Aesthetic and Reconstructive Eyelid Surgery

Question 1

What makes up the anterior, middle, and posterior lamellae of the eyelid?

Answer 1

The three lamellae or “layers” of the eyelid are anatomical divisions that help with the understanding of lid function and lid surgery.
The anterior lamella is defined as the skin and underlying orbicularis muscle.
The middle lamella is the orbital septum and accompanying fatty pads.
The posterior lamella is the conjunctiva and levator apparatus and corresponding lower lid retractors.

Question 2

Describe the surface anatomy findings of the aged eyelid and the underlying structures responsible.

Answer 2

Four key features are apparent on the surface examination of the aged eyelid: contour irregularities, the lid crease,
lid position, and rhytids.
Contour irregularities that are often apparent are because of protruding periorbital fat pads; principally the medial upper fat pad and the lower lid fat pads.
An elevated lid crease represents stretch or dehiscence of the levator apparatus from the tarsal plate and is often a tell-tale sign of lid ptosis.
Lower lid position that is descended away from the corneoscleral limbus is indicative of lower lid laxity and poor canthal support. Often a negative canthal tilt (downward slope of a line drawn from the medial canthus to the lateral canthus) and scleral show (a viewable strip of white sclera between the lower corneoscleral limbus and lid border) are present as well. Upper lid position that encroaches on the upper corneoscleral limbus raises suspicion that ptosis is present.
Brow strain and horizontal forehead rhytids often accompany lid ptosis and dermatochalasis.

Question 3

What are the analogous structures in the upper and lower eyelid?

Answer 3

The levator aponeurosis is specific to the upper eyelid and is analogous to the capsulopalpebral fascia of the lower lid.

Question 4

Describe the anatomy of the orbicularis oculi muscle.

Answer 4

The orbicularis oculi muscle is a complex array of concentrically oriented muscles with origins medial to the medial canthus and insertions lateral to the lateral canthus. Further differentiation is made based on the location relative to the underlying lid structures; oriented in a concentric manner from outside to in they are the orbital orbicularis, preseptal orbicularis, and pretarsal orbicularis. Further divisions (based on function and innervation) can be made, principally the inner canthal orbicularis and the extracanthal orbicularis.

Question 5

Describe the functional role of the orbicularis muscle.

Answer 5

The orbicularis muscle is responsible for eyelid closure (both passive blink and active squint), corneal protection, and lubrication, and as a pump of the lacrimal sac. The inner canthal orbicularis (that orbicularis which resides within 1 cm of the medial canthus) is responsible for passive involuntary blink; the extracanthal orbicularis (that orbicularis which resides outside the inner canthal portion) is responsible for voluntary protective forceful blinking.

Question 6

Describe the location and function of the lacrimal sac.

Answer 6

The lacrimal sac resides lateral and posterior to the base of the nasal sidewall within the lacrimal crest. The upper portion of the sac is wrapped on its anterior and posterior aspects by the anterior and posterior medial heads of the orbicularis muscle, hence the muscle’s pump action on it. The lacrimal system is a conduit for the passage of tears from the eye (exiting via the upper and lower canalicular systems) into the nasal sinus. Obstruction within this low-pressure system can result in epiphora (excess tearing) or mucocele.

Question 7

What is Whitnall’s tubercle?

Answer 7

Whitnall’s tubercle is minor bony spur on the inner aspect of the lateral orbital rim that represents the bony
insertion point of the lateral canthal tendon.

Question 8

What nearby anatomic structure helps locate Whitnall’s tubercle?

Answer 8

Eisler fat pad is a minor fat pad located superficial to and immediately above Whitnall tubercle immediately under
the orbital septum. Identifying Eisler fat pad is one method of locating the insertion of the lateral canthal tendon.

Question 9

What is Bell phenomenon?

Answer 9

This is the reflex upward rotation of the globe during lid closure. This acts as a further protective mechanism of the
cornea. It is present in most patients but not in all.

Question 10

How many fatty compartments are there in the upper eyelid? Describe them. How can they be told apart?

Answer 10

There are two separate fatty pads in the upper eyelid, the nasal or medial pad and the central pad. Both reside directly under the orbital septum and superficial to the levator apparatus. The medial fatty pad is located above the medial canthus and can be identified by its whitish-yellow color. The central fatty pad is more centrally located approximating the level of the medial corneoscleral limbus and is deeper yellow in color.

Question 11

How many fatty compartments are there in the lower eyelid? How can they be told apart?

Answer 11

In contrast to the upper eyelid, the lower eyelid has three fatty compartments; the nasal (or medial), central, and
lateral fatty pads. Similarly, the medial fatty pad is more whitish-yellow in color and the other two are deeper yellow.

Question 12

What structure divides the medial from the central fatty pad in the lower eyelid?

Answer 12

The inferior oblique muscle divides the medial from the central fatty pad in the lower eyelid. It is because of this location that it is at high risk for injury during lower lid procedures. Extreme caution should be exercised when manipulating the central or medial fatty pads to avoid injury to this extraocular muscle.

Question 13

What is the most commonly injured muscle in upper lid blepharoplasty?

Answer 13

The superior oblique. It resides deep and medial to the medial fat pad.

Question 14

Describe the innervation of the orbicularis muscle.

Answer 14

The differing function of the orbicularis is based on its anatomic location and is reflected in its differing nerve input.
The extracanthal orbicularis muscle is primarily responsible for purposeful, voluntary, and forceful lid closure. This portion of the muscle is innervated by branches of the frontal and zygomatic branches of the facial nerve.
The inner canthal orbicularis (that portion of the muscle in proximity to the medial canthus) is responsible for involuntary lid closure and blinking. This muscle is primarily driven by buccal branch innervation. Injury to the buccal branch or inner canthal orbicularis can severely affect proper lid function and corneal lubrication and protection. The extracanthal orbicularis is more expendable.

Question 15

What is the difference between blepharochalasis and dermatochalasis?

Answer 15

Blepharochalasis is characterized by intermittent inflammation of the eyelid with exacerbations and remissions of eyelid edema. This process results in a stretching and subsequent atrophy of the eyelid tissue and over time recurrent episodes and aged appearance. There is typically no associated pain or erythema and it primarily affects young women. Dermatochalasis is defined as an excess of skin of the eyelids that is congenital or age related.

Question 16

What are three common presenting findings in upper lid ptosis?

Answer 16

Depressed lid position, brow strain, and a high-riding lid crease.

Question 17

What are the degrees of levator function?

Answer 17

Levator function is expressed as the distance between excursion of upper lid margin from full down gaze to full up gaze without brow movement. Excellent (>10 mm), good (8–10 mm), fair (5–7 mm), or poor (1–4 mm). The proper procedure for ptosis repair is often based on levator function.

Question 18

What are the common methods of ptosis repair?

Answer 18

Fasanella-Servat procedure is an example of a transconjunctival approach to ptosis repair. Levator advancement is an example of open transcutaneous ptosis repair. Lid suspension to the brow with either fascia or a silicone sling is an example of a procedure used for severe ptosis with minimal levator function.

Question 19

What are the differences between the Asian eyelid and the Occidental eyelid?

Answer 19

Asian eyelids are marked by the presence of epicanthal folds and lack of pretarsal show. The lid crease is significantly lower relative to the ciliary margin than that of Caucasian eyelids (4–6 mm compared with 8–10 mm). The insertion of the orbital septum relative to the tarsus is lower in Asian eyelids, thus periorbital fat is typically seen lower in the eyelid and closer to the lid crease compared with Caucasians. The Asian lid crease may or may not obscure the medial canthus.

Question 20

What are the goals of Asian eyelid surgery?

Answer 20

The “double eyelid surgery” focuses on establishing a modicum of visible pretarsal lid and developing a lid fold that is seen separately from the lid margin, preserving the epicanthal fold. Incisions are made within the lid at the desired level of fold creation, excess fat is removed, and fixation sutures are placed to control the height of the lid crease. It is critical to maintain a low lid crease and the epicanthal fold, lest a Caucasian eyelid result occurs.

Question 21

What are the surgical options for minimal upper lid ptosis repair with good levator function?

Answer 21

For minimal ptosis, Mu ̈eller muscle conjunctival resection or the Fasanella-Servat procedure is proposed.

Question 22

What are the options for moderate ptosis with fair levator function?

Answer 22

Shortening of the levator palpebrae or levator muscle advancement is proposed.

Question 23

What is the treatment for severe ptosis with poor levator function?

Answer 23

For severe ptosis with a levator function <5 mm, a brow/frontalis suspension is indicated.

Question 24

What are the fundamental dictums of eyelid reconstruction?

Answer 24

Reconstruction of any lid defect must take into account lining, support, and coverage. Lining refers to the conjunctiva that will protect the cornea, support refers to the rigid tarsus and lateral canthal tendon, and coverage is the skin and muscle that cover everything. Basically, the three lamellar layers of the eyelid are considered and each one must be accounted for in the reconstruction.

Question 25

How are lid defects of less than 25% of the total lid width repaired?

Answer 25

In general, upper and lower eyelid defects that are less than 25% the total width of the lid can be repaired by primary closure. It is important that portion of the defect that contains the tarsal plate be made at a right angle relative to the ciliary margin. This will facilitate a closure that minimizes any contour irregularity or notching along the lid margin. The remaining portion of the defect outside the tarsus is managed based on the presentation. In cases with poor lower lid laxity consideration must be given to a concomitant lid support procedure such as a canthopexy or canthoplasty.

Question 26

How are lid defects between 25% and 50% of the total lid width repaired?

Answer 26

Lid defects between 25% and 50% the total length of the lid must incorporate the import or rotation of new tissue for reconstruction. Primary lid closure is not feasible in these situations. An assessment must be made as to whether the defect is “shallow and wide” or “deep and narrow.” Shallow and wide defects of the lower eyelid can often be repaired by recruitment of lower eyelid and midface tissue, similar to vertical vector aesthetic lower lid procedures. Deep and narrow defects of the lower eyelid will require rotation and advancement of laterally based tissue. For the lower eyelid, a Tenzel flap, a laterally based rotation advancement flap, is commonly used. Lateral canthal support must be performed as well. A common flap for the upper eyelid is the Tripier flap, an axially based upper eyelid myocutaneous flap.

Question 27

How are lid defects that are greater than 50% of total lid length repaired?

Answer 27

Shallow and wide defects of the lower eyelid may still be reconstructed with midface advancement although a cartilage graft is often needed to reconstruct the tarsal plate. Lateral canthal support must also be performed with intact tissue or imported tissue in the form of the graft or local tissue such as a turn over temporal fascial flap or turn over lateral orbital wall periosteal flap. Total eyelid reconstruction requires a “lid-sharing” technique; a Hewes flap (from the upper lid) to reconstruct the lower eyelid or a Cutler-Beard flap (from the lower eyelid) to reconstruct the upper eyelid.

Question 28

What is a Hewes flap? What is a Hughes flap?

Answer 28

These are both conjunctival lid-sharing flaps from the upper eyelid that include a portion of the tarsal plate. These flaps are best for wide and deep lower lid defects, typically greater than 5 mm in height. The Hewes flap preserves an attachment to the lateral canthal tendon when needed for lower lid reconstruction (best for defects that include the lateral aspect of the lower lid); the Hughes flap does not, it is purely the tarsus and the conjunctiva, no canthal tendon. (A helpful way to differentiate the two, Hewes with an “e” like tendon with an “e.”) These flaps are maintained on their upper lid pedicle for 4 to 6 weeks before separation and inset. Both of these flaps will require some sort of coverage by either a rotational flap or a skin graft.

Question 29

What is a Cutler-Beard flap?

Answer 29

This is a full-thickness flap of skin, muscle, conjunctiva, and/or cartilage from the lower lid used to reconstruct large full-thickness upper lid defects. This lid-sharing flap is maintained on its lower lid pedicle for 4 to 6 weeks before separation and inset.

Question 30

What is a Mustarde ́ flap?

Answer 30

This is medially based facial flap utilized for very large lower lid and malar defects that cannot be reconstructed with the above-listed techniques. A Mustarde ́ flap is a large rotation advancement flap made up of the entire cheek and lower face. The releasing incision is made over the zygomatic arch, continues caudally in front of the ear, and extends down into the neck where the back cut is made.

Question 31

What is an “A-frame” deformity?

Answer 31

The A-frame deformity can be the result of aging or aggressive periorbital fat removal in the upper eyelid. The youthful upper eyelid has a smooth arched contour. The A-frame deformity is a peak-shaped depression of the medial portion of the upper eyelid similar to an A-frame, or two segments meeting at a right angle, thus disrupting the smooth arch. Hollowing of the upper eyelid from age-related fat atrophy or overresection of the medial aspect of the central fat pad can lead to an A-frame deformity.

Question 32

Describe the anatomic features that make up the upper lid crease.

Answer 32

The upper lid crease is a result of the dermal insertion of the tarso-levator muscle as it terminates and inserts onto the tarsal plate. Fibers extend from the upper aspect of the tarsal plate, penetrate the pretarsal orbicularis, and terminate on the dermis of the eyelid skin. The location of these fibers extending into the dermis determines the location of the lid crease.

Question 33

How are the central and medial fatty pads of the upper lid identified?

Answer 33

The central and medial fatty pads of the upper eyelid reside deep to the orbital septum. Interpad septae separate the two and they differ in color, the medial fatty pad is a pale whitish-yellow and the central fat pad is straw yellow in color.

Question 34

What is the open sky technique in upper lid blepharoplasty?

Answer 34

This describes a method of upper lid blepharoplasty that removes excess skin, muscle, and orbital septum en bloc.

Question 35

Describe the general principles behind upper lid markings for blepharoplasty.

Answer 35

Markings on the upper eyelid should be made prior to the skin incision. In general, markings are made to preserve the upper lid crease and levator attachments to the dermis, preserve adequate skin for eyelid closure, and maintain a smooth fold arch. The actual amount of skin and muscle removed from each lid may differ based on patient presentation so it is important to remember that markings are often based on what skin is left behind rather than what skin is removed.

Question 36

Can an upper lid blepharoplasty and a ptosis repair be done at the same time?

Answer 36

Yes, this is considered a transcutaneous ptosis repair. After the removal of the excess skin and muscle, the tarsal plate
and levator muscle can be readily exposed and repaired by tarso-levator advancement.

Question 37

What is lagophthalmos and how is it avoided during blepharoplasty?

Answer 37

Lagophthalmos is an inability to close the eyelid fully. This increases the risk of corneal exposure and damage.
There are three main causes associated with eyelid surgery:
1. excessive upper lid skin removal
2. injury to the buccal branch of the facial nerve that innervates the inner canthal orbicularis muscle responsible for blinking
3. poor lateral canthal support resulting in fish mouth eyelid closure
These complications are avoided by:
1. careful measurement of upper eyelid markings prior to resection and preserving a critical amount of upper lid skin
2. avoiding dissection within the soft tissues of the lower lid medial to the level of the medial corneoscleral limbus
3. performing canthoplasty/pexy and proper lateral canthal support in open lower lid procedures

Question 38

Can a protruding upper medial fatty pad be treated without incising the lid skin?

Answer 38

Yes, by performing a transconjunctival upper lid blepharoplasty. This technique accesses the upper medial fat pad through an upper lid conjunctival incision above and medial to the medial horn of the tarsal plate. This procedure is indicated in the patient without upper lid skin excess but a bulging medial fat pad.

Question 39

What type of patient will get the best result from a transconjunctival lower lid blepharoplasty?

Answer 39

Transconjunctival lower lid blepharoplasty addresses excess periorbital fat by means of fat resection or fat redraping. The best candidates to have only their fat addressed are typically younger patients who have fat protrusion with normal skin tone and minimal wrinkles, and normal lid tone and lid position.

Question 40

What layers in what order are transected during a transconjunctival lower lid blepharoplasty in order to reach the orbital fat?

Answer 40

Beginning from the conjunctiva the layers are as follows: lid conjunctiva, capsulopalpebral fascia, and orbital septum. The preseptal approach is preferred as more precise fat resection can be performed and the fat does not obstruct the view and access to orbital rim. In the direct approach, the capsulopalpebral fascia and septum are bypassed and the lower lid retractors are divided to directly access the periorbital fat.

Question 41

What are the benefits of the lower lid transconjunctival approach?

Answer 41

No visible external scar, quick recovery, less risk for complications such as lower lid malposition.

Question 42

What are the limits of the lower lid transconjunctival approach?

Answer 42

Only effective at fat removal or repositioning. Can be a challenging dissection. Will not treat the skin. Access to the
lateral fat pad can be difficult.

Question 43

What are the findings that indicate a lower lid blepharoplasty patient who is at high risk for postoperative lid malposition?

Answer 43

Lower lid laxity (displacement of the lid more than 10 mm from the globe), poor snap test, exophthalmos, prior lid surgery, scleral show, Grave disease, negative vector midface. If these findings are present, canthal anchoring is considered mandatory during lower lid blepharoplasty.

Question 44

What is a skin-muscle flap and how is it developed during a lower lid procedure?

Answer 44

The skin-muscle flap refers to the flap of lower eyelid skin and underlying orbicularis muscle that is elevated to access the orbital septum and orbital fat. The easiest method to dissect and develop the skin muscle flap is through a subciliary lid incision preserving pretarsal orbicularis and staying within the preseptal plane. This dissection can be brought to the level of the orbital septum and further into the midface if indicated. A portion of the skin and muscle is typically resected during lower lid blepharoplasty to achieve an aesthetic result.

Question 45

What is the orbitomalar ligament and what is achieved by releasing it?

Answer 45

The orbitomalar ligament is a dense extension of fibers from the periosteum of the orbital rim that extends to and through the orbicularis muscle and terminates in the dermis of the overlying lid skin. It is the landmark demarcation between the lower lid and the midface. Releasing the orbitomalar ligament enhances lower lid skin and muscle mobility in a cephalad vector, blunts the lid cheek junction, facilitates reduction of malar festoons, accommodates fat redraping, and provides a gateway to the midface.