects
Amniotic membrane grafts or buccal/gingival mucosal
grafts for larger defects
If involves tarsus and conjunctiva
Primary repair for smaller defects. Ensure parallel
apposition of both edges of tarsus to prevent kinking or
notching.
Tarsal alternatives for larger defects: ear cartilage,
nasal chondromucosal graft (septal cartilage), or hard
palate mucosal graft.
FULL-THICKNESS EYELID DEFECTS
(FIG. 23-5)
Less than 33%
Primary closure (after converting to pentagonal wedge)
with meticulous lid margin repair; lateral canthotomy ±
cantholysis may be required. In elderly patients, preexisting
laxity may allow for closure of larger defects.
Lid margin repair (Fig. 23-6)
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Figure 23-6 Full-thickness eyelid
margin repair. (From Johnson J.
Bailey’s Head and Neck Surgery.
5th ed. Wolters Kluwer; 2014.
Figure 75.7.)
Align lid margin using a vertical-mattress 6-0
Vicryl suture at the gray line.
Evert wound edges to prevent postoperative
notching.
Secure long suture ends under skin sutures
away from the cornea or bury the suture ends.
Repair the tarsal wound using buried interrupted
6-0 Vicryl sutures.
Partial-thickness bites protect the cornea from
suture irritation.
Bury all suture knots closer to the
skin/orbicularis oculi than to the conjunctiva.
Close skin using 6-0 nonabsorbable or
absorbable suture (conjunctival closure is not
required).
Remove skin sutures in 5-7 days. Lid margin
sutures can either be left alone or removed in
7-10 days.
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Complications: notching (most common),
trichiasis, and madarosis.
Between 33% and 50%
Tenzel semicircular flap: advancement of any remaining
lateral eyelid along with a myocutaneous flap (incision
oriented inferiorly for an upper eyelid defect and superiorly
for a lower eyelid defect). Medially, a full-thickness lid repair
is performed. Laterally, the lateral commissure is reformed
with a buried interrupted 6-0 Vicryl suture, and the flap is
secured to periosteum along the lateral orbital rim at the
level of the newly formed lateral canthal angle.
SOOF or midface lift for lower eyelid defects: elevation of
the SOOF or midface can be helpful in supporting the lower
eyelid in addition to adjacent tissue transfer.
Greater Than 50%
*Cutler-Beard flap for upper eyelid defects
First stage: full-thickness flap is developed in the
ipsilateral lower eyelid ~1-2 mm below the inferior
tarsal border and passed beneath the lower lid margin
into the upper lid defect (may include cartilage for
additional support).
Second stage: flap is divided and inset 3-4 weeks
later. Consider longer interval in smokers (ie, 6-8
weeks).
Hughes tarsoconjunctival flap with full-thickness skin
graft for lower eyelid defects
First stage: tarsoconjunctival flap is developed from
the ipsilateral upper eyelid, leaving 4 mm for upper
eyelid support, and is transferred into the lower eyelid
defect. Müller muscle is also included in smokers. A
full-thickness skin graft covers the tarsoconjunctival
flap (preferred site for FTSG: contralateral upper eyelid
skin, pre- or postauricular skin).
Second stage: flap is divided and inset 3-4 weeks
later. Consider longer interval in smokers (ie, 6-8
weeks).
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Free tarsoconjunctival graft from contralateral upper
eyelid with overlying myocutaneous flap (preferred in
monocular patients)
Can also consider ear cartilage, nasal chondromucosal
graft (septal cartilage), or hard palate mucosal graft for
posterior lamellar defect, with myocutaneous flap for
anterior lamellar defect
Paramedian forehead flap for large lower eyelid and
medial canthal defects
Mustardé cheek rotation flap for large vertical lower
eyelid defects
Elevate in a subcutaneous plane for a thinner flap.
Consider deep plane elevation in smokers to reduce
risk of distal flap necrosis.
Anchor flap to the deep temporal fascia and the
periosteum of the infraorbital rim to reduce risk of
postoperative ectropion.
Can combine with a free posterior lamellar graft or
amniotic membrane graft for total lower eyelid defects.
Unipedicled myocutaneous Fricke transposition flap for
large lower eyelid and lateral canthal defects: temporally
based supraciliary forehead flap transposed into a lower
eyelid defect.
Bipedicled myocutaneous Tripier transposition flap:
medially and temporally based upper eyelid flaps
transposed into a lower eyelid defect. Requires redundant
or lax upper eyelid skin. Typically for narrow lower eyelid
defects.
LATERAL CANTHAL DEFECTS
Canthopexy for LCT laxity (Fig. 23-7)
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Figure 23-7 Lateral canthopexy. (From
Spinelli HM. Eyelid malpositions. In:
Spinelli HM, ed. Atlas of Aesthetic Eyelid
and Periocular Surgery. Elsevier;
2004:47.)
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Canthoplasty for any disruption or loss of LCT
Depending on tissue laxity and presence of medial LCT
stump, can either suture to periosteum at inner aspect of
lateral orbital rim or use a lateral tarsal strip (Fig. 23-8) or
periosteal flap
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Figure 23-8 Lateral tarsal strip.
(From Spinelli HM. Eyelid malpositions.
In: Spinelli HM, ed. Atlas of Aesthetic
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