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44 4 Pertinent Anatomy
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a
b
Levator aponeurosis
Müller’s muscle
Capsulo-palpaebral
aponeurosis
Levator aponeurosis
Levator Palpaebri
Superioris
Müller’s
muscle
Fig.4.10 Lid retractors. a Anterior view of the retractor aponeuroses. b Lateral view showing the
relationships of Müller’s muscle to levator, and the capsulo-palpaebral aponeurosis to the inferior
rectus
The shared oculomotor innervation of the eyelid and eye is important for lifting
the upper lid in up-gaze and retracting the lower lid in downgaze.
Inferior Rectus
Capsulo-palpaebral aponeurosis
4.14 Take Home Message 45
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4.13 The Rest
This simplified account of the anatomy misses out a lot. The lacrimal gland and
drainage apparatus are mentioned in Chap. 16. Whitnall’s ligament is of note. It is a
strong fibrous band that runs from the trochlea, where it is narrow, over the surface
of the levator aponeurosis, widening as it inserts into the peri-lacrimal fascia. The
novice is only likely to encounter it when converting a white line advancement
ptosis correction to a levator resection (see Chap. 10).
4.14 Take Home Message
•
The tarsal plate and the pre-aponeurotic fat pads are constant anatomical
landmarks.
•
The orbital septum is a multi-layered structure.
Fundamental Procedures
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Fig. 5.1 Fundamentals
5
5.1 Overview (Fig. 5.1)
•
Lid margin repair
•
Lateral canthal repair
•
The magic suture
•
The tarsal traction suture
•
Emergency canthotomy
Most lid operations are made up of a combination of basic surgical blocks. The
first four techniques listed are integral to many procedures; hence I consider them
to be fundamental. The last, emergency canthotomy, though rarely needed can be
sight saving.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_5
47
48 5 Fundamental Procedures
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5.2 Lid Margin Repair (Fig. 5.2)
Lid margin repair forms part of entropion and ectropion correction, tumour resection and laceration repair. This technique uses absorbable sutures which only
require removal should they loosen and irritate. It works equally well for surgical resections as for traumatic lid lacerations. The same technique, with minor
modification, works at the lateral canthus.
a b
c d
e
Fig. 5.2 Eyelid margin repair. a Turn the wound edge out. b View the cut surface end on to place
the suture. c Push the skin and orbicularis back with the flat of the needle to enters the anterior tarsal
plate surface. d Advance the needle to emerge on the cut surface of the tarsal plate. e Place 3 tarsal
sutures. f Clip the paired suture ends together. g Enter the wound edge through the orbicularis with
a 7/0 suture and rotate the needle to emerge from the lash line. h Re-enter the lid margin through
the meibomian orifice line on the same side to exit the cut tarsal plate surface close to the margin.
i With the same needle re-enter the far side similarly. j Put a loose single throw on this suture and
clip the untied suture ends together. k Tie and cut the preplaced tarsal sutures in reverse order of
placement. l Tighten and tie the pre-placed lid margin mattress suture. m Confirm that it causes the
lid margin join to pout. n Repair the remainder of the skin wound
f
5.2 Lid Margin Repair (Fig. 5.2)49
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g h
i j
k l
m n
Fig. 5.2 (continued)
5.2.1 Considerations
As the tarsal plate forms the skeleton of the lid it is the most important lid margin
structure needing repair.
Ensure that the lid margin union pouts by the end of the repair or a notch will
later form through scar contraction.
50 5 Fundamental Procedures
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5.2.2 Principle
•
Accurately align the two sides.
•
Pre-place all the tarsal plate and lid margin sutures before tying any.
•
Place them so that they are unable to irritate the cornea once tied and cut.
•
Always tie the tarsal suture furthest from the margin first to take the tension.
This makes it easier to subsequently tie the more important marginal sutures
tightly without slippage.
•
Use a buried lid margin mattress suture to make the lid margin pout.
5.2.3 Steps
1. Insert a 6/0 absorbable suture, mounted on an 8 mm spatula, ½ circle needle,
through the tarsal plate on either side to span the wound. Place it as close to
the lid margin as possible. Take particular care to align the suture bites on each
side to avoid creating a step in the margin.
a. Grasp the full thickness of the lid ‘sandwich’ perpendicularly to the mar-
gin, about 2–3 mm from the cut edge, with toothed forceps. Turn this edge
outwards to improve visibility and access (Fig. 5.2a and b).
b. Use the flat surface of the suture needle to push the skin and orbicularis
to the side, so that the needle tip enters the anterior tarsal plate surface
perpendicularly, about 1–1½ mm from the tarsal plate edge (Fig. 5.2c).
c. As soon as the needle tip engages the tarsal plate rotate and advance the
needle so that it emerges close to the conjunctival surface on the cut surface
of the tarsal plate, i.e., after engaging almost the full tarsal plate thickness.
Do not penetrate the conjunctiva. This is particularly important for upper lid
repairs.
d. Retrieve and remount the needle from this first bite and grasp the far side of
the lid margin with tissue forceps, as in step 1a.
e. Insert the needle into the cut surface of the tarsal plate close to its conjunc-
tival surface. Take special care to place this bite at the same distance from
the lid margin as the first bite (Fig. 5.2d).
f. As soon as the needle tip engages tarsal plate rotate and advance the needle
so that it emerges on the anterior surface of the tarsal plate 1–1½ mm from
the wound edge. Avoid engaging the orbicularis and skin. If you do, lift
them off your needle tip.
g. Clip the two untied suture ends together with a bulldog clip and retract them.
2. In the lower lid, place 2 further sutures below the first one in a similar fashion,
spacing them about 1 mm apart (Fig. 5.2e). In the upper lid, which has a wider
tarsal plate, 3 or 4 additional sutures may be required. Again, clip each pair of
untied suture ends together to aid later identification when tying (Fig. 5.2f).
51
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3. Preplace a lid margin horizontal mattress 7/0 absorbable suture so that its knot
will become buried in the lash line. This configuration will cause the lid margin
repair to pout as intended when you eventually tie this suture.
a. With the needle enter the wound edge through the orbicularis, just anterior
to the tarsal plate surface. Rotate the needle so that it emerges from the
skin within the lash line, 1½ mm from the wound edge, having engaged the
orbicularis and skin (Fig. 5.2g).
b. With the same needle re-enter the lid margin perpendicularly through the
meibomian orifice line on the same side (Fig. 5.2h). Rotate and advance the
needle to exit the cut tarsal plate surface close to the margin. Take special
care not to engage accidentally the first preplaced tarsal plate suture from
step 1, as this would prevent it from being tightened when tying.
c. With the same needle enter the far tarsal cut edge perpendicularly and bring
the needle tip out through the meibomian orifice line. Take special care not
to engage accidentally the first preplaced tarsal plate suture from step 1.
d. With the same needle re-enter the lid margin perpendicularly through the
lash line and bring it out through the cut edge of orbicularis (Fig. 5.2i).
e. Put a loose single throw on this suture and clip the untied suture ends
together out of the way (Fig. 5.2j).
4. Now tie firmly and cut the preplaced tarsal sutures in reverse order of place-
ment, i.e., starting with the one furthest from the lid margin (Fig. 5.2k). Once
tied, this first suture takes up most of the wound tension. This makes tying the
remaining tarsal plate sutures easy and their first throws unlikely to slip. By the
end of this step the lid margin wound should be accurately and securely closed.
5. Tighten and tie the pre-placed lid margin mattress suture (Fig. 5.2l). Confirm
that it causes the lid margin join to pout (Fig. 5.2m). Cut its ends short enough
for them to retract into the wound anterior to the tarsal plate (away from the
cornea).
6. Repair the remainder of the skin wound with interrupted 6/0 or 7/0 absorbable
sutures which incorporate the underlying orbicularis into each bite, (Fig. 5.2n)
or suture the orbicularis first, as a separate layer with a ‘magic suture’ (see
below).
5.2.4 Notes
An accurately repaired lid margin will not leave a noticeable scar, notch, or lash
line gap.
52 5 Fundamental Procedures
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a b
c d
e f
g h
Fig. 5.3 Lateral canthal repair. a Grasp the lateral canthal tendon with toothed forceps performing
the ‘tug test’. b Place a 6/0 absorbable suture, through the tendon. c Place a second, double armed
suture in a similar fashion slightly below the first. d Insert the first pair of needles into the tarsal
plate. e Place the second pair of sutures similarly, 1 mm below the first pair. f Preplace a lid margin
horizontal mattress 7/0 absorbable suture so that its knot will become buried in the lash line at the
lateral canthus. g With the same needle enter the canthal tendon/tarsal junction of the opposing lid.
h Put a loose single throw on this suture. i Tie and cut the two preplaced tarsal mattress sutures in
reverse order of placement. j Tighten and tie the pre-placed lateral canthal margin mattress suture.
k Repair the remainder of the skin wound with interrupted 6/0 or 7/0 absorbable sutures
5.3 Lateral Canthal Repair (Fig. 5.3)53
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i
k
Fig. 5.3 (continued)
j
5.3 Lateral Canthal Repair (Fig. 5.3)
5.3.1 Considerations
The lateral canthal angle is formed by the pull of the lateral canthal tendon (LCT).
If the LCT is damaged, repair it. Should that not be possible use an alternative
lateral fixation point such as the orbital rim periosteum or insert a self-tapping bone
screw from which to anchor your suture. Eyelid incisions at the lateral canthus heal
aesthetically without a visible notch.
5.3.2 Principle
This is a modification of the lid margin repair described above. As there is no
lateral tarsal plate, strong fixation relies on suturing to the canthal tendon. A single
horizontal mattress suture is sufficient, but I recommend using two, as a failsafe.
5.3.3 Steps
1. Grasp the presumed lateral canthal tendon with toothed forceps in the lateral
wound edge (Fig. 5.3a). The tendon can be difficult to see, especially if the
lateral palpaebral artery is bleeding. Ask an assistant to pull the lateral canthal
tissues apart to improve visualization. Positively identify that what you are
holding is tendon by performing the ‘tug test’. Tug firmly on the tissue you
54 5 Fundamental Procedures
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are holding. A tendon resists such tugs without any ‘give’, what we might call
‘a hard stop’. If the resistance to your tug is ‘softer’ you are not holding the
tendon. Re-grip presumed canthal tendon and repeat the tug test until you are
certain that you are holding the tendon.
2. Without releasing your grip, place a double armed 6/0 absorbable suture,
mounted on an 8 mm spatula, ½ circle needle, through the tendon. Follow
this with a second, locking, pass, and clip the suture ends together (Fig. 5.3b).
3. Place a second, double armed suture in a similar fashion slightly below the first
(Fig. 5.3c).
4. Insert the first pair of needles into the tarsal plate (Fig. 5.3d), either transcon-
junctivally or through its cut edge, the former being easier.
Note: Normally we avoid breaching the conjunctiva with an abrasive suture, but
at the lateral canthus the chance of the suture irritating the cornea is remote and
it quickly migrates subconjunctivally.
Place the first bite close to the lid margin so that it emerges on the anterior
surface of the tarsal plate 1½ mm from the wound edge. Avoid engaging the
orbicularis and skin. Place the second needle similarly but 1 mm below the
first. Clip the two untied suture ends together with a bulldog clip and retract
them.
5. Place the second pair of sutures similarly, 1 mm below the first pair (Fig. 5.3e).
Clip the untied suture ends together.
6. Preplace a lid margin horizontal mattress 7/0 absorbable suture so that its knot
will become buried in the lash line at the lateral canthus. This configuration
will cause the lateral canthal margin to pout when this suture is eventually tied.
a. With the needle enter the wound edge through the orbicularis, just anterior
to the tarsal plate surface and rotate the needle so that it emerges from the
skin within the lash line, 1½ mm from the wound edge after engaging the
orbicularis and skin.
b. With the same needle re-enter the lid margin perpendicularly through the
meibomian orifice line on the same side (Fig. 5.3f). emerging on the cut
tarsal plate surface close to the margin.
Note: Take special care not to accidentally engage the first preplaced tarsal
plate suture from step 4, as this would prevent it from being tightened.
c. With the same needle enter the canthal tendon/tarsal junction of the opposing
lid (Fig. 5.3g). Bring the needle tip out through the meibomian orifice line.
d. With the same needle re-enter the lid margin perpendicularly through the
lash line and bring it out through the cut edge of the orbicularis at the lateral
canthus.
e. Put a loose single throw on this suture and clip the untied suture ends
together out of the way (Fig. 5.3h).
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