Reconstruction of the Eyelids, Correction of Ptosis, and Canthoplasty Flashcards
1
Q
the
Asians this lid crease can be found significantly lower
A
T
2
Q
The highest point of
the upper lid is typically found just on the center of the pupil
A
F The highest point of
the upper lid is typically found just medial to the center of the pupil
3
Q
lateral canthus is positioned 2 mm higher than the
medial canthus, whereas in Asians this can be found 3 mm higher
A
T
4
Q
Beneath pretarsal
skin, as well as laterally over the medial and lateral canthal ligaments,
the underlying fat is absent
A
T
5
Q
All The orbicularis oculi muscle originate from the medial canthal tendon
A
F Fibers of the orbital portion originate from the
medial orbital margin and medial canthal tendon and sweep around
the orbit in horseshoe fashion to insert back on the medial canthus.
The preseptal and pretarsal subunits originate from the medial canthal tendon and insert on the lateral horizontal raphe
6
Q
Hornor syndrome affect the levator muscle
A
F muller muscle
7
Q
he lateral canthal tendon
passes deep to the orbital septum and inserts 2 mm posterior to the
lateral orbital rim
A
T
8
Q
terminal branches of the ophthalmic
artery, which supply the medial palpebral vessel directly and the
lateral palpebral vessel via the lacrimal artery.
A
T
9
Q
The lateral two-thirds of the upper lid and lateral half of the lower lid
drain primarily through the preauricular lymph nodes
A
T
10
Q
medial portion of the upper and lower lid drain through the submandibular lymph nodes
A
T
11
Q
lymphedema of the eyelids IS a rare complication
A
T
12
Q
Grading of the lower lid lag?
A
(Grade 0), it should spring back immediately to its original position,
Grade ] laxity is observed with 2 to 3-second delay,
Grade II laxity with 4 to 5 seconds delay
Grade III laxity with >5 seconds delay and return to a position with blinking
Grade IV laxity, frank ectropion is maintained without return to the original position.
13
Q
Examination of patients with excess tear accumulation or epiphora
A
dye disappearance test or dilation and irrigation
No. 00 Bowman probe can also be
passed through the lacrimal drainage system
14
Q
Mohs micrographic surgery is frequently employed
in the periorbital region
A
T
15
Q
small defects <5 mm in the upper eyelid
that do not involve the lid margin or canthus may be left to heal
A
T
16
Q
Partial defects in the upper eyelid more than 50% can be treated with skin graft Importantly, grafts may be oversized by approximately 30%, particularly over the preseptal lid to allow for contracture
A
T
17
Q
Complications of the full thickness graft for the upper eyelid
A
hypertrophic scarring in
23% and hypopigmentation in 6%, particularly supraclavicular
and inner arm donor sites
18
Q
options for reconstraction of full thickness defect mor than 25%
A
Hughes advancement/sliding
tarsoconjunctival flap with skin graft or composite graft covered by
a myocutaneous advancement flap
19
Q
Options for composite graft?
A
free tarsal graft with conjunctiva from the
contralateral upper lid
nasal septa! cartilage-mucosa and hard palate mucosa grafts
20
Q
Wich compiste graft is preferable ?
A
free tarsal graft with conjunctiva from the
contralateral upper lid is best option
both nasal septa! cartilage-mucosa and hard palate mucosa grafts are keratinized, potentially placing the cornea at risk of abrasion and damage until metaplasia
21
Q
donorsite complication in the contralateral normal lid could be devastating.
A
T
22
Q
Option for reconstruction of the outer lamella
A
vascularized myocutaneous advancement flap is used to address
the anterior lamella. Commonly employed flaps include a sub-brow
bipedicled skin-orbicularis oculi muscle flap, paramedian forehead
flap, and modified Tenzel flap
23
Q
inverted, modified Tenzel (semicircular) flap can be used to closed up to 50 % of the upper eye;id
A
F tow third of upper eyelid
24
Q
Cutler-Beard flap, have fallen out of favor
A
T
25
For defects more than 75%
mucosalized tarsal graft
and overlying myocutaneous orbicularis oculi flap
lower eyelid switch flap
26
The most frequent late complication in patients undergoing upper
eyelid surgery
is exposure keratopathy, which can be seen in 20%
27
complications after upper eyelid surgery
Asymmetric marginal position
ptosis following eyelid surgery should be monitored for 6 months for spontaneous recovery
exposure keratopathy
lagophthalmos, lid ectropion, orbital hematoma, corneal injury, and
conjunctiva! scarring/symblepharon
28
The lower eyelid is critical for active corneal
coverage,
F the lower eyelid is critical for passive corneal
coverage,
29
Vertical closures should be avoided when possible
T
30
A Frost suspension suture can reduce downward pull on the lower eyelid during the early postoperative period
T
31
Small full thickness defect 30%, moderate defect 30-50% large defect more than 50%
T
32
In tenzer semicircular flap of the lower eyelid need to use with canthotomy and inferior cantholysis is also performed to facilitate the advancement
T
33
When a Hughes flap is not used for posterior
lamellar reconstruction in mustardi flap, a temporary tarsorrhaphy is often useful during
the initial phase of healing to combat the mechanical effect of edema
T
34
A Frost-style
traction suture can be placed for 2 days to provide early postoperative lid support
F A Frost-style
traction suture can be placed for 1 week to provide early postoperative lid support
35
cicatricial ectropion may be noted. This complication has been noted
in 5% of patients
T
36
medial canthal region is complex due to structures that may be involved and contours that are difficult to recreate
T
37
defects in the medial canthus region are associated with a high incidence
of lacrimal system injury
T
38
For small full-thickness defects , healing by secondary intention can be considered
F. For small defects limited to the anterior
lamella, healing by secondary intention can be considered
39
Larg defect in the medial canthus with good vascularized bed should treat with grafting
T
40
in case of full thickness defect with out vascularised bed what are the options for reconstruction
local medially based myocutaneous transposition flap from
the upper eyelid can be performed
a glabellar rotation
advancement flap may be employed
41
thicker flaps result in excess tissue bulk require thinning during a secondary procedure
T
42
In medial canthal injuries anterior fixation alone may not be adequate to restore lid-globe apposition.
T
43
in medial canthal tendon injury, Concomitant lacrimal probing or stent placement should be considered in all cases
F Concomitant lacrimal probing or stent placement should be considered in select cases by
44
Defects involving the lacrimal system and when a dacryocystorhinostomy with or without Jones tube is required primarily repiare of the canalicular system is required
F repair should be deferred until
careful postoperative observation
45
Partial interruptions of the
canaliculus can be repaired over a monocanalicular or bi-canalicular silicone stent, which is generally left in place for 3 months before
removal.
T
46
the quantity of tissue in the lateral canthus that must be reconstructed is often minimal
T
47
Cuses of pseudoptosis?
enophthalmos
brow ptosis
hypertropia.
48
congenital ptosis, fibrofatty
dysgenesis of the levator complex is observed, and ptosis remains
relatively constant throughout life until surgery is performed
T
49
Poor
levator function and lagophthalmos present in congenital ptosis
T
50
Levatore dehiscence considered a form of congenital ptosis
F Various forms of acquired ptosis exist, with
levator dehiscence the most common
51
Classically, acquired ptosis seen from
a dehisced levator aponeurosis is associated with a lid crease that is
higher and an upper sulcus that is deeper than the uninvolved side
T
52
lid crease that is
higher with congenital ptosis
F with acquired ptosis in congenital ptosis is absent
53
Myogenic/neurogenic causes of ptosis
myasthenia gravis, oculopharyngeal muscular dystrophy, and idiopathic late-onset familial ptosis
54
Neurological defects are easy to treat
F These etiologies are particularly difficult to treat as defects are progressive and ocular surface protective mechanisms function poorly
55
risk of corneal complications is high with congenital ptosis
F with Myogenic/neurogenic causes of ptosis
56
Marcus Gunn jaw-winking phenomenon, which accounts
for 2% to 13% of congenital ptosis
T
57
Presentation of patients with Marcus-Gunn
Patients with this syndrome
demonstrate both a variable degree of ptosis at rest and winking associated with jaw movement, sucking, or swallowing
58
These findings are
as a result of aberrant connections between motor branches of CN V
and the superior division of CN III
T
59
Pupillary asymmetry (anisocoria) or deficiencies
in extraocular muscle function may raise the suspicion of Horner
syndrome or CN III palsy as a cause for ptosis
T
60
An age-appropriate visual acuity and visual field test should be performed in all patients with ptosis who are able to cooperate
T
61
Sever ptosis is when upper eyelid ptosis more than 5 ml
F > 4 ml
62
Levator function excursion?
good (> 8 mm), fair (5-7 mm),
and poor (> 4 mm)
63
Which candidates for
Muller muscle-conjunctiva resection?
Patients who demonstrate mild ptosis (2-3 mm), good levator excursion, and an appropriate phenylephrine test are good candidates for
Muller muscle-conjunctiva resection
64
Patients candidate for the muller muscle resection?
Patients who demonstrate mild ptosis (2-3 mm), good levator excursion, and an appropriate phenylephrine test are good candidates for
Muller muscle-conjunctiva resection
65
Putterman have resulted in improved predictability and
minimized anatomic disruption
T
66
The candidate patients for Levator Advancement and Levator Repair
with mild to moderate ptosis and fair to good
levator excursion (>5 mm)
67
Restoration ofthe upper eyelid crease can be achieved
through reattachment of the orbicularis muscle to the levator aponeurosis
T
68
Under correction of the eyelid ptosis is more than over-correction
F Both under and overcorrection have been observed
69
predictability for
bilateral levator advancement is diminished due to Herring phenomenon
T
70
Candidate for frontalis sling
In patients with variable degrees ofptosis and poor levator excursion
(<4 mm), as can be seen in patients with congenital ptosis,
71
the double rhomboid design remains the most often
used in frontalis sling
T
72
stab incisions may be made above the ciliary
margin in older age patients in frontalis sling
F Although analogous stab incisions may be made above the ciliary
margin in young children, an open lid crease technique with tarsal
dissection and sling fixation is typically performed in older patients
73
Most common complication after frontalis sling
Lagophthalmos is common and must
be managed appropriately with liberal ocular surface lubrication
74
management the consequences of lagophthalmos
A
temporary suture tarsorrhaphy, Frost suture, or bandage contact lens
can be helpful in the early postoperative period
75
lid lag was the most frequently noted complication present in 90% with frontalis sling
T
76
complications following ptosis correction
undercorrection, overcorrection,
or discrepancies in lid contour
Lagophthalmos, exposure keratitis, and corneal abrasions
77
Absent of bells phenomenon is relatively contraindication to ptosis surgery
T
78
Patients with ectropion
may have symptoms for months or years before seeking treatment
T
79
The incidence of congenital ptosis
estimated at 2.9%
80
The cuase of lower lid ectropian id acquired conditions only
F congenital or acquired conditions
81
Congenital ectropion is Common
F Congenital ectropion is rarely isolated and may be associated with
blepharophimosis syndrome, microphthalmos, and ichthyosis
82
Causes of acquired ectropion
most commonly involutional in nature, but
paralytic, cicatricial, or mechanical causes
83
Causes Involutional ectropion
occurs with increased horizontal lid laxity due to age-related weakness in canthal ligaments
and pretarsal orbicularis muscle, often coupled with disinsertion of
the capsulopalpebral fascia
Negative vectors
84
Patients with negative orbital vectors are
also at increased risk as 92% of eyelids with involutional ectropion
T
85
scarring of the posterior lamella can considered one of the causes of ectropion
scarring of the anterior
and/or mid lamella
86
Causes of aquired ectropion
facial nerve palsy, scarring of the anterior
and/or midlamella, disinsertion of capsulopalpebral fascia, and lower
eyelid tumors, such as neurofibromas
87
patient with lower lid laxity management?
begins with lubrication if significant corneal exposure is present.
Taping of the inferolateral
canthal skin in a superolateral direction may also provide temporary
relief.
Surgical correction
88
a canthopexy
may have a greater risk of rounding at the reconstructed canthus.
F a canthoplasty
may have a greater risk of rounding at the reconstructed canthus.
89
The candidate patients for tarsal tuck?
mild lid laxity
minimal distensibility and a firm snap back of the lower lid
90
In Tarsal Tuck lateral tarsus is tucked inside the rim and the lateral canthus is
elevated
T
91
patients with involutional ectropion best treated with tarsal tuck
F Lateral Tarsal Strip
92
The candidate for Lateral Tarsal Strip
involutional ectropion
lower lid laxity secondary to paralytic
cicatricial etiologies
93
a lateral tarsal strip has gained ascendency why?
due to the restoration of a sharp lateral canthal angle and avoidance of layered closure of the lid margin, with the associated risk of trichiasis and notching.
94
For repair of frank ectropion, reinsertion of the
capsulopalpebral fascia via a transconjunctival approach is often
required as well to produce a durable result
T
95
the first-line procedure for involutional ectropion with excess horizontal lid laxity is the tarsal tuck
F Tarsal strip
96
adjunctive procedures such as retractor
reinsertion are necessary in all cases
F adjunctive procedures such as retractor
reinsertion are necessary in some cases
97
Complications of the tarsal strip?
lateral canthal irregularity with or without trichiasis and recurrence of laxity
98
in Canthoplasty we can mobilized the upper crus only
Canthoplasty . Mobilization
of both the upper crust and lower crus of the lateral canthal tendon can lengthen the palpebral fissure and reorient the position
of the entire lateral canthus
99
iN canthoplasty division of the lateral canthus always required to achieve mobilization of the lateral canthus
F Depending on the degree of tendinous laxity, the division of the tendon body from the underlying periosteum may or may not
be required
100
Complications following canthoplasty infrequent and most commonly minor
T
101
Causes of Recurrence?
periosteal fixation is not achieved
the eyelids are too lax
other periocular vector forces are not fully addressed
102
Recurrent lid malposition can be noted in up to 20% of patients,
T
103
Lower eyelid fold is absent in children
F. Present
104
Schrimer test is don routinely for. eye ptosis
F
105
lower eyelid fold, particularly in children, can also be found approximately 3 to 5 mm from the lid margin.
T
106
Blood supply to the eye
Facial artery: This vessel forms the angular, lateral nasal, and inferior medial palpebral arteries.
Transverse facial artery: This vessel forms the zygomaticofacial and inferior palpebral arteries.
Superficial temporal artery: This vessel forms the superior medial palpebral artery (peripheral arcade).
Ophthalmic artery: This vessel forms the lacrimal, supraorbital, medial palpebral, and dorsal nasal vessels.
107
a skin crease can be found approximately 8 to 9 mm superior to
the eyelid margin in men and 9 to 11 mm in women
T
108
With the eye open, the palpebral fissure measures 28 to 30 mm
in length and approximately 15 mm in height
F With the eye open, the palpebral fissure measures 28 to 30 mm
in length and approximately 9 mm in height
109
the lid margin resting l to 2 mm below the superior limbus in
adults
T
110
A greater number of sebaceous glands can be found in the nasal portion of the lids
T
111
There is
relatively minimal subcutaneous fat in the eyelids, which can mostly
be found beneath preorbital and preseptal skin
T
112
Beneath pretarsal
skin, as well as laterally over the medial and lateral canthal ligaments,
the underlying fat is absent
T
113
The orbital subunit functions in forced closure, whereas the preseptal and pretarsal subunits are employed for blinking and voluntary winking
T
114
Eyelid retractors
the levator palpebrae superioris and
Miiller muscle in the upper lid, and capsulopalpebral fascia in the
lower lid
115
The levator palpebrae superioris fuse with with the orbital
septum anteriorly after attaching to the superior tarsal plate posteriorly.
F prior to attaching to the superior tarsal plate posteriorly.
116
the sympathetically innervated Miiller
muscle contributes an additional 2 to 3 mm lid elevation
T
117
With decreased sympathetic tone, as in
Horner syndrome, loss of Muller muscle function results in sever ptosis
F results in mild ptosis
118
capsulopalpebral fascia come from the superior rectus muscle
f the inferior rectus muscle
119
capsulopalpebral fascia. insert in the the inferior border of the lower tarsal plate,
only
the inferior border of the lower tarsal plate,
though minor fibers also insert on the conjunctiva of the inferior
fornix,
120
sympathetically innervated fibers are intimately
involved with the posterior surface of the capsulopalpebral fascia,
although they are typically not identifiable as a distinct anatomical layer
T
121
Orbital Septum Has variable
indistinct fusion with tarsal plate , however, can result in more prominent orbital fat
projection in different ethnicities, and with age
T
122
The
central fat pad is broad and yellow secondary to higher levels of
carotenoids and is found in between the orbital septum and levator
aponeurosis
T
123
The medial fat pad, which is more pale yellow or white
in color
T
124
the superior oblique muscle separate The medial fat pad from the central
fat pad
T
125
The inferior oblique
muscle separates the medial and central fat pad
T
126
whereas the arcuate
expansion extending from the capsulopalpebral fascia separates the
medial and lateral fat pads.
T
127
torsional diplopia. can result from the injury to the superior oblique muscle
F inferior oblique muscle
128
The superior tarsal plate is
typically 10 to 12 mm in height centrally, narrowing medially, and
laterally to assume a crescentic shape
T
129
The inferior tarsal plate is more
rectangular and measures approximately 4 mm in height centrally.
T
130
Within the upper and lower eyelid, tarsus can be found
25 to 40 sebaceous meibomian glands.
131
These empty at the lid margin
anterior to the gray line
F These empty at the lid margin
posterior to the gray line
132
The lateral canthal tendon
passes deep to the orbital septum and inserts 2 mm posterior to the
lateral orbital rim on a bony prominence known as Whitnall tubercle.
T
133
The palpebral conjunctiva lines the posterior surface
of the upper and lower eyelid and is firmly adherent to the tarsal
T
134
Goblet cells within the
conjunctiva produce mucin, whereas accessory lacrimal glands are
responsible for basal secretion of aqueous tears
T
135
Conjunctiva! tissue
loss can result in lid malposition and limitation in ocular motility
T
136
The lacrimal glands responsible for the reflex secretion of the aqueous layer of
the tear film
T
137
Two lobes of lacrimal gland are esperated by levator aponeurosis
T
138
nasolacrimal duct open in inferior nasal meatus
T
139
Decreased
tear production can lead to keratoconjunctivitis sicca
T
140
second peripheral arcade
can be found above the tarsal plate on the posterior surface of the
Muller muscle,
F second peripheral arcade
can be found above the tarsal plate on the anterior surface of the
Muller muscle,
141
In the lower eyelid, only one, more rudimentary arcade can be
found approximately 2 mm below the inferior tarsal margin
T
142
lymphedema of the eyelids has high rates of recurrence
T
143
Schirmer's test
a filter paper strip is inserted into the lower
sulcus for 5 minutes to measure moisture. Tear production is considered to be diminished with less than 15 mm in the absence of a topical anesthetic and with 5 to 10 mm when a topical anesthetic is given
144
tear production can also be evaluated by administering
fluorescein eye drops to determine whether there is interpalpebral
staining of the cornea
T
145
For patients with excess tear accumulation or epiphora, a dye disappearance test or dilation and irrigation can be performed
T
146
under sedation and anesthetic, a No. 00 Bowman probe can also be
passed through the lacrimal drainage system to determine the precise
locus of obstruction
T
147
distances in an adult are 8 to 10 mm to
the common canaliculus, 10 to 12 mm to the lacrimal sac, and 24 mm
to the proximal end of the nasolacrimal duct
T
148
tumor resection is the most common indication for
reconstruction of the upper eyelid
T
149
For partial-thickness defects involving
less than 50% of the upper eyelid, primary closure is ideal,
T
150
for larger partial-thickness defects involving greater than 50% of the upper eyelid
Fullthickness skin grafts are preferable to split-thickness skin grafts due
to less contracture postoperatively
151
Depending on laxity, full-thickness defects of the upper lid up to 25%
of the horizontal length may be closed primarily,
T
152
in older
patients defects up to 1/3 may closed primerly
T
153
The lid margin is approximated
with 5-0 or 6-0 silk vertical mattress suture placed through the meibomian gland orifices in a far-far, near-near fashion to help evert the
wound edges.
T
154
Importantly,
4 mm of tarsus is necessary to maintain stability at the lid margin
T
155
A sliding tarsoconjunctival flap can also be
elevated from either the medial or lateral eyelid remnant and swung
into an adjacent defect
T
156
the larger the diameter, the greater the advancement is possible.in inverted, modified Tenzel
T
157
A skin-muscle flap is
undermined in the preseptal plane and kept superficial beyond the
orbital rim to avoid injury to the temporal branch of the facial nerve
T
158
Total or near-total upper eyelid reconstruction
- using a musicalized tarsal graft and overlying myocutaneous orbicularis oculi flap, as previously discussed, but the graft typically has insufficient horizontal length and
needs to be combined with hinged periosteal flaps or other adjunctive techniques.
- lower eyelid switch flap
159
the lower eyelid is shorter in height and less mobile,
and from a functional standpoint, it contributes minimally to closure
t
160
Lowe lid reconstruction must focus on appropriate lid position and tone.
T
161
Local myocutaneous transposition flaps FOR lower eyelid
transposition flaps
temporally hinged monopedicle or bipedicle (Tripier) flaps fromthe ipsilateral
upper lid
162
The
pedicle is kept as wide as possible laterally and should be at least I :4 in
base to length dimensions to preserve vascularity
t
163
With defects less than 30% of the eyelid width, primary closure
can often be performed for lower eyelid
T
164
When
excess tension is encountered, a lateral canthotomy and inferior
cantholysis can be considered. with primery repair of the lower eye lid
T
165
A Tenzel semicircular rotation flap is typically used to repair
lower eyelid defects of larg size
F A Tenzel semicircular rotation flap is typically used to repair
lower eyelid defects of moderate size
166
A Tenzel semicircular rotation flap is typically used to repair
lower eyelid defects of moderate size In tenzel flap
T
167
a Hughes sliding transconjunctival flap contraindicated in
patients sighted only in the involved eye or in younger patients of
amblyogenic age.
168
The largest full-thicknessdefects of the lower eyelid particularly those
involving the entirelid or with a vertical dimension greater than the horizontal one
reconstructed using a Mustarde cheek rotation flap
in conjunction with a composite graft or Hughes flap (
169
Marking the flap well above the level of the lateral canthus
before extending to the periauricular skin is critical to correctly position
the lateral canthal angle. in mustardi
T
170
Dermal anchorage of the Mustarde cheek flap to the lateral orbital rim periosteum is also key to minimizing vertical tension on
the reconstructed lid
T
171
Color and texture match for
full-thickness skin grafts for lateral canthus can best be achieved by harvesting nearby
tissue and the postauricular donor site is frequently employed with
minimal donor-site morbidity
T
172
computed
tomography scanning should be considered in appropriate patients
as part of a preoperative evaluation
T
173
Preoperative evaluation of ptosis patients?
testing orbicularis oculi function, corneal sensation, strength of Bell
phenomenon, and in adults with dry eye symptoms, a Schirmer test
for tear function
174
Severity of ptosis is classified as mild
(1-2 mm), moderate (2-3 mm), or severe (<'.4 mm)
t
175
Normal levator excursion is usually greater than 12 mm
T
176
evaluation of the sympathetically innervated Millier muscle function can be performed by instilling 2.5%
phenylephrine eye drops and evaluating changes to marginal reflex
distance after 10 minutes
T
177
Draw bak of Muller muscle resection
little
room for intraoperative adjustment and violation of the conjunctiva! surface may increase risk for postoperative corneal irritation
178
The levator advancement is widely applicable to
patients with senescent/involutional ptosis, traumatic ptosis, and
even some with congenital ptosis who have some preserved levator
function
t
179
A Wright fascia needle is then passed starting from the brow incisions
in a pre periosteal plane, exiting the lid incisions in the postorbicularis
fascia plane in frontalis sling tech
T
180
lid lag was the most frequently noted complication present in 90%.2 Iwith frontalis sling
T
181
Common complications following ptosis correction
eyelid
asymmetry, which can result from undercorrection, overcorrection,
or discrepancies in lid contour
182
Overcorrection is most frequently observed
Under correction is most frequently
observed and may arise from inadequate advancement ofthe levator
or postoperative relaxation of a frontalis sling
183
Undercorrection is most frequently
observed and may arise from inadequate advancement ofthe levator
or postoperative relaxation of a frontalis sling
t
184
the terms canthoplasty and canthopexy describe distinct procedures. Though both are
designed to provide support to the lower eyelid
T
185
shortening the lid can occur with tarsal tuck
F It provides support without
shortening the lid and can be performed alone or in concert with
other procedures such as lower lid blepharoplasty
186
lateral tarsus is tucked inside the rim and the lateral canthus is
elevated
T
187
in patients with more significant lid laxity,
increased tucking required may result in bunching oftissue and the
lower lid may lose its apposition to the globe. In such patients, a lateral tarsal strip should instead be performed
T
188
A lateral canthotomy and inferior cantholysis are first performed with a lateral tarsal strip
T
189
A triangle of
redundant anterior lamella and lashes is then excised and the lateral canthal angle reformed with tarsal strip
T
190
tightening of the lower eyelid
may result in the upper lid prolapsingover the lower lid margin and
irritation of the upper eyelid palpebral conjunctiva from eyelashes.
In these cases, the upper lid should be concomitantly shortened to
avoid a lid length discrepancy
T
