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Contents xiii
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4.4 Skin ......................................................... 38
4.4.1 Skin Tension Lines (Langer’s Lines) (Fig. 4.3) ...... 38
4.5 Don’t Get Lost (Surgical Landmarks) (Fig. 4.4) . . . ........... 39
4.6 Tarsal Plate (Fig. 4.6) . . ...................................... 40
4.7 The Meibomian Orifice Line ................................. 40
4.8 The Grey Line ............................................... 40
4.9 Pre-aponeurotic Fat .......................................... 41
4.10 Lacrimal Ductules . .......................................... 41
4.11 Blood Supply (Fig. 4.7) ...................................... 41
4.12 Muscles . . ................................................... 43
4.13 The Rest . ................................................... 45
4.14 Take Home Message . . . ...................................... 45
5 Fundamental Procedures ........................................... 47
5.1 Overview (Fig. 5.1) .......................................... 47
5.2 Lid Margin Repair (Fig. 5.2) ................................. 48
5.2.1 Considerations ..................................... 49
5.2.2 Principle . .......................................... 50
5.2.3 Steps .............................................. 50
5.2.4 Notes .............................................. 51
5.3 Lateral Canthal Repair (Fig. 5.3) ............................. 53
5.3.1 Considerations ..................................... 53
5.3.2 Principle . .......................................... 53
5.3.3 Steps .............................................. 53
5.4 The Magic Suture (Fig. 5.4) . ................................. 55
5.4.1 Principle and Considerations . . . .................... 56
5.4.2 Case Selection ..................................... 56
5.4.3 Steps .............................................. 56
5.4.4 Notes .............................................. 58
5.5 Tarsal Traction Suture (Fig. 5.6) . ............................. 58
5.5.1 Principle and Considerations . . . .................... 59
5.5.2 Case Selection ..................................... 59
5.5.3 Steps .............................................. 59
5.5.4 Notes .............................................. 60
5.6 Emergency Cantholysis (Fig. 5.7) . . . ......................... 60
5.6.1 Principle and Considerations . . . .................... 61
5.6.2 Case Selection ..................................... 61
5.6.3 Steps .............................................. 61
5.6.4 Note ............................................... 61
5.7 Take Home Message . . . ...................................... 61
6 Eyelid Malposition .................................................. 63
6.1 Overview (Fig. 6.1) .......................................... 63
6.2 Lid Stability (Fig. 6.2) ....................................... 64
6.2.1 Tarsal Plate Width ................................. 64
6.2.2 Orbicularis Tone . . ................................. 64
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6.2.3 Lid/Globe Apposition and Volume Deflation . ....... 64
6.2.4 Gravity . . .......................................... 65
6.2.5 Retractor Tethering ................................. 65
6.3 The Palpebral Aperture ...................................... 65
6.4 Assessment . . . ............................................... 66
6.5 Significance . . ............................................... 66
6.6 Causation . ................................................... 66
6.7 Don’t Strip! . . ............................................... 67
6.8 Take Home Message . . . ...................................... 68
References . . ........................................................ 68
7 Ingrowing Eyelashes ................................................ 69
7.1 Assessment . . . ............................................... 69
7.2 Treatment Options . .......................................... 70
7.2.1 Epilation (Fig. 7.1) ................................. 70
7.2.2 Electrolysis to the Lash Root . . . .................... 70
7.2.3 Localized Full Thickness Lid Margin Resection . . . . . 70
7.2.4 Localized ‘en bloc’ Lash Resection ................. 71
7.2.5 Lash Cryotherapy . ................................. 71
7.2.6 Anterior Lamellar Repositioning .................... 71
7.3 Take Home Message . . . ...................................... 71
8 Entropion ........................................................... 73
8.1 Overview . ................................................... 73
8.2 Types of Entropion .......................................... 73
8.2.1 Congenital Entropion . . ............................. 73
8.2.2 Involutional (Age Related) Entropion ............... 74
8.2.3 Cicatricial Entropion . . ............................. 75
8.3 Entropion Assessment/Examination . ......................... 76
8.3.1 Lid Tone and Laxity . . ............................. 76
8.3.2 Medial Canthal Tendon and Lateral Canthal
Tendon Integrity . . ................................. 76
8.3.3 Conjunctival Scarring/Symblepharon ............... 76
8.3.4 Orbicularis Over-Riding . . . ......................... 76
8.4 Temporary Lower Lid Involutional Entropion
Management . . ............................................... 77
8.4.1 Taping . . . .......................................... 77
8.4.2 Botulinum Toxin . . ................................. 77
8.4.3 Everting (Quickert) Sutures ........................ 78
8.5 ‘Permanent’ Surgical Correction of Involutional
Entropion . ................................................... 79
8.5.1 Principle . .......................................... 79
8.5.2 The Lid Shortening Rule . . ......................... 79
8.6 Lateral Lid Margin Resection and Modified Bick Repair
(Fig. 8.7) . ................................................... 79
8.6.1 Principle and Considerations . . . .................... 79
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8.6.2 Case Selection ..................................... 79
8.6.3 Steps .............................................. 80
8.6.4 Notes .............................................. 84
8.7 Lower Lid Retractor Plication (Fig. 8.8) . . .................... 84
8.7.1 Principle and Considerations . . . .................... 84
8.7.2 Case Selection ..................................... 86
8.7.3 Steps .............................................. 86
8.8 Posterior Medial Canthal Thermoplasty . . .................... 87
8.8.1 Principle and Considerations . . . .................... 87
8.8.2 Case Selection ..................................... 87
8.8.3 Steps .............................................. 87
8.8.4 Notes .............................................. 89
8.9 ‘Permanent’ Surgical Correction of Moderate Cicatricial
Entropion . ................................................... 89
8.9.1 Anterior Lamellar Repositioning .................... 89
8.9.2 Case Selection ..................................... 90
8.9.3 Steps .............................................. 90
8.10 Mucosal Grafting . . .......................................... 92
8.11 Take Home Message . . . ...................................... 92
References . . ........................................................ 93
9 Ectropion ........................................................... 95
9.1 Overview . ................................................... 95
9.2 Symptoms ................................................... 95
9.3 Types ........................................................ 96
9.3.1 Congenital . . . ...................................... 96
9.3.2 Involutional . . ...................................... 96
9.3.3 Eye Rubbing . ...................................... 96
9.3.4 Cicatricial .......................................... 97
9.3.5 Paralytic . .......................................... 97
9.4 Assessment . . . ............................................... 97
9.4.1 Relative Lid/Globe Laxity (Invariably Present) ...... 97
9.4.2 Medial Canthal Tendon and Lateral Canthal
Tendon Integrity . . ................................. 98
9.4.3 Anterior Lamellar Insufficiency . .................... 98
9.4.4 Orbicularis Tone . . ................................. 98
9.5 Temporary Management ..................................... 98
9.6 Surgical Management . . ...................................... 99
9.7 Operations ................................................... 100
9.7.1 Lid Margin Wedge Resection and Bick Repair ...... 100
9.7.2 Medial Lower Lid Retractor Plication (Fig. 9.6) ..... 104
9.7.3 Central Lower Lid Retractor Posterior Plication
(Fig. 9.7) .......................................... 106
9.7.4 Free Skin Graft (Fig. 9.8) . ......................... 108
9.7.5 Upper to Lower Lid Skin Pedicle Flap (Fig. 9.9) . . . . 111
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9.7.6 Permanent (Overlap) Lateral Tarsorrhaphy
(Fig. 9.10) . . . ...................................... 113
9.7.7 Medial Canthoplasty (Fig. 9.11) .................... 115
9.8 Take Home Message . . . ...................................... 117
10 Ptosis ............................................................... 119
10.1 Overview (Fig. 10.1) . . . ...................................... 119
10.2 Examination .. ............................................... 120
10.2.1 Vertical Palpebral Aperture (PA) .................... 120
10.2.2 Levator Function (LF) . ............................. 121
10.2.3 Skin Crease (SC) and Skin Fold (SF) (Fig. 10.5) . . . . 122
10.2.4 ‘Hang-Up’ in Downgaze (Fig. 10.6) ................ 124
10.3 Types of Ptosis .............................................. 124
10.3.1 Congenital Ptosis . ................................. 124
10.3.2 Acquired Ptosis . . . ................................. 124
10.4 Choice of Operation . . . ...................................... 125
10.5 Operations ................................................... 127
10.5.1 White Line Advancement (Anterior Approach)
Fig. 10.8 . .......................................... 127
10.5.2 Conversion to an Anterior Levator Aponeurosis
Reinsertion/Resection Fig. 10.9 . .................... 131
10.5.3 Levator Resection Fig. 10.10 . . . .................... 133
10.5.4 Addition of a Skin and Muscle Blepharoplasty
Fig. 10.11 .......................................... 134
10.5.5 Müller’s Muscle Resection Fig. 10.12 . . . ........... 137
10.5.6 Frontalis Suspension (Fox’s Pentagon)
Fig. 10.13 .......................................... 138
10.6 General Observations . . ...................................... 142
10.6.1 Lower Lid Traction Suture Fig. 10.14 (See
Chap. 5) . .......................................... 142
10.6.2 ‘On Table’ Lid Height . ............................. 143
10.6.3 Post-operative Adjustment—Early Suture
Removal ........................................... 144
10.6.4 Hering’s See-Saw (Fig. 10.15) . . .................... 144
10.7 Take Home Message . . . ...................................... 145
References . . ........................................................ 145
11 Dermatochalasis and Blepharoplasty ............................... 147
11.1 Overview . ................................................... 147
11.2 Examination .. ............................................... 147
11.3 Considerations ............................................... 147
11.4 Upper Lid Skin and Muscle Blepharoplasty (Fig. 11.1) ....... 148
11.4.1 Principle .......................................... 148
11.4.2 Case Selection ..................................... 148
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11.5 Steps ........................................................ 148
11.6 Notes ........................................................ 151
11.7 Take Home Message . . . ...................................... 151
12 Lid Lumps and Bumps ............................................. 153
12.1 Overview . ................................................... 153
12.2 Cysts ........................................................ 153
12.2.1 Meibomian Cyst Incision and Curettage (I & C) . . . . 154
12.3 Tumour Excision (Fig. 12.2) ................................. 155
12.3.1 First is Best .. ...................................... 156
12.3.2 Clear Cutaneous Margins . . ......................... 157
12.3.3 Stretch . . . .......................................... 157
12.3.4 Deep Excision ..................................... 157
12.3.5 Waste Not, Want Not . . ............................. 157
12.3.6 Beware the Canthi (Fig. 12.3) . . .................... 158
12.3.7 Biopsy: Excision V Incision ........................ 158
12.3.8 Histology First! . . . ................................. 158
12.3.9 One Stop Management ............................. 159
12.4 Full Thickness Lid Margin Tumour Resection (Fig. 12.4) . . . . . 159
12.4.1 Considerations ..................................... 160
12.4.2 Steps .............................................. 160
12.5 Take Home Messages . . ...................................... 160
13 Eye Protection ...................................................... 161
13.1 Overview (Fig. 13.1) . . . ...................................... 161
13.2 Occlusive Dressing .......................................... 162
13.3 Manual Blink (Fig. 13.2) . . . ................................. 162
13.4 ‘Cling Film’ Occlusion ...................................... 163
13.5 Closing the Eye . . . .......................................... 163
13.5.1 Not the ‘Grey Line’! . . ............................. 163
13.5.2 Avoid Toxin Ptosis ................................. 164
13.5.3 The ‘Tarsal Traction Suture’ (see Chap. 5) .. . ....... 164
13.5.4 Non-tarsal Traction (Fig. 13.5) . .................... 166
13.5.5 Temporary Central Suture Tarsorrhaphy
(Fig. 13.6) . . . ...................................... 167
13.5.6 Temporary Lateral Suture Tarsorrhaphy
(Fig. 13.6e) . . ...................................... 167
13.5.7 Notes .............................................. 169
13.6 Permanent Surgical Tarsorrhaphy . . . ......................... 169
13.6.1 Permanent (Overlap) Lateral Tarsorrhaphy
(Fig. 13.7) . . . ...................................... 169
13.6.2 Permanent Medial Canthoplasty (Fig. 13.8) . . ....... 172
13.6.3 Lower Lid Lifting (Fig. 13.9) . . . .................... 173
13.7 Take Home Message . . . ...................................... 174
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14 Lid Reconstruction ................................................. 175
14.1 Overview . ................................................... 175
14.2 The Reconstruction Ladder (Fig. 14.2) . . . .................... 176
14.3 Upper Lid Essential, Lower Lid Optional! .................... 177
14.4 Proof of Cure . ............................................... 178
14.5 Eyelid Tension: Normal and Necessary . . . .................... 178
14.6 Don’t Undermine . . .......................................... 178
14.7 Direct Closure ............................................... 179
14.7.1 Tissue Expansion (Fig. 14.6) . . . .................... 180
14.7.2 No Cantholysis ..................................... 182
14.7.3 Closure Scar Lengthening . ......................... 182
14.8 Direct Closure of Lid Margin Defect (Fig. 14.8) . . . ........... 183
14.8.1 Principles and Considerations . . .................... 183
14.8.2 Case Selection ..................................... 183
14.8.3 Steps .............................................. 183
14.9 The Trans Incisional Tarsal Traction Suture (Fig. 14.9) ....... 187
14.9.1 Principle and Considerations . . . .................... 187
14.9.2 Steps .............................................. 188
14.10 Direct Closure of a Skin Defect (Fig. 14.10) . ................ 188
14.10.1 Principle and Considerations . . . .................... 188
14.10.2 Case Selection ..................................... 188
14.10.3 Steps .............................................. 189
14.11 Directed Laissez-Faire (Incomplete Direct Closure) ........... 190
14.11.1 Principle and Considerations . . . .................... 190
14.11.2 Directed Laissez-Faire of a Lid Margin Defect
(Fig. 14.11) . . ...................................... 190
14.11.3 Directed Laissez-Faire of Skin Defect
(Fig. 14.12) . . ...................................... 192
14.12 Flaps ........................................................ 194
14.12.1 Paper Templates . . ................................. 195
14.12.2 Upper to Lower Lid Skin Flap (Fig. 14.16) . . ....... 196
14.12.3 Cheek Pedicle Flap (Fig. 14.17) .................... 198
14.12.4 Mustardé Lower Lid Switch Flap . . . ................ 199
14.13 Grafts ....................................................... 204
14.13.1 Skin Graft Donor Sites (Fig. 14.20) . ................ 204
14.13.2 Alternative Sites . . ................................. 205
14.13.3 Skin Graft Harvesting (Fig. 14.21) . . ................ 205
14.13.4 Split Skin Grafts . . ................................. 207
14.13.5 Mucous Membrane Grafts . ......................... 207
14.14 Notes ........................................................ 207
14.15 Take Home Message . . . ...................................... 207
References . . ........................................................ 207
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15 Revision Surgery ................................................... 209
15.1 Overview . ................................................... 209
15.2 Avoid ....................................................... 209
15.3 Healing Shrinks . . . .......................................... 209
15.3.1 Pout ............................................... 210
15.3.2 Planes Contract . . . ................................. 211
15.4 Faces Are Mobile . . .......................................... 211
15.5 Delay (Fig. 15.3) . . .......................................... 211
15.6 Analyse . . ................................................... 212
15.7 Lengthen . ................................................... 212
15.8 Transverse Release-Plasty (Fig. 15.5) ........................ 213
15.8.1 Considerations ..................................... 213
15.8.2 Principle . .......................................... 214
15.8.3 Steps .............................................. 214
15.8.4 Notes .............................................. 215
15.9 Take Home Message . . . ...................................... 215
16 Watering Eyes ...................................................... 217
16.1 Overview . ................................................... 217
16.2 Causes (Fig. 16.1) . .......................................... 217
16.3 Assessment . . . ............................................... 218
16.3.1 History . . .......................................... 218
16.3.2 Examination . ...................................... 219
16.3.3 Tests ............................................... 220
16.3.4 Lacrimal Syringing (Fig. 16.2) . .................... 220
16.3.5 Imaging . . .......................................... 222
16.4 Treatment Options . .......................................... 222
16.4.1 Lacrimal Mucocoele Expression (Fig. 16.3) . . ....... 222
16.4.2 Lacrimal Probing (± Silicone Intubation) ........... 223
16.4.3 Punctal Stenosis . . . ................................. 225
16.4.4 Punctal Inversion Surgery (Fig. 16.8) ............... 228
16.4.5 Lid Margin Tightening ............................. 230
16.4.6 Lacrimal Drainage Surgery ......................... 230
16.5 Take Home Message . . . ...................................... 232
References . ........................................................ 232
17 Eye Removal ........................................................ 233
17.1 Overview . ................................................... 233
17.2 Specific Indications .......................................... 233
17.3 Evisceration V Enucleation . ................................. 234
17.4 Evisceration (Fig. 17.1) ...................................... 234
17.4.1 Principle . .......................................... 234
17.4.2 Steps .............................................. 234
17.5 Enucleation (Fig. 17.2) ...................................... 236
17.5.1 Principle . .......................................... 236
17.5.2 Steps .............................................. 236
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17.5.3 Notes .............................................. 239
17.6 Take Home Message . . . ...................................... 239
18 Socket Reconstruction .............................................. 241
18.1 Overview . ................................................... 241
18.2 Socket Lining ............................................... 241
18.3 Orbital Implantation (Fig. 18.1) . ............................. 242
18.3.1 Implant Considerations ............................. 242
18.3.2 Implant Material and Shape ........................ 244
18.3.3 Implantation Following Evisceration (Fig. 18.4) . . . . . 244
18.3.4 Implantation Following Enucleation (Fig. 18.5) . . . . . 246
18.4 Orbital Implant Complications . . ............................. 247
18.4.1 Conjunctival Cysts ................................. 247
18.4.2 Early or Late Wound Dehiscence . . . ................ 249
18.4.3 Implant Migration . ................................. 249
18.4.4 Late Implant Exposure ............................. 250
18.4.5 Post Enucleation Socket Syndrome (Fig. 18.7) ...... 251
18.4.6 Lower Lid Laxity . ................................. 252
18.4.7 Upper Lid Ptosis . . ................................. 252
18.5 Take Home Message . . . ...................................... 252
Reference . . . ........................................................ 252
19 Thyroid Eye Disease ................................................ 253
19.1 Overview (Fig. 19.1) . . . ...................................... 253
19.2 Wet or Dry? . . ............................................... 254
19.3 Immunosuppression of Active TED . ......................... 255
19.3.1 Steroids . . .......................................... 255
19.4 Orbital Triamcinolone Injection [2] . ......................... 256
19.4.1 Case Selection ..................................... 256
19.4.2 Protocol . .......................................... 256
19.4.3 Steps .............................................. 256
19.4.4 Notes .............................................. 257
19.5 Surgical Management of Inactive (Dry) Thyroid Eye
Disease ...................................................... 257
19.5.1 Tips ............................................... 258
19.5.2 Inferior Rectus Recession with Lid Retractor
Recession (Fig. 19.3) . . ............................. 258
19.5.3 Eyelid Recession . . ................................. 264
19.6 Upper Lid Blepharotomy [3] ................................. 265
19.6.1 Case Selection ..................................... 265
19.6.2 Steps (Fig. 19.7) . . ................................. 266
19.6.3 Note ............................................... 267
19.7 No Spacers .. . ............................................... 267
19.8 Lower Lid Retractor Recession . ............................. 267
19.8.1 Considerations and Principle . . . .................... 267
19.8.2 Case Selection ..................................... 268
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19.8.3 Steps .............................................. 268
19.8.4 Note ............................................... 270
19.9 Take Home Message . . . ...................................... 270
References . . ........................................................ 270
20 Conclusion .......................................................... 271
Introduction
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1.1 Overview
•
Is this book for you?
•
This book’s philosophy and style.
1.2 Congratulations
Congratulations on choosing the eyelids as your surgical field! Being functional as
well as aesthetic units, you should find them an absorbing challenge. In terms of
healing, there is no better or more forgiving part of the body, unlike for example
an elderly shin. Consequently, your repairs and grafts should invariably heal well.
However, the outcomes of your endeavours will be very visible (‘in your face’
as they say), so you’d better get them right the first time! I hope that the tips
contained in the following pages help you in this respect.
1
1.3 The Target (Fig. 1.1)
This book is a practical manual for anyone performing eyelid surgery. It is particularly aimed at those in training, including non-oculoplastic surgeons who venture
into this field. Experienced colleagues may find some of the content unconventional (to put it kindly). Please indulge me by not dismissing my novel ideas
and assertions out of hand. Instead, give them your critical consideration, perhaps
even try them out? You might be pleasantly surprised. Dear reader, if you have an
interest in eyelid surgery and an open mind, please read on!
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Tha l l er, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_1
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