Surg Radiol Anat (2008) 30:265–269
DOI 10.1007/s00276-008-0323-8
A N A T O M I C B A S E S O F M ED I C A L , R A D I O L O G I C A L A N D S U R G I C A L T E C H N I Q U E S
The vascular system of the upper eyelid. Anatomical
study and clinical interest
R. Lopez · F. Lauwers · J. R. Paoli · F. Boutault ·
J. Guitard
Received: 12 July 2007 / Accepted: 31 January 2008 / Published online: 21 February 2008
© Springer-Verlag 2008
Abstract Thorough knowledge of the vascular supply is
indispensable for repair and oncologic surgery of the eye-
lids, and has a signiWcant impact on the management of
complex defects of this region. This anatomic study was
performed with Wve fresh cadavers after arterial injection of
coloured neoprene latex. The distribution of the vascular
system of the upper eyelid was examined after dissection
and photographic study. It is made up of three arcades: the
preseptal arcade, the supratarsal arcade, and the marginal
arcade, under the orbicularis oculi muscle. These arcades
are supplied by branches of the ophthalmic artery (supraor-
bital artery, supratrochlear artery and medial palpebral
artery) and branches of the facial artery and temporal
artery. Small vertical branches arising out of these arcades
provide an anastomotic network. This anatomical study
aimed to describe the vascular system of the upper eyelid in
order to search for constant features and to map the blood
supply of the principal upper lid Xaps.
Keywords Vascular system · Upper eyelid · Anatomy
Introduction
In surgical management of eyelid and periorbital defects,
whether after injury or cancer, thorough knowledge of the
vascular system of the eyelid is a prerequisite. The anatomy
R. Lopez (&) · F. Lauwers · J. R. Paoli · F. Boutault
Service de Chirurgie Maxillo-Faciale et Plastique de la face,
CHU Purpan, Place du Dr Baylac, 31059 Toulouse Cedex, France
e-mail: raphaellopez@hotmail.com
R. Lopez · F. Lauwers · J. Guitard
Faculté de Médecine de Toulouse, Laboratoire d’Anatomie de
Purpan, 133 route de Narbonne, 31062 Toulouse, France
textbooks [7, 11, 13, 14, 21] teach us that the upper eyelid
vascular system derives from the medial and lateral palpe-
bral arteries. However, recent publications indicate that it is
considerably richer and more complex [5, 18]. It is supplied
by anastomosis between the internal and external carotid
arteries [8, 9, 18, 20]. These anastomosis run between the
collateral branches of the ophthalmic artery (supraorbital
artery, supratrochlear artery, dorsal nasal artery and lacry-
mal artery) and the collateral and terminal branches of the
external carotid artery: the facial artery (angular artery),
superWcial temporal artery (transverse facial artery, median
temporal artery and frontal and parietal branches). The
branches of the transverse facial artery and the frontal
artery are essential to the blood supply of the eyelids.
The anatomical literature [8, 20] on the vascular system
of the eyelid certainly provides us with some understanding
of its characteristics but these studies are still incomplete.
The goals of this study are in the Wrst place to deWne this
vascular system and secondly to propose an arterial pattern
of the main upper eyelid Xaps used in the reconstruction of
periorobital region defects.
Materials and methods
This anatomical study was performed in the anatomy labo-
ratory of the medical faculty of the Université Paul Saba-
tier, Toulouse. It was carried out on Wve fresh cadavers of
Caucasian origin: three males and two females. Thus, ten
eyelids were dissected.
The material used for the injections consisted of:
– suction tube, used as a large-calibre catheter
– 50-ml Luer lock syringe
– clamp
123
266 Surg Radiol Anat (2008) 30:265–269

– AC 50 red dye (Biodur® Heidelberg, Germany)

– Neoprene Latex 671 (UK, Dupont Limited®)
The basic material was Neoprene Latex 671, 56% latex
diluted in acetone giving a milky-white suspension. It can
be coloured with commercial universal pigment concen-
trates or with special dyes such as Biodur® AC 50 red dye,
which was used in this anatomical study.
Method: After dissection and insertion of two catheters
in the common carotid artery and in the internal jugular
vein on both sides, we injected 50 ml of coloured latex.
Before the latex injection, the common carotid artery
and the internal jugular artery were ligated at the level of
the transverse process of the sixth cervical vertebra to pre-
vent retrograde Xow of the solution. The dissections were
Fig. 1 The palpebral arcades
carried out after 48 h in cool storage.
In all cases, we carried out bilateral comparative dissec-
tion, at a distance from the periorbital region and including
the frontal, malar, jugal and nasal regions. The skin, mus-
cles and Wbroelastic layer were then dissected plane by
plane. Each plane was examined for the type of vessel and
the various anastomoses. The arcades were drawn and pho-
tographed.

Results

Arterial injections

The anastomosis between two carotid arteries

The arterial network of the upper eyelid is made up of anas-

tomoses between the collateral branches of the ophthalmic
artery (supraorbital artery, supratrochlear artery and dorsal
nasal artery), a branch of the facial artery (angular artery)
and the superWcial temporal artery. By these arteries the
internal and external carotid system were anastomosed and
provide the vascular system of the upper eyelid. Fig. 2 The palpebral arcades
We observed in all cases that the frontal branch and the
transverse facial artery (branches of the superWcial tempo-
ral artery) contribute with the angular artery and the supra- – the marginal arcade, lying immediately beneath the free
trochlear artery to form a surrounding vascular network margin of the lid, we consistently observe this arcade
which provides the greatest part of the blood supply of the who arose from the anastomotic network
orbicularis oculi muscle. – the supratarsal arcade, lying above the tarsal plate,
arose in three subjects (60% of cases) directly from the
The arterial arcades of the upper eyelid digitiform network, whereas in one case (20%) it arose
from the marginal arcade and in one case (20%) we
In this anatomic study, three arterial arcades were observed observed a mixed origin.
in the upper eyelid (Figs. 1, 2). The mains arteries which
Theses arcades are directly in contact with the tarsal plate.
contribute to the arcades are the supraorbital, supratrochlear
and the medial palpebral arteries. These arteries form a dig- – the preseptal arcade arose from the supratrochlear and
itiform anastomotic network and from these arise three supraorbital arteries in four cases (80%) and in one case
arcades that were observed in all subjects (Table 1): (20%) directly from the anastomotic network.

123
Surg Radiol Anat (2008) 30:265–269 267

Table 1 Origin of the arcades

Origin Arcades

Marginal (%) Supratarsal (%) Preseptal (%)

Supratrochlear and 0 20 80
supraorbital arteries
Anastomotic network 100 60 20
Mixed 0 20 0

From these arcades arose, in all cases without exception,

small vertical branches forming a plexus of anastomoses on
the tarsal and supratarsal plates. This small vertical
branches run under the oculi orbicularis muscle in the sub-
muscular Wbroelastic layer. (The arcades are of diVerent
origins: if the marginal arcade arose from the anastomotic
network, the preseptal arcade arose from the anastomosis
between the supratarsal and supraorbital arteries.) Fig. 4 Diagram of the vascular system of the upper eyelid (SOA
supraorbital artery, STA supratrochlear artery, MPA medial palpebral
In this way, we identiWed the vascular system of the artery, PA preseptal arcade, SA supratarsal arcade, MA marginal ar-
upper eyelid on two levels: the Wrst level corresponds to a cade, STA superWcial temporal artery, AA angular artery)
surrounding network to the orbicularis oculi muscle (Fig. 3)
and the second level corresponds to the palpebral arcades
which lie in the submuscular Wbroelastic layer. This blood
supply on two levels makes it possible to raise upper lid
Xaps safely and with a reliable vascular basis.
Thus we identiWed the blood supply to the upper eyelid
as composed of three arcades: marginal, supratarsal and
preseptal (Figs. 4, 5), which communicate by an anasto-
motic network of vertical branches. These arcades run
under the orbicularis oculi muscle and represent an impor-
tant vascular system of the upper eyelid derived from the
medial palpebral, supratrochlear, supraorbital, lateral palpe-
bral, facial, and superWcial temporal arteries.

Fig. 5 Sagittal section

In all cases, the lateral region of the upper eyelid

received further blood supply from the branches of the
superWcial temporal artery (collateral of the external carotid
artery) and the lacrimal artery (collateral of the internal
carotid artery via the ophthalmic artery).

The vascular supply of upper eyelid Xaps (Fig. 6)

Fig. 3 The superWcial vascular network of the orbicularis oculi mus-
cle (It was observed after resection of the cutaneous plane of the upper Upper eyelid Xaps, whether they have a medial (1) or lateral
eyelid, on the orbicularis oculi muscle plane) pedicle (2), or are bipedicled (3) or island Xaps (4), are cen-

123
268
Fig. 6 Diagrams of the vascular
supply of upper eyelid Xaps
tred on the supratarsal arcade or the preseptal arcade. Only
the tarsoconjunctival Xap (5) depends for its blood supply
on the marginal arcade, together with the supartarsal arcade
to a varying extent.
Discussion
The upper eyelid network is formed by the anastomosis
from the two arterial carotid systems. The internal carotid
artery by the branches of ophthalmic artery and the external
carotid artery by the facial artery, the superWcial temporal
artery [7–9, 14].
The orbiclaris oculi muscle vascularization is derived
from a constant superWcial surrounding network supply by
branches of the superWcial temporal artery (the frontal
branch and the transverse facial artery), the angular and the
supratrochlear arteries. This agrees with the results of oth-
ers studies [8].
The data of the literature agree that the upper eyelid con-
tains two arcades: a marginal and a peripheral arcade [4, 14,
15, 18]. In our study, we also identiWed these two arcades,
one on each side of the tarsal plate. The marginal arcade
123
Surg Radiol Anat (2008) 30:265–269
runs along the free margin of the eyelid whereas the periph-
eral arcade lies on the tarsal plate a few millimeters above
the marginal arcade. In this study these arcades are noted
marginal arcade and supratarsal arcade.
Tucker et al. [20], dissecting six cadavers injected with a
polymerized monomer and red pigment, also described two
arcades of the upper eyelid, as upper marginal arcade and
upper peripheral arcade. These arcades were formed from
branches of the supraorbital, the supratrochlear, the dorsal
nasal, the lacrimal and the angular arteries.
In own study, another arcade, which runs on the orbital
septum is identiWed as the preseptal arcade. Furthermore this
arcade may correspond to the deep orbital arcade described
by Kawai et al. [8] and seems to be more an anastomosis
between supraorbital and supratrochlear arteries than a
branch of the supratrochlear artery. These data appear to
contradict the results of these authors because they had not
observed anastomosis between the supraorbital artery and
the arcades near the orbital rim (superWcial and deep orbital
arcade). Thus, this artery could not be considered as a pedi-
cle of an upper eyelid Xap considering this observation.
We did not Wnd the superWcial orbital arcade described
by Kawai et al. [8], which according to these authors lies
Surg Radiol Anat (2008) 30:265–269
beneath the skin and directly on the orbicular muscle of the
eyelids.
Although anatomical variations are possible, during our
dissections we found beneath the skin only small vertical
branches resembling perforating vessels. They probably
arise from the marginal and supratarsal arcades to the pre-
septal arcade and contribute to the blood supply of the skin.
These same communicating networks were observed by
Thomas et al. [19] in their study of 21 cadavers.
Reconstruction of defects of the periorbital and eyelid
region is a real challenge to the surgeon and is particularly
diYcult at the medial canthus. Forehead and glabellar Xaps
are often used in this region, in spite of their drawbacks
such as bulkiness, colour diVerences in the long term, and a
donor scar, which may be unsightly.
Another method of reconstruction is by the using of eye-
lid myocutaneous Xap. In 1979, Anderson and Edwards [1]
described a myocutaneous Xap with a lateral pedicle for
reconstruction of lateral periorbital defects. Papp et al. [10]
in 1990, also used this Xap and described its advantages:
defects can be reconstructed in a single procedure, there is
no loss of bulk after healing and the aesthetic results are
excellent. However, Sutula [16] considered that the draw-
backs of the laterally pedicled myocutaneous Xap are,
among others, asymmetry of the lateral canthus and possi-
ble epicanthal fold formation. In 1991, Yoshimura et al.
[22] described another myocutaneous Xap, which can be
raised in the temporal region for eyelid reconstruction. Its
blood supply is provided by the vessels of the orbicular
muscle of the eyelids. This Xap is reliable but bulky and its
use requires secondary procedures.
Other authors, such as Tenzel [17], Boynton [3], Reali
[12], Jelks [6] and Borman [2], used a myocutaneous Xap
with medial pedicle and demonstrated its value for recon-
struction of superWcial defects of the periorbital region.
So, the organization of the vascular system as proposed
in our study also makes it possible to deWne the pedicle of
the uppers eyelid Xaps and their origins [2].
Conclusion
This anatomical study conWrmed some of the Wndings of
the literature, in particular the richness and complexity of
the vascular system of the upper eyelid. It is characterized
by the presence of an anastomotic network between the
internal and external carotid arteries.
By the Wndings of this anatomical study we can propose
a deWnition of the organization of the vascular system of the
269
upper eyelid by three arcades. That make it possible to raise
in safety Xaps with a reliable blood supply which has useful
applications in daily clinical practice.
References
1. Anderson RL, Edwards JJ (1979) Reconstruction by myocutane-
ous eyelid Xaps. Arch Ophthalmol 97:2358–2363
2. Borman H, Maral T (2003) Periorbital reconstruction using varia-
tions of the upper eyelid Xap. Scand J Plast Reconstr Surg Hand
Surg 37:18–21
3. Boynton JR (1993) Semicircular Xap reconstruction “plus”. Oph-
thalmic Surg 24:826–830
4. Ferner H, Pernkopf E (1964) Atlas of topographical and applied
human anatomy, vol 1. Saunders, Philadelphia, pp 181–186
5. Gausas RE (2004) Advances in applied anatomy of the eyelid and
orbit. Curr Opin Ophthalmol 15(5):422–425
6. Jelks GW, Glat PM, Jelks EB, Longaker MT (2002) Medial can-
thal reconstruction using a medially base upper eyelid myocutane-
ous Xap. Plast Reconstr Surg 110:1636–1643
7. Kamina P (2002) Précis d’Anatomie Clinique. Tome 2, Ed Malo-
ine, Paris, pp 350–360
8. Kawai K, Imanishi N, Nakajima H, Aiso S, Kakibuchi M, Hosok-
awa K (2004) Arterial anatomical features of the upper palpebral.
Plast Reconstr Surg 113(2):479–484
9. Macchi C, Catani C (1993) The anatomy and clinical signiWcation
of the collateral circulation between the internal and the external
carotid arteries through the ophthalmic artery. Ital J Anat Embryol
93(1):23–29
10. Papp C, Maurer H, Geroldinger E (1990) Lower eyelid reconstruction
with the upper eyelid rotation Xap. Plast Reconstr Surg 86:563–565
11. Pelletier M (1969) Anatomie Maxillo-Faciale. Ed Maloine, Paris,
pp 326–329
12. Reali UM, Chiarugi C, Borgognoni L (1993) Reconstruction of
medial canthus defect with a myocutaneous Xap. Ann Plast Surg
30:159–165
13. Rosse C, Gaddum-Rosse P (1997) Hollinshead’s textbook of anat-
omy, 5th edn. Lippincott–Raven, Philadelphia, pp 181–186
14. Rouvière H (1981) Anatomie Humaine. Descriptive, Topographi-
que et fonctionnelle. 11. Ed Masson, Paris, pp 365–375
15. Snell RS, Lemp MA (1989) Clinical anatomy of the eye. Black-
well, Boston, p 91
16. Sutula FC (1990) Lower eyelid reconstruction with the upper eye-
lid rotation Xap (discussion). Plast Reconstr Surg 86:566
17. Tenzel RR, Stewart WB (1978) Eyelid reconstruction by semicir-
cular Xap technique. Ophthalmology 85:1164–1168
18. Tezel E, Sonmez A, Numanoglu A (2003) Medial pedicled orbic-
ularis oculi Xap. J Amer Plast Reconstr Surg 112:1964–1965
19. Whetzel TP, Mathes SJ (1992) Arterial anatomy of the face: an
analysis of vascular territories and perforating cutaneous vessel.
Plast Reconstr Surg 89:591–603
20. Tucker SM, Linberg JV (1994) Vascular anatomy of the eyelids.
Ophthalmology 101:1118–1121
21. Williams PL (1995) Gray’s anatomy, 38th edn. Churchill living-
stone, London, pp 1526–1527
22. Yoshimura Y, Nakajima T, YonedaK (1991) Reconstruction of the
entire upper eyelid area with a subcutaneous pedicle Xap based on
the orbicularis oculi muscle. Plast Reconstr Surg 88:136–139
123