Eyelid Reconstruction Flashcards
A 70-year-old man has a biopsy-confirmed squamous cell carcinoma of the upper eyelid. Excision of the lesion will produce a full-thickness defect of the central upper eyelid that is 70% of its width. Reconstruction of the defect with which of the following is most appropriate?
A) Cutler-Beard flap
B) Full-thickness skin graft
C) Hughes flap
D) Primary closure
E) Tenzel flap
The correct response is Option A.
The Cutler-Beard flap is the preferred flap for full-thickness defects of the upper eyelid that are greater than 66% of total eyelid width. This technique utilizes a full-thickness eyelid flap from the lower eyelid to provide a wide flap for eye coverage. In the first stage, the flap is raised and advanced into the upper eyelid defect. The flap is then inset, covering the eye. The inferior pedicle is divided in a second stage at 4 to 6 weeks and final flap inset is performed.
The Tenzel semicircular flap is an excellent technique for anterior lamellar defects of the upper or lower lid, but requires a second flap for posterior lamella reconstruction of full-thickness defects and is not generally the preferred technique for a large defect of the upper eyelid.
The Hughes tarsoconjunctival flap is a similar procedure to the Cutler-Beard flap, but is used for lower lid defects.
Full-thickness skin grafting would not restore the posterior lamellar defect, and direct closure would not likely be able to close a 70% defect of the upper eyelid properly.
2018
A 30-year-old man comes to the physician 2 months after sustaining a deep laceration from forehead to cheek with medial canthal degloving in a motor vehicle collision. His initial workup included a CT scan that showed no facial fractures; the laceration was primarily repaired in the emergency department. Today, his vision is the same as his pre-injury vision. Which of the following is the triad of clinical sequelae that this patient is most likely to report today?
A) Exophthalmos, ptosis, and ophthalmoplegia
B) Lagophthalmos, ptosis, and eyes not closing at night
C) Miosis, ptosis, and anhidrosis
D) Strabismus and ptosis that worsen at night
E) Telecanthus, ptosis, and epiphora
The correct response is Option E.
A medial canthal degloving injury may or may not be associated with a naso-orbito-ethmoid fracture. In this scenario, CT scan showed no fractures.
These injuries can present as vertical lacerations from the forehead to the cheek, crossing the medial canthus. They usually present with the triad of telecanthus (from degloving of the medial canthal tendon, usually the posterior limb that is the weakest limb), ptosis (from avulsion or injury to the upper eyelid), and epiphora (from lacrimal or canalicular injuries). One suggested algorithm is to stage the initial repair of the telecanthus and lacrimal/canalicular repair, and then allow 3 to 6 months of healing before a second stage of ptosis repair.
The other choices are not as consistent with medial canthal degloving: miosis, ptosis, and anhidrosis are incorrect, as these are the triad in Horner syndrome. Exophthalmos, ptosis, and ophthalmoplegia may be seen in superior orbital fissure syndrome. Lagophthalmos, ptosis, and eyes not closing at night may be more associated with congenital ptosis. Strabismus and ptosis, which worsen at night, are suggestive of myasthenia gravis.
2017
A 50-year-old woman is evaluated after undergoing Mohs micrographic surgery of the lower eyelid to remove a basal cell carcinoma 2 days ago. On examination, a 65% defect of the lower eyelid involving both the anterior and posterior lamellae is noted. Nether canthi are involved. Which of the following is the most appropriate reconstructive option for this patient?
A) Hughes tarsoconjunctival flap and Tripier lid switch flap
B) Local cheek V-Y advancement flap and buccal mucosal graft
C) Mustardé flap and hard palate mucosal graft
D) Tenzel semicircular flap and periosteal flap
E) Upper eyelid Cutler-Beard flap and buccal mucosal graft
The correct response is Option A.
Eyelid reconstruction is often a challenging endeavor, and depends upon thorough knowledge of the local anatomy, reconstructive options, and extent of resection. Eyelid defects are commonly classified into three categories—less than 25%, 25 to 50%, and greater than 50%—in order to help the surgeon choose the best reconstructive options. Whenever reconstructing an eyelid defect, it is important to identify the structures involved and be sure to reconstruct the lamellae that have been resected. In this patient, there is a defect that involves both the anterior (skin and orbicularis) and posterior (conjunctiva and tarsus) lamellae, and both must be addressed. Of the available options, the only one that appropriately provides the correct amount and quality of anterior and posterior lamellae for a greater than 50% defect is a Hughes tarsoconjunctival flap and Tripier lid switch flap.
A Tenzel semicircular flap would be appropriate for a 50% or less defect of the lower eyelid, but would not be the best option for a 65% defect.
Although a local cheek V-Y advancement flap and a buccal mucosal graft provides both anterior and posterior lamellar reconstruction, a local V-Y advancement flap of the appropriate size would likely create a cosmetically unappealing contour, and using buccal mucosa for the posterior lamella would not provide the amount of support needed for the lower eyelid to prevent ectropion postoperatively.
Although the combination of a Mustardé flap and a hard palate mucosal graft is a possibility because it provides both anterior and posterior lamellar reconstruction, the use of a hard palate mucosal graft would incorporate keratinized epithelium into the reconstruction, and, therefore, would be less desirable than the use of conjunctiva because it can cause corneal irritation.
The Cutler-Beard flap provides both anterior and posterior lamellar reconstruction and, therefore, the buccal mucosal graft is redundant and unnecessary.
2016
A healthy 65-year-old woman is evaluated because of drooping of the upper eyelids. Examination shows high eyelid creases and 3 mm of ptosis. Levator excursion measures 10 mm. Which of the following is most likely to correct the blepharoptosis in this patient?
A) Brow lift surgery
B) Fasanella-Servat procedure
C) Frontalis sling
D) Levator advancement
E) Upper eyelid blepharoplasty
The correct response is Option D.
The patient described has moderate acquired blepharoptosis characterized by a high eyelid crease and 3 mm of ptosis. Her levator palpebrae muscle excursion is excellent (10 mm). The most likely cause is disinsertion of the levator aponeurosis from the tarsal plate due to chronic stretching of the levator muscle or involutional changes associated with aging. Surgical treatment most commonly involves advancing and reattaching the levator muscle to the tarsal plate.
An upper eyelid blepharoplasty alone or with a browlift would not correct the underlying cause of the ptosis.
The Fasanella-Servat (tarsoconjunctival mullerectomy) procedure classically excises a portion of mucosa, Müller’s muscle, and superior tarsus, thereby shortening the posterior lamella. This can address mild ptosis (1 to 2 mm) in a patient with otherwise excellent levator function.
The frontalis sling procedure uses autologous or alloplastic material tunneled from the brow to upper tarsus to accomplish upper eyelid elevation when levator function is poor. The cause of ptosis in these cases is likely congenital.
2016
A 65-year-old woman comes to the office for consultation on blepharoplasty and rhytidectomy. She notes that her eyelid creases are asymmetric, with the right upper crease higher than the left. She also has difficulty seeing out of her right eye when she is tired. She notes that these symptoms have worsened progressively over the past 5 years. She has levator function of 11 mm with the brow and frontalis muscle in neutral position. This patient most likely has which of the following types of ptosis?
A) Involutional
B) Mechanical
C) Myogenic
D) Neurogenic
E) Traumatic
The correct response is Option A.
The most likely diagnosis is involutional or senile ptosis. In evaluating a patient requesting a blepharoplasty, one must also evaluate for blepharoptosis. If a blepharoplasty is performed without correction of ptosis, the patient will have continuing ptosis and potentially be dissatisfied.
The most common type of blepharoptosis is involutional or senile ptosis. A thorough history and physical examination should assess ophthalmologic and neurologic causes. On physical examination, there is a characteristic high skin crease (greater than 7 mm), thinned upper eyelid, and lid drop on downward gaze. The levator function (amount of lid excursion with the brow and frontalis muscle held in neutral position) should be assessed. Normal function is greater than 10 mm, moderate function is 5 to 10 mm, and poor function is less than 5 mm.
The etiology of ptosis can be classified into neurogenic (oculomotor nerve palsy, Horner syndrome, Marcus Gunn jaw-winking syndrome), myogenic (myasthenia gravis, myotonic dystrophy, mitochondriopathy), mechanical (edema or tumors), traumatic (birth trauma, muscle or nerve damage), congenital, or neurotoxic (such as in envenomation, snake bites, or botulism). None of these are likely, considering this patient’s history and physical examination.
2015
A 60-year-old man undergoes Mohs micrographic resection of an upper eyelid squamous cell carcinoma. A photograph is shown. Which of the following reconstruction procedures will provide the most functional and aesthetically pleasing result in this patient?
A) Free nasoseptal grafting
B) Reconstruction with a forehead flap
C) Reconstruction with a free flap
D) Reconstruction with a glabellar flap
E) Reconstruction with a lid switch flap
The correct response is Option E.
A Cutler-Beard flap is a two-stage lid switch flap, taken from the lower lid.
Some of its disadvantages include two-stage reconstruction requiring eye occlusion for a number of weeks, sacrifice of lower lid tissue (and, commonly, a subsequent ectopion), and lack of intrinsic support. Many modifications have improved on its design including those that provide support. There are many reports of other types of flaps, but for a defect of this size and the anatomic requirements, the best choice is a lid switch flap.
A 50-year-old woman comes to the office 2 weeks after receiving botulinum toxin type A injections for forehead rhytids. She is pleased with the results but has developed unilateral eyelid ptosis. Apraclonidine 0.5% eyedrops are prescribed to improve upper eyelid function. Which of the following best describes the mechanism for improvement of upper eyelid ptosis in this patient?
A) Alpha-2 adrenergic stimulation of the Müller muscle of the upper eyelid
B) Beta-2 adrenergic stimulation of the levator palpebrae superioris
C) Muscarinic parasympathetic inhibition of the levator palpebrae superioris
D) Nicotinic parasympathetic inhibition of the Müller muscle of the upper eyelid
The correct response is Option A.
Apraclonidine is an alpha-2 receptor agonist and is believed to increase muscle tone of the sympathetically innervated Müller muscle located in the upper eyelid.
Beta-2 adrenergic stimulation of the levator palpebrae superioris is not appropriate because apraclonidine does not act as the beta-2 receptor, and it is not believed to stimulate contraction of the levator palpebrae superioris.
Muscarinic parasympathetic inhibition of the levator palpebrae superioris is not appropriate because apraclonidine does not act as the muscarinic parasympathetic receptor.
Nicotinic parasympathetic inhibition of the Müller muscle of the upper eyelid is not appropriate because apraclonidine does not act as the nicotinic parasympathetic receptor.
2015
A 49-year-old woman is evaluated because of a traumatic laceration of the right lower eyelid and cheek. Physical examination shows difficulty with eyelid closure, voluntary squinting, and animation. Which of the following branches of the facial nerve is most likely injured?
A) Buccal
B) Cervical
C) Marginal mandibular
D) Temporal
E) Zygomatic
The correct response is Option E.
Anatomically, the orbicularis oculi muscle is divided into three segments: pretarsal, preseptal, and orbital. However, functionally, the orbicularis oculi muscle is divided into the medial inner canthal orbicularis and the extracanthal orbicularis. The medial inner canthal orbicularis is responsible for blinking, lower lid tone, and the pumping mechanism of the lacrimal system. Innervation to the inner canthal orbicularis is from the buccal branches of the facial nerve. The zygomatic branch of the facial nerve innervates the extracanthal orbicularis, which controls eyelid closure, voluntary squinting, and animation. The temporal, marginal mandibular, and cervical branches do not provide innervation to the orbicularis oculi muscle.
2015
A 65-year-old woman has inadequate tear secretion because of a poorly functioning lacrimal gland. Which of the following aspects of this patient’s tear film is most likely to be affected?
A) The amount of lipid in the tear film
B) The amount of mucin in the tear film
C) The antimicrobial property of the tear film
D) The degree of evaporation of the tear film
E) The dispersion of the tear film
The correct response is Option C.
Tears are a trilaminar fluid. The precorneal layer is formed by mucin-secreting goblet cells in the conjunctiva. This inner layer of the tear film covers the cornea and promotes the dispersion of the overlying aqueous layer. The meibomian glands produce the outer lipid layer. This oil layer helps to prevent the evaporation of the tear film.
The lacrimal gland secretes the middle layer. This aqueous layer is made of water and proteins. This layer promotes osmotic regulation and the control of infectious agents. As a result, dysfunction can result in dryness and an increase in infections.
2015
A 65-year-old woman desires correction of her “sleepy eyes.” Physical examination shows bilateral moderate involutional ptosis of the upper eyelids. Mild lateral displacement of the tarsal plate is noted. Repair of the levator aponeurosis using an anterior approach is planned. Which of the following best describes the proper vertical plane to position the lifting suture in a single-suture technique?
A) Apex of the tarsal plate
B) Lateral limbus
C) Medial limbus
D) Mid pupil
E) Midline of central fat compartment
The correct response is Option D.
To achieve proper contour, the primary lifting suture should be placed on the vertical plane of the mid pupil. It is not uncommon for a patient with involutional ptosis to also have lateral displacement of the tarsal plate. If the central lifting suture is placed at the apex of the tarsal plate, the contour will be abnormally shifted laterally. The medial and lateral limbus position will also cause abnormal contour shifts. The midline of the central fat compartment has an inconsistent location in relation to the pupil.
2015
A 4-year-old boy is brought to the office for treatment and evaluation of lid ptosis. On examination, bilateral lagophthalmos, poor levator excursion, and severe ptosis are noted. Which of the following is the most likely diagnosis?
A) Blepharophimosis syndrome
B) Congenital epiblepharon
C) Congenital euryblepharon
D) Fraser cryptophthalmos syndrome
E) Treacher Collins syndrome
The correct response is Option A.
Blepharophimosis syndrome is the only diagnosis listed that is associated with congenital ptosis.
Blepharophimosis syndrome is associated with a tetrad of findings including ptosis, telecanthus, epicanthus inversus, and decreased horizontal lid fissure. In type I blepharophimosis, patients have epicanthus inversus and ptosis. In type II, findings include telecanthus, ptosis, ectropion of the lower lids, absent epicanthal folds, and insufficient skin in all lids. Type III is notable for telecanthus, ptosis, hypertelorism, slanting palpebral fissures, and insufficient eyelid skin. Correction involves a variety of techniques including, but not limited to, Z-plasty, transnasal wiring of the medial canthal tendon, and ptosis correction with frontalis suspension. Other abnormalities of the blepharophimosis syndrome include flattening of the nasal dorsum, hypoplasia of the superior orbital rim, as well as forehead and ear deformities.
In epiblepharon, the eyelashes are vertical as a result of excess pretarsal muscle and skin overriding the margin of the eyelid, often affecting the lower lids. This causes corneal irritation. If the condition does not resolve spontaneously in the first few years of life, correction involves shortening of the anterior lamella through excision of a horizontal piece of skin and orbicular muscle. Epiblepharon may also be caused by trauma, burns, or fractures.
Euryblepharon refers to widening of the palpebral fissure both laterally and vertically caused by a shortage of eyelid tissue. Treatment involves corneal protection and may require surgical correction with standard techniques used for ectropion repair.
Cryptophthalmos is a failure in embryonic development of the lid fold. The eye is buried in the developing cover of the epithelium and does not differentiate normally. It may be associated with other congenital abnormalities such as syndactyly, cardiac, facial, and ear defects.
Treacher Collins syndrome is a maxillary-zygomatic cleft with a coloboma of the lower eyelid and absent eyelashes.
2014
A 68-year-old woman wants improvement of the appearance of her upper eyelids. She wears contact lenses daily without need for lubricating eye drops. When compared with the left eyelid, the right upper eyelid has a more elevated lid crease and the marginal reflex distance-1 (MRD-1) is 1.5 mm. The MRD-1 for the left eyelid is 3.0 mm. Levator excursion is 12 mm bilaterally. Which of the following eye tests is the most appropriate next step in this patient’s evaluation for surgery?
A) Phenylephrine test
B) Schirmer test
C) Tear breakup time
D) Visual acuity test
E) Visual field test
The correct response is Option A.
The patient presents with unilateral ptosis of the right eyelid. The elevated lid crease suggests levator aponeurosis attenuation or dehiscence as the mechanism for ptosis. This is known as senile ptosis and is the most common etiology. The challenge in these patients is to determine whether the contralateral eye is also ptotic and requires surgery. This phenomenon is explained by Hering’s law (equal and simultaneous innervation of both levator palpebrae muscles). When one eye has ptosis, the brain signals both eyelids to raise. The less ptotic contralateral eye can look normal. The problem occurs when only the more ptotic eye is surgically repaired. The impulse to raise the eyelids is decreased and the contralateral eyelid now descends and appears ptotic. Evaluation demands a way to determine whether contralateral ptosis repair is required. Phenylephrine eye drops put into the more ptotic eye stimulate the Müller muscle to raise the eyelid. In turn, the afferent signals to raise the eyelids decrease. If the contralateral eyelid then falls over the next 10 to 15 minutes, the phenylephrine test is positive and suggests the need for bilateral ptosis repair. Other tests include patching the ptotic eye to decrease the afferent signals or manually raising the ptotic eyelid.
Marginal reflex distance-1 (MRD-1) is the distance in millimeters from the light reflex on the patient’s cornea to the level of the upper eyelid margin with the patient in primary gaze. Normal MRD-1 values are greater than 2.5 mm. Most of the population has MRD-1 values of 4 to 5 mm. The following tests are appropriate for evaluation of blepharoplasty patients, but they are not the most important next step in surgical planning for this patient with unilateral ptosis. Schirmer test evaluates tear production, and tear breakup time measures how quickly the tears evaporate. These tests are appropriate; however, dry eyes are unlikely in this patient because she is able to wear contact lenses without symptoms. Visual field tests are more important for insurance documentation than surgical planning. Visual acuity is for baseline information, not surgical planning.
2019
A 12-year-old girl is evaluated for correction of congenital left unilateral upper eyelid ptosis. She demonstrates moderate left levator muscle function of 8 mm. Which of the following methods is most appropriate for correction of this child’s blepharoptosis?
A) Fasanella-Servat procedure with removal of the tarsus, conjunctiva, and Müller muscle
B) Frontalis muscle flap advancement
C) Frontalis suspension procedure with autogenous fascia lata
D) Müller muscle-conjunctival resection
E) Resection and advancement of the levator aponeurosis
The correct response is Option E.
The most appropriate method for correction of this child’s congenital ptosis is resection and advancement of the levator aponeurosis. This technique is appropriate in patients with greater than 5 mm of levator function. This child has 8 mm of levator function and is therefore a candidate for levator resection and advancement.
Frontalis suspension procedures are reserved for patients with poor levator function or congenital Marcus Gunn jaw-winking syndrome.
The Fasanella-Servat procedure is for correction of minimal ptosis and may alter eyelid contour.
The Müller muscle-conjunctival resection surgery is recommended for patients with fairly good levator function and does not allow for intraoperative adjustment of eyelid height. This child has unilateral blepharoptosis, and achievement of symmetry with the opposite eyelid is crucial.
The frontalis muscle flap is recommended for use in patients with severe ptosis with levator function of less than 4 mm.
2019
A 2-year-old boy is brought to the office for evaluation of unilateral blepharoptosis. Examination shows a 2-mm eyelid ptosis of the right eye with 7-mm of upper eyelid excursion without visual obstruction. The left side shows no abnormalities. Which of the following is the most appropriate treatment in this patient?
A) Frontalis suspension
B) Lenticular skin excision
C) Levator palpebrae advancement
D) Tarsoconjunctival Müllerectomy (Fasanella-Servat procedure)
E) Observation and re-evaluation at age 3
The correct response is Option E.
Correction of mild to moderate eyelid ptosis in children should be delayed until the child can cooperate with the preoperative assessment and post operative care. This would not be reliably possible for a 2-year-old patient. Intervention before age 3 should be considered if there is significant obstruction of the visual axis. Levator advancement provides appropriate correction in pediatric patients with fair to good levator function. Frontalis suspension is generally reserved for instances when levator function is poor (less than 4 mm). Lenticular skin excision will have no reliable effect on lid position.
2019
A 3-year-old boy with minimal levator excursion of the left eyelid (2 mm) is scheduled to undergo ptosis repair. Which of the following materials has the lowest long-term recurrence and complication rate?
A) Autologous fascia lata
B) Polypropylene suture
C) Polytetrafluoroethylene (PTFE) strand
D) Silicone rod
The correct response is Option A.
Although all of the modalities listed have been used for congenital ptosis repair, autologous fascia lata (AFL) grafts have the lowest long-term recurrence rate and complication rates. Although studies have shown GORE-TEX to have a low recurrence rate compared to AFL, the complication rate of infection is higher with GORE-TEX. Grafting with irradiated fascia lata has a lower donor-site morbidity profile since it is allogenic tissue, but the long-term recurrence rate has been reported to be 50%. Polypropylene suture can be useful for temporary ptosis repair until AFL but has been plagued by recurrence secondary to slippage. Finally, silicone rods have been shown to have increased ease of adjustability since they do not incorporate, but they yielded higher complication rates than AFL.
2020
