Eyelid Reconstruction Flashcards
Describe the TC retroseptal approach
In both cases, go through CPF confluence For retroseptal, you go through confluence closer to the fornix, dissect in orbital fat behind septum directly to the orbital floor. Dont disrupt the anterior lamella
Describe TC preseptal approach
In both cases, go through CPF confluence For preseptal (antonyshyn), you got through confluence closer to the tarsus, through the septum, along septum down to rim and then need to divide arcus
Describe retroseptal TC with transcaruncular approach
- paired stay sutures medial and lateral FT through lamella (skin,tarsus,conj) and also medial and lateral through conjunctiva distal to fornix - Identifymarginal arcade and go inferior to arcade - colorado through conunctiva then through CPF and will see fat pop out to know you are thoguth CPF. - use stevens scissors, elevate lower lid with skin hooks and place tips of scissors on orbital rim and spread, then place senns to retract fat
Define Ectropion
Abnormal eversion of lid margin
Define Entropion
Abnormal inversion of eyelid margin
Define epiblepharon
Normal eyelashes inverted by redundant skin fold
Define trichiasis
Ingrowing eyelashes
Define dystrichiasis
Abnormal growth of eyelashes from glands
Define epicanthal fold
Vertical skin fold over medial canthus
Define Ptosis
Upper eyelid margin abnormally displaced inferiorly
Deifne marginal reflex distance
Distance from pupillary light reflex in forward gaze to lid magin
What is a normal MRD
MRD to upper lid is 4mm MRD ot lower lid is 5mm Palpebral fissure distance is 9mm vertically and 30mm horizontally
Where is the normal position of the upper eyelid?
4mm from pupil light in forward gaze (MRD 4mm) or 2mm below limbus
Where is normal position of lower eyelid?
5mm from pupil light in forward gaz e (MRD 5mm) or at inferior limbus
Describe the anatomy and structures of the upper eyelid
Describe the difference in function and innervation between the medial and lateral O.oculi (inner canthalorbicularis and outer canthalorbicularis)
Medial (Buccal br.) fx: blinking, tone of lower lid, pumping mechanism of lacrimal sac
Lateral (Zygomatic br. ) fx: forceful lid closure, animated movements
Describe the origin and insertion of levator palpebrae
O: orbit - ?sphenoid bone
I: inserts on anterior surface of tarsus and penetrates o/oculi to insert on dermis
N: CN3
Fx: normal levator excursion 12mm
transitions from muscle to aponeurosis 15mm ABOVE tarsus
Describe the fx, orgin and insertion of mullers muscle
O: the posterior surface of the levator at jx of muscle and aponeurosis
I: superior edge of tarsus
N: sympathetics
Fx: elevation of upper lid by 2-3mm
Describe the dimensiosn of the tarsal plates
the upper tarsal plate is 10mm by 25mm and the lower tarsal plate is 4mm by 25mm
Why is the preaponeurotic fat an important surgical landmark?
identifies that you have crossed through orbital septum and levator aponeurosis is deep to fat
What composes the canthal tendon (5)?
- lockwoords ligament
- whitnall ligament
- checkrein ligameent
- o/oculi preseptal and pretarsal extensions
- extension of levator aponeurosis
What is the position of the LCT?
10mm inferior to the ZF suture and within the orbit along the lateral orbital wall, 2-4mm posterior to the rim
What provide the vascular supply to the eyelids?
ECA
- STA, transverse facial, angular
ICA - main supply
- supratrocheal, supraorbital
How do you classify defects of eyelids?
Location
Size
Depth
What are principles of reconstructio of the eyelids?
Restore cover, lining and support
Restore movement for upper lid
Restore stability of lower lid
What are the options for reconstruction of the following structures in the eyelid?
- Anterior Lamella
- Support
- Lining
- Composite Lining and support
Anterior lamella
- FTSG
- local flap
Support
- periosteal flap
- fascial flap
- fascial sling
- cartilage graft
Lining
- mucosa
- local conjunctival flap
Composite lining and support
- palate graft
- septal mucoperichondrial graft
- tarsoconjunctival flap
What is your algorithm for reconstruction of Upper lid defects?
According to depth and size
PARTIAL
- FTSG or local flap
FULL
* depends on size of defect
< 25% - direct closure (need pentagonal wedge)
25-50%
- lateral cantholysis and lateral flap for direct closure
- composite graft and Tenzel semicircular flap
- modifed Hughes sliding tarsoconjunctival flap+ MC flap or FTSG
>50%
- Cutler Beard tarsoconjunctival flap + MCflap or FTSG
- composite graft + MC flap
- Mustarde lower lid switch
- Fricke temporal forehead flap
- forehead flap
Describe a Tenzel semicircular flap
Designed to reocnstruct margin and central upper eyelid defect up to 75%
- diameter of circle at least 3cm, drawn inferior to LCT
- elevate deep to orbicularis
- release upper limb of LCT
- recreate LCT by suturing loal flap to periosteum once advanced
Describe modified Hughes sliding tarsoconjunctival flap
Best for medial or lateral defects, up to 50%
- leaving 4mm o caudal end of tarsus, width of flap designed to equal width of defect adn tarsus is incised superiorly.
- dissect tarsus with mullers and conjunctical attachements tp upper limit (origin of mullers) as pedicle is superior palpebral artery lying b/w levator and mullers
- inset into defect and add MCflap or FTSG
Describe Cutler beard flap
Best for defects >50%
- rectangular advancement flap of conjunctiva and skin
- design wdith to match defect and parallel verticla incisions to fornix on conjunctiva
- for skin/muscle, incision down to rim
- cartilage graft from ear sutured to levator aponurosis for functional movement of reconstructed lid
divide after 2wks
What is your algorithm for reconstruction of Lower lid defects?
Depends on depth and size
PARTIAL
- FTSG
- local MC flap
if >50%, use Tripier flap (uni or bipedicled)
FULL
Depends on size
<25%: direct closure (pentagonal wedge)
25-50%:
- lateral cantholysis and MC flap for direct closure
- Hughes tarsoconjunctival flap + FTSG or MC flap
- composite graft and MC flap
>50%
- Hughes tarsoconjunctival flap + FTSG or MC flap
- composite graft and MC flap
- Tenzel semicircular flap
- Mustarde cheek rotation + composite graft
- McGregor temporal Z-plasty
- Fricke temporal forehead flap
- forehead flap
Describe a tripier flap
Designed for >50% partial defects of lower lid
- inferior incision placed in supratarsal crease and amount removed above depends on defect and laxity
- need at least 10mm base for lateral pedicle or do bipedicled
Describe a composite graft and myocutaneous flap
an just use cephalad edge of upper tarsus and conjunctiva as a free graft (instead of pedicled) and a MC flap to perfuse teh rgaft
Describe tensel semicircula flap for lower lid defect
Best for up to 75% defects of lower lid
Similar to description for upper lid, need to do inferior limb cantholysis of LCT
Describes hughes tarsoconjunctival flap
BEst for shallow long defects of lower lid
- preserve 4mm of caudal margin of upper lid
- take muller smsucle and conj as pedicle
- width matches that of defect
- dissection upper limit is the insertion of ullers to levator aponuerosis
- flap division at 2wks
Describe a mcgregor temporal zplasty
It is a lateral orbital transposition flap
Designed laterally w gentle upward curve to temporal hairline
- prehairline incision made to match and be parallel to lid deformity
- zplasty designed to lengthen lid and corresponds to width of wedge resection
- needs a lateral cantholysis
Describe a mustarde cheek advancement
Need in addition to MC flap a composite graft (palatal mucosal graft, nasal chondromucosal graft)
- designed above LCT level
- flap raised in subcut or deep to smas layer - dpeends on whether u need msucle or not
What are options for reocnstruction of MCT, for each anterior lamella and the support (the actual tendon)
Anteriro lamella
- FTSG
- V-Y glabella flap
- forehead flap
MCT
- direct repair
- nasal periosteal flap off anterior lacrimal crest
- y shaped miniplate
- mitek anchor
What are recon options for LCT and anterior lamella
Anterior lamella
- mustarde cheek flap
- fricke temproal forehead
LCT
- periosteal flap
- fascial sling with tensor fascia lata
What are cmplications of eyelid recon
- lid malposition (entropion/entropion)
- blunting of lateral canthal angle
- corneal injury
- ptosis
- conjunctival scarring
What are MC flaps that are functional
- Lower Lid: Mustarde, Tenzel, Tripier
- Upper lid: Tenzel, Fricke
