Video Atlas of

Oculofacial Plastic
and Reconstructive
Surgery
This page intentionally left blank
 Second Edition

Video Atlas of
Oculofacial Plastic
and Reconstructive
Surgery
Bobby S. Korn, MD PhD FACS
Associate Professor of Ophthalmology and Plastic Surgery
Department of Ophthalmology
Division of Oculofacial Plastic and Reconstructive Surgery
Shiley Eye Institute
University of California, San Diego School of Medicine
La Jolla, CA
USA

Don O. Kikkawa, MD FACS

Professor of Ophthalmology and Plastic Surgery
Department of Ophthalmology
Division of Oculofacial Plastic and Reconstructive Surgery
Shiley Eye Institute
University of California, San Diego School of Medicine
La Jolla, CA
USA
© 2017, Elsevier Inc. All rights reserved.
First edition 2011
Second edition 2017
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Notices
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ISBN: 978-0-323-29755-4
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Printed in China
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Foreword to the second edition
This is a first for me. I have had the honor of writing the fore-
word for several books but never for a video atlas. As I reviewed
the first edition of this work and the revisions that will be incor-
porated into the second edition, I found myself wishing that
such a resource had been available in the 1980s when I first
began teaching residents and fellows. Intraoperative photo-
graphs are helpful but static and inherently limiting. As I watch
the videos, however, I am impressed by how much more effec-
tive they are in demonstrating the myriad points that we wish
to make when assisting trainees as they operate. A few exam-
ples that our residents have heard me mumble more than once:
• Inject the anesthetic sloooooowly to minimize discomfort.
• Keep the skin on stretch during the incision but don’t place
pressure on the eye.
• Keep the scalpel parallel to the skin…but bevel it here.
• Incise the skin uphill, or stay ahead of the blood if going
downhill.
• Don’t punish the skin; grasp the edge gently yet firmly, and
only once.
• The scissors are curved for a reason; use that to your
advantage.
• Cut purposefully; don’t nibble or gnaw.
• Sew as closely as possible to the wound edge and space
your sutures closely to avoid a ropey closure.
• Evert the wound edges; approximate, don’t strangulate.
• Don’t let the tissue slip off the needle.
• Don’t let the patients’ eyelids open while you’re closing the
skin; she is having a nice nap and won’t appreciate being
disturbed.
Although as teachers we usually want to critique each of the
dozens (? hundreds ?) of subtle but important steps that we
xii
wish to share with our residents and fellows, most of them have
difficulty remembering more than a few “pearls” from each case
– it’s simply a matter of information overload during what can
be a stressful experience. The opportunity to review the work
of masterful surgeons such as Drs. Korn and Kikkawa and their
collaborators – and to do so at leisure, without the challenges
of communicating, often cryptically with hand signals, while the
patient is awake and listening acutely to every word – is a major
advance.
This new edition has increased its scope from 43 procedures
to more than six dozen, including new information on eyelid
surgery in Asian patients, additional options for the reconstruc-
tion of periocular and facial defects following tumor excision,
multiple perspectives on endoscopic dacryocystorhinostomy,
and chapters on aesthetic topics such as fat grafting, injection
of fillers, and face lifts. In addition to the step-by-step instruc-
tions offered for each procedure, I like the accompanying tables
that summarize potential complications and ways to reduce the
risk of such, as well as the helpful listing of “consumables”
needed for the operation.
I predict that this atlas will be even more successful than its
original iteration – to the benefit of new residents, fellows on
the steep slope of the learning curve, experienced surgeons
who wish to hone their skills, and, most importantly, to the
patients we serve.
George B. Bartley, M.D.
The Louis and Evelyn Krueger Professor
of Ophthalmology, Mayo Clinic
Chair Emeritus, Department of Ophthalmology, Mayo Clinic
Chief Executive Officer Emeritus, Mayo Clinic in Florida
 Foreword to the first edition
This oculofacial video atlas is a true gem. It is the next best
thing to being there in the operating room with the authors.
Drs. Korn and Kikkawa are dedicated teachers who take a “belt
and suspenders ” approach to teaching in this text. First, they
provide exquisite, carefully edited, high-definition videos of all
the surgical procedures. Then, to further clarify each proce-
dure, they have all of the important steps described with high-
definition still frame photographs taken from the videos and
placed in a standard text. Important anatomic structures are
emphasized with color shading overlays in many of the photo-
graphs. Details about the fine points of each procedure are
described in the captions as well.
This video atlas should be helpful to the beginning surgeon
as well as the more experienced surgeon. The procedures
covered range all the way from surgical management of a
chalazion to endoscopic dacryocystorhinostomy and compli-
cated orbital operations. Both functional and cosmetic proto-
cols are carefully and elegantly delineated.
I have known Drs. Korn and Kikkawa very well for many years
and can attest to their vast surgical experience, attention to
every detail, and their unusual ability to transmit their extensive
knowledge to others. Dr. Korn was an outstanding fellow under
Dr. Kikkawa, and I had the distinct privilege of having Dr.
Kikkawa as an exceptional fellow. We have given lectures and
courses together and have collaborated on publications, so I
know well their intellectual integrity, bright minds, surgical skill,
and impeccable academic credentials.
This video atlas combines all of the elements of a true learn-
ing experience for anyone performing oculofacial plastic and
reconstructive surgery.
Richard K. Dortzbach MD, FACS
Professor Emeritus
Former Peter A. Duehr Chair
Department of Ophthalmology & Visual Sciences
University of Wisconsin School of Medicine and Public
Health
Madison, WI
xiii
Preface
Five years ago we embarked on a mission to bring the realm
of oculofacial plastic surgery directly from the operating room
to the practicing surgeon. We are now pleased to release the
Second Edition of the Video Atlas of Oculofacial Plastic and
Reconstructive Surgery. This video atlas is the product of hun-
dreds of hours of oculofacial surgery captured in high definition,
edited and narrated with anatomic overlays and step-by-step
diagrams.
We have made it our goal to include only the highest quality
videos to guide the surgeon through even the most complex
of operations. Highlights of the second edition include new
chapters on fat grafting, face-lifting, orbital fracture repair and
expanded section on Asian eyelid surgery and epicanthoplasty.
xiv
In addition, revised chapters from the first version with re-edited
videos are also included.
The field of oculofacial plastic surgery is still in its infancy.
Many time-honored procedures from the past are no longer
being performed today, being replaced by techniques that
allow for improved results and faster healing. Since inception,
oculofacial plastic surgery has been a discipline passed from
mentor to student and from colleague to colleague. We have
endeavored to maintain this close personal instructional method
in this atlas and hope that the readers enjoy this format.
Bobby S. Korn
Don O. Kikkawa
 List of contributors
Ramzi M. Alameddine, MD Don O. Kikkawa, MD FACS
Senior Clinical Instructor Professor of Ophthalmology and Plastic Surgery
Department of Ophthalmology Vice Chair, Department of Ophthalmology
University of California, San Diego School of Medicine University of California, San Diego School of Medicine
Shiley Eye Institute Shiley Eye Institute
La Jolla, CA La Jolla, CA
USA USA
Christine C. Annunziata, MD Yoon-Duck Kim, MD
Attending Oculofacial Plastic Surgeon Professor of Ophthalmology
Metrolina Eye Associates Samsung Medical Center
Matthews, NC Sungkyunkwan University School of Medicine
USA Seoul
Korea
Weerawan Chokthaweesak, MD
Assistant Professor of Ophthalmology Audrey C. Ko, MD
Mahidol University Senior Clinical Instructor
Ramathibodi Hospital Department of Ophthalmology
Bangkok University of California, San Diego School of Medicine
Thailand Shiley Eye Institute
La Jolla, CA
Morris E. Hartstein, MD, FACS
USA
Director, Oculoplastic Surgery
Assaf Harofeh Medical Center Bobby S. Korn, MD PhD FACS
Department of Ophthalmology Associate Professor of Ophthalmology and Plastic Surgery
Zerifin, Israel University of California, San Diego School of Medicine
Clinical Associate Professor Shiley Eye Institute
Saint Louis University La Jolla, CA
Department of Ophthalmology USA
St. Louis, MO
Bradford W. Lee, MD, MSc
USA
Assistant Professor of Ophthalmology
Eric M. Hink, MD Bascom Palmer Eye Institute
Assistant Professor of Ophthalmology University of Miami, Miller School of Medicine
University of Colorado Miami, FL
Denver, CO USA
USA

xv
Kanjana Leelapatranurak, MD Sang-Rog Oh, MD
Attending Ophthalmologist Attending Ophthalmologist, Division of Oculofacial and
Department of Ophthalmology Reconstructive Surgery
Bumrungrad International Hospital Department of Ophthalmology
Bangkok The Permanente Medical Group
Thailand Sacramento, CA
USA
Dongmei Li, MD
Professor of Ophthalmology Midori H. Osaki, MD, MBA
Beijing TongRen Eye Center Chief, Division of Ophthalmic Plastic and Reconstructive Surgery
Capital Medical University Department of Ophthalmology and Visual Sciences
Beijing Paulista School of Medicine/Federal University of Sao Paulo
China Sao Paulo
Brazil
Lee Hooi Lim, MBBS
Senior Consultant and Director Tammy H. Osaki, MD PhD
Eye Etc. Partners Pte. Ltd. Attending Ophthalmologist, Division of Ophthalmic Plastic and
Reconstructive Surgery
Singapore
Department of Ophthalmology and Visual Sciences
Honglei Liu, MD, PhD Paulista School of Medicine/Federal University of Sao Paulo
Associate Professor of Clinical Ophthalmology Sao Paulo
Vice Chair, Department of Ophthalmology Brazil
No. 4 Hospital
Ayelet Priel, MD
Xi’an City
Goldschleger Eye Institute
China
Sheba Medical Center
Guy G. Massry, MD Ramat-Gan
Clinical Professor of Ophthalmology Israel
University of Southern California, Keck School of Medicine
Karim G. Punja, MD, FRCSC
Los Angeles, CA
Clinical Associate Professor
USA
Department of Surgery, Division of Ophthalmology
Michael S. McCracken, MD University of Calgary
Medical Director, McCracken Eye and Face Institute Calgary, Alberta
Assistant Clinical Professor Canada
University of Colorado Health Science Center
Jack Rootman FRCS
Denver, CO
Professor (Emeritus)
USA
Department of Ophthalmology and Visual Science
Masashi Mimura, MD Department of Pathology and Laboratory Science
Chief, Clinic of Lacrimal Drainage Surgery and Ophthalmic University of British Columbia
Plastic and Reconstructive Surgery
Vancouver, British Columbia
Department of Ophthalmology
Canada
Osaka Medical College
Osaka
Japan

List of contributors

xvi
Mr Richard L. Scawn, MBBS, FRCOphth Patrick T. Yang, MD
Locum Consultant University of Toronto
Adnexal Service Department of Ophthalmology and Vision Sciences
Moorfields Eye Hospital Toronto
London Canada
UK
Suk-Woo Yang, MD
Jeremiah Tao, MD, FACS Professor of Ophthalmology
Associate Professor Department of Ophthalmology and Visual Sciences
Chief, Oculofacial Plastic Surgery Division of Ophthalmic Plastic and Reconstructive Surgery
Department of Ophthalmology Seoul St. Mary’s Hospital
Gavin Herbert Eye Institute The Catholic University of Korea
University of California Seoul
Irvine, CA Korea
USA
Nattawut Wanumkarng, MD
Attending Ophthalmologist
Department of Ophthalmology
Bumrungrad International Hospital
Bangkok
Thailand
Kyung In Woo, MD
Professor of Ophthalmology
Samsung Medical Center
Sungkyunkwan University School of Medicine
Seoul
Korea

List of contributors

xvii
Acknowledgements
We are indebted to the editorial staff at Elsevier for their
support of this project. In particular, we are grateful to Russell
Gabbedy (Executive Content Strategist) who has been a tire-
less supporter of this project since he commissioned the first
edition of the Atlas. We would also like to acknowledge Nani
Clansey (Senior Content Development Strategist) for doing
her best to manage this complex project, Andrew Riley (Project
Manager), Jonathan Davis (Multimedia), Alex Baker (Medical
Illustrations).
This book would not be possible without the support of col-
leagues and friends. First, we thank our teachers for instilling
in us the desire to continue to learn and the passion to practice
Dedication
For our parents, Tom and Tuanjai (BSK) and Robert and Alice
(DOK)
For Wanya, Justin and Bryan (BSK) and Cheryl, Jason, Claire
and Alina (DOK)
xviii
the highest form of art possible. Second, we thank our distin-
guished colleagues for their valued contributions to this book
and for their friendship. Third, we thank all of our fellows and
residents for continually challenging us to find the best surgical
approaches in the care of our patients. Many of our fellows
have contributed to this book making it even more meaningful
to us. Fourth, we thank the members of our academic office,
Annaleah Ariola and Denise Adame for their administrative
support.
Finally, we acknowledge our families for without their unwa-
vering love, patience and support this book would not be
possible.

CHAPTER 1
Foundations of oculofacial plastic surgery
Bradford W. Lee • Ramzi M. Alameddine • Don O. Kikkawa • Bobby S. Korn
INTRODUCTION
Oculofacial surgery is a unique specialty that combines
aspects of ophthalmology, general plastic surgery, head and
neck surgery, dermatology, neurological surgery, and craniofa-
cial surgery. With advances in endoscopic and small incision
techniques, many oculofacial procedures can now be per-
formed safely and effectively with minimal scarring and excel-
lent aesthetic results.
EVALUATION
Oculofacial surgery encompasses both functional and aes-
thetic goals. As such, the evaluation of the oculofacial patient
requires a complete history and physical examination with par-
ticular attention to medical, functional, aesthetic, and psycho-
social details.
A complete medical history should be elicited, with particular
attention to hypertension, diabetes, liver disease, immune
status, current or prior cancer, and trauma. Surgical history
should include any previous facial surgery, ophthalmic surgery
(such as refractive surgery), use of neurotoxins and dermal
fillers, and chemical- or energy-based skin treatments. Medica-
tions, including anticoagulants, tobacco, and alcohol, should
be documented. A history of implanted cardiac devices should
also be noted since this determines which types of cautery can
be safely used. The use of medications, tobacco and alcohol
should be documented.
The physical examination should focus on the areas of patient
concern and the proposed surgical procedure. The entire face
should be examined and the patient can be allowed to point
to areas of concern using a handheld mirror. For most eyelid,
facial, and orbital procedures, documentation of visual acuity,
pupillary function, color vision, slit-lamp examination, intraocu-
lar pressure, eyelid position and closure, and tear film are
minimum requirements. Dilated fundoscopic examination may
be required in select cases if there is any evidence of optic
nerve compromise. Ocular motility in nine positions of gaze
SECTION ONE INTRODUCTION
(Figure 1.1) and globe position by exophthalmometry (Figure
1.2) should be carefully documented for any orbital procedure.
The Naugle exophthalmometer is useful for measuring propto-
sis or enophthalmos when prior surgery has been performed
to remove the lateral orbital rim. Vertical and horizontal globe
displacement should be noted as well. Evaluation of lacrimal
diseases requires functional and anatomic testing. Both dye
disappearance testing and lacrimal probing and irrigation are
useful.
Ancillary testing for oculofacial surgery may include visual
field testing for functional eyelid conditions, dacryoscintigraphy
for lacrimal obstructions, and imaging studies for orbital dis-
eases. Computed tomography (CT) is useful for evaluation of
bony structures and general screening for orbital disease. Mag-
netic resonance imaging (MRI) is better suited for soft-tissue
lesions and optic nerve diseases. Angiography is indispensable
for evaluating vascular malformations.
Photography is an essential component of the oculofacial
examination. Ideally, photographs should be taken during all
aspects of patient care from the preoperative evaluation, intra-
operatively when indicated, and at postoperative visits. Many
third-party insurance carriers require photographic documenta-
tion prior to authorization of functional oculofacial surgeries.
Additionally, photographs are important for the aesthetic patient
to document changes after treatment and for medical legal
protection. Photographs should be taken in the frontal, side,
and three-quarter views. For orbital diseases, eye movements
in the nine positions of gaze are taken. Additionally, a worm’s
eye view (Figure 1.3) is used to document globe position and
closure of the lids to document the presence or absence of
lagophthalmos (Figure 1.4).
Modern digital single lens reflex (DSLR) cameras are ideal in
the oculofacial setting. These DSLRs allow for rapid sequence
photography with excellent resolution and dynamic range com-
pared to pocket-sized cameras with smaller imaging sensors.
Uniform lighting can be difficult and variable depending on
the clinical situation. In general, flash photography is used to
1
Figure 1.1 Standard version photographs showing the eyes in nine positions of gaze.

Figure 1.2 Globe position as measured using a Naugle Figure 1.3 Worm’s eye view in a patient with thyroid-related orbitopathy.
exophthalmometer.

Figure 1.4 Worm’s eye view of a patient gently closing her eyelids with
lagophthalmos on the right side.

SECTION ONE • INTRODUCTION

Chapter 1 Foundations of oculofacial plastic surgery
2
normalize lighting. A dedicated photo room with a blue back-
drop and diffuse lighting is ideal, but for most surgeons, a
DSLR using the pop-up or external flash will suffice. The use
of a 50 mm macro lens is ideally suited for full-time use. Using
the macro function, this lens allows close-up photography of
small lesions on the face. Furthermore, with its fixed focal
length, facial photographs will appear square and consistent,
avoiding the barrel distortion seen when the camera is too
close to the subject. Finally, to achieve uniform focus across
the entire photograph, a small aperture (at least greater than
f/10) should be set to allow for a deep depth of field.
ANESTHESIA
The choice of anesthesia depends on patient age, medical
condition, as well as physician and patient preference. Patient
safety and comfort are an absolute priority, and intraoperative
patient cooperation may be needed during certain oculofacial
procedures. A combination of various anesthetic modalities is
frequently utilized to provide an optimal surgical experience.
Topical anesthesia
Topical anesthetic drops such as proparacaine or tetracaine
are useful for conjunctival procedures and also to prevent
ocular discomfort from prep solutions (e.g., Betadine solution).
Topical anesthetic gels, such as lidocaine gel, with concentra-
tions ranging from 1% to 4%, can be used in more involved
procedures because of their longer-lasting effect. Also, topical
anesthetic creams can be applied to the skin before injection
procedures or minor cutaneous biopsies.
Local infiltration
In most oculofacial procedures, local infiltration of involved
tissues is the preferred method of anesthesia. It entails minimal
risks while allowing adequate patient comfort and cooperation.
Local anesthetic agents include short-acting lidocaine and pro-
caine, or long-acting bupivacaine. A mixture of short-acting and
long-acting anesthetic agents is often used to have a rapid
onset and long duration of action. The mixture of equal parts
of 2% lidocaine with epinephrine at 1 : 100,000 and 0.75%
bupivacaine is an effective combination. The vasoconstrictive
effect of epinephrine improves hemostasis, reduces vascular
absorption, and increases duration of action of the anesthetic.
Other potential additions include hyaluronidase, which facili-
tates anesthetic dispersion through tissues, and bicarbonate,
which buffers the pH, reducing the stinging sensation during
infiltration. The surgeon should be vigilant for possible cardiac
or neurologic side effects, particularly with inadvertent intravas-
cular injections. By withdrawing the plunger and ensuring that
there is no reflux of blood prior to injecting, the risk of intravas-
cular injection can be further reduced. Local anesthetic should
be injected sparingly during external levator advancement and
eyelid retraction repairs, since infiltrating the levator with anes-
thetic can cause artificially reduced levator function. Other risks
include tissue necrosis, although this is unlikely due to the
abundant vascularity of the periorbital area.
When local anesthesia is administered in a clinic setting
without oral or IV sedation, several maneuvers can be per-
formed to minimize discomfort. Performing massage or vibra-
tory distraction at or near the site of injection may decrease
pain perception according to the gate control theory. Dilution
of lidocaine/bupivacaine with sodium bicarbonate (in a 1 : 10
ratio) raises the pH to minimize injection site burning. Pre-
cooling the target area with ice packs is another adjunct, as is
use of topical lidocaine cream for the skin or 4% lidocaine on
cotton tip applicators for mucous membranes. Finally, slow
injection, handholding and talking “talkesthesia” are all useful
in fully conscious patients. Minimizing pain during injection will
go a long way towards maintaining the confidence of your
patients and ensuring subsequent cooperation during the
procedure.
Regional block
Regional blocks can be useful in oculofacial procedures but are
rarely used as a standalone means of anesthesia due to redun-
dant innervation in the facial region (Figure 1.5). It allows the
surgeon to minimize the volume of local infiltration needed,
anesthetize broad regions of the face, and minimize tissue
distortion from local infiltration. Regional blocks of the face
must address one or more branches of the ophthalmic, maxil-
lary, and mandibular divisions of the trigeminal nerve.
Lacrimal nerve
The lacrimal nerve branches off the ophthalmic division of the
trigeminal nerve and supplies the lateral upper eyelid and lac-
rimal gland. It can be blocked by injecting the needle along the
superolateral orbital rim behind the lacrimal gland. Potential
risks include injury or injection into the lacrimal artery. This block
is useful when performing lacrimal gland biopsies or resuspen-
sion procedures (Chapter 70).
Frontal nerve
The frontal nerve is a branch of the ophthalmic division of the
trigeminal nerve. It further divides into the supraorbital and
supratrochlear nerves and supplies the medial and central
upper eyelids and the forehead. It can be fully blocked by inject-
ing anesthetic deep in the orbit along the central orbital roof.
Alternatively, the supraorbital nerve can be selectively blocked
by injecting near its exit from the orbit, at the supraorbital notch
or foramen, around the medial third of the superior orbital rim.
A supraorbital block anesthetizes the central eyelid, eyebrow,
and forehead. Similarly, the supratrochlear nerve can be
blocked by injecting anesthetic near the trochlea at the junction
of the medial and superior orbital rim. A supratrochlear block
anesthetizes the medial eyelid and eyebrow. Prior to injecting,
the surgeon should withdraw the plunger on the syringe to
ensure that inadvertent intravascular injection into the supraor-
bital or supratrochlear arteries does not occur. This block can
be used for any upper eyelid procedure and is well suited for
limited upper eyelid protractor myectomy (Chapter 33).
Nasociliary nerve
The nasociliary nerve is the third branch of the ophthalmic divi-
sion of the trigeminal nerve. It supplies the nasal mucosa and
skin through the anterior and posterior ethmoidal nerves, as
well as the medial canthus and lacrimal sac via the infratroch-
lear nerve. An infratrochlear block is achieved by injecting
deeply under the trochlea above the level of the medial canthal
tendon. A deeper injection at the same location would block
the ethmoidal nerves, but possible injury to the corresponding
3
 Supraorbital
nerve

Supratrochlear
Supraorbital Supratrochlear nerve
Infratrochlear

Lacrimal Infratrochlear nerve

nerve
Zygomatic

Lacrimal
Zygomaticofacial
nerve
Infraorbital

Nasal

Supraorbital nerve

Frontal nerve

Supratrochlear
nerve

Infraorbital
nerve
Mental
nerve

Figure 1.5 Periocular sensory nerves.

ethmoidal arteries can cause orbital hemorrhage. Ethmoidal
nerve blocks can be performed prior to dacryocystorhinostomy
or medial-wall decompression (Chapters 53–59, 64).
Infraorbital nerve
The infraorbital nerve branches off the maxillary division of the
trigeminal nerve and supplies the lower eyelid skin and con-
junctiva, in addition to the medial canthus, lacrimal sac, mid-
face, and maxilla. It can be blocked where it exits the infraorbital
foramen around 7–10 mm inferior to the infraorbital rim. Either
the transconjunctival or sublabial routes can be used for admin-
istration. The foramen can be palpated where it intersects a
line drawn from the nasal ala to the lateral canthal angle. Alter-
natively, deeper orbital injection along the orbital floor can block
the nerve more proximally. This block is useful for nasolacrimal
intubation in the clinic setting (Chapter 60).
Zygomaticofacial nerve
The zygomaticofacial nerve is another branch of the maxillary
division of the trigeminal nerve; it supplies the lateral canthus
and lateral lower eyelid. It can be blocked where it exits the
zygomatic bone through a foramen around 10 mm inferior to
the lateral canthus. This block is useful for adjunctive anesthe-
sia during a zygomaticomaxillary complex fracture repair.

SECTION ONE • INTRODUCTION

Chapter 1 Foundations of oculofacial plastic surgery
4
Mental nerve block
The mental nerve is a branch of the mandibular nerve. Blocking
this nerve can be useful in administering fillers in the lower lip
and chin region. This block can be given through the lower
gingival sulcus just as the mental nerve exits its foramen.
Oral sedation
Oral sedation in conjunction with local anesthetic administration
is preferred for most in-office procedures. Oral benzodi-
azepines such as diazepam are given at least 30–60 minutes
prior to the procedure. Clonidine can be used for both its
anxiolytic and anti-hypertensive properties. Oversedation is
the most common risk, especially with benzodiazepines, in
which case flumazenil (a benzodiazepine antagonist) can be
administered.
Monitored anesthesia care
Monitored anesthesia care combined with local or regional
block is preferred in more complex procedures. It is popular
because of its ability to provide sedation, amnesia, and anxioly-
sis. Intravenous propofol may be given as a bolus at the time
of local anesthetic injection, followed by a steady-state infusion
supplemented with opioids (fentanyl) or benzodiazepines. Pos-
sible side effects include apnea, myocardial depression, and
decreased vascular resistance. For this reason, close monitor-
ing of vital signs, ECGs, and pulse oximetry is necessary.
General anesthesia
General anesthesia is reserved for more prolonged and stimu-
lating procedures, when nasal bleeding is expected, or in chil-
dren and other patients who may have difficulty following
instructions. Local anesthesia with epinephrine is typically
administered as an adjunct for hemostasis and postoperative
pain. Risks involved include laryngospasm, malignant hyper-
thermia, myocardial infarction, and even death. A careful family
history looking for unexplained anesthesia death or malignant
Figure 1.6 Sequential compression device.
hyperthermia should be obtained, since these life-threatening
conditions are more commonly associated with musculoskel-
etal ocular conditions. All cases of surgery under general
anesthesia should employ the use of sequential compression
devices (SCDs) to minimize risk of deep venous thrombosis
(Figure 1.6).
Tumescent anesthesia
Tumescent anesthesia is a technique that provides effective
pain control and hemostasis for larger regions of the face and
body. It can be effectively used in liposuction/lipotransfer, face
and neck lifting, and endoscopic or pretrichial brow lifting
(Chapters 22–24, 47). Care should be taken to ensure the
meticulous dilution and labeling of tumescent anesthetic solu-
tions and to consider the total amount of anesthetic delivered
in order to prevent anesthetic or epinephrine toxicity.
HEMOSTASIS
Hemostasis in oculofacial surgery is of vital importance, since
an orbital hemorrhage can cause compartment syndrome and
possible blindness. Even for non-orbital surgeries, postopera-
tive bleeds or hematomas can result in blood loss and patient
anxiety, compromise of flaps or grafts, inflammation, and
increased postoperative healing time. Prolonged epistaxis after
lacrimal surgery can result in significant postoperative morbidity
and discomfort.
Anticoagulants
Prior to surgery, patients on anticoagulants should be advised
to discuss with their internist, cardiologist, or other prescribing
physician the possibility of stopping them in the perioperative
period. A decision must be made balancing the risks of
intra- and postoperative bleeding versus the risk of potentially
life-threatening thromboembolic events. Where appropriate,
coagulation studies should be ordered preoperatively.
5
 Aspirin and other non-steroidal anti-inflammatory drugs
(NSAIDs) inhibit platelet function and ideally should be stopped
at least 1–2 weeks prior to surgery. Clopidogrel (Plavix) should
also be stopped at least 1 week prior to surgery.
Warfarin (Coumadin) should be stopped at least 5 days prior
to surgery to allow the INR to normalize. It can be restarted the
next day after surgery, given the lag time before the INR
becomes therapeutic again. If anticoagulation is necessary
within this time frame, patients can be bridged on IV unfraction-
ated heparin or low-molecular-weight heparin injections, which
are typically discontinued 4–5 hours (half-life of 45 minutes) and
24 hours (half-life 3–5 hours) prior to surgery, respectively. Of
particular note, newer direct thrombin inhibitors (e.g., dabigat-
ran) and factor Xa inhibitors (e.g., rivaroxaban, apixaban,
edoxaban) are being utilized, which have shorter half-lives,
which mean they can be discontinued and resumed rapidly.
However, these agents lack a reversal strategy and cannot be
tested for activity with PT/INR testing.
Finally, some over-the-counter vitamins and supplements
can have anticoagulant effects and consideration should be
given to discontinuing these prior to surgery. These include
Ginkgo biloba, ginseng, ginger, garlic, fish oil, and vitamin E
which are often overlooked by patients and surgeons as a
source of significant anticoagulant activity.
Coagulation devices
Thermal coagulation with a battery-powered high- or low-
temperature cautery is one modality of coagulation that can be
performed using a disposable handheld probe. This cost-
effective and portable means of cautery can be used for dis-
section or coagulation but it is typically less effective in stopping
brisk bleeding compared to electrocautery. The use of hand-
held thermal cautery may also cause less pain and startle
movement compared to electrocautery. The use of handheld
thermal cautery for clinic-based procedures is ideal because
no bulky electrocautery unit or grounding pads are required.
Electrocautery can be performed using monopolar, bipolar,
or wetfield cautery units. Bipolar cautery conducts current
between the two prongs of the forceps and provides the
most effective coagulation while minimizing thermal injury to
surrounding tissues. Monopolar cautery can alternately cut
and coagulate tissue but requires the use of a grounding
pad and should be avoided in patients who have pacemak-
ers and automatic implantable cardioverter defibrillators
(AICDs), since transmitted currents can result in pace inhibi-
tion, damage to the pulse generator, or inappropriate
antitachycardiac therapy. A smoke evacuator can be fash-
ioned with monopolar cautery using standard IV tubing and
connecting this to standard wall or portable suction (Figure
1.7). Another device that can simultaneously cut and coagu-
late tissue is the carbon dioxide laser. Use of the CO2 laser
requires training, protective eyewear for OR staff and full-
time use of metal corneal shields to prevent corneal damage.
Care should also be taken to use the appropriate laser
settings as excessive energy can lead to charred tissue
edges and wound dehiscence postoperatively.
With all of these agents, it is important to communicate with
the anesthesiologist to avoid excessive supplementary oxygen
use and reduce the risk of fires. Even with lower oxygen use,
SECTION ONE • INTRODUCTION
Chapter 1 Foundations of oculofacial plastic surgery
6
Figure 1.7 Suction and electrocautery setup.
surgical drapes covering the mouth and nose may result in
oxygen pooling, increasing the incendiary risk.
Other hemostatic agents
The most frequently used vasoconstrictive agent in local
anesthesia is epinephrine, which typically comes pre-mixed in
a 1 : 100,000 concentration. This can be further diluted to
1 : 200,000 with similar vasoconstrictive properties and less
cardiotoxity. Local anesthesia should be injected about 15
minutes prior to surgery for maximal effect. Topical 2.5% phe-
nylephrine drops can similarly be applied to the ocular surface
to minimize conjunctival bleeding.
Various other types of hemostatic agents can be used intra-
operatively to assist with hemostasis. These include gelatin
sponges (Gelfoam), absorbable hemostats (Surgicel, Avitene),
hydrogen peroxide, topical thrombin, and fibrin sealant (Evicel).
Direct pressure and the use of cold saline can also assist with
hemostasis. For patients with platelet dysfunction or other
bleeding diatheses, platelet transfusions and perioperative
tranexamic acid can further help hemostasis. Tranexamic acid,
an anti-fibrinolytic agent, must be used cautiously and with
serial compression devices (SCD) to mitigate the risk of venous
thromboses.
During lacrimal surgery, nasal mucosal bleeding can be
reduced with preoperative oxymetazoline nasal sprays and
nasal packing with 1 : 10,000 epinephrine-soaked cotton
pledgets. Other strategies to reduce bleeding include permis-
sive hypotension and placing the patient in reverse Trendelen-
burg position. Intranasal silver nitrate and suction cautery
devices can assist with direct coagulation.
For bone bleeding, paraffin-based bone wax can be directly
applied. In open, accessible areas, the bone wax can be
directly applied by digital application while deeper in the orbit
a small ball of wax can be applied on a cotton-tip applicator.
In select cases, bone marrow space bleeding can be stopped
using a high-speed diamond tip burr by thermal coagulation.
Postoperative bleeding prophylaxis
Postoperative bleeding occurs with greatest frequency within
the first 48–72 hours after surgery but can occur as late as 1–2
weeks postoperatively as clot contraction occurs. Patients
should be instructed to avoid heavy lifting, straining, and
bending, which can result in a transient spike in blood pressure
and subsequent bleeding.
 Pressure patches, head wraps, and sutured foam bolsters
can be used to apply direct pressure to the surgical site to help
prevent postoperative bleeding and hematoma formation. Care
should be taken to avoid pressure patching the eye after orbital
surgery as this may mask symptoms of a retrobulbar hemor-
rhage. When large coronal and facial flaps are performed,
drains such as a Jackson–Pratt drain can assist in evacuating
early postoperative hemorrhage or serosanguineous drainage.

INCISION PLANNING
Relaxed skin tension lines and lines of
maximal extensibility
The aging face has a universal pattern of rhytides that follow
the inherent characteristic skin tension lines (Figure 1.8). First
described by Dupuytren, these lines are also called Langer,
Kocher, or relaxed skin tension lines (RSTL) (Figure 1.9).
Shaped by repeated facial muscle contracture, RSTL are
usually perpendicular to the long axis of underlying muscles.
Lines of maximal extensibility (LME) run perpendicular to the
RSTL, and indicate the direction along which facial skin can be Figure 1.9 Relaxed skin tension lines (RSTL).
maximally extended (Figure 1.10). Incision planning aims to
produce the most inconspicuous scar possible that blends with
the natural facial rhytides. In general this can be achieved by
planning incisions along RSTL, and by placing wound tension
along LME. Incisions can be further camouflaged by placing
them at the junction of facial aesthetic subunits, or where
natural folds and creases exist.
Classic oculofacial incisions
Eyelid crease
The upper eyelid crease incision follows the natural fold ranging
from 4 mm to 10 mm superior to eyelid margin. This cosmeti-
cally pleasing, workhorse incision is the preferred approach
for broad access to the lateral, superior, and medial orbit and
also can be used for wide access to the brow region (Figure
1.11). The medial upper eyelid crease approach can provide
direct and rapid access to the superomedial orbit for biopsy

Figure 1.10 Lines of maximal extensibility (LME).

Figure 1.8 Age-related facial rhytides. Figure 1.11 Upper eyelid crease incision.

7
of orbital masses, as well as optic nerve sheath fenestration
(Chapter 71).
Lateral canthotomy
A lateral canthotomy is performed by making a small horizontal
incision at the angle of the lateral canthus. It is often combined
with an inferior cantholysis, where the inferior crus of the lateral
canthus is identified and released to provide added exposure
to the inferior eyelid and orbit (Figure 1.12). An extended Berke-
style lateral canthal incision can be performed for exposure of
the lateral orbital rim, but preference should be given to an
extended temporal upper eyelid crease incision that can provide
equivalent exposure and superior cosmesis. An urgent indica-
tion for lateral canthotomy/cantholysis is orbital compartment
syndrome (i.e., retrobulbar hematoma), where an additional
superior cantholysis can be performed if further orbital pressure
lowering is necessary.
Transconjunctival
The inferior transconjunctival approach is the preferred method
of access for the lower eyelid, inferior and medial orbit. When
combined with a lateral canthotomy and inferior cantholysis,
this combined swinging eyelid approach can provide wide
access to the deep medial and superomedial portions of the
orbit. The transconjunctival incision is made through the palpe-
bral conjunctiva of the lower lid several millimeters below the
inferior tarsal border (Figure 1.13). Common uses of this
Figure 1.12 Lateral canthotomy and inferior cantholysis.
Figure 1.13 Inferior transconjunctival incision
SECTION ONE • INTRODUCTION
Chapter 1 Foundations of oculofacial plastic surgery
8
approach include lower blepharoplasty (Chapters 9), entropion
repair (Chapter 29), lower eyelid retraction repair (Chapters
34–36), orbital decompression (Chapter 64), and orbital floor
repair (Chapters 67, 68). One can extend this incision just
posterior to the caruncle, and in these cases, disinserting and
later reinserting the inferior oblique muscle at its origin allows
improved surgical access with minimal disruption to anatomical
structures.
Transcaruncular
The transcaruncular incision is placed either between the
caruncle and the plica, or just posterior to the caruncle (Figure
1.14). The dissection plane travels posterior to the posterior
lacrimal crest, avoiding the lacrimal drainage apparatus. It gives
access to the medial orbital wall, and can be combined with
an inferior transconjunctival incision to improve combined
access of the orbital floor and medial wall.
Infraciliary
The infraciliary incision is a transcutaneous incision that is made
approximately 1 mm inferior to the cilia of the lower lid (Figure
1.15). Dissection toward the orbital rim is performed in a pre-
orbicularis plane to avoid transecting and denervating the pre-
tarsal orbicularis oculi muscle. The infraciliary incision is used
in transcutaneous lower eyelid blepharoplasty when skin
removal is necessary (Chapter 10), and ectropion repair with
skin graft placement (Chapter 27). The infraciliary approach
Figure 1.14 Transcaruncular incision
Figure 1.15 Infraciliary incision.
should be used with caution when performing orbital fracture Vicryl is a synthetic, braided, absorbable suture composed of
repair as lid retraction and cicatricial ectropion can result. polyglactin. It is degraded by hydrolysis and maintains its tensile
strength for about 2–3 weeks. It can incite an inflammatory
SUTURES AND NEEDLES reaction when used for skin closures and is preferentially used
for subcutaneous and muscle layer closures.
Sutures can be categorized as absorbable or non-absorbable.
PDS is a synthetic, monofilament suture composed of polydi-
Absorbable sutures degrade over varying lengths of time,
oxanone. It is easy to handle and holds up to one-quarter of
whereas non-absorbable sutures undergo minimal degradation
its tensile strength at 42 days. PDS is mostly used when
over time (Tables 1.1 and 1.2).
extended wound support is desired.
Non-absorbable sutures Staples
Silk is a biologic, braided, non-absorbable suture that is easily Metal staples can be used to close thicker skin and are rapidly
handled but can incite a pronounced inflammatory reaction if administered. They provide excellent tissue eversion and are
left in the skin for prolonged periods of time. It can be used primarily used to close scalp incisions following coronal or
when placing traction sutures through the eyelid margin, for endoscopic brow lift procedures. Staples should never be used
eyelid margin repair, and for ligating blood vessels like the on the visibly exposed parts of the face.
superficial temporal artery. Care should be taken when using
silk for closure of upper eyelid crease incisions as prolonged Surgical needles
removal can lead to visible suture tracks on the skin Needles should be chosen purposefully based on the indica-
postoperatively. tion, and options include cutting, reverse cutting, tapered and
Nylon is a synthetic, non-absorbable monofilament suture that spatulated varieties (Figure 1.16). Cutting and reverse cutting
induces minimal inflammation and is suitable for skin closure. needles are most commonly used on skin and subcutaneous
Prolene is a synthetic, non-absorbable, polypropylene mono- tissues. Taper point needles are more difficult to pass but are
filament suture. Like nylon suture, it is somewhat more difficult useful when tissue trauma and minimal bruising is desired.
to handle due to its propensity to retain “memory.” It causes Spatulated needles are best used when lamellar passes are
minimal tissue reactivity and has the distinct advantage of desired, such as when reattaching extraocular muscles to the
almost fully maintaining its tensile strength over extended sclera.
periods of time. It can be used for skin closures or to secure Surgical needles also come with a variety of curvatures. Half-
deeper tissues. circle or 180° needles are useful in confined spaces, such as
Dacron is a synthetic, braided, non-absorbable suture. It is when attaching a lateral tarsal strip to the periosteum inside
composed of a polyester core that is coated with polybutylate. the lateral orbital rim, or when suturing mucosal flaps during
It is easy to handle, and has less tissue reactivity compared to dacryocystorhinostomy surgery; 135° needles are used for skin
silk. closures; whereas 90° spatulated needles are best used for
Mersilene is a synthetic, non-absorbable braided polyester lamellar passes.
fiber suture. This suture retains its tensile strength and elicits
minimal inflammatory reaction. It is encapsulated over time with SUTURE TECHNIQUES
fibrous connective tissue. There are numerous techniques for wound closure, and the
goals are to reduce wound tension via closure of deep tissues,
Absorbable sutures to minimize tension on the skin incision, and to promote optimal
Plain gut is a biologic suture derived from purified collagen of wound cosmesis.
bovine or sheep intestines. It incites an inflammatory degrada-
tion process and is digested via proteolytic enzymes. Plain gut
retains its tensile strength for around 7 days, whereas fast-
absorbing gut retains its tensile strength for around 5 days.
Chromic gut is essentially plain gut that has been tanned with Table 1.1 Relative amounts of in vivo tensile strength
chromium. It incites less inflammation than plain gut and Suture Percent strength Percent strength at
degrades over a longer period (10–14 days). at 2 weeks 12 weeks
Dexon is synthetic, braided, absorbable suture composed of
polyglycolic acid. It is degraded by hydrolysis and induces a Silk 86 48
small degree of inflammation. Dexon is primarily used for sub-
Nylon 98 91
cutaneous deep closures and lasts about 2–3 weeks.
Monocryl is a synthetic, monofilament, absorbable suture Prolene 100 100
composed of a copolymer of glycolide and epsilon-caprolactone.
This suture is used for deep or subcuticular closures on the Mersilene 100 100
face and skin graft donor sites other than the upper eyelid Dacron 99 90
and has less post-inflammatory changes compared to Vicryl.
Monocryl maintains high tensile strength with a half-life of 7–14 Plain gut 10–50 0
days.
Dexon 8–50 0

9
 Table 1.2 General suture characteristics and strength
Material Relative Relative Tissue Ease of Exposed Available
strength hold time reaction handling ends sizes
Gut 6 1 week 4+ Good Stiff 4-0–6-0
Chromic gut 6 <2 weeks 3+ Good Stiff 4-0–8-0
Braided Vicryl 9 2 weeks 2+ Good Stiff 4-0–9-0
Monofilament 9 2 weeks 2+ Good Stiff 9-0–10-0
Vicryl
Dexon 9 2 weeks 2+ Good Stiff 5-0–8-0
PDS 9 4–6 weeks 2+ Good Stiff 4-0–10-0
Virgin silk 7 2 months 3+ Excellent Softest 8-0–9-0
Braided silk 8 2 months 3+ Good Soft 4-0–9-0
Nylon 9 6 months 1+ Fair Stiff/sharp 3-0–11-0
Prolene 10 >12 months 1+ Fair Stiff/sharp 2-0–10-0
Polyester 10 >12 months 1+ Fair Stiff 4-0–6-0
Mersilene 10 >12 months 1+ Good Soft 4-0–6-0

Point Point

Body
Body

A Taper point needle B Reverse cutting needle

Point Point

Body Body

C Cutting needle D Spatula needle

Figures 1.16A–D Types of surgical needles.

For all skin closures, the goal is to perform a perpendicular
entry and exit through the skin. To achieve enhanced eversion
of wound edges, passes can incorporate some deeper tissue
as well. Ideally, the distance from the needle entry and exit
points to the incision should be equidistant, and sequential
stitches should be spaced at constant intervals and placed
parallel in orientation.
When loading the needle, the needle holder should grasp the
needle approximately two-thirds of the distance from the tip.
To maximize efficiency in a running technique, the needle
should be properly reloaded while still inside the tissues.
Interrupted
Simple interrupted closures are best suited for skin closure
and, while more time-consuming than a running closure, this
technique secures the wound at multiple points and reduces
the chance of a dehiscence if a stitch breaks. For wounds with
mild tension, a surgeon’s knot is utilized (2-1-1). Closure is

SECTION ONE • INTRODUCTION

Chapter 1 Foundations of oculofacial plastic surgery
10
performed from superficial to deep, then deep to superficial to
achieve mild eversion immediately after closure (Figure 1.17).
Buried interrupted closures are best suited for closure of
deep tissues or conjunctiva to prevent the sutures from “spit-
ting” through the skin or onto the ocular surface, respectively.
Buried interrupted sutures place the knot within the incision as
opposed to on the surface (Figure 1.18).
Figure 1.17 Simple interrupted suture technique.
A C
Figures 1.18A-C Buried interrupted suture technique.
Simple running closures are best suited for skin closure and
can close a wound more quickly and with a lesser suture
burden compared to interrupted closures. The risk, however,
is that if the suture breaks, the entire suture can unravel and
may result in a wound dehiscence. When closing the skin with
a running suture, care should be taken to ensure that sequen-
tial passes are both parallel and equidistant to each other
(Figure 1.19).
Running subcuticular closures are typically performed with
monofilament absorbable sutures and have the advantage of
closing the skin with minimal suture passed through the skin.
This results in an aesthetically pleasing appearance of the inci-
sion and reduces the wound inflammation associated with
suture degradation (if an absorbable suture is used). The suture
is passed in a running fashion in a plane just beneath and paral-
lel to the skin surface (Figure 1.20).
Running horizontal mattress closures are similar to simple
running closures except the sutures are passed in an alter-
nating forehand-backhand method (Figure 1.21). When per-
formed properly, this technique provides enhanced tissue
eversion and causes the wound edges to pucker above the
surrounding skin surface. This technique is ideally suited for
closure of thicker, more sebaceous skin (e.g., brow and
forehead skin) and helps to prevent formation of a depressed
scar. When more extreme wound eversion is desired, a
vertical mattress “near-near, far-far” method is used.
WOUND HEALING
Wound healing occurs in three sequential and overlapping
phases: the inflammatory or exudative phase, the fibroblastic
or proliferative phase, and the wound contraction or remode-
ling phase.
11

Figure 1.19 Simple running suture technique.
Figure 1.20 Running subcuticular suture technique.
SECTION ONE • INTRODUCTION
Chapter 1 Foundations of oculofacial plastic surgery
12
Figure 1.21 Running horizontal mattress suture technique.
Inflammatory phase
The inflammatory phase occurs in the first 4 days post-
operatively and is characterized by influx of blood cells,
serum proteins, platelets, and clotting factors from disrupted
blood vessels. These components promote coagulation, while
growth factors and fibrinogen promote cell and leukocyte
migration.
Proliferative phase
The proliferative phase occurs primarily around 5–30 days
postoperatively and begins with wound re-epithelialization. It is
characterized by fibroblast migration and proliferation followed
by new collagen formation. Granulation tissue composed of
fibroblasts, macrophages, and new capillaries is produced
early during this phase.
Remodeling phase
The remodeling phase begins approximately 4 weeks postop-
eratively and continues for approximately 6–12 months or
longer. It is characterized by a gradual reduction in fibroblasts
at the wound site, collagen cross-linking and reorganization,
and increased wound tensile strength. Wound contraction
occurs via differentiation of fibroblasts into myofibroblasts and
peaks around 10–15 days postoperatively. However, the con-
tracture typically continues over numerous weeks and may lead
to tissue cicatrization.
There are three types of surgical wound repair: primary inten-
tion, secondary intention, and tertiary intention.
Primary intention
Primary intention wound repair is indicated in most surgical
wounds. It consists of re-approximating tissues at time of
surgery or wound creation. It helps minimize scarring and GRAFTING
increases comfort during the healing process. Wounds should Autologous grafting is a common technique employed in ocu-
be closed in a layered fashion when possible with minimal lofacial reconstructive surgeries following burns, cicatricial
tension. changes, trauma, and tumor excisions.
Secondary intention Anterior lamella
Secondary intention wound repair occurs when wounds are In the eyelids, the anterior lamella consists of the skin and
allowed to heal by granulation. It results in slower healing and orbicularis muscle as well as the facial skin in the surrounding
typically more prominent scars, and it requires frequent wound regions. Common causes of anterior lamellar shortage include
care. It is most appropriate for infected or open wounds. burns, traumatic or post-surgical cicatricial changes, chronic
actinic damage, and overaggressive excision of skin during
Tertiary intention blepharoplasty surgery. Shortages of the anterior lamella
Tertiary intention wound repair (aka delayed primary closure, can result in cicatricial ectropion, eyelid retraction, and
or secondary suturing) occurs when the wound is left open lagophthalmos.
for a few days prior to closure. This technique is often used Full-thickness skin grafts (FTSGs) contain epidermis and
for infected or contaminated wounds to allow time for the dermis and are preferred for reconstruction of the anterior
inflammatory process to cleanse the wound before definitive lamella on the eyelids whenever possible. They tend to have
closure. less graft contracture and better cosmesis as compared to
split-thickness skin grafts (STSGs). When harvesting FTSGs,
ANTIBIOTIC PROPHYLAXIS the donor site typically must be closed, which can be challeng-
ing if the graft size is large or if there is extensive full-body skin
Antibiotic prophylaxis is somewhat controversial in oculofacial
damage.
surgery given the dearth of prospective randomized, controlled
The ideal skin graft for the eyelids is thin, has a good color
trials. Fortunately, the eyelids and face have a robust vascular
and texture match, is hairless, and is free of significant sun
supply and have a relatively low bacterial burden. Notable
damage. Although the upper eyelids are the preferred sites
exceptions are the paranasal sinuses, nasal mucosa, and oral
(Figure 1.22) for harvesting FTSGs, there may not be sufficient
mucosa, since these sites contain different flora from the facial
excess skin if the patient is young or has had previous blepha-
skin and are difficult to effectively sterilize with surgical prep
roplasty. Other donor sites include the retroauricular (Figure
solutions. In all cases, one must consider the risk of infection
1.23) or preauricular region (Figure 1.24). The retroauricular
versus an adverse event or allergy to the antibiotics, costs of
donor site has the advantage of a concealed incision and
the medication, and antibiotic resistance.
potentially less actinic-related damage, although the graft may
For most eyelid and periocular procedures involving skin or
be limited in size. The inner arm can provide a large surface
conjunctival incisions, postoperative topical antibiotics can be
area graft, but hair-bearing areas should be avoided (Figure
used solely for 1–2 weeks. When skin grafts are involved or if
1.25). Finally, the supraclavicular region can be used as a donor
the surgical site will have a dressing that precludes the applica-
site (Figure 1.26); however, this area may also be prone to
tion of topical antibiotics for several days, one can consider
actinic damage and its proximity to deeper vascular structures
giving a short course of systemic antibiotics.
warrants caution.
Orbital procedures that communicate the orbit with the para-
For skin grafting, once the cicatrix has been lysed, the dimen-
nasal sinuses, such as orbital fracture repairs or orbital decom-
sions of the recipient site are measured and an appropriately
pressions, can be complicated by the development of orbital
sized graft – typically about 10–15% oversized – is harvested
cellulitis from sinus flora. Additionally, when an alloplastic
from the donor site with a minimal amount of subcutaneous
implant is being placed, there is a risk of bacteria seeding the
tissue. The graft is then thinned of residual subcutaneous tissue
implant and causing an implant infection or biofilm formation.
In these cases, both porous and non-porous implants are typi-
cally soaked in antibiotic solution prior to implantation. Prior to
implantation, preoperative intravenous antibiotics are given as
well as postoperative oral antibiotics are commonly adminis-
tered for 5–7 days (e.g., amoxicillin/clavulanate or cephalexin).
For procedures involving the lacrimal sac and nasolacrimal
duct, intraoperative antibiotics can be given, and some physi-
cians will additionally prescribe a short course of postoperative
oral antibiotics in the setting of acute or chronic dacryocystitis.
For external dacryocystorhinostomy, there is a greater risk of
a surgical site infection since a skin incision is made. For
endoscopic procedures, surgery is performed through a nasal
mucosal incision with no skin incision, making a surgical site
infection less common. However, care should be taken to
avoid causing sinus outflow tract obstruction that leads to
sinusitis. Figure 1.22 Upper eyelid full-thickness skin graft donor site.

13
Figure 1.23 Retroauricular full-thickness skin graft donor site.
Figure 1.24 Preauricular full-thickness skin graft donor site.
Figure 1.25 Inner arm full-thickness skin graft donor site.
until the rete pegs are visible in order to reduce the metabolic
needs of the graft and increase the graft viability (Figures 1.27A
and 1.27B). Grafts derive their initial blood supply from the
underlying tissue bed, and a postoperative hematoma or
seroma can reduce oxygen and nutrient supply to the graft.
Foam bolsters, quilting stitches, and/or a pressure patch can
be applied to maintain direct contact between the graft and
recipient bed.
Split-thickness skin grafts (STSGs) consist of epidermis with
a variable thickness of dermis and can be harvested using a
SECTION ONE • INTRODUCTION
Chapter 1 Foundations of oculofacial plastic surgery
14
Figure 1.26 Supraclavicular full-thickness skin graft donor site.
Figure 1.27A Anterior side of full-thickness skin graft.
Figure 1.27B Posterior side of full-thickness skin graft.
dermatome or by manual technique with a blade. Thin grafts
range in thickness from approximately 0.005 to 0.012 inches,
intermediate grafts from 0.012 to 0.018 inches, and thick grafts
from 0.018 to 0.30 inches. STSGs have lower metabolic needs
than FTSGs and are particularly suited for lining sites with poor
vascular supply, such as the orbital walls following an orbital
exenteration (Chapter 74). STSGs can be used for grafting
large recipient sites and can even be meshed to allow coverage
of larger surface areas. However, they are prone to contracture,
pigmentary and textural abnormalities, and significant cosmetic
concerns compared to FTSGs. The donor site re-epithelializes posterior lamella must have a vascular supply to perfuse the
with time and can even be reused as a donor site in the future graft. For example, in a tarsoconjunctival flap, the blood supply
if needed. Potential donor sites should have a large surface of the pedicle is derived from its conjunctival attachment, and
area and smooth contour, such as the abdomen or anterior an anterior lamella FTSG is grafted onto the tarsal surface of
thigh. the pedicle. Alternatively, in the case of a free tarsoconjunctival
graft, a myocutaneous or orbicularis flap is used to provide
Posterior lamella blood supply to the posterior lamella graft (Chapter 43).
The posterior lamella of the eyelid consists of the conjunctiva
and tarsus. Shortages of conjunctiva can result in cicatricial CONCLUSIONS
entropion and fornix foreshortening and may be due to trauma,
The following chapters detail a myriad of specific surgical pro-
chemical burns, cicatrizing conditions, or contracture of con-
cedures. However, overall clinical success and patient satisfac-
junctival incisions. Potential posterior lamella grafts include
tion are determined only in part by what transpires in the
conjunctival autografts, buccal mucosal grafts, and amniotic
operating room. A grounded understanding of the fundamen-
membrane grafts for the bulbar surface.
tals of oculofacial plastic surgery will help ensure optimal clinical
If a tarsal defect is present in the case of large full-thickness
outcomes and should span the entire continuum of patient
eyelid excisions, a tarsoconjunctival flap can be mobilized
care: the clinical evaluation, patient counseling, perioperative
(Chapter 40) or a free tarsoconjunctival graft can be harvested
planning, choice of surgical procedure, operative technique,
from the upper lids (Chapter 43). Care must be taken to ensure
and postoperative care.
that the inferior 4 mm of tarsus of the upper lid is spared to
The field of oculofacial plastic surgery is delightfully nuanced
maintain structural integrity. Other palpebral posterior lamellar
with numerous techniques for addressing the same clinical
grafts include hard palate mucosa, nasal septum, auricular
problem. This video atlas brings to life some of the authors’
cartilage, acellular dermal matrix (Chapter 34), and dermis fat
preferred techniques, and our hope is that readers will find
grafts (Chapter 35).
certain techniques useful and incorporate them to their surgical
When applying grafts, standard surgical principles apply.
armamentarium in the pursuit of better patient care.
For full-thickness eyelid reconstruction, either the anterior or

15
 SECTION TWO EYELID AND FACE
CHAPTER 2
Chalazion incision and drainage
Bobby S. Korn
Table 2.1 Indications for surgery
Refractory to conservative/medical therapy
Multiple symptomatic chalazia
Interference with vision/amblyogenic
Recurrence/concern for neoplasm and need for biopsy
INTRODUCTION
Chalazia are very common eyelid disorders and are seen in all
ages with a higher predilection in patients with ocular rosacea
and chronic blepharitis. A chalazion results from obstruction
of a meibomian gland associated with focal inflammation of
the eyelid. The obstructed meibomian gland secretions accu-
mulate within the tarsal plate and surrounding tissues causing
local erythema and discomfort.
The mainstay of chalazion treatment is medical management
consisting of eyelid hygiene and warm compresses. Patient
SECTION TWO • EYELID AND FACE
Chapter 2 Chalazion incision and drainage
16
Table 2.2 Preoperative evaluation
Assessment for madarosis, eyelid margin ulceration, or conjunctival
hyperemia to suggest neoplasm
Fitzpatrick skin type (for adjunct steroid injection)
Photographic documentation of lesion
History of any prior skin malignancies
compliance with conservative management is essential for
success. Topical or injected steroids may improve the lipogran-
ulomatous component of chalazia but with persistent, non-
resolving lesions, incision and drainage may be indicated. In
children, persistent and large chalazion with associated pyo-
genic granuloma formation may obstruct the visual axis and/or
induce anisometropia potentially causing amblyopia. Chronic,
unilateral chalazion may be a masquerade syndrome for seba-
ceous cell carcinoma and a high index of suspicion should be
maintained. A full thickness eyelid biopsy is necessary for diag-
nosis in this case (Chapter 43).
SURGICAL TECHNIQUE

Figure 2.1 Injection of local anesthetic
In adults, chalazion incision and drainage is a well-tolerated office
procedure. However, in children, symptomatic chalazion should be
addressed in the operating room setting for maximal patient comfort and
surgeon control, as in this case. Subcutaneous local anesthetic is
infiltrated around the chalazion. The eyelid should be distracted from the
orbit while injecting the eyelid to avoid perforation of the globe. In the
office, pretreatment of the palpebral conjunctiva with topical 4% lidocaine
on cotton-tip applicators can minimize discomfort when injecting the local
anesthetic.
Figure 2.2 Incision of tarsal plate
An appropriately sized chalazion clamp is placed on the eyelid with
the guarded surface against the anterior lamella. Antibiotic or lubricating
ointment is placed on the ocular surface to minimize corneal abrasion.
The clamp is sufficiently tightened to allow manipulation of the eyelid and
for hemostasis. A #11 blade is used to make a vertical incision over the
apex of the chalazion. The incision is created in a vertical direction parallel
with the orientation of the Meibomian glands. Care should be taken to
avoid making a full-thickness incision through the eyelid.

A B

Figures 2.3A and 2.3B Decompression of impacted lipid

Once the tarsal plate is opened, copious lipid is often noted (Figures 2.3A and 2.3B). A cotton-tipped applicator is used to express the impacted lipid
through the vertical tarsal incision. If a pyogenic granuloma is present, this can be excised with Westcott scissors. A representative amount of tissue is
typically sent for histopathology and if a malignant neoplasm, such as sebaceous cell carcinoma, is suspected, a full-thickness biopsy is sent.

17
Figure 2.4 Curettage of residual lipid
A curette is then used to facilitate removal of lipid from the tarsus. Care
should be taken to remove all residual lipid to maximize recovery, as this
aids in resolution of the lipogranulomatous inflammation. Manual
compression of the tarsal plate with a cotton tip applicator against the
chalazion clamp will aid in disimpacting inspissated Meibomian glands and
promote normal flow of sebaceous secretions through the orifices.
Figure 2.5 Intralesional steroid injection
Steroid injection is an optional adjunct during chalazion incision and
drainage. Methylprednisolone acetate injection is useful in pediatric
chalazion associated with exuberant pyogenic granuloma formation and
significant tarsal thickening. The risks of skin necrosis, fat atrophy,
pigmentary changes of the skin, and the ocular complications of steroids
should be weighed prior to steroid use.

Table 2.3 Complications

Complications
Misdiagnosis as neoplasm
Hypopigmentation of skin
Recurrence of chalazion
Scarring of tarsal plate
Central retinal artery occlusion
Suggestions to reduce risk
Maintain high index of suspicion for sebaceous cell carcinoma with recurrent unilateral chalazion
Perform full-thickness biopsy to rule out carcinoma
Avoid steroid injection with Fitzpatrick skin types V and VI
Meticulous removal of all residual lipid during drainage
Manual compression of eyelid to unplug Meibomian glands
Perform daily eyelid hygiene and warm compresses
Perform vertical incision of tarsal plate, parallel to Meibomian glands
Inject with low pressure to minimize chance of retrograde arterial flow of steroid particles

SECTION TWO • EYELID AND FACE

Chapter 2 Chalazion incision and drainage
18

Table 3.1 Indications for surgery
Functional dermatochalasis affecting vision
Cosmetically displeasing dermatochalasis and/or upper eyelid
fullness
To correct associated lash ptosis, entropion, blepharitis or
anophthalmic prosthetic instability
Use of upper eyelid dermatochalasis for anterior lamellar skin
grafting elsewhere
INTRODUCTION
Several parameters should be evaluated in the preoperative
blepharoplasty examination. Documentation of functional
symptoms, photographs, and visual-field testing are mandatory
for coverage by many third-party carriers. When photographing
the patient, images should be captured in the frontal plane,
three-quarter profile, and the side plane. Before and after pho-
tographs documenting improvement and changes are essential
particularly for the discerning cosmetic patient. History of dry
eye symptoms, prior facial surgery or trauma and refractive
surgery are elicited. Aesthetic considerations should be ad-
dressed with the patient holding a mirror during the examina-
tion to point out salient features. During the examination, the
CHAPTER 3
Upper blepharoplasty
Bobby S. Korn
Table 3.2 Preoperative evaluation
Prior facial surgery or trauma
Dry eye symptoms
Prior refractive surgery
Degree of dermatochalasis and fat prolapse
Presence of lacrimal gland prolapse
Presence of concurrent eyebrow ptosis and eyelid ptosis
Ethnic differences between Asian and Occidental eyelid crease
degree of dermatochalasis present should be noted as well
as any co-existent brow and/or eyelid ptosis (Figure 3.1A).
The eyelid creases are then measured for symmetry. Asym-
metric eyelid creases are often associated with eyelid ptosis
(Chapters 11–13) and this should be identified and addressed
at the time of blepharoplasty. Often, the higher eyelid crease
is associated with levator dehiscence ptosis (Figure 3.1B).
Lateral eyelid fullness should be noted and palpation may re-
veal a prolapsed or pathologically enlarged lacrimal gland (Fig-
ure 3.1C) and require repositing and possible biopsy (Chapter
70). Examination of the tear film (tear breakup time, tear lake,
Schirmer’s testing) should be performed as well as assessment
for lagophthalmos with the eyelids gently closed (Figure 3.1D).
19
PREOPERATIVE EXAMINATION

A B

C D

Figures 3.1A–D Preoperative examination

SURGICAL TECHNIQUE

A B

Figures 3.2A–D Marking of eyelid crease

The skin marking is one of the most critical parts of upper blepharoplasty. The height of the eyelid crease varies with gender and ethnicity. If a native
eyelid crease is present, the central height corresponding to the pupillary light reflex is marked (Figure 3.2A). In non-Asians, the central eyelid crease
height is typically 6–9 mm in males and 8–11 mm in females (Figure 3.2B).

SECTION TWO • EYELID AND FACE

Chapter 3 Upper blepharoplasty
20
 C D

Figures 3.2A–D Marking of eyelid crease—cont’d

For marking of the Asian eyelid, refer to Chapters 4–6. If the upper eyelid crease is unusually high or asymmetric, concurrent ptosis may be present and
this should be evaluated. The central height is then symmetrically marked on both eyelids and visually confirmed. The mark is then inferiorly tapered in a
gradual fashion towards the medial canthus and then tapered superiorly prior to reaching the punctum (Figure 3.2C). Laterally, the marking also tapers
inferiorly towards the lateral canthus. Beyond the lateral canthus, the marking is directed superiorly if lateral hooding of the skin is present (Figure 3.2D).
Failure to address the lateral hooding will result in residual dermatochalasis after upper blepharoplasty. Once both creases are marked, the two sides are
compared for symmetry.

A B

C D

Figures 3.3A–D Marking of redundant skin

Two toothless forceps are used to pinch the redundant tissue for excision. The inferior tooth of the forceps corresponds to the initial crease marking and
the upper tooth of the forceps delineates the maximum extent of skin removed. The amount of skin removed should not cause any visible lagophthalmos
(Figure 3.3A). Figure 3.3B shows the typical appearance of the upper eyelid skin marking. The skin marking is confirmed and, with eyelid opening, the
upper and lower eyelid markings should superimpose and blend into the native crease (Figure 3.3C). Prior to infiltration of local anesthetic, the skin
markings should be remeasured to ensure adequate eyelid closure. The distance from the inferior brow cilia to the upper skin marking and the distance
from the upper eyelid margin to the lower edge of the skin marking should be at least 20 mm to avoid anterior lamellar insufficiency (Figure 3.3D). In
patients who have waxed the brow cilia or have permanent tattooing, the native brow position should be identified and used as the reference point.

21
 A B

C D

Figures 3.4A–D Removal of skin

Skin incision can be performed with a variety of instrumentation including surgical steel, laser or radio frequency. In this case a #15 blade is used for the
incision. With countertraction on the upper and lower skin, the inferior skin marking is incised first (Figure 3.4A). Then, with continued traction on the
upper and lower eyelid, the upper marking is incised. In this manner, a precise skin incision is performed with minimal deviation from the marking. Then,
the skin only is removed with scissors or cutting cautery (Figure 3.4B). In cases of significant dermatochalasis, removal of a large skin and muscle flap
can lead to lagophthalmos from insufficient orbicularis function. Figures 3.4C and 3.4D show the appearance of the intact orbicularis oculi muscle. An
additional benefit of preserving the orbicularis is that a more youthful volumetric enhancement is often seen in the upper eyelid postoperatively. In
younger patients or those with smaller skin markings and complaints of a bulky upper eyelid, the orbicularis can be selectively thinned prior to skin
closure.

A B

Figures 3.5A–C Removal of upper eyelid fat

Prior to surgery, prolapse of the nasal and/or central fat can be appreciated on the clinical examination and the desired amount of reduction should be
planned accordingly. Typically, there is a greater abundance of the nasal fat than the preaponeurotic (central) fat and this should be kept in mind while
performing upper eyelid fat removal. Figure 3.5A shows the anatomy of the upper eyelid fat pads. The nasal fat has a pale appearance compared to the
orange-colored preaponeurotic fat pad. The lacrimal gland may occasionally be prolapsed and care should be taken to avoid mistaking the gland for the
orbital fat. If the lacrimal gland is prolapsed out of the orbit, it can be reposited as described in Chapter 70. Cutting cautery or sharp dissection is used
to open the orbital septum in the medial eyelid (Figure 3.5B).

SECTION TWO • EYELID AND FACE

Chapter 3 Upper blepharoplasty
22
 Figures 3.5A–C Removal of upper eyelid fat—cont’d
Once the orbital septum has been opened, the nasal fat can be addressed.
If the fat is not readily accessed, gentle digital pressure on the globe can
aid in localization. The nasal fat is then conservatively excised (Figure
3.5C). When removing the nasal fat, avoid excessive deeper dissection and
cautery near this area as the trochlea is situated between the two upper
eyelid fat pads. The preaponeurotic fat can also be accessed from the
medial septal opening and can be conservatively debulked if it is exces-
sively redundant.
C

A B

Figures 3.6A and 3.6B Closure of skin

Prior to skin closure, the upper and lower eyelid skin edges are reapproximated with forceps. If excessive eyelid bulkiness is noted, a thin strip of the
orbicularis can be conservatively removed. Deep closure is then performed with 7-0 Vicryl to approximate the orbicularis (Figure 3.6A). Skin closure is
then performed with a 6-0 Prolene or 6-0 fast-absorbing gut suture (Figure 3.6B). When using a non-absorbable suture, a small loop is placed on both
ends of the running suture to facilitate postoperative suture removal. A combination antibiotic and steroid ointment is given for 2 weeks postoperatively.
Non-absorbable sutures are removed at 1 week postoperatively.

BILATERAL UPPER BLEPHAROPLASTY

PREOPERATIVE POSTOPERATIVE
Figure 3.7 Before and after upper blepharoplasty
This 54-year-old female underwent bilateral upper blepharoplasty with orbicularis and fat preservation.

23
Table 3.3 Complications
Complications Suggestions to reduce risk
Asymmetry Careful measurements after skin marking; rule out co-existent ptosis and eyelid malpositions
Canthal webbing Taper mark nasally and avoid extending past punctum
Corneal abrasion Use corneal shields during surgery
Dry eyes/lagophthalmos Conservative skin markings to retain at least 20 mm of upper eyelid skin; minimize orbicularis removal
Hemorrhage Meticulous hemostasis during procedure; use of tapered needle for skin closure; ice packs postoperatively;
cessation of anticoagulants
Infection Perform procedure after sterile preparation; use of topical antibiotic ointment; be cognizant of
immunosuppressed states
Lacrimal gland injury Recognition of lacrimal gland in the lateral orbit; reposition of a prolapsed gland instead of removal
(Chapter 70)
Ptosis Recognize that levator is posterior to the preaponeurotic fat pad; avoidance of excessive pretarsal dissection
and downward traction of the upper eyelid; treat pre-existing ptosis if present (Chapters 11–13)
Residual dermatochalasis Not a complication per se but rather can be addressed by re-excision of residual skin after 3–6 months have
elapsed after surgery
May result if co-existent brow ptosis is present and not treated at the time of blepharoplasty (Chapters 20–23)
Sulcus deformity Preserve preaponeurotic fat pad; avoid damage to levator
Suture granuloma Use non-absorbable sutures; recognize granulomas early; remove suture if symptomatic and treat with
antibiotic/steroid ointment
Wound dehiscence Avoid eye rubbing; ice packs to minimize hemorrhage and itching; protective eye shields; no heavy lifting after
surgery; avoidance of contact lens use

Table 3.4 Consumables used during surgery

6-0 Prolene suture, C-1 needle Ethicon #8718
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG1408 needle Ethicon #J546G
Kendall Devon Skin Marker Fine Tip #151

SECTION TWO • EYELID AND FACE

Chapter 3 Upper blepharoplasty
24
 CHAPTER 4
Asian upper blepharoplasty
Table 4.1 Indications for surgery
Functional dermatochalasis affecting vision
Creation of a new eyelid crease or revision of an incomplete,
multiple, or faded crease
In conjunction with other eyelid procedures such as ptosis or
entropion repair or epicanthoplasty
INTRODUCTION
Upper blepharoplasty in the Asian patient requires more preop-
erative discussion and planning compared to surgery of the
Occidental eyelid. While the surgical principles are fundamen-
tally similar, there are distinct anatomic differences in the Asian
eyelid. In the Occidental eyelid, the orbital septum fuses with
the levator aponeurosis 2–8 mm above the superior tarsal
border compared to the Asian eyelid where the orbital septum
fuses with the levator several millimeters below the superior
tarsal border (Figure 4.1A). The lower fusion point of the septum
and levator in the Asian eyelid results in more inferior descent
of the preaponeurotic fat pad and, in approximately 50% of
patients, there is no apparent upper eyelid crease. In contrast,
the Occidental eyelid has a defined crease, typically higher and
in a semi-lunar configuration (Figure 4.1B).
Bobby S. Korn
Table 4.2 Preoperative evaluation
Prior facial surgery or trauma, including open or closed crease
fixation surgery
Dry eye symptoms
Prior refractive surgery
Degree of dermatochalasis and fat prolapse
Presence of lacrimal gland prolapse
Presence of concurrent eyebrow ptosis, eyelid ptosis, eyelash
ptosis or entropion
Epicanthal fold and shape
Crease asymmetry
Type of crease desired: nasal taper, parallel, and lateral flare
Blepharoplasty may be the first cosmetic operation, particu-
larly for younger Asian patients and a careful preoperative dis-
cussion should be undertaken, often with the parent or legal
guardian present. The types of creases: nasal taper, parallel,
and lateral flare should be demonstrated to the patient to
educate the differences between the higher crease in the Occi-
dental eyelid (Figure 4.1B). The surgeon must be careful not to
create this semi-lunar crease in the Asian eyelid. Using a mirror,
the postoperative appearance of the upper eyelid can be simu-
lated with a bent paper clip or cotton-tip applicator.
Table 4.3 summarizes the advantages and disadvantages of
the open, external approach covered in this chapter versus the
closed, suture ligation method (Chapter 5). Further discussions
should focus on the anticipated recovery time, myriad of com-
plications, and possible need for revision.
25
 Superior Superior
orbital rim orbital rim Asian
Orbicularis eyelid
muscle
Occidental
eyelid Orbicularis
Preaponeurotic muscle
fat
Orbital Preaponeurotic
septum fat

Levator Orbital
aponeurosis septum
Insertion of
orbital septum on Levator
levator aponeurosis aponeurosis

Terminal Tarsal plate

interdigitations
of levator Insertion site
aponeurosis of septum on
levator aponeurosis
Tarsal
plate

Figures 4.1A and 4.1B Occidental versus Asian Eyelid

SECTION TWO • EYELID AND FACE

Chapter 4 Asian upper blepharoplasty
26
Table 4.3 Surgical approaches to Asian blepharoplasty
Method Advantages Disadvantages
Open/external approach (Chapter 4) More permanent crease formation; can Skin incision and related complications; crease
address redundant skin/muscle/fat; may asymmetry; longer recovery; potential for excessive skin/
concurrently repair ptosis muscle/fat removal
Closed/suture ligation approach Faster recovery; no skin incision Crease tends to fade; cornea may become irritated by
(Chapter 5) exposed tarsal suture; inability to address concurrent
eyelid malpositions

SURGICAL TECHNIQUE

A B

Figures 4.2A–C Marking of the eyelid crease

Meticulous preoperative incision planning is fundamental to the success of
this surgery and formation of a natural Asian upper eyelid crease begins
with the surgical marking. In contrast to the Occidental eyelid, the Asian
crease is 2–4 mm lower, with males averaging 4–6 mm and females
6–8 mm centrally. The position of the lower marking is critical and this
determines the postoperative crease height. A fine-tip surgical pen is used
for the skin marking. If the skin is oily, it should be washed with an
alcohol prep pad and dried to ensure precise markings. First, a caliper is
used to measure the central height of the crease and this is inked lightly
(Figure 4.2A). The fellow eyelid crease height is measured and compared
for symmetry. Next, the crease is tapered in a nasal fashion towards the
C
medial canthus to blend imperceptibly into epicanthal fold (Figure 4.2B).
At the lateral canthus, the mark takes a gentle superior flare (Figure
4.2C). Then, both markings are again compared for symmetry. At this
point, a cotton-tip applicator can be broken into a thin splinter and this
can be used to indent the central marking. As the patient looks upward
with gentle pressure of the wooden splint, the new crease should blend
into the marking.

27
 A B

Figures 4.3A and 4.3B Marking for skin removal

The pinch technique is used to determine the amount of excess skin for removal using toothless forceps. The first forceps is used to tent up the skin,
while the second forceps is used to grasp the redundant skin. One tooth of the forceps is placed at the bottom marking and the upper tooth is inked to
delineate the superior extent of the skin incision (Figure 4.3A). Three points are marked (nasal, central, and temporal) and these markings are united
(Figure 4.3B). When marking the superior border, care should be taken to avoid creating a high superior arch as this could lead to inadvertent creation of
a high, semi-lunar crease. The upper marking should almost parallel the lower marking until coming to an apex at the medial and lateral canthi. Once
the markings are complete, local anesthetic is given.

A B

C D

Figures 4.4A–D Incision and removal of skin

A #15 blade is used to make the skin incision (Figure 4.4A). Only the skin should be incised while sparing the orbicularis. The incision should be in the
center of the incision line, as the ink tends to widen after infiltration of the local anesthetic. Next, the skin is removed with scissors or cutting cautery
(Figure 4.4B). Bipolar cautery is used to achieve meticulous hemostasis (Figure 4.4C). A dry surgical field will allow for more precise crease formation
and lessen postoperative bleeding, which can lead to disruption of the crease. Figure 4.4D shows an intact orbicularis bed after skin excision.

SECTION TWO • EYELID AND FACE

Chapter 4 Asian upper blepharoplasty
28
A B

Figures 4.5A–C Opening of the orbital septum

The orbicularis is then incised linearly at the midpoint between the upper
and lower incision with cutting cautery (Figure 4.5A). Once the orbital
septum is opened, the levator and central, preaponeurotic fat pad are
visible (Figure 4.5B). Unless the central fat pad is overly abundant, the
fat pannus should be left intact to maintain fullness of the central eyelid.
If necessary, judicious excision or gentle coagulation with the bipolar
forceps can be performed. The dissection is then performed medially to
identify the nasal fat pad. The nasal fat is often redundant and can be
C
conservatively sculpted (Figure 4.5C).

A B

Figures 4.6A–C Trimming of pretarsal orbicularis platform

To facilitate formation of a new crease, a small ellipse of pretarsal
orbicularis muscle is excised on the inferior wound edge (Figures 4.6A
and 4.6B). Scissors are used to trim the platform, leaving a 1.0–2.0 mm
cuff of pretarsal orbicularis muscle remaining (Figure 4.6C). Thinning this
cuff of tissue allows for a gentle flattening of the new crease. Occasion-
ally, pretarsal fat can be seen and, if this is excessive, conservation
excision is performed to prevent uneven crease formation. Excess
dissection and removal of the pretarsal orbicularis should be avoided to
prevent prolonged edema and/or multiple creases. Bipolar cautery is used
C
again to control any bleeding along the inferior edge.

29
A B

Figures 4.7A–C Crease formation

Crease formation is achieved by promoting adhesions between the inferior
pretarsal orbicularis platform and the levator aponeurosis. The levator
aponeurosis is secured with a 7-0 Vicryl suture going from deep to
external (Figure 4.7A). Next, the pretarsal orbicularis is purchased and, in
this fashion, the resultant knot will be buried (Figure 4.7B). Three to four
interrupted 7-0 Vicryl sutures are evenly placed along the eyelid for crease
C
formation (Figure 4.7C).

A B

Figures 4.8A–C Skin closure

The skin edges are reapproximated with forceps first (Figure 4.8A). This
helps to identify any areas of redundancy. The skin should come together
without any dog ears. The orbicularis is then closed with 7-0 Vicryl
(Figure 4.8B). Skin closure is performed with running 6-0 Prolene on a
C-1 tapered needle (Figure 4.8C). This tapered needle is useful to
minimize bleeding during skin closure as this may adversely affect optimal
C
crease formation. The suture is removed at 1 week postoperatively.

SECTION TWO • EYELID AND FACE

Chapter 4 Asian upper blepharoplasty
30
 BILATERAL ASIAN UPPER BLEPHAROPLASTY

Preoperative Postoperative

Figure 4.9 Before and after Asian upper blepharoplasty

This 27-year-old female underwent bilateral Asian upper blepharoplasty. Postoperatively, she has a natural, low lying nasally tapered crease.

Table 4.4 Complications

Complications Suggestions to reduce risk
Unexpected formation of a high, Keep superior marking flat and avoid a high arch; minimize removal of central fat and superior margin
semi-lunar crease or hollow orbicularis; keep inferior marking low; consider surgical repair (Chapter 6) or upper eyelid injection of a
superior sulcus hyaluronic acid filler
Multiple creases Careful preoperative marking; avoid excessive pretarsal dissection and resection of tissue; meticulous
hemostasis; preservation of central fat; consider upper eyelid injection of a hyaluronic acid filler to
volumize area of multiple creases
Loss of crease Careful creation of a pretarsal platform and meticulous crease fixation placement; trimming excessive
pretarsal fat
Medial, bifid crease Avoid superior tapering of the nasal marking and blend nasally to the epicanthal fold
Corneal abrasion Use of corneal shields during surgery
Dry eyes/lagophthalmos Conservative skin markings to retain at least 20 mm of upper eyelid skin; minimize orbicularis removal
Hemorrhage Meticulous hemostasis during procedure; use of tapered needle for skin closure; ice packs
postoperatively; cessation of anticoagulants
Infection Perform procedure after sterile preparation; use of topical antibiotic ointment; be cognizant of
immunosuppressed states
Lacrimal gland injury Recognition of lacrimal gland in the lateral orbit; reposition of a prolapsed gland instead of removal
Ptosis Recognize that levator is posterior to the central fat pad; avoidance of excessive pretarsal dissection and
downward traction of the upper eyelid; treat pre-existing ptosis if present
Residual dermatochalasis Not a complication per se but rather can be addressed by re-excision of residual skin after 3–6 months
have elapsed after surgery
May result if co-existent brow ptosis is present and not treated at the time of blepharoplasty
Wound dehiscence Avoid eye rubbing; ice packs to minimize hemorrhage and itching; protective eye shields; no heavy lifting
after surgery; avoidance of contact lens use

31
Table 4.5 Consumables used during surgery
6-0 Prolene suture, C-1 needle Ethicon #8718
7-0 Vicryl, TG140-8 needle Ethicon #J546G
Kendall Devon Skin Marker Fine Tip #151

SECTION TWO • EYELID AND FACE

Chapter 4 Asian upper blepharoplasty
32
 CHAPTER 5
Asian eyelid crease formation (double eyelid
operation) by suture ligation method
Table 5.1 Indications for surgery
Absent or incomplete upper eyelid crease
No anatomic soft-tissue redundancy such as dermatochalasis and
orbital fat prolapse
INTRODUCTION
The suture ligation method is an alternative method of upper
eyelid crease formation in the Asian eyelid. In Chapter 4, the
open technique of Asian upper blepharoplasty was described
and the relative advantages and disadvantages were dis-
cussed. The major advantages of the suture ligation method
as discussed in this chapter are the rapid recovery and mini-
mally invasive nature compared to the open surgical approach.
The primary disadvantage of the suture ligation method is the
tendency of the crease to fade with time.
Yoon-Duck Kim
Table 5.2 Preoperative evaluation
Prior facial surgery or trauma, including open or closed crease
fixation surgery
Dry eye symptoms
Prior refractive surgery
Degree of dermatochalasis and fat prolapse
Presence of lacrimal gland prolapse
Presence of concurrent eyebrow ptosis, eyelid ptosis, eyelash
ptosis or entropion
Epicanthal fold and shape
Crease asymmetry
Type of crease desired: nasal taper, parallel, and lateral flare
Discussion of crease permanence with suture ligation method
When considering the suture ligation method, the preopera-
tive exam should not disclose any significant dermatochalasis,
fat prolapse, ptosis or other eyelid malposition. If present, these
factors can be specifically addressed with an open surgical
approach (Chapter 4). The goal of the suture ligation method
is to create a surgical adhesion between the levator aponeu-
rosis and the overlying subcutaneous tissue while avoiding a
larger, open incision.
33
SURGICAL TECHNIQUE

Figure 5.1A Marking of the eyelid crease height

Careful marking is essential for surgical success. Compared to the
Occidental eyelid, the Asian eyelid crease is 2–4 mm lower, with males
averaging 4–6 mm and females 6–8 mm centrally (Figure 5.1). The
height of the central eyelid crease provides the foundation for the newly
created crease. Calipers are used to mark the central eyelid height
bilaterally and this is compared for symmetry.

B C

D E

Figures 5.1B–E, Continued Marking of the new eyelid crease

Once the central height of the new eyelid crease is determined, three markings are made along this newly proposed crease. A wooden splint is used to
indent the central marking and to simulate the new crease (Figures 5.1B and 5.1C). As the patient is asked to look up and down, the surgeon evaluates
the new crease to determine if it will be natural. If the crease appears too high, then the central height is lowered and a new crease is simulated with
the wooden splint. Once satisfied, nasal and temporal markings are made in line with the new crease (Figures 5.1D and 5.1E). The markings are best
performed while the patient looks down and then reconfirmed when looking up. Excess ink from the marking pen should be blotted with a gauze to
minimize bleeding of the dye on the skin.

SECTION TWO • EYELID AND FACE

Chapter 5 Asian eyelid crease formation (double eyelid operation) by suture ligation method
34
 A B

Figures 5.2A and 5.2B Injection of local anesthetic

Local anesthetic consisting of 1% lidocaine/0.25% bupivacaine with 1 : 200,000 epinephrine is used for anesthesia and hemostasis. To minimize tissue
distortion, small aliquots of 0.25–0.50 ml of local anesthetic are given into each of three cutaneous skin markings (Figure 5.2A). Additional local
anesthetic is given in a subconjunctival fashion along the superior tarsal border (Figure 5.2B). The use of a 27- or 30-gauge needle will facilitate precise
delivery while minimizing discomfort.

B
Before

Overlying skin
is closed to bury
the knots

After
A

Figures 5.3A and 5.3B Stab incision of cutaneous markings

Figure 5.3A shows diagrams of the suture ligation method. Crease fixation sutures are externalized on the three eyelid markings determined preopera-
tively. After the sutures are tied off, the overlying skin is closed to bury the knots. A #15 blade or #11 blade is used to the make 2 mm horizontal stab
incisions through the skin (Figure 5.3B). Care is taken to avoid full-thickness incision and inadvertent globe perforation, particularly with the #11 blade. If
excessive bleeding occurs with the incision, direct pressure should be applied to achieve hemostasis.

35
 Stab
incision

Skin

Orbicularis muscle

Levator aponeurosis

Müller’s muscle
B
A Conjunctiva

C D

Figures 5.4A–D Suture ligation of eyelid crease

Three full-thickness 7-0 nylon sutures are used to form the new eyelid crease. The ligation sutures are placed at the superior edge of the tarsal plate
and encompass conjunctiva, Müller’s muscle, levator aponeurosis, and orbicularis and are buried under the skin (Figure 5.4A). The upper eyelid is
everted and then the 7-0 nylon is passed in a horizontal fashion at the superior tarsal border centrally (Figure 5.4B). Then, the first needle is directed
anteriorly through the central stab incision (Figure 5.4C). For the second pass, a free eyed needle is threaded with the 7-0 nylon suture and this is also
passed anteriorly through the central incision (Figure 5.4D).

A B

Figures 5.5A–D Completion of suture ligation

Once the central ligation sutures are placed, the nasal and temporal crease formation sutures are placed in a similar fashion (Figures 5.5A and 5.5B).
The sutures should be evenly placed along the upper eyelid to prevent bunching after the knots are tied off.

SECTION TWO • EYELID AND FACE

Chapter 5 Asian eyelid crease formation (double eyelid operation) by suture ligation method
36
 C D

Figures 5.5A–D Completion of suture ligation—cont’d

Once all of the sutures are placed, the eyelid is everted and the conjunctiva is inspected to ensure that the nylon suture has been properly placed in a
subconjunctival fashion (Figure 5.5C). No suture should be clearly visible as this can lead to corneal irritation postoperatively and, if present, the nylon
should be removed and repositioned. The 7-0 nylon sutures are then tied off firmly to bury both the subconjunctival and subcutaneous ends of the suture
(Figure 5.5D). A slight dimpling should be seen at the stab incision site as well as the palpebral conjunctiva at the superior tarsal border.

A B

Figures 5.6A and 5.6B Skin closure

Skin closure is performed with interrupted 7-0 nylon sutures (Figure 5.6A). The sutures are removed at the 1-week postoperative visit. Once all incisions
have been closed, the patient is asked to open and close the eyelids to confirm a natural and dynamic crease has been created (Figure 5.6B).

ASIAN EYELID CREASE FORMATION BY SUTURE LIGATION METHOD

Preoperative Postoperative

Figure 5.7 Before and after upper eyelid crease formation

This 24-year-old female underwent bilateral upper eyelid crease formation by the suture ligation method. She has a natural, nasally tapered crease that
is stable at the 6 month postoperative visit.

37
Table 5.3 Complications
Complications Suggestions to reduce risk
Unexpected formation of a high, Keep eyelid crease low and verify with wooden splint prior to skin incision; remeasure marks prior to start
semi-lunar crease of surgery
Multiple creases Careful preoperative marking and ensure that nasal, central, and temporal markings are all aligned during
simulated crease formation
Loss of crease Common and may be caused by loosening, migration or breakage of fixation sutures. Secure fixation
sutures with at least 3 square knots; ensure suture platform has a relatively wide base (2–3 mm); consider
secondary placement of additional sutures vs revision with open approach (Chapter 4)
Corneal abrasion If seen immediately postoperatively, then likely due to sutures not properly placed and sutures not tied off
with sufficient tension to ensure subconjunctival burying
If seen several weeks–months postoperatively, may be due to broken or exposed suture ends and
necessitates removal
Dry eyes/lagophthalmos Uncommon in this procedure as tissue is not removed; watch for exposed suture ends as this may result
in ocular surface symptoms
Hemorrhage Stop anticoagulants prior to surgery; wait at least 10 minutes before incision after giving local anesthesia;
eyelid compression during surgery to maximize hemostasis; ice packs postoperatively
Infection Perform procedure after sterile preparation, use of topical antibiotic ointment, be cognizant of
immunosuppressed states
Ptosis and dermatochalasis Identify preoperatively and address concurrently with open approach

Table 5.4 Consumables used during surgery

7-0 nylon, P-1 needle Ethicon #1696G
Free eyed needle, 3/8 reverse cutting Richard-Allan #212405
Kendall Devon Skin Marker Fine Tip #151

SECTION TWO • EYELID AND FACE

Chapter 5 Asian eyelid crease formation (double eyelid operation) by suture ligation method
38
 CHAPTER 6
Table 6.1 Indications for surgery
Eyelid crease asymmetry
High placement of surgical eyelid crease
Hollowing of superior sulcus
INTRODUCTION
Revision of a high, asymmetric Asian upper eyelid crease is a
challenging surgical problem. There are multiple etiologies
including a high skin crease incision, excessive removal of
orbital fat, damage to the levator, improper placement of crease
formation sutures, and iatrogenic surgical trauma. Prior to
undertaking surgical revision, the patient’s expectations should
be kept low and the need for subsequent surgeries must be
Revision of Asian upper
eyelid crease
Yoon-Duck Kim
Table 6.2 Preoperative evaluation
History of prior surgery to create eyelid crease
Amount of skin reserve above existing crease
Presence or absence of upper eyelid fat
Presence of co-existing ptosis
Shape and height of current and desired crease
discussed. Alternative treatments, such as upper eyelid
hyaluronic acid fillers, can be discussed if revision surgery is
not an option.
The general principles of crease lowering are to excise an
ellipse of skin and orbicularis to the desired level of the new
crease and then inferior advancement of a preaponeurotic fat
pedicle as a buffer to prevent multiple crease formation fol-
lowed by placement of crease formation sutures.
39
SURGICAL TECHNIQUE

A B

C D

Figures 6.1A–D Skin marking

Figure 6.1A shows an asymmetrically high and hollow left superior sulcus compared to the right eyelid. In this case, the patient preferred the lower,
more natural-appearing right upper eyelid crease and desired unilateral correction of the left side. The height of the right upper eyelid crease is noted to
be several millimeters lower than the left eyelid (Figure 6.1B). The new crease height is then marked on the left upper eyelid with a fine tip marker
(Figure 6.1C). The pinch technique can be used to identify redundant skin for removal and in this case corresponds to the site of the prior surgery
(Figure 6.1D). As with any case of upper blepharoplasty, the inferior eyebrow to upper eyelid distance should be measured to ensure adequate anterior
lamella for eyelid closure (Chapter 3).

Figure 6.2 Skin incision

Local anesthetic consisting of 1% lidocaine/0.25% bupivacaine with
1 : 200,000 epinephrine is given in a total volume of less than 2 ml to
minimize distortion of the skin marking. Careful skin incision with a #15
blade is performed within the marking.

SECTION TWO • EYELID AND FACE

Chapter 6 Revision of Asian upper eyelid crease
40
 A B

Figures 6.3A–C Clearance of pretarsal platform

A skin and orbicularis muscle flap is removed with sharp dissection (Figure 6.3A). Dissection is then performed inferiorly in the pretarsal plane (Figure
6.3B). Finally, the pretarsal orbicularis is trimmed, leaving a 1–2 mm cuff of tissue on the inferior incision line (Figure 6.3C). Careful hemostasis is
achieved with bipolar or high temperature cautery. Use of monopolar cautery is avoided as this may cause excessive collateral tissue damage and may
result in an uneven crease formation.

A B

Figures 6.4A and 6.4B Opening of the orbital septum

With inferior traction on the conjoined fascia, the orbital septum is opened (Figure 6.4A). Exuberant scarring of the middle lamella is often seen with
asymmetric eyelid creases after blepharoplasty and this case shows the typical appearance of the orbital septum (Figure 6.4B). Use of high temperature
cautery allows for rapid dissection with minimal bleeding. Care is taken to avoid damage to the underlying levator aponeurosis.

41
 A B

Figures 6.5A–C Development of preaponeurotic fat pedicle

Once the orbital septum has been opened, the preaponeurotic fat pad
and underlying levator aponeurosis is identified (Figure 6.5A). An adequate
preaponeurotic fat pedicle increases the likelihood of surgical success
and prevention of postoperative superior crease migration. If the
prior surgery resulted in exuberant removal of the preaponeurotic fat,
free pearls of fat can be harvested from another site, such as the
periumbilical region, to be used as a tissue buffer (Chapter 47). Residual
attachments to the levator are then released from the preaponeurotic fat
(Figure 6.5B). Once the fat is fully released, it can be fully distracted
C
inferiorly for subsequent fixation (Figure 6.5C).

A B

Figures 6.6A–D Placement of crease formation sutures

Three crease formation sutures are placed in the nasal, central, and temporal sites on the lower eyelid (Figure 6.6A). The levator aponeurosis is secured
with 7-0 nylon and then this is secured to the inferior pretarsal orbicularis platform (Figures 6.6B and 6.6C).

SECTION TWO • EYELID AND FACE

Chapter 6 Revision of Asian upper eyelid crease
42
 C D

Figures 6.6A–D Placement of crease formation sutures—cont’d

The crease formation sutures are placed in a deep-to-anterior fashion to bury the knot as the nylon sutures are permanent (Figure 6.6D). Furthermore,
the sutures are cut right on the knot to minimize palpability and extrusion.

A B

C D

Figures 6.7A–D Redraping of preaponeurotic fat pedicle

Once the crease formation sutures are placed, the preaponeurotic fat pedicle is inferiorly redraped to minimize formation of multiple creases. 7-0 nylon
is used to secure the inferior skin edge, levator aponeurosis, inferior border of the preaponeurotic fat pedicle and finally the superior skin edge (Figures
6.7A–D). Three to four of these redraping sutures are placed along the eyelid for even distribution of the fat pedicle. If there are any areas of upper
eyelid hollowing, further fat redraping sutures can be placed, as well as free fat pearls as needed. If free fat transfer is needed to fill the superior
sulcus, this may be performed using a 0.9mm microinjector (Chapter 47).

43
 A B

C D

Figures 6.8A–D Skin closure

After crease formation and redraping of the preaponeurotic fat pedicle, the patient is asked to open and close the eyelid to evaluate the dynamics of the
revised crease (Figure 6.8A). If there is tethering of the eyelid with dynamic movements, any septal attachments of the fat pedicle are identified and
released as well as checking for proper suture placement. Skin closure is performed in a running fashion with 7-0 nylon (Figures 6.8B–D). Skin sutures
are removed at the 1-week postoperative visit.

REVISION OF LEFT UPPER EYELID CREASE

Preoperative Postoperative

Figure 6.9 Before and after left upper eyelid revision

This 31-year-old female underwent left upper eyelid revision with lowering of the crease and inferior redraping of the preaponeurotic fat. After revision,
the left upper eyelid crease has a symmetric appearance with restoration of the youthful upper eyelid fullness.

SECTION TWO • EYELID AND FACE

Chapter 6 Revision of Asian upper eyelid crease
44
Table 6.3 Complications
Complications Suggestions to reduce risk
Multiple creases or continued Care with surgical technique to minimize iatrogenic trauma; ensure adequate inferior redraping of
high crease preaponeurotic fat pedicle; placement of free fat pearls if insufficient preaponeurotic fat remains (Chapter 47)
Loss of crease May be caused by loosening, migration or breakage of fixation sutures
Secure fixation sutures with at least 3 square knots; ensure suture platform has a relatively wide base
(2–3 mm); consider secondary placement of additional sutures
Hemorrhage Stop anticoagulants prior to surgery; wait at least 10 minutes before incision after giving local anesthesia;
eyelid compression during surgery to maximize hemostasis; ice packs postoperatively
Infection Perform procedure after sterile preparation; use of topical antibiotic ointment; be cognizant of
immunosuppressed states
Ptosis and dermatochalasis Identify preoperatively and address concurrently with open approach

Table 6.4 Consumables used during surgery

7-0 nylon, P-1 needle Ethicon #1696G
Kendall Devon Skin Marker Fine Tip #151

45
CHAPTER 7
Root Z-epicanthoplasty
Kyung In Woo
Table 7.1 Indications for surgery
Cosmetically displeasing epicanthal fold less than 5 mm
In combination with ptosis surgery, double upper eyelid crease
formation or epiblepharon repair
INTRODUCTION
The presence of an epicanthal fold with the absence of a
supratarsal fold (double upper eyelid) is a common finding in
the Asian patient. In patients without a prominent epicanthal
fold, creation of a double eyelid (Chapters 4 and 5) can create
an aesthetically pleasing outcome. However, if a prominent
epicanthal fold is not concurrently addressed during double
eyelid surgery, the resulting outcome may appear suboptimal
due to the apparent shortening of the horizontal palpebral
fissure and widened intercanthal distance.
The classic technique to address epicanthal folds is
Mustardé’s technique, as covered in Chapter 8. Mustardé’s
SECTION TWO • EYELID AND FACE
Chapter 7 Root Z-epicanthoplasty
46
Table 7.2 Preoperative evaluation
Desire for concurrent double eyelid surgery
History of prior hypertrophic scarring of skin or keloid formation
after incisional surgery
Type of epicanthal fold present
No excess upper eyelid dermatochalasis or eyelid ptosis present
Discussion of complications related to scar formation and visibility
of incision lines
epicanthoplasty involves larger incisions and can more power-
fully reduce congenitally anomalous epicanthal folds but may
cause more visible scarring in the medial canthal region. The
root Z-epicanthoplasty, has the benefit of smaller incisions,
which are created with minimal wound tension and can be an
excellent cosmetic adjunct during double eyelid surgery. The
root Z-epicanthoplasty differs from the classic Z-plasty flap in
that the angles of the Z are not equivalent. To allow for rear-
rangement of these flaps, judicious undermining is performed
with conservative debulking of the subcutaneous fibrofatty
tissues and orbicularis muscle fibers which constitute the epi-
canthal fold.
SURGICAL TECHNIQUE

A B

Figures 7.1A and 7.1B Marking the base of the epicanthal fold
All markings are performed prior to infiltration of local anesthesia. If the skin is oily, an alcohol prep should be used to clean the skin surface. A topical
anesthetic such as proparacaine can be given prior to cleansing of the skin surface and marking to reduce discomfort. Toothless forceps are used to first
mark the base of the epicanthal fold to be addressed at the level of the lacrimal lake (Figure 7.1A). This is compared to the fellow eyelid and measured.
In general the root Z-epicanthoplasty is ideally suited for reduction of less than a 5 mm epicanthal fold (Figure 7.1B).

A B

C D

Figures 7.2A–D Marking of root Z-epicanthoplasty

A horizontal mark is first made towards the lacrimal lake from the base of the epicanthal fold and terminating at the lateral extent of the epicanthal fold
(Figure 7.2A). Next, the central axis of the Z-plasty is marked inferiorly along the epicanthal fold (Figure 7.2B). With the epicanthal fold distracted
medially, the central axis can be seen (Figure 7.2C) and then the final marking is made superiorly towards the lacrimal lake (Figure 7.2D). Excessive ink
from the pen should be blotted with a gauze pad to minimize diffusion of the marking. Note that the superior extent of the mark towards the lacrimal
lake is in line with the horizontal marking and that the length of each limb of the Z-plasty is the same.

47
 A B

C D

Figures 7.3A–D Rearrangement of arms with root Z-epicanthoplasty

These figures demonstrate the rearrangement of the two arms that occurs during root Z-epicanthoplasty. The lateral arm, as shown in yellow, is
undermined and then rotated superiorly towards apex A’ (Figures 7.3A and 7.3B). The medial arm, as shown in blue, is then rotated laterally towards
apex B’ (Figures 7.3C and 7.3D). This rearrangement serves to lengthen the central limb of the Z-plasty and to flatten the epicanthal fold.

SECTION TWO • EYELID AND FACE

Chapter 7 Root Z-epicanthoplasty
48
 A B

C D

Figures 7.4A–D Incision of skin flaps

Local anesthetic in a total volume less than 1.5 ml is given in the medial canthal region after skin marking. Precise skin incisions are essential for the
success of the operation. A #11 or #15 blade can be used for skin incision while the epicanthal fold is distracted medially (Figure 7.4A). The sequence
of skin incisions is depicted in Figures 7.4B to 7.4D. When incising the flaps in this order, maximal countertraction is placed on the skin to allow for an
exact skin incision.

A B

Figures 7.5A–D Dissection of skin flaps

Gentle manipulation is performed to minimize trauma to the skin flaps (Figure 7.5A). Both arms are dissected in the subcutaneous plane with Westcott
scissors (Figure 7.5B).

49
 C D

Figures 7.5A–D Dissection of skin flaps—cont’d

Usually, a small amount of fibromuscular tissue under the epicanthal fold is present below the skin. This can be debulked as needed (Figure 7.5C). If the
orbicularis is redundant, a small amount can be dubulked, but this is done in a very conservative fashion. Fine bleeders can be controlled with a bipolar
cautery using a jeweler’s forcep hand piece. Once the flaps have been undermined and the subcutaneous tissues debulked, the flaps should transpose
spontaneously with minimal tension (Figure 7.5D). If the flaps will not approximate without tension, deeper incision into the medial canthal angle and
further undermining is performed.

A B

Figures 7.6A–C Flap rearrangement and skin closure

The flaps are then transposed and closed using skin sutures only. Subcutaneous sutures are avoided to minimize granuloma formation and, if adequately
constructed and executed, there should be minimal tension on the wound. The lower flap is anchored first to the medial canthal angle, which contains
dense canthal tissue (Figure 7.6A). The skin is closed with several interrupted 7-0 nylon sutures that are anchored within 1 mm of the skin edge (Figure
7.6A). If redundant skin is present in the upper flap, a small dog ear of tissue can be excised (Figure 7.6B). Once all skin sutures have been placed, a
nice blunting of the epicanthal fold can be seen (Figure 7.6C). All skin sutures are removed at the 1-week postoperative visit.

SECTION TWO • EYELID AND FACE

Chapter 7 Root Z-epicanthoplasty
50
 ROOT Z-EPICANTHOPLASTY, PTOSIS REPAIR
AND UPPER EYELID CREASE FORMATION

Preoperative Postoperative

Figure 7.7 Before and after root Z-epicanthoplasty

This 21-year-old male underwent root Z-epicanthoplasty, ptosis repair and upper eyelid crease formation by the open approach.

Table 7.3 Complications

Complications Suggestions to reduce risk
Hypertrophic scarring, nodules or keloid formation Avoid excessive wound tension; undermine flaps more; ensure limbs of Z-plasty are
of comparable length; avoid placing subcutaneous Vicryl sutures; use non-
absorbable sutures and remove at 1 week postoperatively; avoid excessive trauma/
cauterization of flap; use fine-tip bipolar cautery for hemostasis; use postoperative
steroid ointment and possible subcutaneous steroid injections
Under-correction of epicanthal fold Anchor the lower skin flap edge to the medial canthal angle to flatten the lower
skin closure arm; increase length of Z-plasty arms; adequately address redundant
dog ear in the upper flap
Asymmetry Careful skin marking; comparison between both sides
Hemorrhage Stop anticoagulants prior to surgery; wait at least 10 minutes before incision after
giving local anesthesia; eyelid compression during surgery to maximize hemostasis;
ice packs postoperatively; use of fine-tip bipolar forceps

Table 7.4 Consumables used during surgery

7-0 nylon, P-1 needle Ethicon #1696G
Kendall Devon Skin Marker Fine Tip #151

51
CHAPTER 8
Mustardé’s epicanthoplasty
Dongmei Li
Table 8.1 Indications for surgery
Epicanthus with moderate–severe telecanthus
Staged repair for blepharophimosis syndrome
INTRODUCTION
Mustardé’s technique of epicanthoplasty is indicated for the
treatment of epicanthal inversus associated with moderate to
severe telecanthus. Mustardé’s epicanthoplasty involves trans-
position of 4 Z-plasty flaps in conjunction with medial canthal
tendon anchoring to the periosteum. In contrast, root Z-
epicanthoplasty (Chapter 7) addresses the epicanthus but
does not alter the position of the medial canthi. Mustardé’s
epicanthoplasty involves longer and more complex incisions
and places the tissues under more tension, potentially resulting
in higher scar-related complications necessitating a discussion
with the patient and family.
Mustardé’s epicanthoplasty is often performed in the
setting of blepharophimosis syndrome. The treatment of
SECTION TWO • EYELID AND FACE
Chapter 8 Mustardé’s epicanthoplasty
52
Table 8.2 Preoperative evaluation
Associated craniofacial syndromes (i.e., Treacher Collins and
Crouzon syndromes)
Type and severity of epicanthal fold present
Degree of telecanthus
Other associated findings of blepharophimosis syndrome (ptosis,
vertical skin deficiency, ectropion)
History of prior surgeries
blepharophimosis syndrome is performed in a staged fashion
and is best performed after the age of 2 years. The first step
is correction of the epicanthus and telecanthus. If the telecan-
thus is severe, Mustardé’s soft-tissue fixation of the medial
canthus alone may not be sufficient to reduce the telecanthus.
In this case, placement of a midline transnasal wire is per-
formed concurrently to powerfully reduce the intercanthal dis-
tance and allow for tension-free closure of the Z-plasty flaps.
Ptosis correction is performed in the next stage and the type
of operation depends on the degree of levator function. Typi-
cally, levator function is poor, which often necessitates frontalis
suspension (Chapter 15). The next stage is correction of any
vertical skin shortage and lateral canthal surgery.
SURGICAL TECHNIQUE

A B

Figures 8.1A and 8.1B Marking of the midline

This is a patient with blepharophimosis syndrome with congenital epicanthal inversus associated with moderate telecanthus (Figure 8.1A). A vertical mark
is made at the patient’s midline (Figure 8.1B).

A B

C D

Figures 8.2A–E Marking of flap

The desired site (P1) of the new medial canthus is marked at one-half the distance between the midline and the pupillary center (Figure 8.2A). This
distance is best measured with the patient looking in the distance without convergence. The mark is made in line with both pupils. A horizontal line is
then drawn from P1 to the original canthus P2. The paramarginal eyelid arms are then marked for a distance of 2 mm less than the length of (P1 – P2)
(Figure 8.2B). Next, the vertical arms are marked, starting at the midpoint between (P1 – P2), and this subtends a 60° angle with the P2 arm (Figure
8.2C). The length of these vertical arms is also (P1 – P2) – 2 mm. Finally, the backcut arms are marked with the same arm length as the others but the
angle subtended is 45° (Figure 8.2D).

53
 Figures 8.2A–E Marking of flap—cont’d
E
Figure 8.2E shows the final marking prior to incision.

Figure 8.3 Incision of skin flaps

The flaps are measured again and, once satisfactory, local anesthetic in
a total volume less than 2.0 ml is given in the medial canthal region after
skin marking. Corneal protectors are placed prior to the start of surgery.
A #11 or #15 blade can be used for skin incision while the epicanthal
fold is distracted medially. At each step, countertraction is maintained on
the eyelid to maximize accuracy with each incision. Bipolar cautery is used
for hemostasis. Prior to the skin incision, a Bowman probe may be placed
in the proximal canalicular system to prevent iatrogenic damage to the
lacrimal system.

A B

Figures 8.4A and 8.4B Dissection of skin flaps

The flaps are gently developed with sharp dissection or cautious use of cautery (Figure 8.4A). The flaps are undermined while leaving the orbicularis
intact. A small amount of fibrofatty tissue is often present above the orbicularis and this may require debulking. When necessary, conservative removal of
portions of the orbicularis may also be performed to facilitate closure. Gentle manipulation is performed to minimize trauma to the skin flaps. Bipolar
forceps can be used to precisely control fine bleeders. Figure 8.4B shows tissue bed prior to closure.

SECTION TWO • EYELID AND FACE

Chapter 8 Mustardé’s epicanthoplasty
54
 A B

C D

Figures 8.5A–D Medial canthal anchoring

Permanent anchoring of the new medial canthus to the periosteum over the frontal process of the maxilla is essential for the long-term success of this
procedure. A non-absorbable braided suture such 4-0 Mersilene or 4-0 Prolene is used to deeply anchor the periosteum at the new canthal site (Figure
8.5A). Blunt dissection can be performed over the periosteum to improve exposure prior to fixation. Care is taken to avoid damage to the angular vein
during dissection. Once the needle is passed, the suture is pulled upwards to ensure rigid fixation to the periosteum (Figure 8.5B). The suture is passed
in a mattress fashion in the vertical orientation to minimize potential cheese wiring of the suture with time. The needle then engages the medial canthal
tendon very close to the canthus itself, but not in a full-thickness fashion (Figure 8.5C). The first throw of the suture is then tied with firm tension, which
brings the canthus medially. Before placing the second throw in the suture, the assistant holds the knot in place with forceps or a locking needle holder
to prevent loosening of the knot (Figure 8.5D). At least four square knots are firmly tied in place. The medial canthus should be distracted posteriorly at
this point and, if not, the periosteal fixation should be replaced and directed more posteriorly on the frontal process of the maxilla.

55
 A B

Figures 8.6A–C Flap rearrangement and skin closure

Once the canthus has been anchored to the periosteum, the Z-plasty flaps should come into closer approximation. The angles and tips of the flap will
often require fine trimming to ensure a nice inset (Figure 8.6A). The tips should not be trimmed too fine as this may result in skin necrosis. The flaps are
then closed with multiple interrupted 6-0 Prolene sutures (Figure 8.6B). Sutures are removed at the 1-week postoperative visit. If suture removal will be
difficult postoperatively, then 6-0 fast-absorbing gut sutures can be placed. Figure 8.6C shows the final postoperative result with reduction of the
telecanthus and blunting of the epicanthal fold. No dressings are placed but parents should be warned to take preventive measures to avoid eye rubbing
(placement of eye shields or arm splints) in the case of younger children.

BILATERAL EPICANTHOPLASTY BY THE MUSTARDÉ

TECHNIQUE AND STAGED LATERAL CANTHOPLASTY AND FRONTALIS SUSPENSION

Preoperative Postoperative
(2 years)

Figure 8.7 Before and after Mustardé’s epicanthoplasty

This patient underwent Mustardé’s epicanthoplasty at 3 years of age. Three months later, the patient underwent lateral canthoplasty and 6 months after,
she had bilateral frontalis suspension surgery. The postoperative photograph was taken 2 years after the initial surgery.

SECTION TWO • EYELID AND FACE

Chapter 8 Mustardé’s epicanthoplasty
56
Table 8.3 Complications
Complications
Hypertrophic scarring,
nodules or keloid formation
Undercorrection of
epicanthal fold
Asymmetry
Hemorrhage
Suggestions to reduce risk
Avoid excessive wound tension; consider revision with Y-V plasty or transnasal wiring if telecanthus is
severe; undermine flaps more; minimize trauma to limbs of Z-plasty; avoid placing subcutaneous Vicryl
sutures; use non-absorbable sutures and remove at 1 week postoperatively; use fine-tip bipolar cautery for
hemostasis; use postoperative steroid ointment and possible subcutaneous steroid injections
Trim Z-plasty flaps during skin closure step; ensure deep posterior fixation of the medial canthus to frontal
process of maxilla
Careful skin marking; comparison between both sides
Stop anticoagulants prior to surgery; wait at least 10 minutes before incision after giving local anesthesia;
eyelid compression during surgery to maximize hemostasis; ice packs postoperatively; use of fine-tip
bipolar forceps

Table 8.4 Consumables used during surgery

4-0 Mersilene on P-3 needle Ethicon #R691G
4-0 Prolene on P-3 needle Ethicon #8634G
6-0 Prolene, C-1 needle Ethicon #8718
6-0 fast-absorbing gut on PC-1 needle Ethicon #1916G
Kendall Devon Skin Marker Fine Tip #151

57
CHAPTER 9
Transconjunctival lower
blepharoplasty with
fat redraping
Bobby S. Korn
Table 9.1 Indications for surgery
Cosmetically displeasing lower eyelid fat prolapse without
significant dermatochalasis
Functionally, when glasses rest upon prolapsed lower eyelid fat and
causes lower eyelid ectropion
INTRODUCTION
Transconjunctival lower blepharoplasty is well suited for patients
with lower eyelid fat prolapse and minimal skin redundancy
(Figure 9.1). This approach is appealing to many patients as a
skin incision is avoided and there is no orbicularis incision and
potential for denervation. The drawbacks of this procedure
compared to the transcutaneous approach (Chapter 10) are
the difficulty with a smaller incision, poorer exposure, potential
for conjunctival chemosis and posterior lamellar shortening.
Several adjunctive procedures can be performed with transcon-
junctival blepharoplasty including: skin pinch, chemical peel/
laser resurfacing, lateral canthoplasty and fat redraping. With
all of these adjuncts, the orbicularis is left intact, minimizing but
SECTION TWO • EYELID AND FACE
Chapter 9 Transconjunctival lower blepharoplasty with fat redraping
58
Table 9.2 Preoperative evaluation
Prior facial surgery or trauma (including symblepharon)
Dry eye symptoms
Prior refractive surgery
Degree of dermatochalasis and fat prolapse
History of prior fillers to lower eyelid
Presence of midfacial ptosis
Presence of double convex deformity of lower eyelid
Presence of lower eyelid laxity or other eyelid malpositions
not eliminating the risk of lower eyelid retraction and
ectropion.
The preoperative evaluation should focus on ruling out co-
exist eyelid malpositions such as ectropion, entropion, lower
eyelid retraction and lagophthalmos which may predispose to
dry eye. A lower eyelid distraction test is performed to assess
laxity (Figure 9.2). Normal eyelid tone is 6 mm or less and any
laxity greater than 6 mm should be addressed with a lid tight-
ening procedure such as a canthoplasty. Post-LASIK patients
should wait at least 3 months after refractive surgery before
considering lower blepharoplasty. The conjunctiva should be
inspected for any signs of cicatricial changes. Minimal skin
redundancy should be noted and if present, a decision to
perform concurrent skin pinch or chemical or laser resurfacing
should be considered at the time of surgery or postoperatively.
Photographs in the frontal, profile, and side planes should be
taken before and after surgery.
In youth, there is a smooth transition from the lower eyelid
to the midface, but with aging, there is unmasking of the inferior
orbital rim and generation of the double convex deformity
(Figure 9.3). Conservative blepharoplasty with fat redraping
should be discussed with younger patients as aged-related fat
atrophy may result in a sunken appearance with senescence if
subtractive blepharoplasty is performed. Fat redraping can
blunt the double convexity and restore a natural eyelid and
midfacial transition.

PREOPERATIVE EVALUATION

Figure 9.1 Evaluation of lower

eyelid contour
The lower eyelid fat pads are evaluated
and documented with natural lighting.
Prolapse of all three lower eyelid fat
pads can be seen in this case with
minimal skin redundancy. In the
preoperative holding area, the lower
eyelid fat pads are marked while the
patient is sitting up and prior to sedation
and infiltration of local anesthetic.

LOWER EYELID DISTRACTION TEST

< 6mm 10mm distraction

Figure 9.2 Lower eyelid distraction test

The lower eyelid is pulled away from the globe. With normal eyelid tone, the distance from the sclera to the eyelid should be 6 mm or less. In the right
panel, there is lower eyelid laxity of 10 mm. During blepharoplasty, lower eyelid tightening should be performed to minimize the risk of postoperative
eyelid malposition (Chapters 25 and 29).

59
 LOWER EYELID AND MIDFACIAL JUNCTION

Smooth contour Double convexity

Figure 9.3 Lower eyelid and midfacial junction

On the left panel, there is a harmonious transition from the lower eyelid to the cheek in the youthful eyelid. With aging, there is unmasking of the orbital
rim leading to the double convex deformity. These changes may be due to loss of orbital and cheek fat, attenuation of the orbitomalar ligament and
maxillary retrusion.

SURGICAL TECHNIQUE

Figure 9.4 Lateral canthotomy and inferior cantholysis

In patients with normal lower eyelid tone, access to the lower eyelid fat
may be difficult. In such cases, a lateral canthotomy and inferior
cantholysis may be necessary to achieve suitable access to the lower
eyelid. The canthotomy is kept small at 1 mm and the cantholysis is
restricted to the inferior crus of the lateral canthal tendon (Figure 9.4).
When performing fat redraping, access to the inferior orbital rim is
enhanced with canthal release.

SECTION TWO • EYELID AND FACE

Chapter 9 Transconjunctival lower blepharoplasty with fat redraping
60
 A B

C D

Figures 9.5A–D Transconjunctival incision Using a protective eyelid plate and corneal protector, a transconjunctival incision is made approxi-
mately 4 mm below the inferior tarsal border with cutting cautery (Figure 9.5A). The cauterization is performed cautiously near the medial eyelid where
iatrogenic punctal injury may occur. Once the conjunctiva has been incised, a preseptal dissection is performed towards the inferior orbital rim (Figure
9.5B). Blunt dissection with a cotton tip applicator can be used to gently dissect in this avascular plane to expose each of the lower eyelid fat pads
(Figure 9.5C). If fat redraping will be performed, then a preperiosteal dissection is performed along the arcus marginalis to expose the inferior orbital rim
(Figure 9.5D). The periosteum along the inferior orbital rim must be kept intact so that the fat can be redraped to the periosteum. Alternatively, fat
pedicles can be redraped in a subperiosteal fashion depending on surgeon preference.

A B

Figures 9.6A–D Development of fat pedicles for redraping

The lower eyelid fat pads are then identified and dissected free (Figure 9.6A). Care is taken near the nasal and central fat pads as the inferior oblique
traverses between these two structures. The orbital septum is then opened horizontally over each fat pad (Figure 9.6B).

61
 C D

Figures 9.6A–D Development of fat pedicles for redraping—cont’d

Forceps are used to develop each fat pedicle with blunt counter traction using a cotton tip applicator (Figure 9.6C). The fat pedicles are then inferiorly
redraped using forceps to simulate the postoperative effect (Figure 9.6D). In some cases, there is an abundance of lower eyelid fat and this can be
conservatively excised prior to redraping.

A B

C D

Figures 9.7A–D Fat redraping

The fat pedicles are redraped with a 6-0 Vicryl suture in a horizontal mattress fashion. The suture is passed through the center of the pedicle so that the
suture will not cheese wire through a distally placed bite (Figure 9.7A). The suture is then passed horizontally several millimeters below the arcus
marginalis on the inferior orbital rim (Figure 9.7B). Similarly, the central fat padicle is developed and redraped along the inferior orbital rim (Figure 9.7C).
Finally, the nasal fat pedicle is redraped (Figure 9.7D). Care is taken in this area as the inferior oblique muscle separates the central and nasal fat pads.
The redraping suture should not incarcarate any portion of the muscle otherwise diplopia may result.

SECTION TWO • EYELID AND FACE

Chapter 9 Transconjunctival lower blepharoplasty with fat redraping
62
 A B

C D

Figures 9.8A–D Lateral canthoplasty

The lower eyelid is then reassessed for any laxity (Figure 9.8A). If no laxity is present, the canthus is then reinserted with two interrupted 6-0 Vicryl
sutures. If laxity is present, a small triangular full-thickness segment is excised to tighten the eyelid (Figure 9.8B). The canthus is then reformed with two
6-0 Vicryl suture passed in a subcutaneous, full-thickness bite through the tarsal plate (Figure 8C). The needle is then passed deeply through the
superior crus of the lateral canthal tendon (Figure 8D). If significant laxity is present, the needle can be used to secure the periosteum over the lateral
orbital rim for added strength and posterior distraction of the new canthus. A second suture is then passed in a similar fashion below the first suture.
Both sutures are tied off and then the skin overlying the canthus is closed with 6-0 fast absorbing gut suture.

BILATERAL TRANSCONJUNCTIVAL LOWER BLEPHAROPLASTY

WITH FAT REDRAPING

Preoperative Postoperative

Figure 9.9 Before and after transconjunctival lower blepharoplasty with fat redraping
This 42-year-old female underwent transconjunctival lower blepharoplasty with fat redraping.

63
Table 9.3 Complications
Complications Suggestions to reduce risk
Lower eyelid hollowing Minimize fat removal; redraping instead of removing lower eyelid fat; consider adjunct hyaluronic acid filler
injection (Chapter 48)
Asymmetry Office-based revision 3 months after surgery; consider removing/redraping residual fat (under correction)
vs. hyaluronic acid filler injection to address over correction
Conjunctival chemosis Use of topical steroids postoperatively; reassurance; needling of conjunctiva; placement of temporary
tarsorrhaphy; thermal conjunctival tightening (Chapter 52); minimal trauma to conjunctiva
Corneal abrasion Use of corneal shields and lid plate during surgery
Dry eyes/lagophthalmos Ocular lubrication; placement of punctal plugs; tighten lax eyelids, minimize skin removal/chemical or laser
resurfacing; tape eyelids shut at night
Hemorrhage Meticulous hemostasis during procedure; use of tapered needle for skin closure; ice packs postoperatively;
cessation of anticoagulants
Infection Perform procedure after sterile preparation; use of topical antibiotic ointment; be cognizant of
immunosuppressed states
Hardening/nodule formation Treat for possible infection first with oral antibiotics (consider MRSA coverage); consider injection of
along inferior orbital rim steroids along inferior orbital rim to address granuloma from fat redraping suture; consider short course of
oral steroids (Medrol dose pack)
Suture granuloma Use non-absorbable sutures; recognize granulomas early; remove suture if symptomatic and treat with
antibiotic/steroid ointment
Wound dehiscence Avoid eye rubbing; ice packs to minimize hemorrhage and itching; protective eye shields; no heavy lifting
after surgery; avoidance of contact lens use

Table 9.4 Consumables used during surgery

6-0 Vicryl, PC-1 needle Ethicon #J833G
6-0 fast absorbing gut, PC-1 needle Ethicon #1916G

SECTION TWO • EYELID AND FACE

Chapter 9 Transconjunctival lower blepharoplasty with fat redraping
64
 CHAPTER 10
Transcutaneous lower blepharoplasty with
orbitomalar suspension and fat redraping
Table 10.1 Indications for surgery
Cosmetically displeasing lower eyelid fat prolapse with
dermatochalasis
Functionally, when glasses rest upon excessive lower eyelid fat
prolapse and causes lower eyelid ectropion
INTRODUCTION
Transcutaneous lower blepharoplasty may be considered when
addressing cosmetic lower eyelid fat prolapse with associated
lower eyelid rhytids. When lower eyelid fat prolapse is the
primary concern, the transconjunctival approach, as discussed
in Chapter 9, is a more appropriate choice.
The preoperative evaluation should focus on aesthetic
changes due to fat prolapse and skin redundancy as well as
the contour changes of the lower eyelid and midfacial junc-
tion. Functional changes such as lower eyelid laxity, eyelid
retraction, lagophthalmos and blink dynamics should be evalu-
ated and addressed at the time of surgery. Patients with a
prior history of blepharoplasty should be evaluated for eyelid
retraction and eyelid closure and treatment should be directed
at correction of these malpositions prior to blepharoplasty
Bobby S. Korn • Ayelet Priel
Table 10.2 Preoperative evaluation
Prior facial surgery or trauma
Dry eye symptoms
Prior refractive surgery
Degree of dermatochalasis and fat prolapse
History of prior fillers to lower eyelid
Presence of midfacial ptosis
Presence of double convex deformity of lower eyelid
Presence of lower eyelid laxity or other eyelid malpositions
(Chapters 34–36). Dry eye and tear film status should be
determined and treated prior to surgery as well. Patients who
have had keratorefractive surgery should have a careful evalu-
ation for dry eye as this may worsen after blepharoplasty.
Patients with a negative vector in which maxillary hypoplasia
and a prominent globe are present are at high risk of lower
eyelid retraction with transcutaneous lower blepharoplasty
(Figure 10.1) and are more appropriate for the transconjunctival
approach (Chapter 9). Photo documentation is essential and
should be performed in the frontal plane, three-quarter, and
side views to demonstrate changes after surgery.
Several adjunctive procedures can be performed during trans­
cutaneous lower blepharoplasty. Redraping of fat pedicles can
address the double convex deformity of the lower eyelid
(Chapter 9). Judicious lower eyelid tightening, conservative
skin removal and suborbicularis oculi fat lifting (orbitomalar
65
suspension) at the time of surgery can minimize the risk of lower blepharoplasty to lessen the risk of lower eyelid malpositions
eyelid retraction and lagophthalmos. We routinely perform orbi- as well as for the aesthetic benefits to the midface.
tomalar suspension on all cases of transcutaneous lower

Figures 10.1 Negative vector

The negative vector is present when the globe projects anterior to
the inferior orbital rim. This may be due to several factors
including thyroid-related orbitopathy, myopia and maxillary
retrusion. The risk of eyelid malposition is high in this group of
patients. Midfacial elevation such as orbitomalar suspension or an
inferior orbital rim implant may be beneficial.

SURGICAL TECHNIQUE

A B

Figures 10.2A and 10.2B Incision planning

Transcutaneous access to the lower eyelid is performed through an infraciliary incision within 1 mm of the eyelashes (Figure 10.2A). The incision should
be marked before the infiltration of local anesthetic to minimize distortion. The marking should initially extend from the punctum to the lateral canthal
angle. Local anesthetic containing 1 : 200,000 epinephrine is given both through the conjunctival approach as well as along the transcutaneous marking
to minimize orbicularis bleeding. When injecting transcutaneously, the needle is injected in a pre-orbicularis plane and used to hydrodissect the skin from
the underlying muscle. A 6-0 silk suture is then passed through the gray line and placed on superior traction (Figure 10.2B). Prior to the start of surgery,
a corneal shield is put in place.

SECTION TWO • EYELID AND FACE

Chapter 10 Transcutaneous lower blepharoplasty with orbitomalar suspension and fat redraping
66
 A B

C D

Figures 10.3A–D Infraciliary incision

With superior traction on the eyelid, the infraciliary incision is made with blunt tip Westcott scissors (Figure 10.3A). The incision should be kept very
close to the eyelashes to maximally conceal the scar. When making this incision, the inferior edge of the skin is tented up with 0.5 forceps to dissect the
skin away from the underlying orbicularis. With adequate delivery of the local anesthetic in the pre-orbicularis plane, the skin should easily dissect free
from the muscle. Minimizing trauma to the pretarsal orbicularis will lessen the chance of developing postoperative ectropion from an atonic muscle.
Using the Westcott scissors, dissection is continued inferiorly with the blunt tips of the scissors directed towards the skin in the pre-orbicularis plane
(Figure 10.3B). Care is also taken when handling the thinned lower eyelid skin as this is reflected inferiorly (Figure 10.3C). The dissection is continued
inferiorly for at least 4 mm below the eyelid margin to expose the preseptal orbicularis (Figure 10.3D).

67
 Pretarsal orbicularis
left intact

Enter preseptal plane

below level of the
pretarsal orbicularis

A B

C D

Figures 10.4A–D Preseptal dissection

Once the dissection in the pre-orbicularis plane is complete, the anterior orbit is entered. Sharp dissection is performed at the level of the preseptal
orbicularis at a level below the pretarsal orbicularis (Figures 10.4A and 10.4B). This preseptal orbicularis window is extended medially and laterally with
sharp dissection. Once the preseptal plane has been exposed, blunt dissection with a peanut sponge or cotton-tip applicator is performed with inferior
countertraction using a Senn retractor (Figure 10.4C). Further blunt dissection in this avascular plane exposes all three lower eyelid fat pads and is
continued to the inferior orbital rim (Figures 10.4D and 10.4E). Any fine bleeders are coagulated with bipolar cautery.

SECTION TWO • EYELID AND FACE

Chapter 10 Transcutaneous lower blepharoplasty with orbitomalar suspension and fat redraping
68
 A B

C D

Figures 10.5A–D Release of orbitomalar ligament

The orbitomalar ligament is the primary retaining ligament of the midface which anchors the suborbicularis oculi fat (SOOF) to the lateral orbital rim.
Release of the orbitomalar ligament and superior suspension of the SOOF provides aesthetic elevation of the midface and protection against lower eyelid
retraction. The orbitomalar ligament has broad midfacial attachments and the stoutest attachments are to the inferolateral orbital rim, as shown in
Figures 10.5A and 10.5B. A malleable retractor is placed along the inferolateral orbital rim with a Senn retractor providing countertraction. Cutting
cautery is used in the dissection along the inferolateral orbital rim to lyse attachments of the orbitomalar ligament (Figure 10.5C). Once the orbitomalar
ligament has been released, a peanut sponge is used to bluntly dissect any residual attachments to the lateral orbital rim (Figure 10.5D). Care is taken
during the inferolateral dissection along the orbital rim as the zygomaticofacial artery and nerve exit via its foramen. If bleeding occurs from this foramen,
gentle bipolar cautery should be applied to prevent significant midfacial hemorrhage. Neurosensory loss is minimal and recovery is rapid and uneventful.

69
 A B

Figures 10.6A–C Arcus marginalis release

The arcus marginalis is the dense band of tissue along the orbital rim where the orbital septum originates (Figure 10.6A). If fat redraping is to be
performed, the arcus marginalis must be released so that orbital fat pedicles can be repositioned along the inferior orbital rim to correct the double
convex deformity. With the shift away from subtractive blepharoplasty, fat preservation by redraping is our preferred treatment option for lower eyelid fat
prolapse. When significant expansion of the orbital fat is present, judicious removal of fat may be necessary but can be recontoured by redraping. The
arcus marginalis is then released by performing a preperiosteal incision along the outer border of the inferior orbital rim (Figure 10.6B). The dissection
should not proceed down to the level of periosteum as this layer of tissue must be preserved for redraping of fat pedicles. The dissection should also
remain outside of the orbital rim as the origin of the inferior oblique on the maxillary bone is just inside of the inferomedial orbital rim. Once the release
has been performed, cotton-tip applicators are used to further expose the periosteum along the inferior orbital rim (Figure 10.6C).

A B

Figures 10.7A–D Development of fat pedicles

The orbital septum is then opened to allow development of fat pedicles for redraping. Cutting cautery or sharp dissection is used to open the orbital
septum approximately 2–3 mm above the inferior orbital rim (Figure 10.7A). The central fat is often prominent and easily accessed first. Once the
septum has been opened, the central fat is gentled teased from the orbit (Figure 10.7B).

SECTION TWO • EYELID AND FACE

Chapter 10 Transcutaneous lower blepharoplasty with orbitomalar suspension and fat redraping
70
 C D

Figures 10.7A–D Development of fat pedicles—cont’d

If any bleeding occurs, gentle bipolar cautery is applied for hemostasis. The fat pedicles should not be forcibly pulled from the orbit as deeper bleeding
may occur. As the septum is opened medially, the nasal fat is identified by its more pale color compared to the central fat pad. Gentle pressure on the
globe will help the fat pads. The inferior oblique muscle divides the nasal and central fat and this muscle should be identified and avoided when
dissecting in this region (Figure 10.7C). The nasal fat pedicle is then developed with blunt dissection (Figure 10.7D). If excessive fat is present,
conservative fat debulking can be performed at this point. Before proceeding to the next stage, all bleeders should be carefully identified and cauterized
for complete hemostasis.

A B

C D

Figures 10.8A–D Redraping of fat pedicles

Fat redraping along the inferior orbital rim addresses the double convex deformity of the lower eyelid by filling in the tear trough. Fat pedicles can be
secured along the inferior orbital rim or alternatively can be redraped with removable sutures and placed on external bolsters through the skin overlying
the tear trough. In this case, a 6-0 Vicryl suture is used to anchor the fat pedicles in a horizontal mattress to the periosteum along the inferior orbital rim
(Figures 10.8A and 10.8B). When redraping the nasal fat pedicle, be careful to avoid incorporating the adjacent inferior oblique into the periosteal bite.
The central fat pedicle is then redraped inferiorly in a similar fashion (Figure 10.8C). The lateral fat pedicle can be redraped similarly but often this fat
pad can be sculpted to address lateral fullness of the lower eyelid (Figure 10.8D).

71
Figure 10.9 Inspection of lower eyelid fat pedicles
Once fat sculpting and redraping has been completed, a final inspection of
the inferior orbit is performed. First, the inferior oblique is identified again
and the muscle is examined to ensure that the redraping suture has not
inadvertently tethered the muscle to the inferior orbital rim. The skin is
redraped over the fat pedicles and the lower eyelid contour is
re-evaluated. With gentle pressure on the globe to simulate the standing
position, any fullness or hollowness of the lower eyelid is noted. Fullness
denotes excess fat and the respective fat pad is sculpted to achieve a
smooth contour. Any hollowness should be filled by reposition of fat
pedicles. Another check is performed to ensure complete hemostasis.
Finally, saline is used to irrigate the surgical bed to wash away coagulated
blood, errant eyelashes, and liquefied fat cells.

A B

C D

Figures 10.10A–D SOOF fixation

After release of the orbitomalar ligament (Figures 10.5A–D), the suborbicularis oculi fat (SOOF) can be visualized (Figure 10.10A). Toothed Adson forceps
are used to purchase the SOOF within the midface (Figure 10.10B). The SOOF is superiorly advanced and then the contour of the cheek is evaluated for
dimpling and bunching as the pull is simulated with the forceps. The optimal fixation point in the SOOF is carefully selected, and once satisfactory, a 4-0
Vicryl suture is used to secure the tissue (Figure 10.10C). Suture placement is confirmed again by pulling the tissue in a superolateral vector (Figure
10.10D). Significant bunching and/or dimpling of the tissue should not be visualized and, if present, the SOOF fixation point is adjusted accordingly.

SECTION TWO • EYELID AND FACE

Chapter 10 Transcutaneous lower blepharoplasty with orbitomalar suspension and fat redraping
72
 A B

Figures 10.11A–C Orbitomalar suspension

To achieve orbitomalar suspension and midfacial elevation, the
suborbicularis oculi fat (SOOF) suture is pulled in a superolateral vector. A
small, curved hemostat is used to bluntly dissect an inferior pocket from
the upper eyelid crease incision. This inferior pocket is lateral to the lateral
canthal tendon and should be in the preperiosteal plane. The SOOF suture
is then retrieved through this pocket and directed superiorly (Figure
10.11A). In conjunction with fat redraping, the elevation of the SOOF
further blends the eyelid–midfacial junction to eliminate the double convex
deformity (Figure 10.11B). The SOOF flap is secured to the periosteum
overlying the frontozygomatic suture line (Figure 10.11C). The bite is taken
perpendicular to the lateral orbital rim to minimize the possibility of
C
“cheese-wiring” of the suture postoperatively.

A B

Figures 10.12A–D Lower eyelid tightening

If lower eyelid laxity was noted during the preoperative examination, this is addressed after orbitomalar suspension. Failure to address laxity may result in
eyelid retraction or ectropion from bunching of the lateral eyelid after orbitomalar suspension. A 1-mm lateral canthotomy and inferior cantholysis is
performed with Westcott scissors (Figure 10.12A). A triangular, full-thickness wedge of lateral eyelid is appropriately excised according to the degree of
laxity (Figure 10.12B).

73
 C D

Figures 10.12A–D Lower eyelid tightening—cont’d

Two 5-0 Vicryl sutures are used to secure the upper and lower poles of the tarsus to the superior crus of the lateral canthal tendon (Figures 10.12C and
10.12D). Fixation to the lateral canthal tendon should be deep to prevent anterior distraction of the lower eyelid after the canthoplasty. A 7-0 Vicryl
suture can also be placed at the canthal angle uniting the gray lines of the upper and lower eyelids. This suture ensures precise alignment of the eyelids
and creates a sharp canthal angle.

A B

C D

Figures 10.13A–D Skin removal and closure

After orbitomalar suspension and lower eyelid tightening, excess skin can be noted at the lateral canthus. A skin marking is extended inferiorly past the
lateral canthus (Figure 10.13A). The lateral extent of the marking should not extend past the lateral point of the upper blepharoplasty incision. The skin
only is incised and this flap is draped superiorly to identify redundancy (Figure 10.13B). This triangular flap of skin is marked horizontally and excised in
a similar fashion to a Burow’s triangle (Figure 10.13C). A small degree of redundant orbicularis may be present and this is conservatively excised lateral
to the canthus. Finally, a thin strip of skin only is excised towards the punctum (Figure 10.13D). Care is taken to minimally remove skin, particularly
medially to avoid punctal ectropion. At most, 2–3 mm of skin is removed from the infraciliary region. The patient can also be asked to open their mouth
to assess for adequacy of the anterior lamella prior to skin excision.

SECTION TWO • EYELID AND FACE

Chapter 10 Transcutaneous lower blepharoplasty with orbitomalar suspension and fat redraping
74
 A B

Figures 10.14A and 10.14B Skin closure

Skin closure is performed with 6-0 fast-absorbing gut closure starts at the lateral canthus and proceeds nasally (Figure 10.14A). Closure in this manner
minimizes the formation of dog ears at the end of the running suture (Figure 10.14B).

BILATERAL UPPER AND LOWER BLEPHAROPLASTY

Preoperative Postoperative

Figure 10.15 Before and after upper and lower blepharoplasty

This 51-year-old female underwent upper and lower blepharoplasty with fat redraping and orbitomalar suspension through the transcutaneous approach.

Table 10.3 Consumables used during surgery

6-0 silk, G-7 needle Ethicon #765G
4-0 Vicryl PC-1 needle Ethicon #J835G
5-0 Vicryl, PC-3 needle Ethicon #J844G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G

75
Table 10.4 Complications
Complications Suggestions to reduce risk
Lower eyelid retraction Minimize fat removal; tighten lower eyelid; conservative skin removal; minimize cauterization to middle lamella;
minimize trauma/removal of pretarsal orbicularis; avoid transcutaneous approach in patients with a negative vector
Lower eyelid hollowing Minimize fat removal; redraping instead of removing lower eyelid fat; consider adjunct hyaluronic acid filler
injection (Chapter 48)
Lower eyelid ectropion Minimize skin removal; upward massage of lower eyelid; consider steroid injection to pretarsal orbicularis
Punctal ectropion Minimize skin removal medially; upwards massage of lower eyelid; consider medial spindle procedure (Chapter
26); consider full-thickness skin graft placement (Chapter 27)
Asymmetry Office-based revision 3 months after surgery; consider removing/redraping residual fat (undercorrection) vs
hyaluronic acid filler injection to address overcorrection
Conjunctival chemosis Use of topical steroids postoperatively; reassurance; needling of conjunctiva; placement of temporary
tarsorrhaphy; thermal conjunctival tightening (Chapter 52); minimize trauma to conjunctiva
Corneal abrasion Use of corneal shields and lid plate during surgery
Dry eyes/lagophthalmos Ocular lubrication; placement of punctal plugs; tighten lax eyelids, minimize skin removal/chemical or laser
resurfacing; tape eyelids shut at night; lower eyelid retraction repair (Chapters 34–36)
Hemorrhage Meticulous hemostasis during procedure; use of tapered needle for skin closure; ice packs postoperatively;
cessation of anticoagulants
Infection Perform procedure after sterile preparation; use of topical antibiotic ointment; be cognizant of
immunosuppressed states
Hardening/nodule formation Treat for possible infection first with oral antibiotics (consider MRSA coverage); consider injection of steroids
along inferior orbital rim along inferior orbital rim to address granuloma from fat redraping suture; consider short course of oral steroids
(Medrol dose pack)
Suture granuloma Use non-absorbable sutures; recognize granulomas early; remove suture if symptomatic and treat with
antibiotic/steroid ointment
Wound dehiscence Avoid eye rubbing; ice packs to minimize hemorrhage and itching; protective eye shields; no heavy lifting after
surgery; avoidance of contact lens use

SECTION TWO • EYELID AND FACE

Chapter 10 Transcutaneous lower blepharoplasty with orbitomalar suspension and fat redraping
76
 CHAPTER 11
Ptosis repair by external levator
Christine C. Annunziata • Bobby S. Korn
Table 11.1 Indications for surgery
Functional ptosis affecting vision
Cosmetically displeasing ptosis
Amblyopia in visually maturing children
Ptosis affecting prosthesis function in the anophthalmic socket
INTRODUCTION
The normal position and contour of the eyelids must be recog-
nized before undertaking ptosis repair. The position of the
upper and lower eyelids is defined by the margin to reflex dis-
tance (MRD), which is the distance from the central corneal
advancement
Table 11.2 Preoperative evaluation
Prior facial surgery or trauma
Dry eye symptoms/lagophthalmos present
Quality of Bell’s phenomenon
Prior refractive surgery
Co-existent dermatochalasis and/or eyebrow ptosis
Amount of levator function
Need to avoid posterior conjunctival ptosis repair (i.e., strabismus,
glaucoma filtration surgery/drainage device, cicatricial conjunctival
diseases, fornix shortening)
Degree of ptosis present
Rule out myasthenia gravis
Presence of Hering’s law/contralateral ptosis
Desire for upper eyelid crease (particularly with Asian patients)
Potential for revision/asymmetry
light reflex to the upper eyelid (MRD1) and the lower eyelid
(MRD2). The definition of functional ptosis varies by source, but
in general it is less than or equal to 2.5 mm. In the upper eyelid
the contour of the lid is characterized by a peak that is nasal
to the central corneal light reflex, while in the lower eyelid this
peak is lateral (Figure 11.1).
77
 The evaluation of the ptosis patient begins with the classifica-
tion of the specific subtype. Aponeurotic or involutional ptosis
is the most common type and is caused by disinsertion of the
levator aponeurosis. Myogenic ptosis is associated with a dys-
functional levator and can be seen with myasthenia gravis,
chronic progressive external ophthalmoplegia (CPEO) and con-
genital ptosis. Neurogenic ptosis may be caused by cranial
nerve III palsy or Horner’s syndrome. Mechanical ptosis is
associated with an eyelid mass.
The MRD1, upper eyelid crease position and levator function
are documented during the evaluation. Normal levator function
is at least 12 mm of upper eyelid excursion. Hering’s law should
be tested in cases of presumed unilateral ptosis. The ptotic
eyelid is manually elevated and the MRD1 of the fellow eyelid
is recorded. If the fellow eyelid falls after lifting of the ptotic
PREOPERATIVE EVALUATION
Figure 11.2 Test for Hering’s law
This patient presents with left-sided unilateral ptosis (Figure 11.2A). With manual elevation of the left upper eyelid, the right eyelid lowers (Figure 11.2B)
owing to Hering’s law of equal innervation. The optimal treatment plan in this patient is bilateral upper eyelid ptosis repair, starting with the left side first.
SECTION TWO • EYELID AND FACE
Chapter 11 Ptosis repair by external levator advancement
78
eyelid, bilateral ptosis exists (Figure 11.2). Failure to treat con-
tralateral ptosis with a Hering’s response can result in a post-
operative surprise. Ptosis associated with decreased levator
function may be addressed by levator resection (Chapter 14)
or frontalis suspension (Chapter 15) depending on the amount
of levator function. The anterior approach, external levator
advancement procedure, is ideal for patients with normal
levator function and severe ptosis (MRD1 <1.5 mm). With the
anterior approach, there is no conjunctival incision, which is
relevant with patients who may need or have had glaucoma
filtration surgery or strabismus surgery, or those with cicatricial
conjunctival disease. The surgery does require patient coop-
eration to achieve optimal eyelid position and is not optimally
performed under general anesthesia.
Figure 11.1 Normal eyelid position
The normal upper and lower eyelid positions rest just inside of the corneal
limbus, covering 1mm of the iris. The peak of the upper eyelid is nasal to
the pupillary center while the lower eyelid is laterally peaked. With aging,
there is often lateral shifting of the upper eyelid peak and this can be
corrected at the time of surgery.
SURGICAL TECHNIQUE

Figure 11.3 Skin marking Figure 11.4 Dissection through orbital septum
An upper eyelid crease incision provides excellent access for external Prior to incision, a corneal protector is placed. Skin incision is performed
levator advancement surgery. In cases of co-existent dermatochalasis, this with a #15 blade and if a concurrent blepharoplasty is performed, then
approach also allows the surgeon to perform concurrent blepharoplasty the skin only is removed with sharp dissection while preserving the
during ptosis repair. In cases where blepharoplasty is not indicated, the orbicularis. Then, a horizontal incision is made through the orbicularis and
incision can be limited to the central one-third of the eyelid (Chapter 12). continues through the white, fibrous orbital septum. Using cutting cautery
The upper eyelid crease is marked as described in Chapters 3 and 4. or sharp dissection, the septum is opened for the length of the incision
Note that the eyelid crease may be significantly elevated with advanced while the assistant provides inferior countertraction. Achieving meticulous
involutional ptosis and the crease should be marked lower on the eyelid hemostasis is of paramount importance to ensure maximal levator function
instead of the superiorly migrated position and confirmed bilaterally. This when performing intraoperative eyelid level assessment.
well-camouflaged incision should be carefully marked and measured in
cases where the eyelid crease is elevated or ill-defined due to levator
aponeurotic dehiscence. Levator surgery is performed under local
anesthesia with minimal IV sedation to ensure maximal levator effort and
patient cooperation during surgery. Local anesthetic consisting of 2%
lidocaine with 1:200,000 epinephrine is given in a maximum volume of
1.25–1.50ml to minimize levator weakness. Additional smaller amounts of
local anesthetic can be given intraoperatively as needed.

A B

Figures 11.5A and 11.5B Identification of the levator aponeurosis

After the orbital septum is opened, the levator aponeurosis is identified. Typically, the white, avascular aponeurosis band is seen immediately upon
opening the orbital septum and may be noted to be slightly disinserted from the tarsal plate. In more severe cases of levator dehiscence, the underlying
Müller’s muscle and tightly adherent palpebral conjunctiva may be noted immediately upon opening of the septum. The peripheral vascular arcade is an
important landmark that overlies Müller’s muscle and care must be taken to avoid dissection through this layer (Figures 11.5A and 11.5B). In this case,
the dehisced edge of the levator aponeurosis is seen higher in the dissection field, while in other cases the aponeurosis may not be as retracted.

79
 A B

Figures 11.6A and 11.6B Preaponeurotic fat as a surgical landmark

The preaponeurotic fat pad serves as an important surgical landmark for identifying the posteriorly located levator muscle and aponeurosis (Figures
11.6A and 11.6B). This is particularly important in cases of severe dehiscence. Typically, the fat is the first structure visualized after opening of the
septum but, in this case, the fat has retracted superiorly along with the levator aponeurosis. Occasionally, the orbital septum may be mistaken for the
levator aponeurosis. When in doubt, ask the patient to open their eyes and note the gentle traction caused by the pull of the levator. The levator is then
freed from residual attachments of the preaponeurotic fat prior to advancement.

Figure 11.7 Creation of pretarsal pocket

A plane is created between the tarsal plate and the overlying orbicularis
for the upper one-third to one-half of the tarsus. Excessive inferior
dissection in the pretarsal plane is unnecessary. Care should be taken to
avoid trauma to the tarsal plate as this tissue serves as the point of
attachment for the levator aponeurosis. The use of blunt-tipped scissors
can be used to dissect in this plane safely. Electrocautery can be
performed but patients may notice increased discomfort and inadvertent
tarsal trauma can occur. Careful dissection of the epitarsal tissues will
facilitate passage of suture in a lamellar fashion in the next step.

A B

Figures 11.8A and 11.8B Advancement of levator

After identification of the levator and creation of a pretarsal pocket, the levator can be advanced to the upper tarsal border. Using toothed forceps, the
surgeon performs gentle superior traction on the upper border of the tarsus and checks the eyelid contour. Once a suitable location is identified, a single
6-0 Prolene suture is passed horizontally and in a lamellar fashion through the upper one-third of the tarsal plate (Figure 11.8A). A tapered C-1 style
needle is useful during the tarsal pass to minimize intratarsal bleeding and cheese wiring of the tarsus. Prior to completing the pass, the needle is left
buried in the tarsal plate and then the partial thickness depth can be verified by everting the eyelid and looking for posterior break-through of the needle
(Figure 11.8B). If the needle is visualized on the posterior surface of the tarsus, a more shallow bite is taken to avoid corneal irritation by the advance-
ment suture. The suture is then passed in a horizontal mattress fashion through the levator aponeurosis and tied with a temporary bow tie for intraopera-
tive level assessment. If the eyelid position is adequate but the eyelid is too peaked, additional advancement sutures may be placed medial and lateral to
the initial suture until the desired contour is achieved. Alternatively, the eyelid may be peaked if there is excessive, pre-existing upper eyelid laxity and
this should be addressed with eyelid tightening.

SECTION TWO • EYELID AND FACE

Chapter 11 Ptosis repair by external levator advancement
80
 A B

Figures 11.9A and 11.9B Intraoperative eyelid assessment

After temporary levator advancement, the corneal protector is removed and eyelid level is assessed (Figure 11.9A). If the patient is alert and cooperative,
eyelid level assessment can be performed in the supine position. If cooperation is poor, the patient can be placed in the upright position. The height and
contour are compared for symmetry. Additional levator advancement sutures can be placed at this point to address any contour abnormalities. In more
severe cases of levator dehiscence or levator atrophy, multiple sutures are often required. In general, the eyelid height should be corrected by 1–1.5 mm
to compensate for weakness of the levator from the local anesthetic. This amount varies with surgeon and anesthesiologist, and an individual “surgeon
factor” should be taken into account. Permanently tying off the suture advances the levator aponeurosis onto the anterior face of the tarsus and secures
it in position. In this case, a single fixation point was sufficient for excellent eyelid height and contour (Figure 11.9B). If there is redundant aponeurosis
upon advancement, this can be excised after suture fixation. Also, at this point, any redundant orbital fat can be conservatively removed as needed after
optimal eyelid height and contour is achieved.

A B

C D

Figures 11.10A–D Eyelid crease fixation

With significant levator dehiscence, the upper eyelid crease may be artificially elevated. Supratarsal crease fixation can restore the native eyelid crease,
and in Asian patients this is particularly relevant. The eyelid crease is refixated by first securing a 7-0 Vicryl suture to the inferior cut edge of the
pretarsal orbicularis (Figures 11.10A and 11.10B). Then, this suture is secured to the levator aponeurosis slightly higher than the fixation point of the
levator advancement (Figures 11.10C and 11.10D). Three or four fixation sutures are placed, evenly along the length of the inferior skin incision.

81
Figure 11.11 Skin closure
The skin incision is then closed using a running 6-0 Prolene suture
and removed at the 1-week postoperative visit. Alternatively, 6-0
fast-absorbing gut suture can be used.

BILATERAL UPPER BLEPHAROPLASTY AND

PTOSIS REPAIR BY EXTERNAL LEVATOR ADVANCEMENT

Preoperative Postoperative

Figure 11.12 Before and after upper eyelid ptosis repair by external levator advancement and upper blepharoplasty
This 64-year-old male underwent upper eyelid ptosis repair by external levator advancement with single suture fixation and concurrent upper blepharo-
plasty. Postoperatively, he has improved upper eyelid position as well as restoring the nasal peak of the upper eyelid.

SECTION TWO • EYELID AND FACE

Chapter 11 Ptosis repair by external levator advancement
82
Table 11.3 Complications
Complications Suggestions to reduce risk
Asymmetry Maximize patient cooperation, sit up patients during assessment if needed, minimize use of IV sedation,
control hemostasis
In patients with a large glaucoma filtration bleb, leave the eyelid position a bit lower to avoid superior
riding of the eyelid from the conjunctival dome
Conjunctival prolapse Avoid excessive levator dissection and resection superiorly
Watch for conjunctival prolapse and perform fornix repair if noted at the end of the case
See Chapter 16 for repair of conjunctival prolapse
Contour deformity/peaking Add additional advancement sutures medial and laterally, lengthen bite of the tarsal pass (original
suture passed to short horizontally on tarsal plate), tighten eyelid if laxity is present
This may occur as well in patients who have undergone previous posterior ptosis approaches such as
Fasanella–Servat and careful fixation is important
Corneal abrasion Use of corneal shields during surgery and careful placement of suture in a partial-thickness pass
through the tarsal plate
Dry eyes/lagophthalmos Conservative advancement of levator (particularly in cases with moderate to low levator function), avoid
fixation of levator to orbital septum, superior rectus or superior oblique
Eyelid crease/fold differences Mark incision at level of desired crease, placement of crease fixation sutures, advancement of
preaponeurotic fat to superior tarsus or injection of hyaluronic acid fillers
Hemorrhage Meticulous hemostasis during procedure, use of tapered needle for skin closure, ice packs
postoperatively, cessation of anticoagulants
Infection Perform procedure after sterile preparation, use of topical antibiotic ointment, be cognizant of
immunosuppressed states
Overcorrection of eyelid If overcorrected in the first postoperative week, perform clinic revision to recess advancement suture or
replace entirely at desired height
Unmasking of dermatochalasis Counsel patients preoperatively of the potential for unmasking of dermatochalasis if ptosis is performed
in isolation
Address with concurrent blepharoplasty if indicated
Undercorrection If significantly undercorrected, wait until postoperative week 2 and perform office revision with
placement of new advancement suture
Upper eyelid ectropion Replace advancement suture to a more superior position on the tarsal plate
Suture granuloma Use non-absorbable sutures, recognize granulomas early, remove suture if symptomatic and treat with
antibiotic/steroid ointment
Wound dehiscence Avoid eye rubbing, ice packs to minimize hemorrhage and itching, protective eye shields, no heavy
lifting after surgery, avoidance of contact lens use

Table 11.4 Consumables used during case

6-0 Prolene, C-1 needle Ethicon #8718
7-0 Vicryl, TG140-8 needle Ethicon J546G
6-0 fast-absorbing gut, PC-1 needle Ethicon 1916G

83
CHAPTER 12
Ptosis repair by small incision
external levator advancement
Bobby S. Korn
Table 12.1 Indications for surgery
Functional ptosis affecting vision
Cosmetically displeasing ptosis
Need for levator advancement but without excess dermatochalasis
Ptosis affecting prosthesis in anophthalmic socket
Ptosis repair in non-Asians when crease fixation is not necessary
INTRODUCTION
Small incision levator advancement compared to traditional
external levator advancement (Chapter 11) is performed
through an incision less than 12 mm. The procedure is ideally
suited when a levator advancement is needed but when an
upper blepharoplasty is not necessary. In patients who have
failed posterior approach ptosis repairs, small incision levator
advancement may be considered. For the Asian patient who
SECTION TWO • EYELID AND FACE
Chapter 12 Ptosis repair by small incision external levator advancement
84
Table 12.2 Preoperative evaluation
Prior facial surgery or trauma
Dry eye symptoms/lagophthalmos present
Quality of Bell’s phenomenon
Prior refractive surgery
Co-existent eyebrow ptosis
Amount of levator function
Need to avoid posterior conjunctival ptosis repair (i.e., strabismus,
glaucoma filtration surgery/drainage device, cicatricial conjunctival
diseases, fornix shortening)
Degree of ptosis present
Rule out myasthenia gravis
Presence of Hering’s reflex
Potential for revision/asymmetry
desires a well-defined eyelid crease, the small incision approach
may not be suitable, as this does not allow for wide crease
fixation across the entire eyelid. Typically only one suture is
required for levator advancement with the small incision
approach and the lateral and medial horns of the levator are
left undisturbed. As with any levator technique, this procedure
is performed under local anesthesia with minimal IV sedation
to ensure optimal levator function. See Chapter 11 for a more
detailed discussion of the preoperative evaluation.
SURGICAL TECHNIQUE

A B

Figures 12.1A–C Skin marking

Small incision external levator advancement is ideally suited for aponeurotic repair when no co-existing dermatochalasis is present or when a prior
blepharoplasty has been performed (Figure 12.1A). A small incision in the central eyelid crease is marked and typically measures 8–12 mm (Figure
12.1B). Comparison of the fellow eyelid crease should be performed to ensure symmetry. When advanced levator dehiscence is present, the upper eyelid
crease may be artificially elevated over 10 mm. If this is the case, the upper eyelid crease height should be lowered to a suitable height based on the
gender and ethnicity of the patient. Prior to surgery, local anesthetic consisting of 2% lidocaine with 1 : 200,000 epinephrine in a maximum volume of
1.0 ml is given (Figure 12.1C). Additional local anesthetic can be given as needed, but start with a minimal amount to avoid unwanted levator paralysis.

A B

Figures 12.2A–C Dissection to tarsal plate

Prior to start of surgery, a corneal protector is placed. A #15 blade is used to make an incision through the skin only (Figure 12.2A). Cutting cautery or
scissors are used to dissect posteriorly through the orbicularis layer (Figure 12.2B).

85
Figures 12.2A–C Dissection to tarsal plate—cont’d
Once the orbicularis is opened, the tarsal plate should be noted (Figure
12.2C). Further dissection of the epitarsal tissues is performed to expose
the superior one-third of the tarsal plate. Care is taken to keep the
dissection below the superior border of the tarsus while avoiding trauma
to the levator or Müller’s muscle located at the upper tarsal border.
C

A B

C D

Figures 12.3A–D Identification of the levator aponeurosis

The assistant provides inferior traction on the conjoined fascia at the inferior cut edge of the incision (Figure 12.3A). The surgeon then performs superior
countertraction on the upper eyelid lid while performing sharp dissection through the orbital septum. The levator aponeurosis is often immediately
identified as a broad white band of tissue superior to the tarsus (Figure 12.3B). In cases of significant levator dehiscence, the aponeurosis may be
superiorly retracted and the peripheral vascular arcade over Müller’s muscle may be noted instead. Care should be taken to avoid iatrogenic damage to
Müller’s muscle and the underlying conjunctiva. The use of a corneal shield also gives an extra layer of protection in the case of inadvertent dissection
through the conjunctiva. The orbital septum is then opened above the levator aponeurosis (Figure 12.3C). Once the levator has been identified, residual
attachments of the orbital septum are released along the length of the incision (Figure 12.3D).

SECTION TWO • EYELID AND FACE

Chapter 12 Ptosis repair by small incision external levator advancement
86
 A B

C D

Figures 12.4A–D Levator advancement

Suture placement is critical in the small incision technique since typically one suture is used for advancement. Toothed forceps are used to grasp the
tarsus at the proposed fixation point. The contour of the eyelid is noted and, if satisfactory, a 6-0 Prolene suture is used to advance the levator (Figure
12.4A). The suture is then passed horizontally through the upper one-third of the tarsal plate (Figure 12.4B). During the tarsal pass, the needle should
pass in a partial-thickness, lamellar fashion to avoid subsequent corneal abrasion (Figure 12.4C). A tapered C-1 style needle is useful during the tarsal
pass to minimize intratarsal bleeding. To ensure a partial-thickness pass, the needle is left in the tarsal plate and the eyelid is everted to ensure that the
needle is not visible (Figure 12.4D).

A B

Figures 12.5A and 12.5B Intraoperative eyelid level assessment

A temporary bow tie knot is placed in the levator advancement for eyelid level assessment (Figure 12.5A). The corneal protector is then removed and the
patient is asked to open the eyes to determine optimal eyelid position (Figure 12.5B). Typically, this can be done with the patient in the supine position.
However, if cooperation is poor, the patient is asked to sit up to judge eyelid position. The eyelid position may be overcorrected by 1–1.5 mm to adjust
for local-anesthetic-induced weakness of the levator. This degree of overcorrection should be constantly re-evaluated taking into account surgeon factors
as well as the degree of sedation used. The peak of the upper eyelid should be nasal to the lower eyelid peak, as discussed in Chapter 11.

87
 A B

Figures 12.6A–C Skin closure

Once the optimal eyelid height and contour are achieved, the 6-0 Prolene
suture is permanently tied off and the excess suture cut right on the knot
(Figure 12.6A). A single interrupted 7-0 Vicryl suture can be used to
approximate the orbicularis for added strength of eyelid closure. The skin
is closed with a 6-0 Prolene suture or a 6-0 fast-absorbing gut suture in
C
a running fashion (Figures 12.6B and 12.6C).

BILATERAL SMALL INCISION LEVATOR ADVANCEMENT

Preoperative Postoperative

Figure 12.7 Before and after upper eyelid ptosis repair by small incision external levator advancement
This 58-year-old female underwent upper eyelid ptosis repair by small incision levator advancement with single suture fixation.

SECTION TWO • EYELID AND FACE

Chapter 12 Ptosis repair by small incision external levator advancement
88
Table 12.3 Complications
Complications Suggestions to reduce risk
Asymmetry Maximize patient cooperation; sit up patients during assessment if needed, minimize use of IV
sedation, control hemostasis
In patients with a large glaucoma filtration bleb, leave the eyelid position a bit lower to avoid
superior riding of the eyelid from the conjunctival dome
Contour deformity/peaking Optimize single suture placement and adjust as needed on the field
Corneal abrasion Use of corneal shields during surgery and careful placement of suture in a partial-thickness pass
through the tarsal plate
Dry eyes/lagophthalmos Conservative advancement of levator (particularly in cases with moderate to low levator function),
avoid fixation of levator to orbital septum, superior rectus or superior oblique
Eyelid crease/fold differences Avoid procedure in Asian patients or when crease fixation is desired
Hemorrhage Meticulous hemostasis during procedure, use of tapered needle for skin closure, ice packs
postoperatively, cessation of anticoagulants
Infection Perform procedure after sterile preparation, use of topical antibiotic ointment, be cognizant of
immunosuppressed states
Overcorrection of eyelid If overcorrected in the first week postoperative week, perform clinic revision to recess
advancement suture or replace entirely at desired height
Unmasking of dermatochalasis Avoid procedure with pre-existing dermatochalasis or counsel patients preoperatively
Undercorrection If significantly undercorrected, wait until postoperative week 2 and perform office revision with
placement of new advancement suture
Upper eyelid ectropion Replace advancement suture to a more superior position on the tarsal plate
Suture granuloma Use non-absorbable sutures, recognize granulomas early, remove suture if symptomatic and treat
with antibiotic/steroid ointment
Wound dehiscence Avoid eye rubbing, ice packs to minimize hemorrhage and itching, protective eye shields, no heavy
lifting after surgery, avoidance of contact lens use

Table 12.4 Consumables used during surgery

6-0 Prolene C-1 needle Ethicon #8718
7-0 Vicryl, TG140-8 needle Ethicon J546G
6-0 fast-absorbing gut, PC-1 needle Ethicon 1916G

89
CHAPTER 13
Ptosis repair by conjunctival
Müller’s muscle resection
Bobby S. Korn

Table 13.1 Indications for surgery Table 13.2 Preoperative evaluation

Functional ptosis affecting vision Prior facial surgery or trauma
Cosmetically displeasing ptosis Dry eye symptoms/lagophthalmos present
Ptosis developing after cataract, refractive surgery, or prolonged Quality of Bell’s phenomenon
contact lens use
Prior refractive surgery
Ptosis repair under general anesthesia or when patient cooperation
Co-existent dermatochalasis and/or eyebrow ptosis
is not necessary
Amount of levator function and response to topical phenylephrine
No history of glaucoma, strabismus, cicatricial conjunctival disease,
cicatricial entropion or fornix shortening or congenital ptosis
Degree of ptosis present
Rule out myasthenia gravis
Presence of Hering’s reflex
Desire for upper eyelid crease (particularly with Asian patients)
Potential for revision/asymmetry

poor levator function, see Chapters 14 and 15. Caution should

INTRODUCTION
Conjunctival Müller’s muscle resection (CMMR) is a posterior
approach ptosis repair technique that is suitable for correction
of 3 mm or less of upper eyelid ptosis. CMMR is the preferred
posterior ptosis procedure over the Fasanella–Servat proce­
dure as tarsus is not removed during the procedure. CMMR is
not indicated for patients with congenital ptosis or cicatricial
conjunctival diseases. For treatment of congenital ptosis with
be exercised in patients with glaucoma or prior history of filtra­
tion surgery as well as patients who may need strabismus
surgery. Repeat CMMR should also be performed cautiously
as this may significantly shorten the conjunctival fornix leading
to symblepharon. CMMR does not require patient cooperation
and can be performed under general anesthesia. Upper eyelid
ptosis that develops after cataract surgery, refractive surgery
or prolonged contact lens use tends to respond well to CMMR.

SECTION TWO • EYELID AND FACE

Chapter 13 Ptosis repair by conjunctival Müller’s muscle resection
90
Furthermore, CMMR is ideally suited for ptosis repair of the adjustments of one’s “surgeon factor” can be employed to
cosmetic patient because of its predictable outcome and aes­ further optimize the procedure. In contrast to levator ptosis
thetically pleasing contour. Concurrent upper blepharoplasty techniques, CMMR can be performed under general anesthe­
and CMMR can be performed as well as crease fixation at the sia, as the decision making in terms of amount of resection
time of surgery. is determined during the clinical examination and not
A positive phenylephrine test affirms that CMMR is a suitable intraoperatively.
procedure for the eyelid in question. Topical 2.5% phenyl­
ephrine is given in the affected eye, followed by a second set
of drops 1–2 minutes later. At 5 minutes after instillation of the
Table 13.3 Conjunctival Müller’s muscle resection
drops, the MRD1 is documented (Figure 13.1). The position of
the fellow eye should also be noted as the phenylephrine test Amount of ptosis Amount of resection of
may unmask ptosis from Hering’s law. Topical 10% phenyl­ to correct conjunctival Müller’s muscle
ephrine is unnecessary and may lead to cardiotoxicity and
other studies have shown no difference in efficacy between the 1.0 mm ptosis 4 mm
two concentrations. 1.5 mm ptosis 6 mm
Table 13.3 provides a useful basis for titrating the amount of
conjunctival Müller’s muscle resection and the desired amount 2.0 mm ptosis 8 mm
of eyelid lift. These numbers should be considered as a starting
point for one’s surgical decision making. With experience, 3.0 mm ptosis 9–10 mm

PHENYLEPHRINE TEST

Figures 13.1A and 13.1B Phenylephrine test

Prior to testing, photographs are taken to document the native eyelid position as well as visual field testing if applicable (Figure 13.1A). Then, two sets of
topical 2.5% phenylephrine drops are placed on the ptotic side. Photographs are taken 5 minutes after instillation of the drops to document any effect by
the drop. In this case, the left upper eyelid responds favorably to the drops and indicates the patient may a suitable candidate for CMMR ptosis repair
(Figure 13.1B). Attention should also be directed to the fellow eyelid to ensure that ptosis was not unmasked by Hering’s law.

SURGICAL TECHNIQUE

Figure 13.2 Injection of local anesthetic

Regardless of the method of sedation used during surgery, approximately
2–3 ml of 2% lidocaine with 1 : 200,000 epinephrine is infiltrated into the
upper eyelid crease near the superior tarsal border. We have not observed
any cases of overcorrection from the inclusion of epinephrine in the
anesthetic and the hemostatic benefits outweigh any potential risk (Figure
13.2). Additionally, the procedure is well tolerated in the office procedure
room setting without the use of a frontal nerve block.

91
 A B

Figures 13.3A and 13.3B Exposure of palpebral conjunctiva

The upper eyelid is everted with a Desmarres retractor to expose the palpebral conjunctiva (Figure 13.3A). In the clinic setting without oral or IV sedation,
this step may cause the most discomfort for the patient as the tissues are distended. If excessive local anesthetic is given in the upper eyelid, particularly
in the setting of a prior upper blepharoplasty, eyelid eversion may be difficult. Gently massage to redistribute the excess local anesthetic and consider
placement of a 6-0 silk traction suture at the eyelid margin to facilitate eversion. Finally, a corneal shield is not routinely used during CMMR as this
makes eversion of the eyelid more difficult. The superior border of the tarsal plate is identified as well as the curvature and peak of the tarsal plate are
noted for subsequent marking (Figure 13.3B).

A B

Figures 13.4A and 13.4B Marking of conjunctiva

Once the desired amount of ptosis correction is determined, the amount of tissue to be resected is divided in half (Table 13.3). A caliper is used to mark
this distance from the superior tarsal border centrally, laterally and medially (Figure 13.4A). The central marking should correspond to the central peak of
the tarsal plate. In this case, a 8-mm resection is desired and 4 mm is marked superior to the tarsal border as shown (Figure 13.4B). The upper eyelid
should be everted with even pressure and care is taken to avoid over-everting the eyelid as this may lead to overmarking and potential overcorrection
postoperatively. Likewise, in patients with an excessively lax upper fornix upon eversion, an extra 1–1.5 mm of excision may be considered, but weigh
this carefully with the risk of fornix shortening.

A B

Figures 13.5A and 13.5B Traction suture placement

A 6-0 silk suture on a G-7 semicircle needle is used to secure conjunctiva and Müller’s muscle (Figures 13.5A and 13.5B). The surgeon holds one arm
of the traction suture while the assistant provides countertraction to the opposite arm of the suture. This retracts the conjunctiva and Müller’s muscle flap
away from the tarsal plate.

SECTION TWO • EYELID AND FACE

Chapter 13 Ptosis repair by conjunctival Müller’s muscle resection
92
 Figure 13.6 Placement of ptosis clamp
A Müller’s muscle resection clamp is then placed on the conjunctival
Müller’s muscle flap, paying attention not to incorporate any part of the
tarsal plate. The silk traction suture is then removed once the tissue flap
is secured. The surgical assistant can also place countertraction on the
tarsal plate to ensure that no tarsal tissue is incarcerated in the clamp.
Additional local anesthetic can be given in the palpebral conjunctiva
superior to the ptosis clamp at this time if needed.

A B

Figures 13.7A and 13.7B Suturing of conjunctiva and Müller’s muscle

Absorbable or removable sutures may be used during CMMR. In the case of removable sutures, a 6-0 Prolene on a tapered C-1 needle is ideal for
minimizing intraoperative bleeding. This tapered needle may be initially difficult to use as the smooth needle easily rotates in a needle holder but the
lower risk of hemorrhage with each pass outweighs its challenges in handling. The suture is first directed from the upper eyelid crease and emerges
high in the superior fornix. A horizontal mattress suture pattern is then used to secure the clamp with six passes (Figure 13.7A). Once the mattress has
been completed, the suture is exited high in the fornix. When using absorbable sutures, a 6-0 fast-absorbing gut is the ideal choice. The suture is
similarly secured on the upper eyelid skin or, in the case of concurrent upper blepharoplasty, the suture is secured to the inferior edge of the orbicularis
muscle (Figure 13.7B).

Figure 13.8 Excision of conjunctival Müller’s muscle flap

A #15 blade is then used to excise the flap while exerting upward
pressure on the ptosis clamp. The blade should be oriented 45° against
the flat surface of the ptosis clamp in a metal (blade) on metal (ptosis
clamp) fashion to minimize inadvertent cutting of the fixation suture. If the
suture is accidentally severed, a new suture is placed in the upper eyelid
and the cut edges of the conjunctiva are reapproximated in an end-to-end
fashion, paying careful attention to potential exposure of the suture to the
corneal surface.

93
Figure 13.9 Securing suture
When using Prolene, the suture is externalized to the upper eyelid and tied
with minimal tension to allow for postoperative edema. The suture is
removed at the 1-week postoperative visit. When using fast-absorbing gut
suture, the opposite end of the suture is secured to the inferior orbicularis
edge.

RIGHT UPPER EYELID PTOSIS REPAIR BY

CONJUNCTIVAL MÜLLER’S MUSCLE RESECTION

Preoperative Postoperative

Figure 13.10 Before and after upper eyelid ptosis repair by conjunctival Müller’s muscle resection
This 34-year-old female underwent right upper eyelid ptosis repair by an 8-mm conjunctival Müller’s muscle resection.

SECTION TWO • EYELID AND FACE

Chapter 13 Ptosis repair by conjunctival Müller’s muscle resection
94
Table 13.4 Complications
Complications Suggestions to reduce risk
Asymmetry Wait until 3 months postoperatively for revision
Contour deformity/peaking Shift peak of the excision nasally if excessive lateral tarsal distraction is present
Corneal abrasion Place mattress suture high in the fornix
Dry eyes/lagophthalmos Avoid excessive conjunctival Müller’s muscle resection
Eyelid crease/fold differences Careful preoperative examination and counseling; perform concurrent upper eyelid crease incision
with placement of crease fixation sutures
Hemorrhage Intraoperatively, use tapered needles for suture placement; postoperatively, consider use of
topical 2.5% phenylephrine to promote vascular contraction; ice packs and gentle pressure; stop
anticoagulants if permissible; hemorrhage typically exits through fornix onto ocular surface and
rarely accumulates retroseptal
Infection Perform procedure after sterile preparation, use of topical antibiotic ointment; be cognizant of
immunosuppressed states
Overcorrection of eyelid Wait 3 months after surgery to re-evaluate; watch for contralateral ptosis and reflex upper eyelid
retraction from Hering’s law, if truly overcorrected, consider upper eyelid retractor recession
(Chapter 17)
Unmasking of dermatochalasis Counsel patients preoperatively of the potential for unmasking of dermatochalasis if ptosis is
performed in isolation; address with concurrent blepharoplasty if indicated
Undercorrection Common in first 1–2 weeks postoperatively from tissue edema – reassurance; if persistent after
3 months, consider external levator advancement (Chapter 11 and 12)
Suture granuloma Use non-absorbable sutures; recognize granulomas early; remove suture if symptomatic and treat
with antibiotic/steroid ointment
Wound dehiscence Avoid eye rubbing; ice packs to minimize hemorrhage and itching; protective eye shields; no
heavy lifting after surgery; avoidance of contact lens use; consider revision at 3 months
postoperatively

Table 13.5 Consumables and instruments used during surgery

6-0 Prolene suture, C-1 needle Ethicon #8718
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
6-0 silk suture, G7 needle Ethicon #765G
Müller’s muscle resection clamp Bausch and Lomb Surgical E2508

95
CHAPTER 14
Congenital ptosis repair by
levator resection
Bobby S. Korn

Table 14.1 Indications for surgery Table 14.2 Preoperative evaluation

Poor levator function ptosis, greater than or equal to 5 mm Prior facial surgery or trauma
Myogenic ptosis Dry eye symptoms/lagophthalmos present
• Congenital ptosis
Quality of Bell’s phenomenon (particularly with myogenic etiologies)
• Double elevator palsy
• Blepharophimosis Prior refractive surgery
• Congenital fibrosis syndrome Co-existent dermatochalasis
Amblyopia in visually maturing children Amount of levator function
Functional ptosis affecting vision Extraocular motility (may unmask diplopia with ptosis repair)
Brow position and frontalis muscle function
Upper eyelid crease height (MRD1), eyelid position, contour
Eyelid position with vertical eye movements (eyelid lag)
Presence of lagophthalmos
Corneal examination
Presence of jaw wink
Potential for revision/asymmetry
History of anesthesia complications such as malignant
hyperthermia

SECTION TWO • EYELID AND FACE

Chapter 14 Congenital ptosis repair by levator resection
96
INTRODUCTION
Congenital ptosis is caused by maldevelopment of the levator
muscle. The condition can be unilateral or bilateral and the
severity of the ptosis is dependent on the number of viable
striated levator muscle fibers. Congenital ptosis often has a
family lineage, although sporadic cases are common.
The most concerning complication of congential ptosis is the
development of amblyopia in the growing child. Depending on
the degree of ptosis, induced anisometropia and even occlu-
sion can profoundly affect visual maturation. In general, con-
genital ptosis repair should be delayed until 4–5 years of age.
For severe cases in younger patients, manual taping of the
ptotic eyelid can be performed to stimulate visual development
until the child is old enough for surgery. Patching and optimiz-
ing any refractive errors is performed with any signs of amblyo-
pia. The loss of a head tilt in a unilateral case should also
prompt patching of the fellow eye as suppression is occurring
in the ptotic eye.
In 1979, Beard described a useful grading scheme for the
management of congenital ptosis (Table 14.3). During the evalu-
ation, the position of the upper eyelid (MRD1) and levator func-
tion with the brow suspended inferiorly are carefully determined.
These measurements are a starting point for determining the
amount of levator to resect to achieve an adequate eyelid posi-
tion. Beard’s table provides a useful starting point and, with
experience, one should modify these numbers with their own
surgeon’s factor. Levator function less than 5 mm may warrant
frontalis suspension (Chapter 15), although a supermaximal
levator resection may be considered first.
The expectations and complications should be discussed in
depth with the parents prior to surgery. It should be explained
to the parents that in addition to the functional visual improve-
ments with ptosis correction, the cosmetic improvement in the
eyelid position has also shown to improve social development.
Indeed, from a functional standpoint, congenital ptosis repair
is not considered a cosmetic operation but rather a reconstruc-
tive surgery.
Common complications include over- and under-correction
and eyelid contour asymmetry. Lagophthalmos is seen in virtu-
ally all patients, particularly with large (≥18 mm) levator resec-
tions. Children tolerate this corneal exposure particularly well,
probably as a combination of a good Bell’s reflex and a health-
ier tear film compared to adults. It should be explained to the
parents that this will likely be seen and may improve with time.

SURGICAL TECHNIQUE

Table 14.3 Beard’s congenital ptosis table

Degree of ptosis Levator function Amount of levator resection
Mild (1.5–2 mm) Good (8 mm or more) Small (10–13 mm)
Moderate (3 mm) Good (8 mm or more) Moderate (14–17 mm)
Fair (5–7 mm) Large (18–22 mm)
Poor (4 mm or less) Maximum (23 mm or more)
Severe (4 mm or more) Poor (4 mm or less) “Super maximum” (23 mm or more) or Frontalis sling
Fair (5–7 mm) Maximum (23 mm or more)

A B

Figures 14.1A and 14.1B Skin marking

With congenital ptosis, there is often a poorly defined upper eyelid crease. The heights of both upper eyelid creases are measured and for the case of
unilateral ptosis, the height of the normal, fellow eyelid is marked on the ptotic eyelid (Figure 14.1A). For unilateral cases, the eyelid height should be set
according to gender and ethnicity. The marking should extend to approximately 75% of the intercanthal distance (Figure 14.1B). The incision can be
extended during the surgery as needed. After the marking, local anesthetic consisting of 1% lidocaine, 0.25% Marcaine with epinephrine 1 : 200,000 is
then given.

97
 A B

C D

Figures 14.2A–D Skin incision and exposure of tarsal plate

A corneal shield is placed before the start of surgery. Skin incision is performed with a #15 blade (Figure 14.2A). Cautery or sharp dissection is then
performed through the orbicularis (Figure 14.2B). The dissection proceeds to identify the superior border of the tarsal plate. Once the tarsal plate has
been identified, the upper one-third is exposed (Figure 14.2C). Care is taken to avoid trauma to the tarsal plate as a healthy platform of tissue is needed
for suture advancement of the levator. The edge of the levator aponeurosis can often been seen superiorly after it has been disinserted from the tarsal
plate (Figure 14.2D). The surgeon should also be aware of peripheral vascular arcade that overlies Müller’s muscle. Trauma to this muscle can result in
significant bleeding and may distort the surgical anatomy.

SECTION TWO • EYELID AND FACE

Chapter 14 Congenital ptosis repair by levator resection
98
 A B

C D

Figures 14.3A–D Identification and dissection of levator

With superior traction on the orbicularis and inferior traction on the conjoined fascia, cautery is used to dissect between these two structures (Figure
14.3A). Often, the preaponeurotic fat pad will immediately come into view (Figure 14.3B). This important landmark helps to identify the underlying levator
aponeurosis. The levator is then sequentially freed from the orbital septum and the preaponeurotic fat pad (Figure 14.3C). A Desmarres retractor is then
used for superior traction and dissection should continue in the superior orbit until Whitnall’s ligament can be visualized (Figure 14.3D). The levator
muscle is often noted to be infiltrated with fat owing to its maldevelopment.

99
 A B

Figures 14.4A and 14.4B Dissection of levator from Müller’s muscle

Based on the preoperative examination, the expected amount of the levator to resect is predetermined. In this case of moderate left upper eyelid ptosis with
levator function of approximately 10 mm, a 14-mm resection is planned (Figure 14.5A). To advance this much levator, its attachment to Müller’s muscle
must be freed (Figure 14.5B). Dissection can be performed with Westcott scissors or cutting cautery. Any bleeders are carefully cauterized using bipolar
cautery. Care is taken to avoid creating a button hole through the underlying palpebral conjunctiva. If any conjunctival lacerations are created, these are
repaired with interrupted 6-0 fast-absorbing gut sutures. It is essential to have a corneal shield in place during this dissection to protect the globe.

A B

C D

Figures 14.5A–D Levator advancement

Once the levator has been dissected free from Müller’s muscle, a malleable retractor is placed between these two layers and a 6-0 Prolene suture is then
passed through the levator (Figure 14.6A). The needle is then passed horizontally, in a partial thickness pass through the upper one-third of the tarsal plate
(Figure 14.6B). The needle can be left in place during the tarsal pass and the eyelid everted to ensure a lamellar pass was performed. The needle is then
passed back through the levator and a temporary bow-tie knot is tied (Figure 14.6C). The contour and height are evaluated and, in this case, the temporal
eyelid is still ptotic (Figure 14.6D). Additional sutures are placed as needed until a satisfactory contour and height are achieved. In general, the eyelid should
be overcorrected by 1 mm. In the absence of an active Bell’s reflex or globe rotation, the eyelid position on the table should approximate the final postopera-
tive result.

SECTION TWO • EYELID AND FACE

Chapter 14 Congenital ptosis repair by levator resection
100
 A B

C D

Figures 14.6A–D Levator resection and eyelid crease formation

The redundant levator muscle is then excised after advancement. Westcott scissors or cutting cautery is used to trim the levator to leave a 1.5-mm cuff
below the advancement sutures (Figure 14.7A). Supratarsal crease fixation sutures are used to create a stable eyelid crease after levator resection. A
7-0 Vicryl suture is passed from the inferior pretarsal orbicularis (Figure 14.7B) and then a bite is taken through the levator at or above the level of the
Prolene advancement suture (Figure 14.7C). Additional crease fixation sutures are placed evenly along the upper eyelid (Figure 14.7D).

A B

Figures 14.7A and 14.7B Skin closure

The skin is then closed with a running 6-0 fast-absorbing gut suture. Non-absorbable sutures are rarely used as removal is difficult in the clinic setting
for younger patients.

101
 LEFT UPPER EYELID PTOSIS REPAIR BY LEVATOR RESECTION

Preoperative Postoperative

Figure 14.8 Before and after congenital ptosis repair of the left upper eyelid
This 5-year-old underwent a 14-mm levator resection in the left upper eyelid for congenital ptosis.

Table 14.4 Complications

Complications Suggestions to reduce risk
Asymmetry/contour deformity/peaking Careful preoperative measurements of levator function; placement of sufficient levator
advancement sutures; wider levator advancement suture placement to prevent cheese-wiring;
meticulous hemostasis during levator and Müller’s dissection
Undercorrection Ensure levator advancement sutures are placed with wide enough bites and through muscle;
overcorrect by 1 mm or more; consider revision after 2–3 months; consider frontalis sling with
poor levator function less than 5 mm
Conjunctival prolapse Minimize dissection of levator from Müller’s muscle beyond Whitnall’s tubercle; identify
intraoperatively and consider placement of fornix forming sutures (Chapter 16)
Corneal abrasion Use of corneal shields during surgery and careful placement of suture in a partial-thickness pass
through the tarsal plate; cautious dissection between levator and Müller’s muscle
Dry eyes/lagophthalmos Lagophthalmos is common and expected after levator resection; management with artificial
tears/lubricants; downward eyelid massage
Eyelid crease/fold differences Placement of sufficient crease fixation sutures
Hemorrhage Meticulous hemostasis during procedure, use of tapered needle for skin closure, ice packs
postoperatively, cessation of anticoagulants
Infection Perform procedure after sterile preparation; use of topical antibiotic ointment; minimize physical
activity/playtime for 2 weeks after surgery
Overcorrection of eyelid Downward eyelid massage; manage corneal exposure medically; consider revision after 4 weeks
of no improvement
Unmasking of dermatochalasis Consider removal of 1–2 mm of skin during primary surgery
Suture granuloma Use non-absorbable sutures, recognize granulomas early, remove suture if symptomatic and
treat with antibiotic/steroid ointment
Wound dehiscence Avoid eye rubbing, ice packs to minimize hemorrhage and itching, protective eye shields,
minimize activity in children; consider use of arm splints

SECTION TWO • EYELID AND FACE

Chapter 14 Congenital ptosis repair by levator resection
102
Table 14.5 Consumables used during case
7-0 Vicryl, TG140-8 needle Ethicon #J546G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
6-0 Prolene, C-1 needle Ethicon #8718

103
CHAPTER 15
Frontalis suspension with
silicone rod
Sang-Rog Oh • Bobby S. Korn

Table 15.1 Indications for surgery Table 15.2 Preoperative evaluation

Poor levator function ptosis, <5 mm Prior facial surgery or trauma
Myogenic ptosis Dry eye symptoms/lagophthalmos present
• Congenital ptosis
Quality of Bell’s phenomenon (particularly with myogenic etiologies)
• Double elevator palsy
• Blepharophimosis Prior refractive surgery
• Congenital fibrosis syndrome Co-existent dermatochalasis
• Chronic progressive external ophthalmoplegia (CPEO)
• Oculopharyngeal muscular dystrophy (OPMD) Amount of levator function (consider for less than 5 mm function)
• Myotonic dystrophy (MD) Extraocular motility (may unmask diplopia with ptosis repair)
Neurogenic ptosis
Brow position and frontalis muscle function
• Cranial nerve III palsy
• Myasthenia gravis Allergy/prior reaction to silicone
• Blepharospasm with apraxia of eyelid opening
Corneal examination
Amblyopia in visually maturing children
Cardiac clearance with Kearns–Sayre syndrome
Functional ptosis affecting vision
Potential for revision/asymmetry
Maximize medical management of myasthenia gravis

INTRODUCTION evaluated preoperatively to minimize corneal damage from

Frontalis suspension surgery is primarily indicated for ptosis
associated with poor levator function (less than 5 mm). Table
15.1 summarizes some of the indications for surgery. In this
ptosis repair technique, the powerful lifting ability of the frontalis
muscle is coupled to the tarsal plate to provide eyelid elevation.
The quality of the Bell’s phenomenon should be carefully
postoperative lagophthalmos. A poor Bell’s phenomenon is
often seen with double elevator palsy, CPEO, OPMD, myotonic
dystrophy, cranial nerve III palsy and myasthenia gravis, so
exercise caution in these patients. Unmasking of binocular
diplopia may also occur with eyelid elevation, necessitating
careful preoperative evaluation of extraocular motility and ocular

SECTION TWO • EYELID AND FACE

Chapter 15 Frontalis suspension with silicone rod
104
misalignment. For patients with Kearns-Sayre syndrome, pre-
operative clearance should be obtained to rule out associated
cardiac arrhythmias. Medical management of patients with
myasthenia gravis should be maximized first prior to consider-
ing frontalis suspension.
For congenital ptosis with levator function greater than 5 mm,
consider levator resection as a primary operation first (Chapter
14). Two commonly used sling materials include silicone rod
and autologous or donor fascia. Autologous fascia lata should
not be harvested in patients younger than 5 years of age. The
benefits of autologous fascia lata are biocompatibility and dura-
bility, but are complicated by the difficulty with revision and
donor-site morbidity. Silicone rod allows for postoperative
eyelid height adjustment and no donor-site complications but
may be susceptible to breakage, extrusion, and allergic
reactions.

SURGICAL TECHNIQUE

A B

Figures 15.1A and 15.1B Eyelid and brow markings

An incision line is drawn in the upper eyelid crease and three marks are made at the upper brow line, in line with the medial canthus, pupil, and lateral
canthus. The incisional scars are hidden in the natural eyelid crease and the hair-bearing region of the eyebrows. The eyelid and the upper brow stab
incisions form a pentagon (Fox technique), allowing the vector of force from the frontalis muscle to elevate the eyelid while maintaining its natural
contour (Figures 15.1A and 15.1B).

A B

Figures 15.2A and 15.2B Creation of pretarsal pocket

The skin is incised with a #15 blade at the upper eyelid crease and then dissection continues posteriorly through the orbicularis to reach the pretarsal
plane (Figure 15.2A). Dissection continues to expose a pretarsal pocket in the upper one-third of the tarsal plate (Figure 15.2B). Further dissection
inferiorly is not necessary and if the sling is anchored too far inferiorly along the tarsal plate, anterior distraction of the eyelid from the globe may occur
with frontalis action.

105
 A B

Figures 15.3A and 15.3B Tarsal fixation of silicone rod

Once the upper third of the tarsal plate is exposed, the silicone rod can be fixed to the tarsal plate. Prior to fixation, forceps can be used to superiorly
retract the tarsal plate to simulate the contour with frontalis elevation. The silicone rod is then secured to the tarsus by passing a 6-0 Prolene suture in a
partial-thickness fashion (Figures 15.3A and 15.3B). Medial and lateral fixation is performed to secure the sling. If there is any suspicion of a full-thick-
ness corneal pass, the eyelid should be everted for examination. Care must be taken to ensure that the sutures are not passed full thickness to avoid
corneal abrasion.

A B

Figures 15.4A and 15.4B Evaluation of eyelid contour after tarsal fixation
The ends of the silicone sling are then raised, simulating the action of the frontalis muscle, and the eyelid contour is noted. This is done in line with the
medial and lateral brow markings prior to passage of the sling superiorly. In this case the vector of pull results in a temporal peak of the upper eyelid
(Figures 15.4A and 15.4B). Normally, the upper eyelid peak is nasal to the corneal light reflex.

SECTION TWO • EYELID AND FACE

Chapter 15 Frontalis suspension with silicone rod
106
 A B

Figures 15.5A and 15.5B Adjustment of sling platform

A narrow sling platform can result in an unnatural eyelid peak. To create a more natural eyelid contour with its peak nasal to the mid-pupil position, the
sling platform is widened. The sling is raised to recheck the eyelid contour. Additional fixation sutures are placed medially to widen the platform (Figures
15.5A and 15.5B).

A B

Figures 15.6A and 15.6B Passage of silicone rod

A #11 blade is used to make stab incisions in the three brow markings. Blunt dissection is performed with a hemostat to gently widen the opening and
to facilitate passage of the silicone rod. Next, the needle supplied with the silicone rod set is bent with a gentle curve. The needle is passed deep to the
orbital septum and directed towards the medial or lateral brow incision (Figures 15.6A and 15.6B). After proper passage, the needle is retrieved through
the medial and lateral brow incisions.

107
 A B

Figures 15.7A and 15.7B Verification of silicone rod passage

Once both the medial and lateral ends of the sling have been passed through the eyelid, it is raised once again through the brow incisions to stimulate
the action of the frontalis muscle (Figures 15.7A and 15.7B). The silicone rod should be barely felt if placed at the appropriate depth. The contour of the
eyelid should also be verified with lifting as well as ensuring that the eyelid elevates but does not anteriorly distract away from the ocular surface.

A B

C D

Figures 15.8A–D Uniting the sling centrally

To complete the frontalis sling, the two ends of the silicone rod are united at the central incision site. The needle is passed from the lateral and medial
incision sites in a plane deep to the subcutaneous layer and anterior to the frontalis muscle, and retrieved centrally (Figure 15.8A). Then, the supplied
silicone sleeve is cut in half and this is placed through a fine tip hemostat and placed on stretch (Figure 15.8B). The two ends of the silicone rod with
the needle still attached are placed through the sleeve (Figure 15.8C). The two ends of the silicone rod are then tightened to achieve the desired eyelid
height with frontalis activation. Any slack within the silicone rod should be tightened within the course of its passage in the eyelid. The target lift of the
eyelid should be overcorrection by 1–2 mm on the field. Care should be taken to observe for any lagophthalmos which may become clinically significant
in patients with a poor Bell’s reflex (i.e., CPEO, OPMD, MD). Once a satisfactory tension has been determined, the two ends of the sling are tied off with
6-0 Prolene suture (Figure 15.8D). The suture should be tied off with moderate but firm tension to prevent cheese wiring through the silicone rod with
time. Finally, the silicone rod is trimmed to leave a 3-mm tail that can be used for subsequent revision if necessary.

SECTION TWO • EYELID AND FACE

Chapter 15 Frontalis suspension with silicone rod
108
 A B

Figures 15.9A–C Wound closure

The sling and sleeve unit should then be deposited deep into the central incision. The tails of each silicone rod should be buried flush with the subcuta-
neous wound to prevent subsequent extrusion (Figure 15.9A). The brow incisions are then closed in a layered fashion with 5-0 Vicryl for the subcutane-
ous tissues (Figure 15.9B). To achieve adequate wound eversion, the skin is closed with a 5-0 fast-absorbing gut suture in a horizontal mattress fashion
(Figure 15.9C). The upper eyelid incision is closed with 7-0 Vicryl for the orbicularis layer and 6-0 fast-absorbing gut for the skin. Non-absorbable
sutures can be used for either skin closure and are removed at the 1-week postoperative visit.

PTOSIS REPAIR BY RIGHT FRONTALIS SLING

Preoperative Postoperative

Figure 15.10 Before and after right frontalis sling with silicone rod
This 38-year-old female underwent right frontalis sling with silicone rod after a traumatic right cranial nerve III palsy.

109
Table 15.3 Complications
Complications Suggestions to reduce risk
Asymmetry Assess the MRD prior to securing with silicone sleeve to ensure proper height
Maximize patient cooperation; sit up patients during assessment if needed, minimize use of IV
sedation, control of hemostasis
Contour deformity/peaking Place the sling on a wide platform on the tarsus to ensure a natural contour and with a nasal peak
Corneal abrasion Use of corneal shields during surgery and careful placement of suture in a partial-thickness pass
through the tarsal plate
Dry eyes/lagophthalmos Conservative tightening of the silicone rod over the sleeve, be cautious of poor Bell’s reflex and
undercorrect if present
Eyelid crease/fold differences Maintain consistent height of eyelid crease incisions
Hemorrhage Meticulous hemostasis during procedure, use of tapered needle for skin closure, ice packs
postoperatively, cessation of anticoagulants
Infection Perform procedure after sterile preparation, use of topical antibiotic ointment, be cognizant of
immunosuppressed states, consider intraoperative and postoperative antibiotic use (silicone rod as a
foreign body)
Overcorrection of eyelid If overcorrected in the first postoperative week, perform clinic revision to recess silicone rod through
central brow incision
Unmasking of dermatochalasis Counsel patients preoperatively of the potential for unmasking of dermatochalasis if ptosis repair is
performed in isolation
Address with concurrent blepharoplasty if indicated
Undercorrection If significantly undercorrected, wait after postoperative week 2 and perform office revision by
tightening sling through central brow incision
Upper eyelid ectropion/eyelid Move silicone rod fixation suture higher on the tarsal plate and pass silicone rod more posterior in
distraction from globe the orbit (initial pass with needle was likely preseptal)
Suture granuloma Use non-absorbable sutures, recognize granulomas early, remove suture if symptomatic and treat
with antibiotic/steroid ointment
Wound dehiscence Avoid eye rubbing, ice packs to minimize hemorrhage and itching, protective eye shields, no heavy
lifting after surgery, avoidance of contact lens use

Table 15.4 Consumables and implant used during case

5-0 Vicryl, PC-3 needle Ethicon #J844G
7-0 Vicryl, TG140-8 needle Ethicon #J546G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
6-0 Prolene, C-1 needle Ethicon #8718
5-0 fast-absorbing gut, PC-1 needle Ethicon #1915G
Frontalis suspension set (Seiff) BVI Visitec #585192

SECTION TWO • EYELID AND FACE

Chapter 15 Frontalis suspension with silicone rod
110
 CHAPTER 16
Repair of conjunctival prolapse
Table 16.1 Indications for surgery
Conjunctival prolapse
• After a large levator resection in congenital ptosis repair
• After craniofacial surgery with cerebrospinal fluid leak
INTRODUCTION
Prolapse of the superior conjunctiva is an uncommon compli-
cation that may occur after levator resection surgery for con-
genital ptosis. This condition is more likely to occur with large
and supermaximal resections (22 mm or more) of the levator
(Chapter 14). Craniofacial surgery involving the superior orbit
with cerebrospinal fluid leak has also been reported to cause
superior conjunctival prolapse even in the absence of levator
surgery.
The superior cul-de-sac is formed by the suspensory liga-
ment of the fornix which contains fine, sheath-like fibers
between Müller’s muscle and the conjunctiva. With large levator
dissections, these fascial connections may be severed. This
results in a disparity in length between the redundant conjunc-
tiva and the now relatively short levator. Fluid and hemorrhage
may then fill this potential space, causing the conjunctiva to
prolapse inferiorly.
Bobby S. Korn
Table 16.2 Preoperative evaluation
History of prior congenital ptosis repair or craniofacial surgery
Adequacy of superior conjunctival fornix
Presence of symblepharon
Corneal examination
Upper eyelid position and contour
Presence of lagophthalmos
Clinically, prolapse of the superior fornix can result in con-
junctival hyperemia, keratinization, and corneal irritation as well
as a displeasing appearance. Furthermore, the prolapsed
tissue can obstruct the visual axial and induce astigmatism that
may promote amblyopia.
If prolapse of the conjunctiva is noted during levator resec-
tion, prophylactic fornix-deepening sutures should be placed
at the time of ptosis surgery. Spontaneous resolution is not
expected with this complication. An alternative treatment for
conjunctival prolapse is excision of the prolapsed tissue;
however, this may result in significant forniceal shortening,
symblepharon, loss of ocular surface stem cells and restrictive
strabismus. Additionally, resection of conjunctiva may also
include Müller’s muscle, which could lead to postoperative
eyelid retraction. Our preferred treatment is placement of
fornix-deepening sutures, which encourages adhesions
between the levator and the conjunctiva.
111
SURGICAL TECHNIQUE

A B

Figures 16.1A and 16.1B Exam under anesthesia

This 5-year-old child was referred with conjunctival prolapse after congenital ptosis repair performed elsewhere. With elevation of the left upper eyelid,
the conjunctiva is noted to prolapse onto the cornea (Figure 16.1A). The conjunctiva also appears hyperemic and keratinized owing to chronic exposure.
The conjunctiva can be manually reposited superiorly into the fornix with a muscle hook (Figure 16.1B). However, with gentle traction on the upper
eyelid, the conjunctiva prolapses spontaneously.

Fornix deepening
sutures
Conjunctival
fornix

A B

C D

Figures 16.2A–D Placement of initial fornix-deepening suture

To promote adhesions between the conjunctiva and levator, a series of fornix-deepening sutures are placed as illustrated in Figure 16.2A. A small volume
(less than 1.5 mL) of local anesthetic containing 1% lidocaine/0.25% bupivacaine with 1:200,000 epinephrine is given prior to suture placement. Either 6-0
Vicryl or chromic gut sutures are suitable and the use of double-armed needles facilitates the operation. The first needle is passed at the apex of the
prolapsed conjunctiva and this is directed high into the fornix (Figure 16.2B). The needle is retrieved above the level of the eyelid crease and just below the
superior orbital rim (Figure 16.2C). The second needle is passed 2 mm lateral to the first pass and retrieved at the same height and level (Figure 16.2D).
When passing the needles, extra care is taken to avoid inadvertent trauma to cornea and sclera. The sutures are left untied for the time being.

SECTION TWO • EYELID AND FACE

Chapter 16 Repair of conjunctival prolapse
112
 A B

Figures 16.3A–C Placement of additional fornix-deepening sutures

Depending on the horizontal extent of the conjunctival prolapse, additional fornix deepening sutures are placed. In this case, additional sutures are
placed centrally and temporally as described above (Figures 16.3A and 16.3B). Figure 16.3C shows the position of the free sutures in the upper eyelid.
Once satisfactory, the sutures are tied off. The knots should be tied off with enough tension to ensure adequate conjunctiva and Müller’s muscle
approximation. Antibiotic ointment or drops are used, but steroids are omitted so that a pro-inflammatory condition can be induced to promote adhesions
in the superior cul-de-sac.

LEFT CONJUNCTIVAL REPOSITION AFTER MAXIMAL LEVATOR RESECTION

Preoperative Postoperative

Figure 16.4 Before and after repair of left conjunctival prolapse

Review of this 5-year-old child’s operative report disclosed a 22-mm levator resection complicated by conjunctival prolapse. Initial treatment consisted of
topical lubrication followed by placement of three fornix-deepening sutures. At 3 months postoperatively, the patient has no recurrence of the conjunctival
prolapse and an acceptable left upper eyelid height.

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Table 16.3 Complications
Complications Suggestions to reduce risk
Recurrence of conjunctival Use Vicryl or chromic gut sutures and allow for spontaneous resorption; consider conservative conjunctival
prolapse resection with recurrence
Symblepharon formation Ensure that sutures are placed at apex of the prolapse and that bulbar and palpebral conjunctiva are not plicated
together while exiting through the skin
Restrictive strabismus Avoid conjunctival resection if possible; perform forced duction testing after suture placement to ensure that
superior rectus was not captured during placement of fornix-deepening sutures
Corneal abrasion/globe Use of corneal shields during surgery; place sutures high in the fornix to prevent corneal irritation; topical
perforation lubrication postoperatively
Hemorrhage Consider preoperative instillation of 2.5% phenylephrine to constrict vasculature with hyperemic conjunctiva
Infection Perform procedure after sterile preparation; use of topical antibiotic ointment
Ptosis May require interval levator repair or frontalis suspension

Table 16.4 Consumables used during surgery

6-0 Vicryl, SS-14 double-armed needle Ethicon #J670G
6-0 chromic gut, G-6 double-armed needle Ethicon #794G

SECTION TWO • EYELID AND FACE

Chapter 16 Repair of conjunctival prolapse
114
 CHAPTER 17
Upper eyelid retraction repair
Table 17.1 Indications for surgery
Upper eyelid retraction
• Associated with thyroid-related orbitopathy
• After upper eyelid ptosis repair, blepharoplasty, or brow lifting
• After trauma
INTRODUCTION
Upper eyelid retraction repair is most commonly performed for
thyroid-related orbitopathy (TRO). With upper eyelid retraction,
there is often associated lagophthalmos and corneal exposure
in addition to the startled appearance characteristic of this
disfiguring disease. Upper eyelid retraction can also be seen
after ptosis overcorrection as well as aggressive upper eyelid
blepharoplasty and brow-lifting procedures.
When upper eyelid retraction is seen after ptosis repair, con-
servative measures such as downward eyelid massage should
be performed, particularly early in the postoperative course.
These maneuvers will frequently improve without surgical inter-
vention. If the upper eyelid retraction is still present after 6
weeks, surgery can be considered.
The management of TRO-associated upper eyelid retrac-
tion is the final stage of surgical rehabilitation. Orbital
Bobby S. Korn
Table 17.2 Preoperative evaluation
History of thyroid-related orbitopathy
Prior facial surgery or trauma
Dry eye symptoms
Prior refractive surgery
Degree of dermatochalasis and fat prolapse
Presence of corneal exposure/lagophthalmos
decompression is performed first if indicated (Chapter 64).
Strabismus surgery is performed second for refractory diplopia
followed by upper eyelid retraction repair. The surgical reha-
bilitation of the TRO patient should proceed after quiescence
has been established unless vision-threatening corneal expo-
sure or compressive optic neuropathy is present.
Several procedures have been described for repair of upper
eyelid retraction associated with TRO, including full-thickness
blepharotomy and posterior retractor recession techniques.
Our preferred method is an anterior approach, single unit
recession of the upper eyelid retractors (levator and Müller’s
muscle). In this technique, the conjunctiva is kept intact and
the amount of recession is titrated based on the degree of
upper eyelid retraction. The surgery is performed conscious
with minimal IV sedation so that an optimal eyelid height and
contour can be achieved.
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SURGICAL TECHNIQUE

A B

C D

Figures 17.1A–D Skin incision

Upper eyelid retraction repair is performed through a standard upper eyelid crease incision. If redundant dermatochalasis is present, a concurrent
blepharoplasty can be performed, as in this case. A corneal shield is placed at the start of the case (Figure 17.1A). Local anesthetic consisting of 1%
lidocaine, 0.25% bupivacaine with 1 : 200,000 epinephrine is given in a maximum initial volume of 1.5 mL (Figure 17.1B). This small amount of
anesthetic is given to achieve anesthesia without akinesia. The skin incision is made with a #15 blade and cutting cautery is used to remove the skin
only (Figure 17.1C). Once the skin is removed, the intact orbicularis oculi bed remains (Figure 17.1D). Preservation of the orbicularis minimizes
lagophthalmos, as well as maintaining upper eyelid volume.

A B

Figures 17.2A–D Dissection to superior tarsal border

After skin removal, dissection begins through the inferior edge of the orbicularis muscle (Figure 17.2A). The dissection proceeds in a slightly inferior
direction to identify the tarsal plate using cutting cautery (Figure 17.2B).

SECTION TWO • EYELID AND FACE

Chapter 17 Upper eyelid retraction repair
116
 C D

Figures 17.2A–D Dissection to superior tarsal border—cont’d

Once the tarsal plate has been identified, the dissection is performed with Westcott blunt-tip scissors (Figure 17.2C). The scissors are used to dissect
through the epitarsal tissues and to disinsert the levator aponeurosis. The use of the blunt-tip scissors minimizes trauma to the underlying tarsal plate.
Any fine bleeders that are encountered are controlled with bipolar cautery. As a starting point in the dissection, the central 15 mm of the tarsal plate is
exposed (Figure 17.2D). With severely retracted upper eyelids, this can be extended during subsequent steps.

A B

Figures 17.3A–C Single unit retractor recession

In this surgical approach, the upper eyelid retractors (levator and Müller’s muscle) are recessed from the superior tarsal border as a single unit. The
orbital septum and the underlying preaponeurotic fat are kept intact. This helps to minimize superior migration of the upper eyelid crease with retractor
recession. Figure 17.3A shows the dissection after opening the orbicularis and disinsertion of the levator from the tarsal plate. Care is taken during the
dissection to avoid trauma to the peripheral arcade and Müller’s muscle. Cutting cautery or a high-temperature, battery-powered handpiece is used to
carefully recess the upper eyelid retractors from the superior border of the tarsal plate (Figure 17.3B). It is essential that the corneal shield remains in
place at all times during the recession, as this protects the underlying cornea. Inferior traction on the eyelid is held with a two-prong hook or a silk
suture placed through the gray line. The dissection proceeds carefully along the upper tarsal border to expose bare palpebral conjunctiva (Figure 17.3C).

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 A B

Figures 17.4A–C Titration of recession

As the operation is performed with minimal local and IV sedation, discomfort may be experienced during retractor recession. If the patient experiences
discomfort during retractor recession, local anesthetic on a 30-gauge needle, 1-ml syringe can be used to titrate microliter amounts of anesthetic without
causing significant akinesia (Figure 17.4A). As the dissection continues, levator and Müller’s muscle are progressively recessed superiorly with bare
conjunctiva seen again above the backdrop of the black corneal shield (Figure 17.4B). If any air bubbles are present between the corneal shield and
conjunctiva, they are removed to minimize trauma or buttonholing of the tissues. If a full-thickness conjunctival buttonhole is created, interrupted 6-0
fast-absorbing gut suture can be used to repair the defects. The amount of vertical recession depends on the degree of preoperative upper eyelid
retraction. In general, we start with a 6-mm vertical recession for an upper eyelid margin to reflex distance-1 (MRD1) of 7 mm. In this case with a
preoperative MRD1 of 12 mm, a 10-mm recession was the initial starting point (Figure 17.4C).

Figure 17.5 Intraoperative eyelid level assessment

Retractor recession and eyelid lowering does not follow a linear 1 : 1 relationship. Periodically, the corneal shield is removed and the upper eyelid height
and contour are evaluated after retractor recession (Figure 17.5). A slight 1-mm overcorrection is desired as the upper eyelid tends to retract a small
degree after surgery analogous to upper eyelid ptosis repair after levator advancement. During the eyelid level assessment, the height and contour are
evaluated. If the eyelid is still too high, the recession continues vertically for a total of 18–20 mm from the superior tarsal border. If this recession
produces a satisfactory position, then dissection ceases. If the eyelid is still retracted, the dissection is extended further medially and laterally and, if
necessary, the medial and lateral horns of the levator may be disinserted. On the contrary, if the eyelid is too ptotic after retractor recession, a hangback
suture with 6-0 Vicryl can be placed. Closure is performed in a layered fashion with 7-0 Vicryl to the orbicularis followed by skin closure with 6-0
Prolene or 6-0 fast-absorbing gut suture. Absorbable sutures are removed at 1 week postoperatively.

SECTION TWO • EYELID AND FACE

Chapter 17 Upper eyelid retraction repair
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 BILATERAL UPPER EYELID RETRACTION REPAIR

Preoperative Postoperative

Figure 17.6 Before and after upper eyelid retraction repair

This 46-year-old female has a history of thyroid-related orbitopathy. She has minimal exophthalmos and no diplopia and her primary symptoms are
corneal exposure from upper eyelid retraction. She underwent a large, 20-mm retractor recession to lower her preoperative MRD1 from 12 mm to 5 mm.

Table 17.3 Complications

Complications Suggestions to reduce risk
Overcorrection/ptosis Start with 6–8 mm of retractor recession; consider placement of 6-0 Vicryl suture as a hangback suture to
re-advance levator to superior tarsal border
Undercorrection Minimize local anesthetic use; consider intraoperative steroid or postoperative 5-FU injection to minimize
post-surgical scarring/retraction; repeat retractor recession after 3 months
Flattened eyelid contour Consider central levator hangback suture to raise central contour
Corneal abrasion Use corneal shield at all times
Hemorrhage Meticulous hemostasis during procedure; use of tapered needle for skin closure; ice packs postoperatively;
cessation of anticoagulants
Infection Perform procedure after sterile preparation; use of topical antibiotic ointment; be cognizant of
immunosuppressed states
Suture granuloma Use non-absorbable sutures; recognize granulomas early; remove suture if symptomatic and treat with
antibiotic/steroid ointment
Wound dehiscence Avoid eye rubbing; ice packs to minimize hemorrhage and itching; protective eye shields; no heavy lifting
after surgery; avoidance of contact lens use

Table 17.4 Consumables used during surgery

6-0 Prolene suture, C-1 needle Ethicon #8718
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG140-8 needle Ethicon #J546G

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CHAPTER 18
Levator extirpation and frontalis
suspension
Tammy H. Osaki • Midori H. Osaki • Bobby S. Korn
Table 18.1 Indications for surgery
Marcus Gunn syndrome with functional or cosmetically displeasing
jaw wink
Unilateral ptosis with poor levator function requiring frontalis
suspension
INTRODUCTION
Eyelid ptosis repair with levator extirpation and concomitant
frontalis suspension may be performed for a symptomatic jaw
wink associated with Marcus Gunn syndrome as well as severe
unilateral, poor levator ptosis.
Marcus Gunn syndrome is characterized by aberrant innerva-
tion between cranial nerve III and V resulting in synkinetic
movements of the levator palpebrae superioris and the ipsilat-
eral pterygoid muscles. The synkinetic movement can be seen
during infancy as variable upper eyelid retraction with opening
of the mouth, chewing, and sucking. Lateral, side-to-side jaw
movements may also bring about the jaw wink associated with
this syndrome. Marcus Gunn is typically unilateral, but bilateral
cases have been described.
SECTION TWO • EYELID AND FACE
Chapter 18 Levator extirpation and frontalis suspension
120
Table 18.2 Preoperative evaluation
Ptosis evaluation (MRD1, levator excursion, frontalis function, eyelid
malpositions, lagophthalmos)
Photographic and/or video documentation of eyelid position with
opening, closing and side-to-side movements of the jaw (synkinetic
movement)
Rule out amblyopia
Presence of Bell’s phenomenon
Evaluation for associated strabismus (including monocular elevation
deficiency)
Slit lamp examination/ocular surface evaluation
The clinical presentation of Marcus Gunn is variable, depend-
ing on the degree of aberrant miswiring. Ipsilateral ptosis from
levator dysgenesis may be the prominent presentation neces-
sitating levator resection (Chapter 14) or frontalis suspension
(Chapter 15). Alternatively, the levator function may be pre-
served and the most symptomatic finding is the displeasing
wink seen with jaw movements.
The evaluation of Marcus Gunn should include documenta-
tion of eyelid position and levator excursion with full jaw move-
ments. Photographic and video documentation are useful to
educate patient and parents about the condition and surgical
outcomes. An evaluation for associated strabismus, in particu-
lar co-existent superior rectus dysfunction, should be per-
formed. Any amblyopia from strabismus or anisometropia must
be addressed with spectacle correction and patching before
considering eyelid surgery.
If the jaw winking phenomenon does not objectively improve
with age or if the patient is unable to mask the synkinesis,
levator extirpation with frontalis suspension may be considered
for treatment of this displeasing jaw wink. The decision of uni-
lateral versus bilateral surgery is a controversial topic. Parents
typically opt for unilateral surgery of the aberrantly innervated
side to spare the normal side from surgical intervention. The
primary benefit of surgery on both sides is to drive bilateral
frontalis function when eyelid elevation is desired.
The surgical approach involves disinsertion of the levator
aponeurosis from the tarsal plate and then extirpation of the
levator. Multiple approaches have been described including
anterior and posterior approaches as well as extirpation of the
muscle at the level of Whitnall’s ligament and even to the orbital
apex. The risks of recurrence of the jaw wink with suboptimal
levator extirpation versus damage to the superior rectus with
more aggressive muscle removal must be weighed carefully.
Our preferred technique for mild-to-moderate jaw wink is a uni-
lateral, anterior approach levator extirpation to the level of Whit-
nall’s ligament with disinsertion of the medial and lateral horns of
the levator. Frontalis suspension is then performed with fascia
lata or silicone rod. Silicone rod affords the advantage of easy
reversibility, and this is important especially in patients with
reduced corneal protection (poor Bell’s phenomenon). Further-
more, in patients under 2 years of age, harvesting of autologous
fascia lata is not recommended.

SURGICAL TECHNIQUE

$ %

Figures 18.1A and 18.1B Skin marking

With levator dysgenesis, a well-formed eyelid crease may not be present in the affected side. Using a caliper, the upper eyelid crease of the normal side
is marked and this is transposed to the surgical side at same height (Figure 18.1A). In this case, the crease is set to 6 mm to correspond to the normal
eyelid. Then, three markings are made at the superior limit of the brow cilia: medial, central and lateral, 3–4 mm in length. The upper eyelid incision
marking, in conjunction with the three eyebrow marks, outlines Fox’s pentagonal configuration (Figure 18.1B). Local anesthetic containing 1 : 200,000
epinephrine is given in the upper eyelid and brow incisions to aid with hemostasis.

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Figures 18.2A–C Exposure of tarsal plate and disinsertion of levator

After inserting a corneal protector, the upper eyelid crease incision is made using a #15 blade (Figure 18.2A). Once the eyelid crease incision is
complete and the underlying orbicularis muscle is exposed, dissection is continued in the pretarsal plane, using cautery (Figure 18.2B). Once the
superior tarsal border is identified, the dissection continues to expose the anterior face of the tarsal plate. The dissection continues inferiorly to expose
the upper two-thirds of the tarsal plate (Figure 18.2C). The dissection to this level serves to disinsert the levator aponeurosis and provides a platform for
silicone rod fixation after levator extirpation. Care is taken to avoid incising into the tarsal plate during dissection.

SECTION TWO • EYELID AND FACE

Chapter 18 Levator extirpation and frontalis suspension
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Figures 18.3A–D Identification of levator aponeurosis

While the assistant provides inferior traction on the conjoined fascia, the orbital septum is incised slightly superior to its union (Figure 18.3A). Using
cautery, horizontal dissection continues through the orbital septum. Once the septum is opened medially and laterally for the entire length of the incision,
the central, preaponeurotic fat pad is exposed (Figure 18.3B). Preaponeurotic fat pad is an important surgical landmark as the levator aponeurosis is
located directly posterior (Figure 18.3C). The fat then is dissected from levator aponeurosis to facilitate further dissection in the superior orbit (Figure
18.3D). The levator muscle can often be noted to have fatty infiltration from congenital dysgenesis.

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Figures 18.4A–C Dissection of levator aponeurosis

Once levator aponeurosis is dissected from fat, medial and lateral horns of the aponeurosis are released (Figures 18.4A and 18.4B). Cutting cautery
should be directed slightly inwards towards the levator muscle to prevent damage to the trochlea medially and the lacrimal gland laterally. If the skin
incision is too narrow, this may be extended to fully release both horns. Levator aponeurosis is then carefully dissected from Müller’s muscle (Figure
18.4C). The peripheral vascular arcade is an important landmark which overlies Müller’s muscle and this muscle should be kept intact. Care is taken to
avoid incising Müller’s muscle, which may bleed if traumatized. The dissection continues in the superior orbit until Whitnall’s ligament is reached. With
severe jaw winking, the dissection can continue beyond Whitnall’s ligament to excise terminal portions of the levator muscle, but care should be taken to
avoid damaging the superior rectus, which is posterior to levator.

SECTION TWO • EYELID AND FACE

Chapter 18 Levator extirpation and frontalis suspension
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Figures 18.5A–C Extirpation of levator

Extirpation of levator can be performed after the medial and lateral horns are severed and the aponeurosis is dissected from Müller’s muscle. Figure
18.5A shows the fully dissected levator aponeurosis and Whitnall’s ligament in the superior orbit. If deeper extirpation of the levator muscle is desired for
severe jaw winking, a von Graefe muscle hook can be used to follow the muscle more posteriorly and dissecting a plane above the superior rectus.
Forced duction testing can confirm that the superior rectus has been dissected free from the levator. The levator muscle can then be cauterized across
its width. In this case the levator aponeurosis is removed at the level of Whitnall’s ligament (Figure 18.5B). Figure 18.5C shows an intraoperative view
after extirpation of levator aponeurosis.

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Figures 18.6A–C Fixation of silicone rod to tarsal plate

Once levator extirpation is complete, the next step is the frontalis suspension procedure. Autologous or donor fascia lata or silicone rod can be employed
as the sling material, with the latter used in this case. Forceps are used to grasp the superior tarsal plate and an optimal tarsal fixation point is
determined (Figure 18.6A). With the upper two-thirds of the tarsal plate previously exposed, two 6-0 Prolene sutures are passed in a vertical, partial
thickness tarsal pass to secure the silicone rod (Figure 18.6B). The tarsal bites are equidistant from the previously determined optimal fixation point and
are placed 2 mm below the superior tarsal border (Figure 18.6C). Additional fixation sutures may be placed if the platform is too narrow and the eyelid is
peaked with elevation of the sling. Care must be taken to ensure that the sutures are not passed full thickness to avoid corneal abrasion. Depth of suture
can be checked, by everting the eyelid prior to completing the suture pass and looking for posterior breakthrough of the needle.

SECTION TWO • EYELID AND FACE

Chapter 18 Levator extirpation and frontalis suspension
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Figures 18.7A–C Passage of silicone rod to brow incisions

Stab incisions are made through the three marks in the brow region using a #11 blade (Figure 18.7A). Hemostasis is achieved with bipolar cautery in
this vascularized area. A gentle curve is made with the supplied silicone rod needles and each needle is passed deep to the central fat pad, towards the
superior orbital rim, medially and laterally. The needle then passes in a preperiosteal plane along the superior orbital rim, and exiting in the center of the
medial and lateral brow incisions, respectively (Figure 18.7B). If fascia lata is used, a Wright fascia needle is used to direct the tissue superiorly. Once
the silicone rod is externalized, inspection along the course of the sling material is performed to ensure there is no palpability (Figure 18.7C). If the sling
is not optimally placed, the silicone rod is retracted from the brow incision with the needle attached and placed deeper in the orbit.

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Figures 18.8A–D Titration of silicone rod tension

The medial and lateral ends of the silicone rod are then passed deeply to the subcutaneous layer towards the central brow incision, where the fusion of
the sling occurs. A Watzke-style sleeve is supplied with the silicone suspension set and, after cutting it in half, the sleeve is placed on stretch with a
hemostat (Figure 18.8A). The medial and lateral ends of the sling are then passed through the sleeve and pulled tight to adjust the eyelid to the desired
height. A slight overcorrection is recommended when using silicone rod to take into account slack in the material as well when repositing the sleeve
subcutaneously (Figure 18.8B). Care should be taken when Bell’s phenomenon is poor. In order to eliminate slack in the silicone rod, the eyelid is
inferiorly distracted (Figure 18.8C). Once a satisfactory eyelid height, eyelid contour, and desired tension on the sling are achieved, 6-0 Prolene suture is
used to secure both ends of silicone rod (Figure 18.8D). The sutures should be not be overtightened as this will lead to erosion through the silicone rod
with time.

SECTION TWO • EYELID AND FACE

Chapter 18 Levator extirpation and frontalis suspension
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Figures 18.9A–C Reposition of silicone sleeve

The ends of the silicone rod are trimmed to approximately 2–3 mm on each side. The sleeve is then atraumatically reposited into the subcutaneous layer
of the central pocket (Figure 18.9A). A curved hemostat or needle holder can be used to reposit the sleeve, but use of toothed forceps is avoided as this
can damage the silicone rod. The cut ends of the silicone rod should be placed flush in the wound to prevent subsequent extrusion with time (Figure
18.9B). The three brow incisions are closed in a layered fashion with 6-0 Vicryl in the subcutaneous layer (Figure 18.9C).

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Figures 18.10A–C Skin closure

The orbicularis at the eyelid crease incision is closed with three interrupted 7-0 Vicryl sutures and the skin is closed with a running 6-0 fast-absorbing
gut suture (Figures 18.10A and 18.10B). The skin over the brow incisions is closed with one to two horizontal mattress sutures with 6-0 fast-absorbing
gut suture (Figure 18.10C). The skin should be slightly everted to account for postoperative wound contraction.

LEFT LEVATOR EXTIRPATION AND FRONTALIS SLING WITH SILICONE ROD

Preoperative Postoperative

Figure 18.11 Before and after the procedure

This 4-year-old girl presented with ptosis of the left upper eyelid and severe jaw winking secondary to Marcus Gunn syndrome. She underwent left
levator extirpation and frontalis suspension with silicone rod. With spectacle correction, she is able to spontaneously elevate the left brow to achieve an
excellent functional and aesthetic outcome.

SECTION TWO • EYELID AND FACE

Chapter 18 Levator extirpation and frontalis suspension
130
Table 18.3 Complications
Complications
Occlusion amblyopia
Recurrence of jaw wink
Damage to superior rectus
muscle
Undercorrection of eyelid ptosis
Silicone rod extrusion
Corneal abrasion
Lagophthalmos/exposure
keratopathy
Ectropion/distraction of eyelid
with frontalis action
Wound dehiscence
Suture granuloma
Infection
Table 18.4 Consumables used during surgery
6-0 Prolene, C-1 needle
6-0 fast-absorbing gut, PC-1 needle
6-0 Vicryl, SS-29 needle
Frontalis suspension set (Seiff)
Suggestions to reduce risk
May occur with unilateral surgery with no drive to use frontalis muscle; patch good eye; maximize
spectacle correction; consider levator extirpation on fellow eye with frontalis suspension
Consider additional levator muscle extirpation; fixation of terminal muscle end to arcus marginalis at
superior orbital rim
Caution during dissection in the superior orbit beyond Whitnall’s ligament; perform forced duction testing
to isolate superior rectus from levator muscle
Consider revision surgery with tightening of silicone rod over sleeve; ensure that tarsal fixation has not
loosened; see above for occlusion amblyopia; careful handling of silicone rod to prevent breakage
Careful subcutaneous brow closure; ensure that ends of silicone rod are reposited flush to the skin
Ensure that Prolene fixation sutures are not full thickness; ensure the silicone rod was not passed too
posteriorly in the orbit; use corneal shield throughout the surgery
Commonly occurs in the immediate postoperative period; downward massage on upper eyelid; ocular
lubrication with drops and ointments; consider recession of sling if keratopathy worsens
Ensure that silicone rod is passed posterior to orbital fat and not too anterior; move silicone rod higher on
tarsal plate
Avoid eye rubbing; ice packs to minimize hemorrhage and itching
Early recognition of granulomas; remove suture if symptomatic and treat with antibiotic/steroid ointment
Perform procedure under sterile preparation; use of topical antibiotic ointment; consider oral antibiotics
postoperatively; removal of silicone rod if chronic infection is resistant to antibiotics (infected foreign body/
biofilm); replace with fascia lata
Ethicon #8718
Ethicon #1916G
Ethicon #J556G
BVI Visitec #585192
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CHAPTER 19
Upper eyelid loading with
platinum weight
Bobby S. Korn • Don O. Kikkawa
Table 19.1 Indications for surgery
Paralytic lagophthalmos
Exposure keratopathy
CN VII palsy
Symptomatic dry eye
INTRODUCTION
Adequate closure of the eyelid is essential to maintain clarity
and comfort of the ocular surface. This includes a normal blink
as well as complete closure during rest. Patients with adequate
lubrication and a good Bell’s phenomenon can tolerate
some degree of lagophthalmos in maintaining ocular surface
integrity.
Patients with uncompensated lagophthalmos may develop
ocular symptoms of pain, foreign body sensation, and dryness.
Their cornea may show signs of punctate epithelial defects.
An assessment of corneal sensation should be made as these
patients may develop rapid corneal decompensation and
even perforation. Idiopathic facial nerve palsy should first be
managed medically for spontaneous resolution unless corneal
SECTION TWO • EYELID AND FACE
Chapter 19 Upper eyelid loading with platinum weight
132
Table 19.2 Preoperative evaluation
Bell’s phenomenon
Degree of lagophthalmos
Corneal epithelial staining
Orbicularis strength
Anterior or posterior lamellar shortage
Prior eyelid, facial surgery or trauma
Corneal sensation
Office testing of external weight loading to determine
appropriate size
compromise occurs. In contrast, other patients may have per-
manent facial nerve palsy, i.e., after removal of parotid gland
tumors where no recovery of nerve function is expected.
If maximal medical therapy with ocular lubricants and eyelid
occlusion fails, patients with symptomatic dry eye and corneal
findings may be candidates for eyelid loading. An external load
can be placed to determine the appropriate weight. The lightest
load to allow complete closure is the goal without inducement
of ptosis. External weights for daily use are available with
double stick adhesive (MedDev, Palo Alto, CA) if the patient
wishes to experience eyelid loading prior to implantation
(Figures 19.1A and 19.1B)
Different techniques of placement and choices of weight
exist. Platinum is a suitable choice as a weight for eyelid
loading. Compared to gold, the same platinum weight has a
thinner profile owing to its lower molecular weight. Furthermore,
certain patients have an allergy to gold (or to nickel, a common
element that is used in production). While some surgeons
have advocated more superior implantation, above the tarsus
beneath the levator, our preference is for tarsal fixation within
a relatively superior pretarsal pocket. The weight is secured
through the pre-existing holes directly to the tarsal plate. It is
important to perform layered closure with the orbicularis to
prevent exposure. A small graft of temporalis fascia may also
be used if tissues are thinned and atrophic. In long-standing
cases of paralytic lagophthalmos, unopposed levator action for
many years may have caused some contraction and a levator
recession may be necessary to allow the eyelid to close
(Chapter 17).
If a properly selected weight is determined during the preop-
erative examination, the eyelid load should be adequate to
close the eyelid at rest. Patients may need to be aware to more
consciously allow eyelid closure from gravity, as there may be
some momentary time lag. If the eyelid load is too light or too
heavy, it may be easily removed and replaced. In cases where
facial nerve function returns, the weight may be explanted.

PREOPERATIVE EVALUATION

Figures 19.1A and 19.1B Office testing of external eyelid load

This patient has right paralytic lagophthalmos. On attempted eyelid closure, there right lagophthalmos (Figure 19.1A). In the office, a sample external
weight is temporarily taped to the determine the correct eyelid load. The lightest weight that gives maximum eyelid closure and does not induce ptosis is
selected as the proper size for implantation (Figure 19.1B).

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SURGICAL TECHNIQUE

A B

Figures 19.2A and 19.2B Skin incision

An upper eyelid crease marking is utilized for the surgical approach (Figure 19.2A). The marking is kept on the high side so that the skin incision is at or
above the upper edge of the weight. The incision is performed with a #15 blade, keeping the depth of the incision limited to the skin only while
preserving the pretarsal orbicularis muscle (Figure 19.2B).

A B

C D

Figures 19.3A–D Creation of pretarsal pocket

After skin incision, the dissection continues towards the superior tarsal border using cutting cautery or sharp dissection through the orbicularis (Figure
19.3A). The inferior pretarsal orbicularis is kept intact as this will serve as an important barrier against inferior migration (Figure 19.3B). The pretarsal
pocket is dissected inferiorly within 2–3 mm of the lashes (Figure 19.3C). A healthy pretarsal band at the inferior edge of the weight also prevents
subsequent extrusion. The dimensions of the desired weight are measured and then the tarsus is exposed sufficiently to accommodate the weight (Figure
19.3D).

SECTION TWO • EYELID AND FACE

Chapter 19 Upper eyelid loading with platinum weight
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 A B

C D

Figures 19.4 A–D Fixation of upper eyelid weight

The weight should be secured closer to the superior tarsal border (Figure 19.4A). Most weights have three predrilled fixation holes. Interrupted 7-0 Vicryl
sutures are passed through the tarsal plate in a partial thickness manner and then this is secured through the holes in the weight (Figure 19.4B). Each
of the knots should be vertically oriented to minimize vertical migration of the weight (Figure 19.4C). The inferior hole is also secured and this serves to
minimize rotational migration of the implant postoperatively (Figure 19.4D). Alternatively, a permanent suture such as 6-0 Prolene can be utilized for
fixation. Once the sutures are secured, the knots can be rotated posteriorly towards the weight to prevent palpability of the suture.

A B

Figures 19.5A and 19.5B Closure of orbicularis and skin

The wound is closed in a layered fashion, starting first with the orbicularis. Meticulous closure of the orbicularis is performed with multiple interrupted
7-0 Vicryl sutures along the entire length of the incision (Figures 19.5A and 19.5B). The orbicularis layer provides an additional barrier to minimize the
risk of extrusion.

135
 A B

Figures 19.6A and 19.6B Closure of skin

Skin closure is then performed with a 6-0 Prolene or 6-0 fast-absorbing gut suture (Figures 19.6A and 19.6B). Non-absorbable sutures are removed at
the 1-week postoperative visit. A combination antibiotic and steroid ointment is given for 2 weeks postoperatively.

LEFT UPPER EYELID LOADING WITH PLATINUM WEIGHT

Preoperative Postoperative

Figure 19.7 Before and after left upper eyelid loading with platinum weight
This 67-year-old female with left paralytic lagophthalmos underwent placement of a 1.2 g platinum weight in the left upper eyelid. After the operation,
there was correction of the lagophthalmos in the left eye with minimal impact on the left upper eyelid.

SECTION TWO • EYELID AND FACE

Chapter 19 Upper eyelid loading with platinum weight
136
Table 19.3 Complications
Complications Suggestions to reduce risk
Continued lagophthalmos Remove and replace with heavier weight; also consider levator recession to allow eyelid to close
Ptosis Remove and replace with lighter weight; consider levator advancement
Hemorrhage Proper hemostasis; cessation of anticoagulant usage prior to surgery
Abnormal eyelid contour Center the weight over mid-pupil or just slightly nasal to mid-pupil
Weight extrusion Good layered closure over weight; consider additional coverage with temporalis fascia if tissues are too thin
and atrophic; limit inferior pretarsal dissection to within 2 mm of the lashes
Weight displacement Keep pretarsal dissection limited in size and localized to upper portion of tarsus; fixate all three suture holes
with 6-0 Prolene with partial-thickness sutures to tarsus
Suture granuloma Consider use of non-absorbable sutures; recognize granulomas early; remove suture if symptomatic and
treat with antibiotic/steroid ointment
Wound dehiscence Make sure knots tied with appropriate tension with adequate soft tissue incorporation; avoid smoking, lifting
and bending; use of eye shield; avoid manipulation of wound

Table 19.4 Consumables and implant used during surgery

6-0 Prolene, C-1 needle Ethicon #8718
7-0 Vicryl, TG140-8 needle Ethicon #J546G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
ThinProfile™ Platinum Eyelid Implant MedDev (LL 6006 – LL 6018)

137
CHAPTER 20
Direct browplasty
Bobby S. Korn • Don O. Kikkawa

Table 20.1 Indications for surgery Table 20.2 Preoperative evaluation

Brow ptosis below orbital rim causing visual obstruction Magnitude of brow ptosis
Heavy brows with thick brow cilia Age and gender of patient
Pre-existing supraciliary rhytids Forehead rhytids
Paralytic eyebrow ptosis (CN VII palsy) Frontalis function
Location of hairline
Quality and quantity of eyebrow cilia
Prior eyelid, facial surgery or trauma
Presence of concurrent upper dermatochalasis and/or eyelid ptosis

INTRODUCTION women, with men having a more flat brow across the entire
The normal eyebrow position rests at or above the superior length and women having the lateral tail of the brow higher than
orbital rim. Eyebrow configuration varies between men and the medial aspect of the brow (Figure 20.1).

Female Male

Figure 20.1 Gender variations in eyebrow configuration

The configuration of the brow in men and women differ. Note in women, the tail of the brow is higher than the body forming a “C” configuration. In
men, the brow is flatter, forming a “T” configuration.

SECTION TWO • EYELID AND FACE

Chapter 20 Direct browplasty
138
 With aging, the eyebrows can descend below the superior
orbital rim. This can cause a sensation of heaviness in the
eyelids and objectively cause visual obstruction with worsening
of dermatochalasis. Evaluation of visual obstruction should
include an independent assessment of dermatochalasis in the
natural state and also with manual elevation of the eyebrow to
assess full impact of eyebrow ptosis. Browplasty should be
performed before any upper eyelid surgery as this may affect
the amount of upper eyelid tissue marked and subsequently
removed.
The choice of direct browplasty as a procedure to elevate
the brow depends on several factors. Direct browplasty has
the advantage of giving a great amount of lift for the amount
of skin excised. Patients with heavy brows with thicker eyelid
cilia respond best to direct browplasty. If kept laterally, scarring
can be minimal and inconspicuous. In the thicker skin of the
eyebrow region wounds heal best with maximal wound ever-
sion, as can be obtained with a horizontal mattress suture. The
procedure is primarily a functional procedure to elevate a heavy
brow causing visual obstruction. It can be performed in women
but is best kept laterally as the medial brow tends to show the
incision more visibly when healed.
Direct browplasty procedure also works well for patients with
paralytic eyebrow ptosis from CN VII palsy. In these cases,
fixation of the eyebrow to the deeper periosteum can provide
more long-lasting elevation. Small incision direct browplasty
has also been described and can also be used for suture fixa-
tion to the periosteum. Avoidance of the supraorbital nerve is
critical with any deeper suture pass.

Figure 20.2 Delineation of supraorbital notch

The supraorbital notch is palpated and a 10-mm zone is demarcated
around this area. Surgery in this area is avoided because of possible
damage to the supraorbital neurovascular bundle. Furthermore, extension
of the skin incision medially may cause more conspicuous scarring.

A B

Figures 20.3A and 20.3B Direct browplasty marking

Typically, the lateral brow has the highest degree of ptosis. The lower mark should be made at the superior border of the brow cilia to best camouflage
the incision (Figure 20.3A). The incision is typically extended several millimeters past the lateral brow to account for the lateral ptosis of the brow. The
medial aspect of the marking should stop prior to the supraorbital zone previously marked (Figure 20.3B). If significant medial brow ptosis is present,
alternative approaches such as the endoscopic (Chapter 22) or pretrichial (Chapter 23) approach should be considered. Often, direct browplasty is
performed in conjunction with upper blepharoplasty and, if this is the case, the browplasty should be performed first, followed by blepharoplasty. Prior to
upper blepharoplasty, the skin markings should be reconfirmed to assess anterior lamellar adequacy of at least 20 mm (Chapter 3).

139
 A B

Figures 20.4A and 20.4B Skin incision

A #15 blade is used to make the skin incision. The blade is positioned in a beveled fashion such that the incision is parallel to and not transecting the
brow cilia. In general, the brow cilia are directed inferiorly and, as such, the blade should be beveled superiorly (Figures 20.4A and 20.4B). The inferior
border of the marking is incised first and then the superior marking is incised in a similar beveled approach to allow the wound edges to heal properly.

A B

Figures 20.5A and 20.5B Removal of skin and subcutaneous tissue

Cutting cautery or sharp dissection is used to remove the skin and subcutaneous tissue en bloc (Figure 20.5A). As much of the subcutaneous tissue
should be removed as possible, while preserving the frontalis muscle. Prior to closure, meticulous hemostasis should be achieved of the highly
vascularized brow (Figure 20.5B).

A B

Figures 20.6A and 20.6B Subcutaneous closure

The subcutaneous tissues are closed with multiple 5-0 Vicryl sutures (Figures 20.6A and 20.6B). Several interrupted sutures are placed along the length
of the brow to minimize tension during skin closure. Additionally, the inferior edge of the brow incision can be fixated to the periosteum for additional
vertical support if needed.

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Chapter 20 Direct browplasty
140
 A B

C D

Figures 20.7A–D Skin closure

Absorbable or removable sutures may be used during direct browplasty. In the case of removable sutures, a 5-0 Prolene suture on a tapered C-1 needle
is ideal for minimizing intraoperative bleeding (Figure 20.7A). Alternatively, a 5-0 fast-absorbing, plain-gut suture can be used. The skin is closed with a
deep horizontal mattress suture in either an interrupted or running fashion (Figure 20.7B). Particular attention should be paid towards achieving sufficient
wound eversion to minimize postoperative wound contraction and scar formation (Figures 20.7C and 20.7D). Non-absorbable sutures are removed at the
1-week postoperative visit.

BILATERAL UPPER AND LOWER BLEPHAROPLASTY AND DIRECT BROWPLASTY

Preoperative Postoperative

Figure 20.8 Before and after direct browplasty

This 68-year-old male underwent direct browplasty with concurrent upper and lower blepharoplasty with direct excision of the lower eyelid festoons.

141
Table 20.3 Complications
Complications Suggestions to reduce risk
Depressed scar Consider horizontal or vertical mattress suture for better wound eversion
Loss of brow cilia Bevel incision parallel to cilia to avoid follicular damage
Hemorrhage Proper hemostasis; cessation of anticoagulant usage prior to surgery
Abnormal eyebrow contour Lack of attention to natural brow configuration between men and women; follow guidelines for gender
differences (Figure 20.1)
Hypertrophic scarring Keep wound tension minimized with layered closure; avoid excessive cautery
Suture granuloma Consider use of non-absorbable sutures, recognize granulomas early, remove suture if symptomatic and
treat with antibiotic/steroid ointment
Wound dehiscence Make sure knots tied with appropriate tension with adequate soft-tissue incorporation; avoid smoking,
lifting and bending; use of eye shield; avoid manipulation of wound

Table 20.4 Consumables used during surgery

5-0 fast-absorbing gut, PC-1 needle Ethicon #1915G
5-0 Prolene, C-1 needle Ethicon #8725H
5-0 Vicryl, P-3 needle Ethicon #J493H

SECTION TWO • EYELID AND FACE

Chapter 20 Direct browplasty
142
 CHAPTER 21
Bobby S. Korn • Weerawan Chokthaweesak •
Table 21.1 Indications for surgery
Minimal eyebrow ptosis below orbital rim
Prevention of eyebrow descent in conjunction with upper
blepharoplasty
Stabilization of eyebrow position
INTRODUCTION
Eyebrow position is dynamically controlled through the inter-
play between the eyebrow depressors (orbicularis oculi,
corrugator supercilii, procerus and depressor supercilii) and
the eyebrow elevator (frontalis). Elevation of the eyebrows can
occur through the use of selective targeting of brow depressors
by neurotoxins or by surgical elevation. The surgeon should be
cognizant of the differences in eyebrow shape and contour
between the genders (Chapter 20).
Different techniques exist to surgically elevate the eyebrow.
The selection of operation depends on the goals of the surgery,
the magnitude of the eyebrow ptosis, and the age and gender
of the patient. To best conceal the incision, the upper eyelid
crease incision and either behind or within the hairline are the
most inconspicuous. The internal brow ptosis repair (or internal
brow pexy) is performed through an upper eyelid crease
Internal browplasty
Don O. Kikkawa
Table 21.2 Preoperative evaluation
Position of eyebrow
Age and gender of patient
Magnitude of eyebrow ptosis
Quality and quantity of eyebrow cilia
Prior eyelid, facial surgery or trauma
incision and allows for simultaneous upper blepharoplasty with
the ability to perform corrugator and procerus myectomy
through the medial aspect of the incision if desired.
Internal browplasty will not elevate a severely ptotic brow
and, in general, this operation should be considered when
minimal brow ptosis is present or if stabilization and prevention
of descent of the eyebrow is desired. The dissection occurs
deep to the orbicularis oculi in the plane of the ROOF (retro-
orbicularis oculi fat) just superficial to the periosteum. Fixation
to the periosteum of the frontal bone at least 1 cm above the
superior orbital rim lateral to the supraorbital nerve allows for
modest elevation. It is important to avoid injury to the supraor-
bital nerve to avoid numbness or hyperesthesia. After placing
the periosteal pass of the suture, it is best to target the thicker
portion of the ROOF to avoid superficial dimpling of the skin.
Typically, 1–2 sutures are placed.
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SURGICAL TECHNIQUE

A B

Figures 21.1A and 21.1B Upper eyelid crease approach

Internal brow ptosis repair is a useful adjunct during upper blepharoplasty. The technique utilizes a standard upper eyelid crease incision for correction of
brow ptosis. When marking the skin for both blepharoplasty and brow ptosis repair, the brow should be elevated to the expected position and then the
skin marked for blepharoplasty. Note that internal brow ptosis repair will not adequately address significant brow ptosis with thicker heavier brows. In
such cases of severe brow ptosis, alternative approaches, such as direct, endoscopic or pretrichial are more appropriate (Chapters 20, 22, and 23). The
internal brow approach is most effective for minimizing post brow descent after blepharoplasty and/or eyelid ptosis repair. A standard upper eyelid crease
incision is performed (Figures 21.1A and 21.1B).

A B

Figures 21.2A and 21.2B Preperiosteal incision

A Desmarres retractor is used to provide upward traction of the eyelid. The superior orbital rim is then identified (Figure 21.2A). Cutting cautery is used
to make a preperiosteal incision along the superior orbital rim (Figure 21.2B). Subperiosteal dissection is avoided since this would disrupt the periosteum
that will be used for brow fixation.

Figure 21.3 Subcutaneous brow dissection

After a preperiosteal plane is created, further blunt dissection is performed
superiorly in this plane. A peanut sponge is useful for this atraumatic
dissection. Meticulous hemostasis of brow vasculature is critical during
this step as postoperative hematoma formation can cause postoperative
rupture of the brow fixation suture and even an orbital compartment
syndrome. The dissection continues for at least 10 mm above the superior
orbital rim.

SECTION TWO • EYELID AND FACE

Chapter 21 Internal browplasty
144
 A B

Figures 21.4A and 21.4B Marking of fixation point

Once superior dissection is completed, a mark is placed approximately 10 mm to the superior orbital rim (Figures 21.4A and 21.4B). For larger, more
ptotic brows, two to three fixation points can be marked medial to lateral. The peak of the mark typically corresponds to the lateral corneal limbus.

A B

Figures 21.5A and 21.5B Periosteal fixation

A 5-0 Prolene suture on a tapered needle is used to purchase the periosteum at the previously marked site (Figure 21.5A). Once the suture is passed,
gentle upward traction is performed to confirm a rigid periosteal bite. Within the ROOF, the submuscular brow tissue is then purchased at a site below
the brow cilia and permanently tied off (Figure 21.5B). Once the brow is secured, gentle downward traction is placed on the brow to confirm adequate
suture fixation. If there is excessive dimpling of the brow, the subcutaneous bite should be replaced more superficially or at a higher level in the thicker
brow tissue.

145
Figure 21.6 Skin closure
Absorbable or removable sutures may be used during skin closure. Care
should be taken during upper blepharoplasty marking to prevent anterior
lamellar shortage and lagophthalmos.

Table 21.3 Complications

Complications Suggestions to reduce risk
Lack of brow elevation Place suture higher in periosteum and lower in brow tissue
Dimpling of skin Place brow pexy suture through thicker ROOF
Hemorrhage Proper hemostasis; cessation of anticoagulant usage prior to surgery; emergency management if
orbital compartment syndrome is present-open wound and cauterize bleeders and consider adjunct
lateral canthotomy and cantholysis if indicated
Abnormal eyebrow Lack of attention to natural brow configuration between men and women; follow guidelines for
contour gender differences as discussed in Chapter 20
Suture granuloma Consider use of non-absorbable sutures, recognize granulomas early, remove suture if symptomatic
and treat with antibiotic/steroid ointment
Wound dehiscence Make sure knots tied with appropriate tension with adequate soft tissue incorporation; avoid smoking,
lifting and bending; use of eye shield; avoid manipulation of wound

Table 21.4 Consumables used during surgery

6-0 Prolene suture, C-1 needle Ethicon #8718
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG140-8 needle Ethicon #J546G
5-0 Prolene suture, C-1 needle Ethicon #8725H

SECTION TWO • EYELID AND FACE

Chapter 21 Internal browplasty
146
 CHAPTER 22
Table 22.1 Indications for surgery
Forehead rhytids
Moderate brow ptosis
Temporal hooding
Facial nerve palsy with brow ptosis
INTRODUCTION
The endoscopic forehead lift is primarily a cosmetic operation
and is useful for moderate brow ptosis. It can smoothen out
forehead rhytids, weaken brow depressors, and elevate the tail
of the brow. For mild brow ptosis, an internal brow elevation
can be performed (Chapter 21). This procedure is most effec-
tive in preventing post-upper blepharoplasty brow descent but
provides minimal brow elevation. For moderate brow ptosis
where function takes precedence over form, a direct brow-
plasty can be performed to elevate a ptotic brow (Chapter 20).
For more severe brow ptosis in select patients, pretrichial
browplasty can be performed (Chapter 23).
Critics of the endoscopic technique claim that this procedure
is not as effective in lifting the brow as an open procedure and
that the effects are not long lasting. However, we have found
Endoscopic browplasty
Don O. Kikkawa • Bobby S. Korn
Table 22.2 Preoperative evaluation
Position of brow
Age and gender of patient
Magnitude of brow ptosis
Location of hairline and quantity of follicles
Prior eyelid, facial surgery or trauma
Qualitative and quantitative assessment of tear film
the procedure to be useful in mild-to-moderate brow ptosis
with good long-term results. Furthermore, the endoscopic pro-
cedure has the advantage of resulting in less hair loss, hypes-
thesia, and skin scarring compared to open brow approaches.
The procedure involves the creation of three optical cavities
through five incisions: one central, two paramedial, and two
temporal. All pockets are communicated into one larger cavity.
After release of the periosteum and weakening of the brow
depressors, the forehead flap is elevated and fixated. Options
for central fixation include an absorbable Endotine Forehead
implant (MicroAire, Charlotesville, VA) removable screw, and
surgeon-drilled bone tunnels. Our preferred fixation method is
use of bone tunnels. Temporally, the superficial temporalis
fascia is advanced and secured to the deep temporalis fascia.
Skin incisions are then closed with staples or sutures.
147
SURGICAL TECHNIQUE

A B

C D

Figures 22.1A–D Marking of incision sites

Five incision sites are typically made for endoscopic browplasty (Figure 22.1A). A vertically oriented central incision is made 3–4 mm posterior to the
hairline. Paired paramedial marks are made in line with the peak of the brow which corresponds to the lateral corneal limbus. The two temporal marks
are made at a location bisected by a plane parallel to the preauricular crease and a line extrapolated from the nasal ala through the lateral canthus. Prior
to the start of surgery, the hair is parted with multiple rubber ties. The supraorbital notches are palpated and a 10-mm safe zone is marked (Figure
22.1B). When performing concomitant upper blepharoplasty, the brow should be manually lifted while marking the skin for excision (Figure 22.1C). This
prevents over-resection of skin after browplasty. The incision sites are injected with 2% lidocaine and 1 : 100,000 epinephrine at least 10 minutes prior
to incision for maximal hemostasis. The forehead and temporal region down to the brow and zygomatic arch are infiltrated with 50 to 100cc of dilute 2%
lidocaine with epinephrine 1 : 100,000 and saline diluted down to a 1 : 5 ratio (Figure 22.1D). At least 10 minutes should elapse for maximal vasconstric-
tive effect. A full face sterile preparation is performed to include the hair. A plastic bag is placed under the head rest to capture any bleeding or saline
rinses during and after surgery.

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Chapter 22 Endoscopic browplasty
148
 A B

C D

E F

Figures 22.2A–F Incision of central and paramedial sites

The central incision and paramedial incisions are performed with a #15 or #10 blade down through the pericranium to expose bone (Figure 22.2A). With
adequate local anesthetic, bleeding from the incision should be minimal and excessive cautery should be avoided to prevent the development of localized
alopecia. Point bleeders can be controlled with conservative bipolar cautery. Senn retractors are used for horizontal exposure to identify the calvarium
(Figure 22.2B). A Freer or periosteal elevator is then used to perform a subperiosteal dissection inferiorly towards the brow (Figure 22.2C). Once the
periosteum near the incision is elevated, #5 endoforehead frontoglabellar dissector is introduced in the subperiosteal plane (Figure 22.2D). The dissection
is continued inferiorly towards the glabellar complex to gently elevate the procerus muscle (Figure 22.2E) Aggressive dissection lateral to the midline
should be avoided to minimize trauma to the supraorbital and supratrochlear nerves as well as to prevent damage to the corrugator and depressor
supercilii which may result in lateral splaying of the brow. Finally, the dissection is continued posteriorly towards the occiput (Figure 22.2F). These
portions of the dissection can be performed safely without endoscopic visualization as long as the dissectors remain on the calvarium in the subperiosteal
plane.

149
 A B

C D

Figures 22.3A–E Temporal incision

A fresh #15 blade is used to make the temporal incision through the subcutaneous tissue (Figure 22.3A). The thin, fibrous, superficial temporalis fascia
(temporoparietal fascia) is first encountered after dissection through the subcutaneous tissue (Figure 22.3B). Branches of the superficial temporal artery
are often seen and avoided. Bipolar cautery is used to coagulate any arterial bleeders. Forceps are then used to pick up the superficial temporalis fascia
and scissors are used to dissect down through this layer to expose the deep temporalis fascia (Figure 22.3C). The deep temporalis fascia is more robust
than the superficial layer and has a smooth white sheen. If there is doubt as to which fascial layer has been dissected, a small, 3-mm nick can be made
in the putative fascial layer (Figure 22.3D). If the temporalis muscle fibers are seen, this confirms that this layer is indeed the deep temporalis fascia
(Figure 22.3E). The dissections in the temporal incision are performed between the deep temporalis and superficial temporalis fascial layers to avoid
damage to the frontal (temporal) branch of the facial nerve.

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Chapter 22 Endoscopic browplasty
150
 A B

C D

Figures 22.4A–E Temporal dissection

At this point, endoscopic visualization is now used. The endoscope tower is placed at the foot of the bed. The endoscope sleeve is used and elevation
with the sleeve creates an optical cavity. For right-handed surgeons, the endoscope is held in the left hand while the dissector is controlled with the right
hand. Once the superficial and deep temporalis fascias are dissected, a #4 endoforehead “T” dissector is introduced (Figure 22.4A). All dissections in
the temporal pocket are performed in a temporal to nasal direction (Figure 22.4B). Dissection then proceeds carefully between the two fascial layers
under direct visualization (Figure 22.4C). A gentle lifting motion is performed followed by pivoting the dissector to the right and left as the temporal to
nasal dissection continues. The dissection is continued to the superior orbital rim and approximately 10 mm above the zygomatic arch. The sentinel vein
may be encountered and should be avoided as the frontal branch of the facial nerve courses superior to the vessel (Figure 22.4D). The dissection
centrally elevates the conjoint fascia and communicates with the central pocket through the temporal line of fusion (Figure 22.4E).

151
 A B

C D

Figures 22.5A–E Release of periosteum at superior orbital rim

Complete release of the periosteum at the superior orbital rim is essential for temporal brow elevation. The endoscope is now placed through the central
incision and the periosteum along the superior orbital rim is noted to be adherent at the arcus marginalis (Figure 22.5A). A #5 endoforehead or “toe
down” dissector is used to elevate the periosteum along the superior orbital rim (Figure 22.5B). The dissection is performed in a temporal to nasal
direction along the superior orbital rim. Once the periosteal release is complete, endoscopic scissors are used to incise the periosteum along the rim but
stopping short of the 10-mm safe zone around the supraorbital notch (Figure 22.5C). As the periosteum is slit, the overlying retroorbicularis oculi fat can
often be seen (Figure 22.5D). At the medial brow, care is taken to avoid damage to the supraorbital nerve which can often be visualized (Figure 22.5E).
A conservative release of the corrugator and procerus muscle can be performed with the endoscopic scissors. Aggressive dissection of these protractors
should be avoided and can result in widening of the inter-brow distance.

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Chapter 22 Endoscopic browplasty
152
 A B

C D

Figures 22.6A–E Creation of cortical bone tunnels

There are several methods of fixation. If absorbable lactide implants (Endotine) are used, these are secured at the two paramedial incisions. If cortical
bone tunnels are used, bone tunnels are created at the two paramedial incisions and if medial brow ptosis is to be addressed, a central bone tunnel can
be created (Figure 22.6A). The bone tunnels are started at the superior edge of the incision using a 1.5-mm drill bit with a 6-mm stop (Figure 22.6B).
The drill should be made obliquely at a 45° angle to the calvarium and to a depth of 3 mm to prevent inadvertent entry through the inner table (Figure
22.6C). An opposing hole is made approximately 4 mm apart at the same depth to communicate the tunnel within the diploic cancellous space (Figure
22.6D). Once the holes are united, saline is irrigated and aspirated through the opposite hole to rinse any bony debris still present in the tunnel
(Figure 22.6E). This helps to ensure smooth passage of the fixation suture in the subsequent step.

153
 A B

C D

E F

Figures 22.7A–F Elevation and fixation of forehead

Fixation of the forehead can be achieved with non-absorbable or absorbable sutures. Animal studies have shown that periosteal readherence is complete
at 12 weeks and thus a long-acting suture such as 2-0 PDS can be used. Our preference is to use a permanent 2-0 Prolene suture for fixation. The
needle is passed through the inferior edge of the incision to incorporate subcutaneous issue, galea and pericranium in a double pass (Figure 22.7A). The
free end of the suture is then twisted several times around a needle holder or hemostat to create a gentle curve (Figures 22.7B and 22.7C). The curved
end is then fed through the inferior hole of the tunnel and retrieved (Figure 22.7D). The surgical assistant provides superior traction on the brow while
the first knot is tied (Figure 22.7E). A locking needle holder is then placed over the knot and the brow is inspected for height and contour (Figure 22.7F).
Once satisfied, five square knots are then placed and the suture is cut on the knot. At the temporal incisions, an ellipse of skin on the anterior side can
be excised up to 10 mm for an additional lateral lift. The superficial temporalis fascia is then advanced to the deep temporalis fascia with 3-0 Maxon
suture. All scalp incision are closed with staples and removed at 10–14 days postoperative. At the conclusion of the case, a gentle head wrap is placed
and postoperative antibiotics, oral steroids, and analgesics are prescribed for 1 week.

SECTION TWO • EYELID AND FACE

Chapter 22 Endoscopic browplasty
154
 UPPER BLEPHAROPLASTY AND ENDOSCOPIC BROWPLASTY

Preoperative Postoperative

Figure 22.8 Before and after endoscopic browplasty

This 47-year-old female noted heavy upper eyelids and sagging of her brows. She underwent a conservative upper blepharoplasty and endoscopic
browplasty.

Table 22.3 Complications

Complications Suggestions to reduce risk
Lack of brow elevation Complete periosteal release; bone tunnels too narrow and may have broken; insufficient and incorrect
placement of knots
Dimpling of skin Sutures placed too superficially in dermis
Forehead hypesthesia Avoid excessive manipulation of supraorbital nerve during periosteal release
Frontalis paresis For the temporal pocket, dissect from lateral to medial in the planes between the superficial temporalis
fascia and the deep temporalis fascia
Hemorrhage Proper hemostasis; cessation of anticoagulant usage prior to surgery
Abnormal eyebrow contour Lack of attention to difference in natural brow configuration between men and women; excessive
elevation/resection of skin at temporal incision
Splaying of medial brow Avoid over-resection/dissection of glabellar complex

Table 22.4 Consumables used during surgery

2-0 Prolene, CT-1 needle Ethicon #8411H
2-0 PDS, CTB-1 needle Ethicon #PDPB345
3-0 Maxon, P-13 needle Syneture #SMM-5536
PROXIMATE PX skin stapler Ethicon #PXR35

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CHAPTER 23
Pretrichial browplasty
Bobby S. Korn • Don O. Kikkawa
Table 23.1 Indications for surgery
Forehead rhytids
Brow ptosis below superior orbital rim
Heavy brows with thick brow cilia
Pre-existing supraciliary rhytids
Paralytic eyebrow ptosis (CN VII palsy)
High forehead with hair to conceal incision
INTRODUCTION
Pretrichial browplasty can be performed for both cosmetic and
functional purposes to treat severe brow ptosis. This technique
is similar to the coronal browplasty in which a horizontal strip
of the forehead is excised, effectively tightening the forehead
and raising the brows. Compared to the coronal technique, the
pretrichial incision is made just below the hairline, sparing the
loss of any cilia. By excising forehead tissue, the brows are
raised while the hairline is lowered and, as such, the pretrichial
technique is well suited for patients with a high hairline and
enough hair to conceal the incision.
With significant lateral brow ptosis, the incision can be
extended temporally along the hairline to achieve a satisfactory
elevation. The dissection can be extended inferiorly to the level
of the forehead depressors where the corrugator, procerus and
depressor supercilii can be weakened; however, we rarely
perform dissection to this level. Horizontal forehead rhytids can
be very effectively treated with pretrichial skin excision similar
to the endoscopic technique (Chapter 22). Patients with
SECTION TWO • EYELID AND FACE
Chapter 23 Pretrichial browplasty
156
Table 23.2 Preoperative evaluation
Magnitude of brow ptosis
Age and gender of patient
Frontalis function
Location of hairline and hairstyle (bangs/fringe are best)
Quality and quantity of eyebrow cilia
Prior eyelid, facial surgery or trauma
Presence of concurrent upper dermatochalasis and/or eyelid ptosis
unilateral or asymmetric brow ptosis can undergo unilateral or
more relative forehead excision on one side to address differ-
ences in brow position. A midforehead lift can be considered
in unilateral facial nerve palsy where dense brow ptosis is
present on the ptotic side with no rhytids and severe forehead
rhytids from compensatory brow elevation on the normal side.
The midforehead incision can be blended into an existing fore-
head rhytid but the risk of a cosmetically noticeable scar should
be discussed with the patient.
If a concurrent upper blepharoplasty is to be performed, the
brow ptosis should be corrected first. After establishing the
new brow position, the excess skin is then marked for excision.
Patients should also be counseled about the risk of hypesthe-
sia, but this typically resolves spontaneously. Although the
plane of dissection is subcutaneous and pregaleal, caution
should still be given with lateral dissection near the course of
the frontal branch of the facial nerve. The pretrichial incision
typically heals well but may be noticeable in some patients and
this should be appropriately discussed.
SURGICAL TECHNIQUE

A B

C D

Figures 23.1A–D Skin marking

Pretrichial browplasty is routinely performed under local anesthesia with intravenous sedation. The incision is marked 1 mm anterior to the first row of
cilia at the hairline (Figure 23.1A). To address lateral brow ptosis, the marking is extended laterally and may be extended into the hairline to preserve the
temporal hair tuft. The supraorbital notch is palpated and marked vertically. A 10-mm radius is marked around the notch as a safe zone for dissection to
avoid the supraorbital nerve (Figure 23.1B). Horizontal forehead rhytids can also be marked. At the pretrichial incision line, a mixture of 1% lidocaine with
1 : 100,000 epinephrine and 0.25% bupivacaine is infiltrated to achieve maximal hemostasis (Figure 23.1C). Dilute anesthetic solution consisting of 0.1%
lidocaine and 1 : 1,000,000 epinephrine is injected subcutaneously throughout the forehead for tumescence to aid dissection and to provide a vascular
tourniquet (Figure 23.1D). A sterile preparation of the face and the hair is performed prior to draping. If upper blepharoplasty is also planned, this is
marked and injected after completion of the pretrichial browplasty to avoid development of lagophthalmos.

A B

Figures 23.2A and 23.2B Pretrichial incision

The pretrichial incision is made with a #10 or #15 blade. The incision is beveled to avoid follicular transection and to allow the retained follicles the
ability to grow through the beveled flap (Figure 23.2A). At least 10 minutes should elapse after anesthetic infiltration before skin incision to allow for
adequate hemostasis. Any residual bleeders can be conservatively coagulated with bipolar cautery (Figure 23.2B). Exuberant cauterization should be
avoided as this may lead to alopecia.

157
 A B

C D

Figures 23.3A–E Subcutaneous dissection

A Cottle thumb hook is used to retract the forehead while a blunt tip tenotomy scissor is used to begin the subcutaneous dissection for the first 10 mm
inferior to the incision line (Figure 23.3A). The dissection is performed in the plane between the subcutaneous tissue and the galea aponeurosis (Figure
23.3B). The galea has a white sheen with fine fibers interspersed along its surface. Once this pregaleal dissection plane has been established, curved
blunt tip facelift scissors can be used for more rapid dissection (Figure 23.3C). Both sharp and blunt dissection is used to extend the plane inferiorly.
Care is taken to avoid buttonholing through the forehead skin during the dissection. The dissection continues towards the orbital rim until the supraorbital
safe zone is reached (Figure 23.3D). By staying in the pregaleal plane, the major branches of the supraorbital nerve are avoided. While there may be
temporary hypesthesia, sensation to the forehead and scalp should be preserved. Near the lateral brow, care should be taken near the course of the
temporal branch of the facial nerve which runs approximately 2 cm above the brow (Figure 23.3E).

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Chapter 23 Pretrichial browplasty
158
 A B

C D

E F

Figures 23.4A–F Pretrichial skin excision and subcutaneous closure

Once the forehead has been dissected, pretrichial skin excision is performed. Excision of the redundant pretrichial skin lowers the hairline while
simultaneously raising the brows. An Allis clamp is used to elevate the forehead while applying downward pressure on the hair-bearing skin to identify
the amount of skin to be removed (Figure 23.4A). Once the excess skin is determined, a vertical incision is made to the desired level (Figure 23.4B). A
skin staple is placed to temporarily hold the central incision together (Figure 23.4C). At the temporal aspect of the incision, the excess forehead skin is
identified, incised vertically, and secured with a skin staple. A strip of the forehead skin is then excised. In this case, a 15 mm strip of skin is removed
(Figure 23.4D). Subcutaneous closure is performed with multiple interrupted circular 5-0 Monocryl sutures (Figure 23.4E). We prefer using Monocryl over
Vicryl as this suture is less inflammatory and potentially minimizes hair loss. At the temporal ends of the incision, more skin may be removed to account
for temporal brow ptosis (Figure 23.4F).

159
 A B

Figures 23.5A–C Skin closure

Skin closure is then performed with a 5-0 Prolene suture in a running horizontal mattress fashion (Figure 23.5A). Two separate running closures are
performed for each half of the forehead (Figure 23.5B). Excellent wound eversion is critical to avoid a noticeable depressed incision postoperatively
(Figure 23.5C). The Prolene sutures are removed 7 days after surgery.

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Chapter 23 Pretrichial browplasty
160
 PRETRICHIAL BROWPLASTY AND BILATERAL
UPPER BLEPHAROPLASTY

Preoperative Postoperative

Preoperative Postoperative
Figures 23.6A and 23.6B Before and after pretrichial browplasty
This 57-year-old female underwent pretrichial browplasty and upper blepharoplasty. She notes marked improvement in her superior visual field as well
as aesthetic improvement in forehead rhytids (Figure 23.6A). Examination of the pretrichial incision line shows a well-healed incision as well as lowering
of the hairline (Figure 23.6B).

161
Table 23.3 Complications
Complications Suggestions to reduce risk
Depressed scar Achieve good wound eversion with mattress closure of skin; place sufficient subcutaneous sutures to
relieve tension at skin edge
Loss of hair Bevel incision parallel to follicles to avoid follicular damage; avoid aggressive cauterization at wound
edge
Damage to facial nerve (frontal Keep dissection directly subcutaneously in the pregaleal plane avoid posterior dissection through galea
branch) and frontalis muscle
Hemorrhage Proper hemostasis; cessation of anticoagulant usage prior to surgery
Abnormal eyebrow contour Lack of attention to natural brow configuration between men and women; follow guidelines for gender
differences (Chapter 20)
Hypertrophic scarring Keep wound tension minimized with layered closure; avoid excessive cautery
Suture granuloma Use Monocryl instead of Vicryl for subcutaneous closure; recognize granulomas early; remove suture if
symptomatic and treat with antibiotic/steroid ointment
Wound dehiscence Make sure knots are tied with appropriate tension with adequate soft tissue incorporation; avoid
smoking, lifting, and bending; use of eye shield; avoid manipulation of wound

Table 23.4 Consumables used during surgery

5-0 Monocryl, PC-1 needle Ethicon #Y834G
5-0 Prolene, C-1 needle Ethicon #8718

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Chapter 23 Pretrichial browplasty
162
 CHAPTER 24
Facelift by minimal access
cranial suspension (MACS)
Table 24.1 Indications for surgery
Lower face and neck laxity
Jowling and marionette lines
Heavy nasolabial folds
Blunting of the cervicomental angle
INTRODUCTION
There are various methods for performing face and neck lifting,
including plication of the superficial musculoaponeurotic system
(SMAS), SMAS-ectomy, and deep plane facelifts. Each has its
benefits and drawbacks and can work very well in the appropri-
ate patient. The short incision facelift, also known as the minimal
access cranial suspension (MACS) lift, which was described by
Tonnard and Verpaele, has the benefit of being safe, fast, and
having a rapid recovery period. Rather than extending the flap
incision posterior to the ear, the MACS lift incision extends only
Bradford W. Lee • Bobby S. Korn
Table 24.2 Preoperative evaluation
History of prior facial surgery/trauma
History of smoking/anticoagulant use
Extent of midface, lower face and neck laxity
Platysmal banding
Facial nerve function
Extent of submental fat in the neck
to the base of the earlobe. Elevation of the SMAS is achieved
with placement of a vertical and oblique purse-string suture
that is secured to the deep temporalis fascia (Figure 24.1).
However, in patients with a dramatic amount of excess skin or
heavy necks, various additions to the MACS lift or alternative
facelift methods are recommended to achieve an optimal
result.
The preoperative evaluation should focus on the presence of
lower face and neck laxity, jowls, marionette lines, nasolabial
folds, and blunting of the cervicomental angle. The MACS lift
can be combined with an anterior or posterior cervicoplasty
163
and is often combined with neck liposuction to help sculpt the
neck. However, thick necks with substantial laxity may be
better candidates for a SMASectomy, SMAS flap facelift or a
deep-plane facelift.
Other considerations should include whether concurrent pro-
cedures would be beneficial, such as a brow lift, upper and
lower blepharoplasty, fat grafting or fillers, botulinum toxins, or
laser skin resurfacing.
Careful photographs of the face and neck taken from the
primary position, profile, and oblique angle should be taken
at all visits. A full and informed consent should be performed
to ensure appropriate expectations and that postoperative
instructions are followed. Patients should stop all anticoagu-
lants at least 7 days prior to surgery with approval from
their primary care physician and/or cardiologist. Smokers
must strictly cease all tobacco use, which can affect viability
of the facelift flap. Immediately after surgery, a facial pres-
sure wrap is placed and at the 24 hour postoperative visit,
any drains placed are removed. Throughout the first 2 weeks,
the patients should be encouraged to call the office or
return sooner if there is a non-resolving fluid collection under
the flap. Skin sutures are removed 5–7 days after surgery.

2.0

2.0 1.8

Figure 24.1 Facelift by Minimal Access Cranial Suspension

The MACS lift is achieved by using a vertical and oblique purse-string suture to plicate the SMAS and lift it towards its suspension point on the deep
temporalis fascia just above the posterior zygomatic arch. Figure 24.1 shows the safe and danger zones of the facial nerve. The temporal branch of the
facial nerve leaves the parotid gland anteriorly, crosses over the zygomatic arch, approximately 1.8 cm anterior to the tragus (shaded in red), and runs
superiorly to innervate the frontalis muscle in the forehead. Keeping the plication sutures within the substance of the SMAS and anchoring the sutures
posterior and superior to the arch minimizes risk of injury to the facial nerve.

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Chapter 24 Facelift by minimal access cranial suspension (MACS)
164
SURGICAL TECHNIQUE

Figure 24.2A and 24.2B Skin marking

The skin marking should run from the base of the earlobe within the earlobe crease, make a perpendicular cut across the intertragal sulcus, follow the
rim of the tragus, continue up the anterior border of the helix, and then continue along the sideburn and temporal hairline. The incision along the
sideburn and temporal hairline can be either curvilinear or saw-toothed in design, which can help disguise incision lines (Figure 24.2A). The incision can
also be placed just within the fine hairs at the front-most extent of the hairline to further camouflage the incisions. The anterior extent of the dissection
plane should be marked and extends from approximately 1 cm above the zygomatic arch down to the angle of the mandible. At its most anterior extent,
the dissection extends about 5–6 cm anterior to the tragus (Figure 24.2B).

165
Figure 24.3 Injection of tumescent anesthetic
Tumescent anesthetic is injected on a 22-gauge spinal needle using a
dilute solution as outlined in Table 24.3. Careful attention is paid to
injecting the incisions and then continuing in a subcutaneous plane.
Approximately 20–30 mL of anesthetic are injected on each side of the
face in this fashion, and additional tumescent anesthetic can be injected
into the neck if neck liposuction will be performed (Figure 24.3). Before
performing skin closure as the final step on the first side, tumescent
anesthetic is injected on the contralateral side to allow for maximal
hemostasis prior to making the incisions.

Table 24.3 Tumescent anesthetic solution

Component Concentration Amount
Normal saline 0.9% 450 ml
Lidocaine (plain) 1% 50 ml
Epinephrine 1 : 1000 (1 mg/ml) 0.5 ml
Sodium bicarbonate 8.4% 0.5 ml
Triamcinolone (optional) 10 mg/ml 0.5 ml

A B

Figures 24.4A and 24.4B Skin incision

The incisions are made with a #15 blade starting at the earlobe and moving superiorly (Figure 24.4A). While performing the skin incision along the
tragus, care is taken to avoid damage to the underlying fibrocartilage. Along the sideburn, the blade can be beveled in a trichophytic manner to allow
hair growth through the incision for camouflaging of scars (Figure 24.4B). Along the sideburn, the incision is made in a zigzag pattern to further conceal
the incision site.

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Chapter 24 Facelift by minimal access cranial suspension (MACS)
166
 A B

C D

E F

Figures 24.5A–F Elevation of facelift flap

The facelift flap is dissected in a subcutaneous plane which is safely above any motor branches of the facial nerve. After the skin incision, a #15 blade is
used to develop the subcutaneous dissection plane (Figure 24.5A). The use of a thimble hook retractor allows the surgeon to control the skin retraction
and develop the dissection plane (Figure 24.5B). The surgical overhead lights can be directed perpendicular to the anterior face of the flap to allow for
transillumination and creation of a flap of uniform thickness (Figure 24.5C). After the flap has been developed for 2 cm, dissection is performed with
curved, blunt tip facelift scissors (Figure 24.5D). The undermining is performed predominantly with a blunt, spreading technique to minimize trauma and
bleeding (Figure 24.5E). Dissection is facilitated by having the surgical assistant provide diffuse medial countertraction on the face. Care is taken to avoid
creating a button-hole or making the flap too thin. Frequent lifting of the flap to examine under transillumination will help to create a flap of uniform
thickness. The flap is dissected to the 5 cm point anterior to the tragus and inferiorly to the angle of the mandible. The use of a lighted retractor or
surgical headlight can also facilitate visualization. Once the flap has been fully elevated, meticulous hemostasis is achieved using bayonet bipolar forceps
(Figure 24.5F).

167
 2.0

2.0 1.8

A B

C D

E F

Figures 24.6A–F Dissection to deep temporalis fascia

Figure 24.6A shows a schematic of the two key purse-string sutures placed in the SMAS. In this case, the vertical and oblique purse-string sutures have
been marked on the skin to demonstrate the lift achieved with the MACS lift (Figure 24.6B). Both purse-string sutures are attached cranially to the deep
temporalis fascia (DTF) above the zygomatic arch. Figure 24.6C shows the course of the temporal branch of the facial nerve as it cross over the
zygomatic arch 1.8 cm in front of the tragus. Deeper dissection in this danger zone can damage this motor branch. Approximately 1 cm anterior to the
helix and 1 cm above the zygomatic arch is a safe zone where no branches of the facial nerve course (Figure 24.6D). Additional local anesthetic
consisting of 1% lidocaine and 1 : 200,000 epinephrine is given here down to the temporal bone (Figure 24.6E). Scissors are then used to create a small
window through the SMAS in this safe zone and dissection is carried down to expose the deep temporalis fascia for subsequent passage of the
purse-string sutures (Figure 24.6F). Care is taken in this region as the superficial temporal artery runs in this area. The vessel can be cauterized or
ligated with a surgical clip if significant bleeding occurs but care should be taken to avoid the vessel if at all possible.

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Chapter 24 Facelift by minimal access cranial suspension (MACS)
168
 A B

C D

E F

Figures 24.7A–F Placement of vertical purse-string suture

The vertical purse-string suture addresses the cervicomental angle. A 2-0 Prolene suture on a tapered needle is passed through the SMAS window and
securely anchored to the deep temporalis fascia (DTF) (Figure 24.7A). The suture is then woven vertically by taking 1.5 cm long and 0.5 cm deep bites
through the SMAS (Figure 24.7B). At the angle of the mandible, a 1 cm U-turn is performed and the suture is woven superiorly to complete the
ascending portion of the loop (Figure 24.7C). As the suture is elevated, a vertical lift can be noted in the deeper tissue planes (Figure 24.7D). Sufficiently
deep suture bites should be placed within the SMAS to ensure the suture does not cheese-wire through the tissues. Along the course of the vertical
purse-string suture, the facial nerve runs within the parotid gland, well below the SMAS imbrication suture. The suture is then buried with a final pass
through the deep temporalis fascia (Figure 24.7E). With firm superior traction by the assistant, the suture is strongly tied off by placing at least five
square knots (Figure 24.7F). After the suture is tied off, skin dimpling may be seen and this is freed after placement of the oblique purse-string suture.

169
 A B

C D

Figures 24.8A–D Placement of oblique purse-string suture

The oblique purse-string suture is more oval shaped and provides superolateral lifting of the SMAS. This augments the correction of the cervicomental
angle as well as flattening the nasolabial fold. A second 2-0 Prolene purse-string suture is then woven from the same originating point through the DTF
and imbricated through the SMAS with 1–1.5 cm bites (Figure 24.8A). After the oblique loop is completed, the suture is again passed through the DTF
and tied off under firm tension (Figure 24.8B). The SMAS window over the DTF is then closed with interrupted 5-0 Vicryl sutures (Figure 24.8C). Any
surface irregularities of the SMAS are then cautiously trimmed at the surface using the facelift scissors, taking care to not excise deeply below the SMAS
or to cut the purse-string sutures. There is typically some rippling/dimpling of the skin due to residual cutaneous attachments following SMAS plication.
The facelift scissors are then used to further release these attachments and ensure that the flap lies smoothly over the plicated SMAS (Figure 24.8D).

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Chapter 24 Facelift by minimal access cranial suspension (MACS)
170
 A B

C D

E F

Figures 24.9A–F Redraping and resection of skin

The reason that the MACS lift does not need to extend posterior to the earlobe is that redraping of the skin occurs in a vertical vector, rather than in a
horizontal vector. The skin is redraped vertically and a mark is made where the skin meets the root of the helix (Figure 24.9A). The skin is then cut at
this mark and secured with a skin staple (Figure 24.9B). The excess vertical skin below the sideburn is then trimmed with the same angle used for the
original trichophytic skin incision (Figure 24.9C). The anterior pivot point will often have a dog-ear redundancy and this is excise with a Burow’s triangle
(Figure 24.9D). Next, the earlobe is addressed. With the superior vector created by the purse-string sutures, the earlobe is often elevated. The earlobe
should be delivered into a normal position by creating as minimal of an incision as possible inferiorly to place it in an anatomic position (Figure 24.9E).
Minimal horizontal skin redundancy is present after the vertical lift but this is conservatively excised if present (Figure 24.9F). In particular, there should
not be any tension on the skin overlying the tragus as this will lead to anterior migration of the retrotragal incision and effacement of the pretragal
sulcus.

171
 A B

C D

Figures 24.10A–E Skin closure

The incision is closed with buried 5-0 Vicryl or Monocryl sutures through the subcutaneous layer (Figure 24.10A). Meticulous placement of the subcuta-
neous sutures in a superior to inferior direction will minimize dog ear formation. The skin is then closed around the sideburn with a running, horizontal
mattress suture (Figures 24.10B and 24.10C). At the preauricular line, the skin is closed with a simple running 6-0 Prolene suture (Figure 24.10D). A
sterile IV tubing can be placed under the flap as a drain for the first 24 hours (Figure 24.10E). A pressure dressing is placed and the drain is draped
behind the neck and wrapped in extra gauze to collect any serosanguinous discharge. The sutures are removed 5–7 days postoperatively. Postopera-
tively, patients are given prophylactic antibiotics, oral analgesics for pain control, and antibiotic ointment for the incisions. Patients are instructed to sleep
on their backs when possible and to avoid any significant turning of the head that would place traction on the suture lines.

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Chapter 24 Facelift by minimal access cranial suspension (MACS)
172
 MACS FACELIFT

Preoperative Postoperative
Figures 24.11A–C Before and after MACS facelift
This 60-year-old female presented for aesthetic consultation. Preoperatively, she had jowling, mid-facial descent, deep marionette lines, and blunting of
the cervicomental angle. She underwent MACS facelift combined with conservative upper blepharoplasty and ptosis repair. Postoperatively, she has
marked improvement in jowling, mid-facial descent, marionette lines, and cervicomental angle. (Figures 24.11A to 24.11C).

173
B

Preoperative Postoperative

Preoperative Postoperative
Figures 24.11A–C cont’d

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Chapter 24 Facelift by minimal access cranial suspension (MACS)
174
Table 24.4 Complications
Complications
Injury to facial nerve
Hematoma/seroma
Flap ischemia/necrosis
Infection
Ridges or dimpling of the skin
Residual anterior platysmal banding
Residual posterior vertical skin folds
Temporal pain and limitation in opening
mouth
Unsatisfactory scars
Wound dehiscence
Posterior dog-ear
Table 24.5 Consumables used during surgery
2-0 Prolene, CT-2 needle
5-0 Monocryl, PC-3 needle
5-0 Vicryl, PC-3 needle
6-0 Prolene, C-1 needle
Suggestions to reduce risk
Minimal risk due to lack of sub-SMAS dissection; do not sew purse-string suture excessively
deep below the SMAS as this may imbricate the parotid gland
Careful hemostasis with bipolar cautery, placement of compression dressing and drains for
first 24 hours; early evacuation of hematoma if necessary; cessation of anticoagulants
(pharmacologic and dietary)
Rare, counsel patients on smoking cessation; if occurs, evaluate for hematoma and consider
hyperbaric oxygen; keep subcutaneous flap thicker; avoid excessive skin excision and ensure
that skin incisions are free of tension
Postoperative antibiotics
This can be avoided by making sure to release cutaneous adhesions with facelift scissors after
applying the purse-string sutures
Evaluate preoperatively; consider a conservative anterior corset platysmaplasty following
placement of SMAS pursestring sutures if medial platysmal bands are still prominent with
simulated MACS lift
Evaluate preoperatively and if there is significant skin laxity; discuss possibility of posterior
cervicoplasty for skin redraping when necessary
Avoid incarcerating muscle fibers of temporalis when suturing to the deep temporalis fascia;
consider anchoring to the immobile SMAS just anterior to the superior extent of the tragus
Avoid excessive tension on skin incisions, can treat with laser resurfacing or intralesional
injection of 5-fluorouracil/triamcinolone
Place sufficient deep buried sutures; consider leaving some sutures in place beyond 7 days in
very elderly, diabetic, or smoker patients
Reassurance as this typically resolves over the first 2 months
Ethicon #8411H
Ethicon #Y844G
Ethicon #J844G
Ethicon #8718
175
CHAPTER 25
Ectropion repair by retractor
reinsertion and lateral tarsal strip
Bobby S. Korn • Don O. Kikkawa
Table 25.1 Indications for surgery
Lower eyelid ectropion
Eversion of the eyelid margin
Horizontal lower eyelid laxity
Keratinization of the palpebral conjunctiva
Epiphora and foreign body sensation secondary to ectropion
INTRODUCTION
Eversion of the lower eyelid margin occurs as a spectrum, first
starting with punctal ectropion, leading eventually to frank tarsal
ectropion. Symptoms develop as the lower eyelid pulls away
from the ocular surface and loses the tone required to maintain
the lacrimal pump. Presenting symptoms may include tearing,
foreign body sensation, ocular irritation and redness.
Several risk factors exist in the development of ectropion.
First, there is an ethnic influence on the development of eyelid
malposition. Asians are more prone to developing entropion
than ectropion. This may be due to increased adipose in the
preseptal and postseptal planes providing additional support.
Second, actinic changes in the skin can cause vertical contrac-
tion leading to an increased eyelid eversion. Third, eyelid laxity
SECTION TWO • EYELID AND FACE
Chapter 25 Ectropion repair by retractor reinsertion and lateral tarsal strip
176
Table 25.2 Preoperative evaluation
Lower eyelid snap back test
Lower eyelid distraction test
Finger test to manually tighten eyelid – look at puncta for inversion
Orbicularis tone
Assess for anterior lamellar shortage to determine need for
skin graft
Prior eyelid, facial surgery or trauma
Assess for co-existent lacrimal duct obstruction
Evaluation for negative vector
leads to instability in horizontal tension, allowing vertical forces
to dictate eyelid position. Disinsertion or attenuation of the
lower eyelid retractors in conjunction with decreased orbicularis
tone allows the eyelid to evert.
Assessment of the ectropic eyelid should focus on several
factors. Eyelid laxity should be measured. Floppy eyelid syn-
drome should be ruled out. Anterior lamellar contraction and
actinic damage may be the primary cause of eyelid eversion. If
insufficient or if there is too much contraction, skin grafting may
be necessary (Chapter 27). Occult cutaneous malignancy
should also be considered. An in-office evaluation by the physi-
cian should include manually tightening of the lower eyelid later-
ally and observation of the medial eyelid. If the eyelid inverts, the
ectropion can likely be treated with lower eyelid tightening only.
If eversion persists, tightening of the eyelid retractors will also be
necessary. The globe and position of the inferior orbital rim
should be evaluated to rule out a negative vector (Chapter 10).
Correction of the ectropion should address components
identified in the clinical evaluation. Horizontal shortening with
a tarsal strip is typically required in most cases. In more severe
cases, the vertical component will also need to be addressed.
Transconjunctival reinsertion of the lower eyelid retractors to
the inferior tarsal border is our preferred approach. With long-
standing tarsal ectropion, the conjunctiva becomes redundant
and a small strip can safely be excised without risk of sym-
blepharon or fornix shortening. If a prominent negative vector
is present, performing a tarsal strip may exacerbate lower
eyelid retraction (pot-belly effect). In such cases, after lower
eyelid retractor reinsertion, a canthoplasty that anchors the
lower eyelid to the superior crus of the lateral canthal tendon
instead of the lateral orbit rim will minimize this complication
(Chapter 29).
One final concern is the entropion that can occur after repair
of long-standing ectropion. As the everted eyelid margin rests
against the skin, the lashes become vertically oriented and lose
their natural growth curvature outward. As the eyelid is then
inverted surgically, these lashes then may abrade the cornea.
With time, the natural outward growth of the lashes typically
returns; however, epilation may be necessary. Eyelid margin
rotation should be considered in such recalcitrant cases
(Chapters 29, 30, 31).

SURGICAL TECHNIQUE

A B

Figures 25.1A and 25.1B Lateral canthotomy and cantholysis

In this case, significant lower eyelid laxity with tarsal eversion from retractor disinsertion is present. To facilitate access to the lower eyelid retractors and
shortening of the eyelid, a 2-mm lateral canthotomy is performed (Figure 25.1A). Once the canthotomy is created, the Westcott scissors are used to
strum the inferior crus of the lateral canthal tendon. With gentle lateral traction on the eyelid, the inferior crus of the lateral canthal tendon is lysed until
the lower eyelid freely can be distracted from the globe (Figure 25.1B). In the setting of lower eyelid laxity alone without retractor disinsertion, skip to
Figure 25.5 for the tarsal strip procedure.

A B

Figures 25.2A and 25.2B Shortening of palpebral conjunctiva

With long-standing tarsal eversion, the palpebral conjunctiva becomes attenuated and redundant. A shield is preplaced to protect the cornea and then
the lower eyelid is placed on inferior traction and a 2–3-mm ellipse of conjunctiva is outlined from the inferior tarsal border with a marking pen (Figure
25.2A). Cutting cautery is used to incise the tissue and then a small ellipse of conjunctiva is excised (Figure 25.2B). Use of the cautery helps to minimize
bleeding from this chronically inflamed and hyperemic conjunctiva. Care is taken to avoid damage to the tarsal plate and inferior punctum during the
conjunctival excision (Figure 25.2B).

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 A B

Figures 25.3A and 25.3B Identification of lower eyelid retractors

Once the conjunctival ellipse has been removed, the lower eyelid retractors are sought. Analogous to the levator aponeurosis of the upper eyelid, the
lower eyelid retractors are identified as a broad white band (Figures 25.3A and 25.3B). With advanced involutional changes, the retractor band may be
inferiorly displaced and attenuated. When in doubt, the putative retractor band is held in traction while the patient is asked to look up and down. The
retractor band should be distinguished from the orbital septum. Mistaking the orbital septum as the lower eyelid retractors will cause postoperative eyelid
retraction after reinsertion. The orbital septum originates from the orbital rim and superior traction on the septum will identify its firm bony attachment at
the arcus marginalis, while the lower eyelid retractors will lack this firm attachment at the rim.

Figure 25.4 Reinsertion of lower eyelid retractors

The lower eyelid retractors are then reinserted onto the inferior tarsal
border using a running 6-0 fast-absorbing gut suture. To avoid corneal
abrasion, the suture is buried by starting the initial suture pass inferior to
superior on the lower eyelid retractors. Once the retractors have been
reinserted, the eyelashes are often noted to take a vertical configuration
owing to long-standing eversion. With time, the lashes should return to
their native outward curvature. If frank entropion develops, the reinsertion
suture should be recessed.

A B

Figures 25.5A and 25.5B Division of eyelid margin

Next, attention is directed towards developing the tarsal strip. First, the anterior (skin and orbicularis) and posterior lamellae (tarsus and conjunctiva) of
the lateral eyelid is split at the gray line (Figures 25.5A and 25.5B). Cutting cautery or sharp dissection can be used to separate the two lamellae. The
amount that is split depends on the degree of eyelid laxity to be treated. During the dissection, care should be taken to avoid cutting into the tarsus.

SECTION TWO • EYELID AND FACE

Chapter 25 Ectropion repair by retractor reinsertion and lateral tarsal strip
178
 A B

Figures 25.6A and 25.6B Trimming of eyelid margin

Once the anterior and posterior lamellae have been split to the desired amount of eyelid shortening, the mucosa at the eyelid margin is trimmed off. This
can be achieved with Westcott scissors or use of the cautery. Complete removal of this mucus-secreting lining is necessary to avoid development of
postoperative conjunctival cysts. The conjunctiva on the posterior tarsal face can also be denuded with a #15 blade. Again, the removal of this mucosa
should not include any tarsus.

Figure 25.7 Shortening of tarsal strip

The tarsal strip is appropriately shortened as it is approximated to the lateral
orbital rim. A horizontal relaxing incision is made below the inferior tarsal
border to release the conjunctiva and lower eyelid retractors. Care should be
taken to avoid excessive shortening, particularly in the case of medial canthal
tendon laxity. If the lower eyelid is excessively shortened, the lower punctum
can be significantly lateralized, resulting in poor tear outflow. Finally, during
the preoperative evaluation, the relative prominence of the globe should be
noted with respect to the lower eyelid (negative vector). In cases of lower
eyelid retraction and ectropion in the setting of proptosis, excessive tarsal
shortening will lead to worsening lower eyelid retraction from a “pot-belly”
effect. A canthoplasty with the lower eyelid secured to the superior crus of
the lateral canthal tendon is more appropriate, as described in Chapter 29.

A B

Figures 25.8A and 25.8B Fixation of tarsal strip to lateral orbital rim
The lower eyelid is secured to the periosteum overlying the lateral orbital rim with two interrupted sutures placed on the upper and lower poles of the
tarsal strip (Figures 25.8A and 25.8B). The use of a P-2 semicircular needle on a 5-0 Vicryl suture is useful in obtaining a deep purchase of the
periosteum for stable fixation. The suture should be secured at least 1.5 mm from the lateral tarsal edge to minimize cheese-wiring of the suture.
Maintenance of a healthy and robust tarsal strip during the previous steps also helps to minimize tearing of the tarsal strip postoperatively. To facilitate
exposure of the lateral orbital rim periosteum, a malleable retractor can be used to medially distract the globe. Further exposure can be performed by
extending the lateral canthotomy a few millimeters as well. A slight overcorrection is desired in order to allow for postoperative stretching of the tissues.

179
 A B

Figures 25.9A and 25.9B Closure of skin

A small amount of skin and a small number of eyelashes will require excision after securing the tarsal plate (Figure 25.9A). The skin overlying the lateral
canthus is secured with multiple 6-0 fast-absorbing gut sutures (Figure 25.9B). Additionally, a buried 7-0 Vicryl suture can be used to reform the canthal
angle by approximating the upper and lower eyelid at the gray line.

RIGHT ECTROPION REPAIR BY RETRACTOR REINSERTION AND LATERAL TARSAL STRIP

Preoperative Postoperative

Figure 25.10 Before and after right lower eyelid ectropion repair with retractor reinsertion and lateral tarsal strip
This 82-year-old male noted tearing and foreign body sensation in the right eye. A lower eyelid retractor reinsertion and lateral tarsal strip was performed
to restore the eyelid to its native state.

SECTION TWO • EYELID AND FACE

Chapter 25 Ectropion repair by retractor reinsertion and lateral tarsal strip
180
Table 25.3 Complications
Complications
Consecutive ectropion
Consecutive entropion
Cheese-wiring of tarsal strip
Lateralization of punctum
Hemorrhage
Lower eyelid retraction
Suture granuloma
Wound dehiscence
Suggestions to reduce risk
Reinsertion of retractors and possible skin grafting (Chapter 27); inadequate horizontal shortening
Limit posterior lamellar excision; epilate lashes and allow time for natural outward lash growth to occur;
consider eyelid margin rotation in severe cases (Chapters 29–31)
Avoid thinning tarsal plate during separation of anterior and posterior lamellae and eyelid margin trimming;
secure tarsal strip at least 1.5 mm from lateral edge
Consider medial canthal tendon plication with conservative lateral canthal shortening
Proper hemostasis; cessation of anticoagulant usage prior to surgery
Avoid excessive advancement of the lower eyelid retractors.
Consider use of non-absorbable sutures, recognize granulomas early, remove suture if symptomatic and
treat with antibiotic/steroid ointment
Make sure knots tied with appropriate tension with adequate soft tissue incorporation; avoid smoking,
lifting, and bending, use of eye shield, avoid manipulation of wound

Table 25.4 Consumables used during surgery

5-0 Vicryl, P-2 needle Ethicon #J503G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G

181
CHAPTER 26
Ectropion repair by medial spindle
Bobby S. Korn • Don O. Kikkawa
Table 26.1 Indications for surgery
Vertical puncta
Punctal eversion or ectropion
Epiphora and foreign body sensation secondary to ectropion
INTRODUCTION
Punctal eversion is often the first sign of ectropion. Normally,
the punctum rests apposed to the globe and with slight inver-
sion of the medial eyelid. Under slit lamp examination, the
punctum is normally not visible. With relaxation and attenuation
of the lower eyelid retractors, punctal eversion begins. If the
punctum becomes vertical or everted, by definition, punctal
ectropion is present.
Symptoms occur as the punctum loses its apposition to the
ocular surface and tear film. Epiphora begins and worsens as
the punctum continues to evert. If eversion worsens, eyelid
imbrication may occur with blinking as the upper eyelid closes
internally to the lower eyelid. This can cause further irritation to
SECTION TWO • EYELID AND FACE
Chapter 26 Ectropion repair by medial spindle
182
Table 26.2 Preoperative evaluation
Lower eyelid snap back test
Lower eyelid distraction test
Finger test to manually tighten eyelid – look at puncta for inversion
Orbicularis tone
Assess for anterior lamellar shortage to determine need for skin graft
Prior eyelid, facial surgery or trauma
Assess for co-existent punctal stenosis
Assess for co-existent lacrimal duct obstruction
the ectropic lower eyelid and irritation to the tarsal conjunctiva,
resulting in discomfort, foreign body sensation, and redness.
Often co-existent with punctal eversion is punctal stenosis.
With the punctum not in contact with the tear film, there is no
flow of tears and the punctum may become stenotic. Puncto-
plasty may be necessary to allow tears to drain, in addition to
punctal ectropion repair (Chapter 63).
Repair of the ectropic medial eyelid margin alone is often
successful in alleviating symptoms. However, also frequently
present is horizontal eyelid laxity, which can be addressed
simultaneously with an eyelid-shortening procedure or can-
thopexy. Additionally, canalicular irrigation should be performed
to rule out lacrimal outflow obstruction, as this may occasion-
ally be present.
SURGICAL TECHNIQUE

A B

Figures 26.1A and 26.1B Marking of conjunctiva

Normally, the inferior puncta should not be visible unless the eyelid is everted (Figure 26.1A). Lacrimal irrigation should always be performed preopera-
tively to rule out nasolacrimal duct obstruction even in the presence of punctal ectropion. A diamond-shaped wedge is marked on the conjunctiva directly
posterior to the puncta (Figure 26.1B). For more extensive medial ectropion and punctal eversion, an extended horizontal ellipse can be marked. The
vertical height of the marking averages 4–6 mm with the apices directed towards the punctum.

A B

Figures 26.2A and 26.2B Excision of wedge of conjunctiva and lower eyelid retractors
Cutting cautery is used to excise a diamond of conjunctiva while incorporating a small portion of the lower eyelid retractors. This shortens the posterior
lamella and allows for inward rotation of the punctum. Care is taken to avoid cauterization of punctum and the use of an eyelid plate protects the corneal
surface. A Bowman probe can be placed during the excision for protection of the proximal lacrimal system. Also, dissection should not proceed to the
level of the orbicularis.

183
 Figure 26.3 Reinsertion of lower eyelid retractors
The lower eyelid retractors are then reapproximated to the inferior tarsal
border with two to three interrupted and buried 7-0 Vicryl sutures. This
serves to turn in the punctum towards the ocular surface. Additionally, the
sutures can be directed externally and tied off on the skin to exert
additional inward rotation. This should be done cautiously as symblepharon
may result. Lower eyelid laxity often co-exists with punctal ectropion and
this can be treated concurrently (Chapter 25).

Table 26.3 Complications

Complications Suggestions to reduce risk
Canalicular or punctal damage Careful suture placement to avoid punctum and canaliculus; place Bowman probe during procedure to
isolate and avoid damage to the lacrimal system
Continued epiphora Consider punctoplasty or eyelid tightening (Chapter 63); rule out concomitant nasolacrimal duct
obstruction with lacrimal irrigation
Shortened fornix or symblepharon Avoid excessive removal of conjunctiva and cauterization
Hemorrhage Proper hemostasis; cessation of anticoagulant usage prior to surgery
Lower eyelid retraction Avoid over advancement of the lower eyelid retractors
Suture granuloma Consider use of non-absorbable sutures; recognize granulomas early; remove suture if symptomatic
and treat with antibiotic/steroid ointment
Wound dehiscence Make sure knots tied with appropriate tension with adequate soft tissue incorporation; avoid smoking,
lifting, and bending; use of eye shield; avoid manipulation of wound

Table 26.4 Consumables used during surgery

7-0 Vicryl , TG140-8 needle Ethicon #J546G

SECTION TWO • EYELID AND FACE

Chapter 26 Ectropion repair by medial spindle
184
 CHAPTER 27
Table 27.1 Indications for surgery
Symptomatic cicatricial ectropion (tearing, mucoid discharge,
conjunctival keratinization, corneal exposure)
INTRODUCTION
Cicatricial ectropion is characterized by a deficiency in the
anterior lamellae of the eyelid. This condition may occur on
the upper and/or lower eyelids. With a shortage of the skin, the
eyelid everts, resulting in ectropion. Functionally, this can result
in tearing from poor lacrimal outflow, corneal exposure, and
keratinization of the palpebral conjunctiva.
A careful history to elucidate the cause of the cicatricial
ectropion is necessary to prevent recurrence after treatment.
Chemical burns or thermal injury are particularly challenging to
treat and often require repeated skin grafting. Chronic derma-
tologic conditions should be maximized medically before con-
sidering surgical treatment. Periocular reconstruction after skin
cancer removal may also result in cicatricial ectropion if exces-
sive tension is present in the vertical meridians. Blepharoplasty
with excessive skin removal can result in cicatricial ectropion
as well as eyelid retraction particularly when eyelid laxity is not
concurrently treated.
Ectropion repair with full
thickness skin grafting
Bobby S. Korn
Table 27.2 Preoperative evaluation
History of trauma (chemical/burns), prior cosmetic surgery,
reconstructive surgery to face (trauma/post cancer removal),
actinic/radiation exposure
Underlying dermatologic disorders (ichthyosis, contact dermatitis,
scleroderma)
Degree of anterior lamellar shortening
Presence of lower eyelid laxity, lagophthalmos, lower eyelid
retraction
Slit lamp examination
Lysis of the anterior lamellar cicatrix followed by placement of
a full thickness skin graft is the mainstay of treatment for cica-
tricial ectropion. Lower eyelid tightening with a subperiosteal
midface lift and posterior lamellar spacer graft is useful for
eyelid retraction alone, but with severe cicatricial ectropion, a
skin graft is often necessary. For patients who are not candi-
dates for skin grafting, a Z-plasty with the central limb oriented
vertically can be used to treat lower eyelid cicatricial ectropion.
The decision between a full thickness or split thickness skin
graft as well as donor site choices are discussed in Chapter 1.
The primary benefits of a full thickness skin graft are minimal
contraction, improved color and texture, and no need for a
dermatome. Multiple donor sites are available such as upper
eyelid, preauricular, retroauricular, and supraclavicular (Figures
1.22-1.27, Chapter 1). When possible the upper eyelid should
be used for the most ideal match.
Postoperative management of a full thickness skin graft is
equally as important as the surgery itself. Full thickness skin
185
grafts exchange nutrients and metabolic wastes through diffu-
sion by a process known as plasma imbibition. Within the first
24 to 48 hours, vascular inosculation between the graft and
recipient bed occurs. Between 48 and 72 hours, capillary buds
start to grow into the graft and, by 5 days, a blood supply has
been established. Several conditions can adversely affect this
process. Shearing of the graft can cause bleeding and disrupt
neovascularization. A hematoma between the graft and bed
affects diffusion and firm immobilization of the graft with a pres-
sure patch is essential to maximize graft survival. Antibiotic
prophylaxis can minimize infection at the interface and strict
avoidance of smoking to prevent ischemia is essential.

SURGICAL TECHNIQUE

A B

Figures 27.1A and 27.1B Lateral canthotomy and inferior cantholysis

Lower eyelid laxity is often a component in cicatricial ectropion in addition to the anterior lamellar deficiency. Eyelid distraction greater than 6 mm
indicates significant laxity and should be treated. A 1-mm lateral canthotomy and inferior cantholysis is performed to release the canthal attachment of
the lower eyelid (Figures 27.1A and 27.1B). There are several options for lower eyelid tightening. For mild to moderate eyelid laxity with 8 mm or less of
eyelid distraction, a horizontal full thickness wedge of the eyelid can be excised and secured to the superior crus of the lateral canthal tendon, as
described in Chapter 9, Figure 9.8. For moderate to severe eyelid laxity with greater than 8 mm of eyelid distraction, a lateral tarsal strip or even drill
hole fixation of the canthus can be performed (Chapter 28). In this case, a tarsal strip procedure is chosen with the patient’s moderate eyelid laxity.

A B

Figures 27.2A–D Formation of tarsal strip

After lateral canthotomy and inferior cantholysis, the eyelid is divided at the gray line into the anterior and posterior lamellae (Figure 27.2A). Care is
taken to not incise the tarsus during the separation of the two lamellae. The eyelid is split according to the desired amount of shortening. The inferior
border of the tarsal strip is then cut to release the lower eyelid retractors and conjunctival attachments (Figure 27.2B).

SECTION TWO • EYELID AND FACE

Chapter 27 Ectropion repair with full thickness skin grafting
186
 C D

Figures 27.2A–D Formation of tarsal strip—cont’d

The mucosa at the eyelid margin is then carefully excised with Westcott scissors (Figure 27.2C). Removal of this mucosa is essential to prevent
formation of epithelial inclusion cysts after fixation of the tarsus deep within the orbit. A #15 blade can be used to debride the epithelium on the
posterior surface and eyelid margin (Figure 27.2D). Finally, the tarsal strip is pulled to the lateral orbital rim to determine the amount of shortening
needed. A slight overcorrection is desired.

A B

C D

Figures 27.3A–D Anchoring of tarsal strip

A 4-0 Vicryl suture on a P-2 needle is used for tarsal anchoring. Two interrupted sutures are passed on the superior and inferior poles of the lateral
tarsal strip. The needle is passed 2 mm from the lateral edge of the tarsal strip to prevent cheese-wiring after securing to the periosteum (Figure 27.3A).
The P-2 needle is small in diameter and semicircular in shape and is useful for deep periosteal fixation to the inner aspect of the lateral orbital rim
(Figure 27.3B). A malleable retractor can be used to protect the globe and to provide exposure during the needle pass. The periosteum at the lateral
orbital rim is thick and a firm bite should be taken during the pass. Once the needle is passed, the suture should be pulled outwards to confirm rigid
fixation to the periosteum (Figure 27.3C). The second suture is passed through the inferior pole of the tarsal plate in a similar fashion. The sutures are
tied off and then the skin containing the eyelashes is trimmed off (Figure 27.3D).

187
 A B

C D

E F

Figures 27.4A–F Release of lower eyelid cicatrix

Once the lower eyelid has been tightened, attention is directed towards release of the lower eyelid cicatrix. A 6-0 silk suture is placed through the gray
line for superior traction (Figure 27.4A). The end of the silk is tied off and then a hemostat is placed to provide traction. An infraciliary mark is made
1–1.5 mm below the lashes (Figure 27.4B). Westcott scissors are then used to make the skin incision (Figure 27.4C). The dissection should be
continued inferiorly in the pre-orbicularis muscle plane (Figure 27.4D). When manipulating the inferior edge of the skin, care should be taken to minimize
further trauma to this already thin skin. The use of fine hooks minimizes repeated crush trauma to the skin that occurs with use of forceps (Figure
27.4E). Maintaining a viable recipient bed is essential to supplying a full thickness skin graft and every attempt should be made to keep the orbicularis
intact. Often, cicatricial bands will be encountered during the dissection and these should be removed until a fresh orbicularis bed remains (Figure
27.4F). The release of the cicatrix should continue until the eyelid returns to its native position. The eyelid should now be elevated and any final
cicatricial bands are identified and released.

SECTION TWO • EYELID AND FACE

Chapter 27 Ectropion repair with full thickness skin grafting
188
 A B

C D

E F

Figures 27.5A–F Harvest of full thickness skin graft

With the lower eyelid tightened and the inferior cicatrix lysed, the eyelid should elevate to its natural position. The height and width of the recipient site is
then measured for harvesting (Figure 27.5A). Several donor sites are available, as discussed in Chapter 1. The ideal donor site is the upper eyelid owing
to its texture, thickness, and color compatibility, but often, sufficient upper eyelid skin is not available, particularly in patients with cicatricial ectropion
from actinic damage. Other donor sites include the preauricular, retroauricular, supraclavicular and inner aspect of the upper arm. In this case, the upper
arm is used and a non-hair-bearing region is marked and slightly oversized by 10–15% (Figure 27.5B). An ellipse of skin should be marked with a ratio
of length to width from 3 : 1 to 4 : 1 (Figure 27.5C). An ellipse of this ratio allows for primary closure with minimal redundancy (dog ears) at the apices.
The graft is then incised with a #15 blade and then sharp dissection with scissors is used to remove the graft (Figure 27.5D). Cautery should not be
used to remove the graft as this may cause thermal damage to the skin. Once the graft has been removed, the tissue is wrapped in saline-moistened
gauze and set aside for thinning. Subcutaneous undermining of the donor site is then performed and multiple interrupted 4-0 Vicryl or Monocryl sutures
are used to reapproximate the subcutaneous tissue (Figure 27.5E). Once a sufficient number of subcutaneous sutures have been placed, the skin edges
should easily unite under minimal tension. A running subcuticular closure is performed with 5-0 Vicryl or Monocryl (Figure 27.5F). Benzoin adhesive is
applied to the skin and then sterile adhesive strips are applied transverse to the incision for added strength.

189
 A B

Figures 27.6A–C Preparation of full thickness skin graft

After closure of the donor site, the full thickness skin graft is thinned. The epidermal side is placed face down over the index finger, exposing the dermal
face of the graft (Figure 27.6A). Westcott scissors are then used to meticulously remove all subcutaneous tissue while taking care to avoid creating
buttonholes in the graft (Figure 27.6B). The end point of the thinning is the shiny appearance of the dermal surface (Figure 27.6C). Several nodules that
are evenly distributed over the surface will be noted after thinning, which represent the rete pegs. Skin grafts from the preauricular, retroauricular, and
supraclavicular areas tend to be thicker than the upper arm and eyelid and can be thinned further to match the thickness of native eyelid skin.

SECTION TWO • EYELID AND FACE

Chapter 27 Ectropion repair with full thickness skin grafting
190
 A B

C D

Figures 27.7A–D Placement of graft to recipient bed

The recipient bed is examined and meticulous hemostasis is achieved with bipolar cautery. Excessive cauterization should be minimized as charring of
the orbicularis bed may impair neovascularization of the graft. The donor skin is then draped over the recipient bed (Figure 27.7A). Some redundancy
should be present as the graft is slightly oversized. The graft is secured in placed with several interrupted 6-0 fast-absorbing gut sutures on the inferior
edge of the graft (Figure 27.7B). The nasal apex of the graft is secured first and then sequentially towards the lateral apex. The interrupted sutures are
placed 3–4 mm apart. At the lateral apex, the redundant tissue is excised and then the upper border of the graft is closed with a running 6-0 fast-
absorbing gut suture, starting temporal to the nasal area (Figure 27.7C). Prior to final closure, a cotton-tipped applicator should be used to milk out any
residual blood so that there is minimal interference with nutrient exchange at the orbicularis and skin graft interface (Figure 27.7D).

191
 A B

C D

E F

Figures 27.8A–F Placement of Frost suture and pressure patch

Immobilization of the graft against the recipient bed is essential for the first 3–5 days. The sterile foam insert from a suture needle box can be used as a
bolster (Figure 27.8A). The foam is cut to size to match the graft size but if this not available, a sterile non-adherent bandage (Telfa pad) or cotton balls
soaked in a petroleum-based antibiotic ointment can be used as a bolster. Double-armed 5-0 Prolene sutures on a tapered C-1 needle are then passed
though the medial portion of the foam and then passed through the center of the graft to exit through the gray line of the lower eyelid (Figure 27.8B).
The tapered needle minimizes bleeding, which can accumulate under the graft. The needle is then passed through the gray line of the upper eyelid and
finally passed above the level of the eyebrow (Figure 27.8C). A second double-armed Prolene suture is passed through the lateral portion of the foam. At
the brow, a small rectangular foam bolster is placed over the sutures to prevent cheese-wiring through the skin (Figure 27.8D). Antibiotic and steroid
ophthalmic ointment is applied under the bolsters and benzoin adhesive is applied to the skin above the brow and on the cheek (Figure 27.8E). Two
eye pads are then applied for firm pressure patching and removed at 5–7 days after surgery (Figure 27.8F). Oral antibiotics are given during the
postoperative period. Patients are instructed to avoid ice/cold compresses as well as strict avoidance of smoking, as these will inhibit vascularization of
the graft. When removing the patch, care is taken to avoid peeling off the skin graft in cases where the tissue has adhered to the patch.

SECTION TWO • EYELID AND FACE

Chapter 27 Ectropion repair with full thickness skin grafting
192
 CICATRICIAL ECTROPION REPAIR WITH FULL THICKNESS
SKIN GRAFT AND LATERAL TARSAL STRIP

Preoperative Postoperative

Figure 27.9 Before and after cicatricial ectropion repair with full thickness skin graft
This 79-year-old male presented with tearing, mucoid discharge, and erythema of the right lower eyelid. Past history was significant for Mohs micro-
graphic excision of a squamous cell carcinoma followed by primary reconstruction of the right infraorbital region. The patient underwent release of the
lower eyelid cicatrix through an infraciliary incision, followed by lateral tarsal strip and placement of a full thickness skin graft from the contralateral
upper eyelid. Postoperatively, he has resolution of the ectropion and improved tear drainage with return of the inferior punctum to its native position.

Table 27.3 Complications Table 27.4 Consumables used during surgery

Complications
Necrosis of skin graft
Recurrent ectropion
Consecutive entropion
Suggestions to reduce risk 5-0 Prolene suture, C-1 needle Ethicon #8725H
Immobilize with Frost suture; avoid use 6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
of ice postoperatively; consider oral
4-0 Vicryl, P-3 needle Ethicon #J494H
antibiotic prophylaxis; cessation of
anticoagulants; no smoking; meticulous 5-0 Vicryl, P-3 needle Ethicon #J493H
hemostasis during surgery; avoid 6-0 silk, G-7 needle Ethicon #765G
vigorous activity and exertion after
surgery
Increase size of skin graft; tighten
eyelid more if necessary; leave Frost
suture in longer
Trim skin graft if excessive; assess for
lower eyelid retractor disinsertion and
correct; consider Wies procedure if
significant (Chapter 30)

193
CHAPTER 28
Canthus sparing drill
hole canthoplasty
Bobby S. Korn • Don O. Kikkawa
Table 28.1 Indications for surgery
Lateral canthal rounding/loss of almond-shaped eye
Lateral canthal dystopia
Shortened horizontal palpebral aperture, dynamic phimosis
Lateral canthal surgery in conjunction with lower eyelid retraction
repair
Lateral canthal disinsertion
INTRODUCTION
Lower eyelid retraction, lateral canthal rounding, and inferior
canthal dystopia are stigmata of unfavorable aesthetic eyelid
surgery. Multiple factors contribute to these sequelae including
exuberant resection of anterior lamellae, middle lamellar scar-
ring, failure to treat lower eyelid laxity, and surgical misalign-
ment of the canthus. Patients may present with symptomatic
complaints of foreign body sensation, epiphora, and dry eyes.
With complete disinsertion of the lateral canthal ligament from
its bony attachment, dynamic phimosis may occur as the
lateral canthal angle approaches the corneoscleral limbus with
each blink. Combined lateral canthal dystopia and lower eyelid
retraction following cosmetic blepharoplasty presents a special
challenge to the oculofacial surgeon.
SECTION TWO • EYELID AND FACE
Chapter 28 Canthus sparing drill hole canthoplasty
194
Table 28.2 Preoperative evaluation
History of prior surgery
Shape and location of lateral canthus
Horizontal and vertical palpebral aperture size
Presence of associated eyelid malposition, i.e. lower eyelid
retraction, ectropion, lagophthalmos
Sufficiency of anterior lamella
Middle lamellar scarring
Symptomatic dry eye, foreign body sensation, epiphora
Many techniques have been described to correct canthal
disinsertion and rounding in an effort to restore the almond-
shaped eye. For mild cases, a canthopexy alone may be suf-
ficient. In severe cases, however, suture fixation alone may be
inadequate due to strong cicatricial contractile forces. Rigid
fixation through the use of a bone tunnel provides the strongest
attachment and more accurately replicates the native attach-
ment of the lateral canthal tendon to Whitnall’s tubercle.
For drill hole fixation of the canthus, several options exist. The
surgeon may make use of either one or two bone tunnels,
depending on the desired effect. A single drill hole can be used
to pass a single armed suture (Figure 28.1A). This attachment,
while firm, may bring the canthal complex slightly anteriorly. A
second option for use of a single drill hole is to use the bone
tunnel as a fulcrum and fixation point to bring the canthus
posteriorly in combination with midfacial elevation and orbito-
malar suspension anteriorly (Figure 28.1B). This technique has
the advantage of simultaneously fixating the canthus and
recruiting anterior lamella with a single fixation point, joining the
two sutures just external to the bone tunnel. Finally, if two bone
tunnels are made, a double-armed suture is used, bringing the
canthus posteriorly and passing each of the sutures through a
separate tunnel and joining the two ends externally along the
lateral orbital rim (Figure 28.1C). This technique is useful if
posterior canthal fixation is solely desired. In cases of middle
lamellar scarring and eyelid retraction, the drill hole cantho-
plasty can be combined with posterior lamella spacer grafts
to also correct lid retraction (Chapters 34, 35 and 36). Skin
grafts can also be used in cases of severe anterior lamellar
deficiency, but in our experience, this is rarely necessary and
while functional, does not lend well to aesthetic improvement
(Chapter 27).
A sharp lateral canthal angle provides an aesthetically pleas-
ing appearance to the eyelid shape. Anatomical reattachment
of the eyelid via lateral canthal fixation to a bone tunnel can
also precisely control the vertical position of the canthus and
preserve eyelid function. In our experience, fixation of the lateral
canthus through a bone tunnel provides the strongest and
longest lasting attachment.

SURGICAL TECHNIQUE

A B C

Figures 28.1A–C Different methods of lateral canthal tendon fixation

A single drill hole lateral canthoplasty can be used to anchor the lateral canthal tendon (Figure 28.1A). This method provides a firm basis for lateral
canthal fixation but does not provide deep posterior migration of the canthal complex. Figure 28.1B shows a single drill hole canthoplasty combined with
elevation of the suborbicularis oculi fat (SOOF). This method provides rigid lateral canthal support as well as midfacial recruitment to support a retracted
lower eyelid. Double drill hole canthoplasty provides robust fixation of the lateral canthal complex and strong posterior displacement of the entire canthus
(Figure 28.1C).

195
 A B

Figures 28.2A and 28.2B Lateral canthus sparing incision

Drill hole canthoplasty is typically performed under monitored anesthesia care. A horizontal marking 2 mm lateral to the canthal angle is marked for a
distance of 6 mm (Figure 28.2A). Local anesthetic consisting of 1% lidocaine, 0.25% bupivacaine, and 1 : 200,000 epinephrine is infiltrated under the
skin marking and deeply along the lateral orbital rim and the surrounding periosteum. A #15 blade is used to make an incision through the skin and
subcutaneous tissues (Figure 28.2B). If severe canthal rounding and scarring is present, the lateral canthus may be divided and any laxity is addressed
by eyelid shortening. A new canthal angle is then formed by uniting the upper and lower eyelid with 4-0 Vicryl suture.

A B

Figures 28.3A–C Exposure of lateral orbital rim

After skin incision, cutting cautery is used to score the bone along the lateral orbital rim to split the periosteum (Figure 28.3A). If there is discomfort
during this part of the dissection, additional local anesthetic is given under the periosteum. A Freer elevator is then used to vertically dissect a 6-mm
window outside the lateral orbital rim (Figure 28.3B). Once the outer rim has been dissected free of periosteum, attention is directed to the inner aspect
of the lateral orbital rim. A thin malleable retractor is used to gently reflect the canthus and globe medially while the Freer elevator reflects the perios-
teum internally (Figure 28.3C). The periosteum should be reflected 4 mm internally and externally from the anterior aspect of the lateral orbital rim to
facilitate later drill hole placement.

SECTION TWO • EYELID AND FACE

Chapter 28 Canthus sparing drill hole canthoplasty
196
 A B

Figures 28.4A and 28.4B Internal lateral cantholysis

Residual attachments of the lateral canthal tendon usually remain despite reflection of the periosteum from the lateral orbital rim. Using Westcott
scissors, the closed tips are used to strum and identify canthal remnants and these are sequentially released (Figure 28.4A). Care should be taken to
preserve the conjunctiva at the lateral canthus and avoid creating a buttonhole in this tissue during the internal cantholysis. Once the lateral canthus has
been fully released, forceps can be used to freely distract the canthal angle (Figure 28.4B). Any bleeders are controlled with bipolar cautery but
aggressive cauterization should be avoided as this may affect regional lymphatic drainage.

A B

C D

Figures 28.5A–D Release of orbitomalar ligament

Canthoplasty alone is typically insufficient to treat post-blepharoplasty canthal dystopia as lower eyelid retraction with middle lamellar scarring is often
present. Release of the orbitomalar ligament, the primary midfacial suspensory ligament of the suborbicularis oculi fat (SOOF) with superior suspension
provides excellent midfacial support for the retracted lower eyelid in conjunction with lateral canthoplasty. The orbitomalar ligament contains stout
inferolateral attachments to the orbital rim and these are carefully released with a combination of sharp dissection with scissors and cutting cautery
(Figure 28.5A). Care is taken to avoid trauma to the zygomaticofacial artery and nerve which exit 4–5 mm below the inferior orbital rim. If this vessel is
lacerated, gentle bipolar cautery is applied. Through this small skin incision, a Freer elevator is used to continue the release of the orbitomalar ligament
in a subperiosteal fashion (Figure 28.5B). Adson forceps are used to secure and elevate the SOOF (Figure 28.5C). If any residual attachments are
identified, these are released until the midface is freely mobile (Figure 28.5D).

197
 A B

C D

Figures 28.6A–D Creation of drill hole at lateral orbital rim

Once the canthal tendon and orbitomalar ligament have been released, 0.5 forceps are used to elevate the lateral canthus to the desired height (Figure
28.6A). A marking pen is then used to ink the lateral orbital rim 2 mm higher than the proposed height to account for postoperative descent. The depth
of the marking on the lateral orbital rim should be approximately 3 mm from the anterior aspect of the lateral orbital rim, so that a robust rim of bone
remains to support the fixation sutures (Figure 28.6B). Fine, two-prong skin hooks are then used for vertical traction while a thin malleable retractor is
placed inside of the orbit to protect the globe (Figure 28.6C). A 1.3-mm drill bit is then used to create the hole at the desired mark (Figure 28.6D). The
hole should be drilled in a plane parallel to the floor of the orbit with the patient faced squarely. If the drill hole enters the orbit too deeply, fixation suture
placement will be more difficult. In this case, the sutures are tied off external to the orbital rim; however, if posterior distraction of the lateral canthus is
desired, an additional drill hole can be started outside of the rim for deeper retroplacement of the canthus (see Figures 28.1C).

SECTION TWO • EYELID AND FACE

Chapter 28 Canthus sparing drill hole canthoplasty
198
 A B

C D

Figures 28.7A–D Placement of orbitomalar suspension suture

Orbitomalar and lateral canthal suspension is performed using a permanent polyester fiber suture (Mersilene). This suture comes on a 8-mm S-2
half-circle needle, which is well suited to pass through the small and tight confines of the lateral orbit and can be retrieved through the drill hole at the
orbital rim (Figure 28.7A). As the suture is a permanent foreign body, meticulous sterile technique must be employed as any microbial seeding can lead
to suture abscess and need for subsequent removal. Toothed Adson forceps are used to identify a suitable fixation point through the SOOF that will not
lead to tissue bunching or dimpling with elevation of the suture (Figure 28.7B). Once the proper site has been located, the 4-0 Mersilene suture is
passed through the SOOF (Figure 28.7C). With superior traction on the suture, excellent mobilization of the anterior lamellae of the midface can be noted
(Figure 28.7D). The suture is then tagged with a bulldog clamp and left untied.

199
 A B

C D

Figures 28.8A–D Passage of suture through drill hole

Long-lasting lateral canthal anchoring is achieved using a permanent suture placed through the lateral orbital rim drill hole. The lateral canthal tendon is
secured with 4-0 Mersilene with two deep passes (Figure 28.8A). Once the tendon has been engaged, the S-2 needle is passed from the inner aspect
of the lateral orbital rim drill hole while a malleable retractor is placed to protect the globe (Figure 28.8B). The semi-circular S-2 needle is perfectly sized
to pass through the lateral orbital rim without bending of the needle or use of a guidewire. Once the lateral canthal suture has been passed, attention is
directed towards passage of the orbitomalar suspension suture. The previously placed 4-0 Mersilene suture is then passed through the same drill hole
from outside of the rim and retrieved from the inside of the rim (Figure 28.8C). When passing the needle through the drill hole, care is taken to avoid
cutting the lateral canthal Mersilene suture that was previously placed (Figure 28.8D). The needle can also be passed in a reverse configuration so that
the sharp point has a lower chance of cutting the first suture.

SECTION TWO • EYELID AND FACE

Chapter 28 Canthus sparing drill hole canthoplasty
200
 A B

C D

Figures 28.9A–D Fixation of suspension sutures

The orbitomalar suspension suture is tied off first. After the first throw is passed, a locking needle holder is used to hold the knot to prevent loosening as
the Mersilene suture tends to slip if not held under tension (Figure 28.9A). At least four square knots are then placed with even tension for maximal
strength (Figure 28.9B). Once the orbitomalar suspension suture has been tied off, the lateral canthal anchoring suture is tied off in a similar fashion
(Figures 28.9C and 28.9D). Care should be taken to ensure that the appropriate amount of tension has been placed with each suture. If the tension is
insufficient, the Mersilene must be cut and replaced completely.

201
 A B

Figures 28.10A–C Skin closure

The subcutaneous tissues are then closed with interrupted 7-0 Vicryl sutures (Figure 28.10A). Skin closure is achieved with interrupted 6-0 fast-
absorbing gut sutures (Figure 28.10B). At the conclusion of the case, there should be a sharp canthal angle with firm elevation of the midface (Figure
28.10C).

SECTION TWO • EYELID AND FACE

Chapter 28 Canthus sparing drill hole canthoplasty
202
 BILATERAL CANTHUS SPARING DRILL HOLE CANTHOPLASTY

Preoperative Postoperative

Figures 28.11A–C Before and after bilateral canthus sparing drill hole canthoplasty
This 68-year-old female underwent upper and lower blepharoplasty 20 years prior to presentation. She noted rounding of her lateral canthi as well as
narrowing of the horizontal palpebral fissures after her initial surgery. She underwent bilateral canthus sparing drill hole canthoplasty with orbitomalar
suspension and notes widening of her horizontal palpebral fissures (Figure 28.11A) as well as restoration of her eyes from a round to almond-shaped
configuration with sharp lateral canthal angles (Figures 28.11B and 28.11C).

203
Table 28.3 Complications
Complications Suggestions to reduce risk
Recurrent lateral Possible inadequate fixation, possible cheese-wiring of canthal fixation suture, possible suture slipping with second
canthal rounding throw; pass “whipstitch” with second tissue bite for better tissue fixation, lock suture prior to passing second throw
Recurrent lower eyelid Perform midface lift with SOOF elevation and fixation; consider posterior lamellar grafting
retraction

Table 28.4 Consumables used during surgery

4-0 Mersilene, S-2 needle Ethicon #1779G
4-0 Vicryl, P-3 needle Ethicon #J494G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG140-8 needle Ethicon #J546G

SECTION TWO • EYELID AND FACE

Chapter 28 Canthus sparing drill hole canthoplasty
204
 CHAPTER 29
transconjunctival approach
Table 29.1 Indications for surgery
Lower eyelid entropion
Inversion of the eyelid margin
Punctate epithelial erosions of the cornea
Epiphora and foreign body sensation secondary to ectropion
INTRODUCTION
Inward rotation of the eyelid margin or entropion causes symp-
toms as the lashes and keratinized epidermis rub on the ocular
surface. Symptoms include tearing, foreign body sensation,
ocular irritation, and redness. Normally, the Meibomian gland
orifices are visible as the most posterior aspect of the eyelid
margin, just anterior to the ocular surface. The first noticeable
sign is when this landmark begins to rotate posteriorly and
become masked. With foreign body sensation, orbicularis
spasm may occur, worsening the entropion.
Classic causes of involutional entropion are: lower eyelid
laxity, attenuation disinsertion of the lower eyelid retractors, and
overriding of the preseptal orbicularis. Enophthalmos can be
an additional risk factor, although this condition can be seen in
patients with normal globe position and even exophthalmic
globes.
Clinical examination of the entropic eyelid should focus on
several findings. Eyelid laxity should be assessed with the eyelid
distraction test (Figure 9.3, Chapter 9). Cicatricial changes in
Entropion repair by
Bobby S. Korn • Don O. Kikkawa
Table 29.2 Preoperative evaluation
Lower eyelid snap back test
Lower eyelid distraction test
Manual eversion of eyelid
Assess orbicularis tone – is there a spastic component?
Assess for posterior lamellar shortage or symblepharon
Prior eyelid, facial surgery or trauma
the posterior lamellar can cause contraction and symblepha-
ron, and may be the primary cause of eyelid eversion. If cica-
tricial entropion is present, posterior lamellar grafting or
rotational sutures may be necessary (Chapters 30 and 31).
Occult cutaneous malignancy such a squamous cell carcinoma
of the conjunctiva should also be ruled out. Manual eversion of
the entropic eyelid should be possible and taping of the eyelid
should allow temporary relief. Orbicularis override can be visible
as an elevated horizontal ridge of preseptal orbicularis. Severe
spasm also may be amenable to neurotoxin injection as a
temporizing measure.
Over 100 operations have been described to correct entro-
pion. In our experience the best surgical correction of involu-
tional entropion addresses each individual component causing
the condition. The transconjunctival route is our preferred
approach. First, a small strip of overriding preseptal orbicularis
muscle is excised. Second, the lower eyelid retractors must be
reinserted. Finally, horizontal shortening of the lax eyelid is
performed.
205
SURGICAL TECHNIQUE

Figure 29.1 Lateral canthotomy and cantholysis
The transconjunctival approach is well suited for lower eyelid involutional
entropion. The transcutaneous approach may also be considered, but this
involves a potentially visible incision postoperatively. The procedure begins
with a lateral canthotomy and inferior cantholysis to provide access to the
lower eyelid.
Figure 29.2 Transconjunctival incision
The lower eyelid is everted and cutting cautery is used to create a
transconjunctival incision 1–2 mm below the inferior tarsal border. The
cautery is moved efficiently over the conjunctiva to minimize tissue
contraction. Alternatively, scissors can be used to perform this incision;
however, significant hemorrhage often results from the vascularized
palpebral conjunctiva.

A B

Figures 29.3A and 29.3B Identification of lower eyelid retractors

Next, blunt dissection is performed inferiorly until the white band of the lower eyelid retractors are identified (Figures 29.3A and 29.3B). The retractors
can be identified while providing superior traction on the posterior edge of the conjunctiva while cutting cautery is used to dissect inferiorly. Alternatively,
blunt dissection with a cotton-tipped applicator can be used to identify the retractor band. As with retractor disinsertion seen in ectropion, the lower
eyelid retractor band may be attenuated and inferiorly retracted. To confirm identification of the lower eyelid retractors, the patient is asked to look up
and down with traction on the retractor band to confirm movement.

SECTION TWO • EYELID AND FACE

Chapter 29 Entropion repair by transconjunctival approach
206
 A B

C D

Figures 29.4A–D Myectomy of overriding preseptal orbicularis

Preseptal orbicularis muscle override is the first mechanism that is addressed in the transconjunctival approach. Figure 29.4A shows the posterior view
of the overriding preseptal orbicularis muscle. Prior to the surgery, local anesthetic can be given in a subcutaneous fashion to hydrodissect the orbicula-
ris from the skin and to facilitate hemostasis. Westcott scissors are used to excise a 4-mm tall strip of preseptal orbicularis (Figure 29.4B). Special care
is taken to excise only the orbicularis, as inadvertent full thickness buttonholing is possible during the myectomy. If there is any doubt about the depth of
the excision, the skin is everted and inspected for any full thickness holes in the skin. After the myectomy, the thin preseptal skin can be appreciated
(Figures 29.4C and 29.4D).

A B

Figures 29.5A and 29.5B Creation of pretarsal pocket

Blunt dissection is then performed between the pretarsal orbicularis and the inferior tarsal border (Figures 29.5A and 29.5B). This creates a pocket for
the subsequent reinsertion of the lower eyelid retractors. Blunt-tipped Westcott scissors are used to carefully dissect towards the eyelash bulbs. Care
should be taken to avoid perforation through the skin. Creation of a 1–2 mm pretarsal pocket is usually more than enough to provide a platform for
successful reinsertion of the lower eyelid retractors.

207
 A B

Figures 29.6A–C Reinsertion of lower eyelid retractors

Reinsertion of the lower eyelid retractors is the most critical part of the lower eyelid entropion repair and in some cases of involutional entropion,
disinsertion is the primary pathologic feature noted. The lower eyelid retractors are secured with double-armed 6-0 Vicryl in a horizontal mattress fashion
(Figures 29.6A and 29.6B). Then, one arm of the suture is used to purchase the anterior and inferior edge of the tarsal plate (Figure 29.6C). This
configuration allows for outward rotation of the entropic eyelid. Proper suture placement is key. If the suture is passed too posteriorly, the eyelid margin
will be inadequately rotated. If the suture is passed too anteriorly, then frank ectropion may result. Three of these interrupted sutures are used for
retractor reinsertion. The knots are cut close to prevent corneal irritation.

SECTION TWO • EYELID AND FACE

Chapter 29 Entropion repair by transconjunctival approach
208
 A B

Figures 29.7A–C Tightening of lower eyelid

The final step in this procedure is lower eyelid tightening. If significant lower eyelid laxity is present, a tarsal strip procedure can be performed (Chapter
25). In this case, mild lower eyelid laxity was present and the lower eyelid is tightened by removal of a small full thickness wedge of the lateral eyelid
(Figure 29.7A). The canthus is then reconstructed by securing two interrupted 6-0 Vicryl sutures anchoring the lateral tarsus to the superior crus of the
lateral canthal tendon (Figures 29.7B and 29.7C). The skin overlying the canthus is closed with interrupted 6-0 fast-absorbing gut sutures.

Table 29.3 Complications

Complications Suggestions to reduce risk
Consecutive entropion Reinsertion of retractors; re-evaluation to rule out cicatricial component. Inadequate horizontal shortening
Consecutive ectropion Retractors advanced too high on anterior surface of tarsus; place sutures lower on tarsus with less
advancement; inadequate horizontal shortening
Eyelid retraction Avoid over-resection of orbicularis muscle
Hemorrhage Proper hemostasis; cessation of anticoagulant usage prior to surgery
Suture granuloma Consider use of non-absorbable sutures, recognize granulomas early, remove suture if symptomatic and treat
with antibiotic/steroid ointment
Wound dehiscence Make sure knots tied with appropriate tension with adequate soft tissue incorporation; avoid smoking, lifting, and
bending; use of eye shield; avoid manipulation of wound

Table 29.4 Consumables used during surgery

6-0 Vicryl, P-3 needle Ethicon #J492H
6-0 Vicryl, double-armed S-29 needle Ethicon #J555G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G

209
CHAPTER 30
Entropion repair by
Wies procedure
Don O. Kikkawa • Bobby S. Korn
Table 30.1 Indications for surgery
Upper or lower eyelid entropion – involutional or cicatricial
Inversion of the eyelid margin
Punctate epithelial erosions of the cornea
Epiphora and foreign body sensation secondary to ectropion
INTRODUCTION
Transverse blepharotomy with margin rotation was first
described by Wies in 1955. This is a powerful method to evert
the eyelid margin and can be performed for either involutional
or cicatricial causes of entropion.
The goal of the Wies procedure is to create a full thickness
eyelid incision, from skin to conjunctiva, which heals as a barrier
for migration of the preseptal orbicularis over the pretarsal
orbicularis. Everting sutures are placed in conjunction with the
full thickness blepharotomy to rotate the eyelid margin. The
incision for blepharotomy is typically made 4 mm in distance
from the eyelid margin in the lower eyelid and 2–3 mm in the
upper eyelid. This incision should be made below the marginal
arcade to ensure vascular integrity.
SECTION TWO • EYELID AND FACE
Chapter 30 Entropion repair by Wies procedure
210
Table 30.2 Preoperative evaluation
Assess for posterior lamellar shortage or symblepharon
Assess for eyelid laxity
Ability to manually evert eyelid
Prior eyelid, facial surgery or trauma
Any history of infections, chemotherapy, topical medication use,
oral ulceration
Clinical examination should focus on the underlying cause of
the entropion. While the Wies procedure can be performed for
either involutional or cicatricial causes, it works best for cicatri-
cial entropion. Forniceal depth must be adequate to allow the
transverse blepharotomy incision to be made, as the procedure
will cause some forniceal shortening. If the eyelid has horizontal
laxity, this must also be addressed through either tightening at
the lateral canthus or wedge excision centrally combined with
the transverse blepharotomy in the “four snip” procedure.
Complications include overcorrection, recurrence of the
entropion, and possible necrosis of the eyelid margin segment.
If overcorrection occurs with the development of consecutive
ectropion, the everting sutures may be released in the early
postoperative period. Recurrence of entropion is rare, as well
as necrosis of the eyelid margin segment, owing to the robust
vascular supply to the eyelids and face.
SURGICAL TECHNIQUE

A B

Figures 30.1A and 30.1B Marking of inferior tarsal border

The Wies procedure provides a powerful rotation of the eyelid by utilizing a full thickness blepharotomy followed by retractor reinsertion. The lower eyelid
is everted and a caliper is used to measure the vertical height, which is on average 4 mm. A caliper is then used to mark the skin at this height (Figure
30.1A). The horizontal length of the inferior tarsal marking corresponds to the extent of the entropion (Figure 30.1B).

Figure 30.2 Incision of skin

A #15 Bard-Parker blade is used to make a skin incision through the skin
only. Note that a corneal protector is present throughout the case. The
skin incision is made perpendicular to the skin and parallel to the eyelid
margin. Alternatively, a large chalazion clamp can be placed over the
lower eyelid. The clamp has the added benefit of hemostasis and corneal
protection.

211
 A B

C D

Figures 30.3A–D Full thickness blepharotomy

Westcott scissors are then used to dissect through the orbicularis muscle (Figure 30.3A). The sharp dissection should continue until the inferior edge of
the tarsal plate is identified (Figure 30.3B). Care is taken to avoid any trauma to the tarsal plate. Then, a small full thickness buttonhole incision is made
at the junction of the inferior tarsal border and the conjunctiva and lower eyelid retractors (Figure 30.3C). This incision is then extended medially and
laterally to correspond to the skin incision (Figure 30.3D).

SECTION TWO • EYELID AND FACE

Chapter 30 Entropion repair by Wies procedure
212
 A B

C D

Figures 30.4A–D Placement of margin rotational sutures

Rotational sutures are anchored from the lower eyelid retractors to externalize below the eyelashes. These sutures are analogous to the Quickert-style
rotational sutures except this is done in conjunction with a full thickness blepharotomy. A 6-0 Vicryl double-armed suture is used to purchase the lower
eyelid retractors (Figure 30.4A). The needles are then exited in a pretarsal plane below the eyelashes (Figure 30.4B). The second arm of the needle is
similarly passed, completing the horizontal mattress suture (Figure 30.4C). Two to three of these horizontal mattress rotating sutures are placed along
the eyelid as needed (Figure 30.4D).

A B

Figures 30.5A and 30.5B Closure of skin

With the rotational sutures in place, the eyelid margin should be noted to rotated outwards (Figure 30.5A). If insufficient rotation has been achieved, the
sutures are replaced and the needles are exited closer to the eyelashes. The skin is then closed with a running 6-0 fast-absorbing gut suture (Figure
30.5B).

213
Table 30.3 Complications
Complications
Consecutive entropion
Consecutive ectropion
Eyelid retraction
Eyelid margin necrosis
Suggestions to reduce risk
Proper placement of everting sutures; exit sutures closer to eyelashes
Suture tied too tight and with cutaneous exiting suture too close to eyelash line; address horizontal eyelid laxity
May occur if fornix is too short; grafting of posterior lamella to lengthen fornix
Proper hemostasis; cessation of anticoagulant usage prior to surgery; avoid incision too close to eyelid margin

Table 30.4 Consumables used during surgery

6-0 Vicryl, double-armed S-29 needle Ethicon #J555G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G

SECTION TWO • EYELID AND FACE

Chapter 30 Entropion repair by Wies procedure
214
 CHAPTER 31
Table 31.1 Indications for surgery
Cicatricial entropion with lashes abrading cornea
Posterior lamellar scarring with transverse cicatricial bands
Corneal erosions and foreign body sensation secondary to
entropion
INTRODUCTION
Cicatricial entropion caused by posterior lamellar contraction
has many causes. Infectious, inflammatory, medication-
induced, and autoimmune are the most common etiologies.
Prior to definitive surgical repair, systemic medical control of the
underlying disease is paramount. Foreign body sensation, irrita-
tion, and redness occur as the posterior aspect of the eyelid
margin rotates inward. Corneal involvement with epithelial
defects arises as the lashes begin to abrade the ocular surface.
For mild cicatricial entropion, anterior lamellar repositioning
will typically suffice. For moderate to severe cicatricial entro-
pion, the posterior tarsotomy is particularly effective and simply
means to rotate the eyelid margin and reduce the cicatricial
forces causing inversion. For severe cicatricial entropion,
Entropion repair by
posterior tarsotomy
Karim G. Punja • Bobby S. Korn •
Don O. Kikkawa
Table 31.2 Preoperative evaluation
Assess posterior lamella with eyelid eversion; look for transverse
horizontal bands
Assess eyelid laxity
Quantify horizontal length of eyelid involvement
Prior eyelid, facial surgery or trauma
Any history of infections, chemotherapy, topical medication use,
oral ulceration
placement of a posterior lamellar graft such as autologous hard
palate may be required.
The posterior tarsotomy differs from the Wies procedure
(Chapter 30) in that only the tarsus is incised. A full thickness
tarsal incision is made 1.5 mm from the eyelid margin within
the horizontal transverse bands of the tarsus on the upper
eyelid. On the lower eyelid, the incision is made 1 mm from the
eyelid margin. Blunt and sharp dissection then allows the eyelid
to rotate with placement of everting sutures. The tarsotomy can
be tailored to the degree of horizontal involvement and it can
be performed segmentally if desired. Slight overcorrection is
desired, as a mild degree of inversion will gradually occur
postoperatively.
215
SURGICAL TECHNIQUE

A B

Figures 31.1A and 31.1B Placement of traction suture

Adequate exposure of the posterior tarsal surface is critical for success of the tarsotomy procedure. Difficulty in this exposure is also amplified by
the cicatricial changes in the tarsal plate. A 6-0 silk suture with a G-7 needle is placed at the gray line at three equidistant points to facilitate traction
(Figure 31.1A). The suture bites should be placed sufficiently deep within the eyelid to prevent cheese-wiring during the eyelid eversion. Then, using a
large chalazion clamp, the instrument is pivoted on the upper eyelid crease and the long ends of the silk suture are wrapped about the clamp’s
tension screw (Figure 31.1B). The tension screw should be tightened before wrapping the sutures around the threads, otherwise the silk will be cut as
the tension screw is tightened. With gentle eversion of the clamp, the inferior and posterior edge of the tarsal plate should be readily exposed.

A B

Figures 31.2A–C Posterior tarsal marking

With the posterior tarsal surface exposed, a caliper is used to mark 1.5 mm from the eyelid margin (Figure 31.2A). The horizontal extent of the tarsal
marking correlates with the degree of entropion and is made parallel with the eyelid margin (Figure 31.2B). When marking the tarsus, care is taken to
precisely measure the 1.5 mm distance from the upper eyelid margin. When performing tarsotomy on the lower eyelid, the marking is made 1 mm from
the eyelid margin owing to the smaller height of the lower tarsal plate. The marginal arterial arcade lies on the anterior face of the tarsal plate and is
variably located 2–4 mm from the upper eyelid margin (Figure 31.2C). Incisions through the marginal arcade may result in distal eyelid necrosis and thus
the markings should be as accurate as possible. The accuracy of this marking is further complicated by the nature of cicatricial entropion where the
tarsal plate is often thickened and scarred.

SECTION TWO • EYELID AND FACE

Chapter 31 Entropion repair by posterior tarsotomy
216
 A B

Figures 31.3A–C Posterior tarsotomy

A #15 blade is used to make a full thickness horizontal incision along the marking perpendicular to the plane of the tarsal plate (Figure 31.3A). It is not
unusual for the tarsal plate to be thicker in these patients with cicatricial entropion. The tarsus should be incised in the same initial plane and lamellar
cuts should be avoided. Once the tarsus has been incised in a full thickness manner, the pretarsal orbicularis should be visible (Figure 31.3B). Then, the
#15 blade or blunt tip Westcott scissors are used to extend the full thickness tarsotomy medially and laterally (Figure 31.3C). Bleeding should be minimal
if the marginal arcade has been spared. Occasionally, distal perforating branches may bleed and these are delicately controlled with bipolar forceps.

A B

Figures 31.4A and 31.4B Pretarsal dissection

Once the tarsal plate has been fractured, a pocket is created between the pretarsal orbicularis and the tarsal plate. Blunt dissection is performed towards
the lashes in this plane (Figure 31.4A). Dissection is continued along the entire incision, taking care to avoid creating a buttonhole through the skin
(Figure 31.4B). The lash bulbs are often seen during this dissection and they should not be transected. Creation of a deep and open pretarsal pocket is
critical for successful rotation of the distal eyelid margin.

217
 Eyelid
rotation
A B

C D

Figures 31.5A–D Placement of rotational sutures

Figure 31.5A illustrates the effect of the rotational sutures during posterior tarsotomy. Rotational sutures are placed in the superior, cut edge of the tarsal
plate and then these are externalized through the pretarsal pocket to exit above the lashes. In this manner, the distal eyelid margin can theoretically
rotate 90° superiorly. The closer the sutures are externalized to the lashes, the more the rotational effect. Double-armed 6-0 Vicryl sutures are first
placed in a partial thickness fashion through the cut edge of the remaining superior tarsus (Figure 31.5B). The sutures are carefully placed in this
lamellar fashion to spare the cornea from abrasion. Next, the remaining two needles are passed through the tarsal pocket to exit above the lashes
(Figure 31.5C). The horizontal spacing on the tarsal bites should equal the distance when exiting the skin to minimize horizontal kinking of the tarsus. To
assess the efficacy of the rotational sutures, the Vicryl sutures are manually tightened and the superior border of the tarsus should tuck nicely into the
pretarsal pocket (Figure 31.5D). Three to four of these rotational sutures are placed as needed.

SECTION TWO • EYELID AND FACE

Chapter 31 Entropion repair by posterior tarsotomy
218
 LOWER EYELID ENTROPION REPAIR BY POSTERIOR TARSOTOMY

Preoperative Postoperative

Figure 31.6 Before and after lower eyelid entropion repair by posterior tarsotomy
This 52-year-old female underwent right lower eyelid entropion repair by a posterior tarsotomy approach.

Table 31.3 Complications

Complications Suggestions to reduce risk
Overcorrection Don’t overtighten sutures; place sutures exiting skin just above lashes; recheck terminal eyelid position and rotation
prior to finishing surgery
Consecutive entropion Complete release of cicatricial bands and ensure dissection between pretarsal orbicularis and eyelid margin to allow
for the rotation of eyelid margin; consider posterior lamellar grafting with hard palate for severe and refractory cases
Kinking of eyelid Sutures passes too far apart; keep distance between skin exit 1–1.5 mm in distance and tarsal pass no more than
margin 2 mm
Eyelid margin necrosis Very uncommon with robust blood supply of eyelid but usually due to laceration of marginal arcade and aggressive
cauterization to stop bleeding; carefully measure 1.5 mm margin marking and don’t dissect too far superiorly along
anterior face of tarsal plate

Table 31.4 Consumables used during surgery

6-0 Vicryl, double-armed S-29 needle Ethicon #J555G
6-0 silk suture, TG140-8 needle Ethicon #1732G

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CHAPTER 32
Epiblepharon repair
Audrey C. Ko • Bobby S. Korn
Table 32.1 Indications for surgery
Recurrent corneal abrasions, keratitis or infections
Corneal scarring
Visual impairment secondary to corneal compromise or
astigmatism
INTRODUCTION
Epiblepharon is an eyelid condition in which excess orbicularis
muscle and skin override the upper or lower eyelid margin. The
etiology of this congenital anomaly is likely due to inadequate
lower eyelid retractor development, where there is a lack of
fenestrating fibers from the retractor aponeurosis which inserts
under the skin. It can also be secondary to pretarsal orbicularis
muscle that inserts abnormally close to the eyelid margin. This
condition exhibits a familial tendency in an autosomal dominant
pattern and can also present in patients with prominent cheeks.
Found most commonly in Asian and Hispanic infants due to
nasal bones that elevate at a later age, epiblepharon typically
resolves spontaneously within the first 2 years of life as the
patient undergoes facial bone growth, resulting in vertical skin
and muscle extension and greater tension on the retractors.
In the evaluation of patients with epiblepharon, a history of
tearing, photophobia, chronic ocular irritation, eye rubbing,
and mucous discharge is commonly elicited. The patient may
report tearing or a constantly wet and mattered eye. Symptoms
may be exacerbated in downgaze, which maximizes ciliary-
SECTION TWO • EYELID AND FACE
Chapter 32 Epiblepharon repair
220
Table 32.2 Preoperative evaluation
Assess for degree of anterior lamellar redundancy
Assess for eyelash-corneal touch and horizontal extent of eyelid
eversion
Assessment of the effects of astigmatism and corneal integrity on
vision
Corneal staining with fluorescein to detect epithelial defects,
irregularities, and scarring
corneal contact. Decreased visual acuity with significant astig-
matism may be present as a consequence of frequent eyelid
squeezing or rubbing in response to foreign body sensation.
The eyelid and margin exam will reveal a redundant fold of
eyelid skin and underlying orbicularis present bilaterally, typi-
cally involving the medial one-third to one-half of the upper
or lower eyelid. This prominent fold may result in the vertical
misdirection of a few or many cilia towards the ocular surface,
especially along the nasal half of the lower eyelid. A slit-lamp
biomicroscopic examination is performed to determine if the
eyelashes are rubbing against the conjunctiva or cornea. Signs
of keratitis include conjunctival injection, epithelial defects that
stain with fluorescein dye, corneal infiltrates, and corneal
neovascularization.
Patients usually tolerate this condition well and treatment is
only necessary if the eyes become inflamed or irritated. Since
the eyelashes are fine and soft, the cornea typically responds
to ocular lubricants in most cases. Patients need regular follow-
up for surveillance and treatment for corneal and conjunctival
irritation and abrasions. If left untreated, the long-term sequelae
of chronic ocular irritation secondary to epiblepharon can range
from corneal punctate erosions in mild cases to keratitis, infec-
tion, and permanent scarring in severe cases.
Although this condition usually resolves spontaneously,
surgical intervention is indicated in patients who experience
significant corneal involvement or visual compromise. The
underlying principle of surgical correction is to effect an external
rotation of the cilia away from the globe. The placement of
full thickness everting sutures is a simple and quick method
of everting the eyelid. However, since this method of repair
is associated with occasional suture infections and a high
recurrence rate, it is considered a temporizing rather than a
definitive measure. Our preferred approach is removal of the
excess anterior lamellae and placement of eyelid rotational
sutures from the orbicularis to the distal tarsal border. Epi-
canthal folds may be associated with epiblepharon and cor-
rection, if desired, can be performed concurrently with a medial
epicanthoplasty as described in Chapter 7. Surgical correction
of epiblepharon is associated with a high success rate but
may infrequently lead to complications such as ectropion,
scarring of the conjunctival cul-de-sac, and lower eyelid
retraction.

A B

Figures 32.1A–B Lower eyelid epiblepharon

This child of Asian descent presents with recurrent corneal irritation secondary to lower eyelid epiblepharon which is refractory to medical management.
On examination, there is epiblepharon of the nasal half of the lower eyelid (Figure 32.1A). Excess lower eyelid skin and pretarsal orbicularis contribute to
this condition (Figure 32.1B).

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SURGICAL TECHNIQUE

A B

Figures 32.2A–C Skin marking

All markings are made prior to infiltration with local anesthetic. First, an infraciliary incision 1 mm below the eyelashes is carefully marked to encompass
the horizontal extent of the epiblepharon. Then, with the lower eyelid skin pulled down, a 2–3 mm ellipse of skin is marked (Figure 32.2A). The pinch
technique similar to upper blepharoplasty can be performed but generally no more than 3 mm of vertical skin should be marked for excision. Once
downward traction on the lower eyelid is relaxed, the two markings should superimpose (Figure 32.2B). At this point, local anesthetic consisting of 1%
lidocaine, 0.25% bupivacaine and 1 : 200,000 epinephrine is given in a suborbicularis plane. A 6-0 silk suture on a G-7 needle is placed through the
gray line for superior traction (Figure 32.2C). A corneal shield is kept in place throughout the entire procedure.

SECTION TWO • EYELID AND FACE

Chapter 32 Epiblepharon repair
222
 A B

C D

Figures 32.3A–D Excision of skin and pretarsal orbicularis

Redundant skin and pretarsal orbicularis is a common pathologic finding with epiblepharon. The infraciliary incision is made first with the use of Westcott
scissors (Figure 32.3A). A #15 blade can be used but this often results in occasional lash transection and affords less control. The inferior incision is
then continued with the scissors. Then, this skin and pretarsal orbicularis flap is removed as a single unit (Figure 32.3B). With exposure of the lower
eyelid, the pretarsal orbicularis and the inferior border of the tarsal plate can be seen (Figures 32.3C and 32.3D). If residual pretarsal orbicularis remains,
this can be judiciously removed with scissors. With severe epiblepharon and eyelid rotation, a pretarsal pocket can be dissected under the orbicularis
muscle to improve rotation in the subsequent step. This pretarsal dissection should be performed in case of recurrent epiblepharon after surgery.

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 A B

C D

Figures 32.4A–D Eyelid rotation sutures

In addition to removal of the excess anterior lamellae, placement of rotational sutures between the pretarsal orbicularis and the inferior tarsal border
provides additional rotational forces. A 7-0 Vicryl suture is passed in a lamellar fashion through the inferior aspect of the tarsal border (Figure 32.4A).
Care should be taken to avoid a full thickness tarsal pass to prevent corneal irritation. The tarsal plate may be everted to inspect the conjunctival side to
verify lamellar (rather than full thickness) passage of the suture. The second pass of the sutures is directed through the pretarsal orbicularis (Figure
32.4B). In this manner, the pretarsal orbicularis is rotated inferiorly towards the inferior tarsal plate, drawing the cilia downwards. Two to three of these
rotational sutures are placed along the horizontal length of the eyelid, depending on the degree and extent of epiblepharon (Figures 32.4C and 32.4D).

SECTION TWO • EYELID AND FACE

Chapter 32 Epiblepharon repair
224
 A B

Figures 32.5A–C Closure of skin

Once the silk traction suture is removed, the cilia now should be directed away from the ocular surface owing to the effect of the eyelid rotational sutures
(Figure 32.5A). Skin closure is performed in a running fashion with a 6-0 fast-absorbing gut suture (Figures 32.5B and 32.5C). The wound is closed
from a temporal to nasal direction to avoid creating a dog ear. Note the outward rotation in the final postoperative outcome, resulting in the horizontal
direction of the lower eyelashes away from the globe. Non-absorbable sutures are not usually placed, as these are difficult to remove in children. In
young adults with recurrent epiblepharon and a history of hypertrophic scarring, non-absorbable sutures such as 6-0 Prolene can be used for closure
and are removed at 1 week postoperatively.

RIGHT LOWER EYELID EPIBLEPHARON REPAIR

Preoperative Postoperative
Figure 32.6 Before and after lower eyelid epiblepharon repair
This 14-year-old male presented with recurrent epiblepharon in the right eye associated with chronic mucoid discharge and ocular surface irritation. He
underwent bilateral surgical correction elsewhere at 7 years of age. Epiblepharon repair was performed in the right lower eyelid with resolution of the
eyelash misdirection and associated ocular symptoms.

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Table 32.3 Complications
Complications
Recurrence of epiblepharon
Worsening of epicanthal fold
after surgery
Lower eyelid ectropion and/
or retraction
Inferior conjunctival
symblepharon
Dry eyes/lagophthalmos
Hemorrhage
Infection
Suture granuloma
Wound dehiscence
Suggestions to reduce risk
Removal of more redundant skin and/or orbicularis; placement of more marginal rotational sutures; more
complete dissection in pretarsal plane prior to placement of rotational sutures
Consider adjunct epicanthoplasty after 3 months (Chapter 7).
Caused by excessive skin and/or orbicularis removal; consider lower eyelid retraction repair with posterior
lamellar graft (Chapters 34–36); avoid over-rotation with everting sutures
Avoid full thickness dissection through inferior conjunctival cul-de-sac during removal of skin and orbicularis
Conservative removal of skin and/or orbicularis
Meticulous hemostasis during procedure; use of tapered needle for skin closure; ice packs postoperatively;
cessation of anticoagulants
Perform procedure after sterile preparation; use of topical antibiotic ointment; be cognizant of
immunosuppressed states
Use non-absorbable sutures; recognize granulomas early; remove suture if symptomatic and treat with
antibiotic/steroid ointment
Avoid eye rubbing; use ice packs to minimize hemorrhage and itching; protective eye shields

Table 32.4 Consumables used during surgery

6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG140-8 needle Ethicon #J546G
6-0 silk, G-7 needle Ethicon #765G

SECTION TWO • EYELID AND FACE

Chapter 32 Epiblepharon repair
226
 CHAPTER 33
Limited upper eyelid protractor
Table 33.1 Indications for surgery
Eyelid closure from blepharospasm causing inability to perform
activities of daily living
Recalcitrant blepharospasm not responsive to maximally tolerated
medical therapy, including neurotoxins
INTRODUCTION
Essential blepharospasm is part of a spectrum of disorders
referred to as cervicofacial dystonia, affecting approximately 1
in 10,000 individuals. The cause is unknown, but is likely a
combination of genetic and environmental that leads to an
increase of activity in the basal ganglia, which controls eyelid
and facial movements. Neurotoxins provide the mainstay of
therapy, although some oral agents have also been shown to
be effective in some cases. The symptoms of blepharospasm
are bilateral and abate during sleep as compared to hemifacial
spasm which is typically unilateral with symptoms that persist
at all times.
Blepharospasm consists of powerful contraction of the
eyelid protractors. These muscles include the orbicularis oculi,
corrugator supercilii, depressor supercilii, and procerus.
myectomy
Bobby S. Korn • Don O. Kikkawa
Table 33.2 Preoperative evaluation
History of prior neurotoxin use and dosage
Orbicularis strength
Assess for upper and lower eyelid malpositions
Assess for eyelid apraxia
Corneal sensation
Tear film quality and quantitative tear production
Prior eyelid, facial surgery or trauma
Involuntary spasm of these muscles leads to closure of the
eyelids, affecting vision and rendering patients unable to
function.
Neurotoxins have revolutionized the treatment of blepharo­
spasm and the vast majority of patients are able to resume
normal activities with regular injections. Surgical intervention
should be considered when maximally tolerated medical
therapy with neurotoxins and oral agents are ineffective in
reducing symptoms.
Protractor myectomy offers the opportunity to selectively
weaken the muscles directly involved with involuntary forceful
eyelid closure. While full myectomy was initially the procedure
performed for blepharospasm, it has been associated with side
effects, such as prolonged lymphedema, scarring, and lagoph­
thalmos. Our preference is to consider limited upper eyelid
protractor myectomy when indicated. Patients should be
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advised that neurotoxin use will likely continue to be needed
after surgery, but will be more effective and that the main goal
of the surgery is to improve their functional capacity.
Apraxia of eyelid opening is an associated phenomenon
that prevents voluntary eyelid opening in the setting of blepha­
rospasm. It may account for continued inability to open the
eyes despite neurotoxin-induced protractor weakness. Limited
protractor myectomy may improve symptoms related to
apraxia of eyelid opening, but additional help is likely needed
in the form of frontalis suspension to assist in eyelid opening
(Chapter 15).

SURGICAL TECHNIQUE

A B

Figures 33.1A and 33.1B Surgical planning

The eyelid protractors consist of the orbicularis oculi muscle, corrugator supercilii, depressor supercilii, and procerus. Myectomy of the protractors is
considered when blepharospasm is refractory to maximal chemodenervation. An upper eyelid crease incision is performed to gain access to the eyelid
protractors (Figure 33.1A). During limited upper eyelid protractor myectomy, the orbital (OO), preseptal (PSO), and pretarsal (PTO) divisions of the
orbicularis oculi muscle and corrugator supercilii (CS) and depressor supercilii (DS) are removed (Figure 33.1B). The procerus (P) is typically spared
during the limited myectomy. Local anesthetic consisting of 1% lidocaine with 1 : 100,000 epinephrine and 0.25% bupivacaine is given generously in the
preorbicularis plane to cover each of the muscle groups to be addressed.

A B

Figures 33.2A–E Dissection to eyelid margin

A #15 blade is used to the make the upper eyelid crease incision (Figure 33.2A). Dissection is then performed in the subcutaneous, preorbicularis plane
(Figure 33.2B). Blunt-tip Westcott scissors or a hand-held high temperature cautery can be used for the dissection. The latter is useful for rapid
dissection while achieving excellent hemostasis. The dissection is continued along the inferior tarsal border to the eyelid margin.

SECTION TWO • EYELID AND FACE

Chapter 33 Limited upper eyelid protractor myectomy
228
 C D

Figures 33.2A–E, cont’d

Dissection is performed in the pretarsal plane to reflect off the orbicularis from the tarsal plate (Figure 33.2C). Care is taken at the inferior extent of the
tarsal plate as a buttonhole may be created inadvertently. During the dissection, the eyelash follicles may become visible and dissection should not
continue past this point. Once the inferior border of the tarsal plate has been freed of orbicularis, the dissection continues superiorly to clear the upper
border (Figure 33.2D). The extent of the inferior dissection continues to the pretarsal orbicularis at the eyelid margin as indicated by the forceps in
Figure 33.2E.

A B

Figures 33.3A and 33.3B Superior dissection

The dissection is then performed superiorly towards the orbital rim (Figure 33.3A). During the dissection, care is taken to free all orbicularis fibers from
the skin. Transillumination of the skin using the overhead light can identify any residual fibers on the dermal side of the skin. This dissection liberates the
preseptal and orbital divisions of the orbicularis muscle. Near the brows, the subcutaneous fat thickens and this layer can be left as long as all orbicula-
ris fibers after dissected off. Here, forceps delineate the superior extent of the dissection (Figure 33.3B). The dissection of skin from orbicularis is
continued from the medial canthus to the lateral canthus using a combination of Westcott scissors and high-temperature cautery.

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 A B

C D

Figures 33.4A–E Extirpation of orbicularis

Once the skin has been completely freed, a buttonhole can be made superiorly along the arcus marginalis. Blunt dissection can be performed to free the
postorbicularis fascia from the orbital septum to the superior border of the tarsal plate (Figure 33.4A). Blunt dissection can then be performed in the
preseptal plane medially and laterally. Extirpation of the orbicularis begins with freeing the muscle fibers at the lateral raphe from its attachments to the
zygomatic bone. Cutting cautery is used to dissect the postorbicularis fascia from the orbital septum while noting the presence of the preaponeurotic fat
(Figure 33.4B). As the extirpation continues medially, the superficial orbicularis fibers are carefully dissected from the medial canthal tendon, taking care
to not lyse the tendon (Figure 33.4C). The posterior pretarsal orbicularis fibers that invest the lacrimal fascia should be avoided to retain lacrimal pump
function while avoiding damage to the sac itself. Figure 33.4D shows the complete exposure of the preaponeurotic and nasal fat pads after removal of
the orbicularis. Figure 33.4E shows the completely extirpated muscle.

SECTION TWO • EYELID AND FACE

Chapter 33 Limited upper eyelid protractor myectomy
230
 A B

C D

Figures 33.5A–D Myectomy of the corrugator and depressor supercilii

Attention is next directed towards myectomy of the corrugator and depressor supercilii muscles. The course of these muscles is shown in Figure 33.1B.
Blunt dissection is performed medially above the level of the medial canthal tendon. The supraorbital nerve (cotton-tipped applicator over the supraorbital
notch and the supratrochlear nerve bundles) should be visualized (Figure 33.5A). Fibers of the corrugator and depressor supercilii muscles can be noted
in Figure 33.5B. These two muscles are transected down to the bone with cutting cautery (Figure 33.5C). Blunt dissection is used to separate the
muscle ends (Figure 33.5D). A segment of the muscles can also be excised, but care should be taken to avoid damaging the two sensory nerves in this
region of the orbit. The procerus is more medially located; however, we rarely address this muscle.

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 A B

Figures 33.6A–C Skin closure

Multiple 7-0 Vicryl sutures are placed through the dermis for subcutaneous closure (Figure 33.6A). The orbicularis should be removed and the skin will
be quite thin at this point. The skin is then closed with a running 6-0 fast-absorbing gut or Prolene suture (Figures 33.6B and 33.6C).

SECTION TWO • EYELID AND FACE

Chapter 33 Limited upper eyelid protractor myectomy
232
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 A B

C D

Figures 33.7A–D Reverse Frost suture placement

The upper eyelid is placed on inferior traction using two 6-0 silk sutures placed through the gray line (Figures 33.7A and 33.7B). Benzoin adhesive is placed
on the cheek and sterile adhesive strips are used for inferior traction (Figure 33.7C). A pressure patch is applied for 5 days postoperatively (Figure 33.7D).

Table 33.3 Complications

Complications Suggestions to reduce risk
Continued recalcitrant Inadequate removal of eyelid protractors; meticulous dissection of orbicularis muscle with removal of
blepharospasm pretarsal, preseptal, and orbital portions of the muscle; continue use of neurotoxin
Medial brow depression Inadequate removal of the brow depressors; identify corrugator, procerus, and depressor muscles with
extirpation
Hypesthesia of forehead Avoid supraorbital, supratrochlear nerve injury
Anterior lamellar shortage Perform unilateral surgery with reverse Frost suture and pressure patching for 3–5 days
Hemorrhage Proper hemostasis; cessation of anticoagulant usage prior to surgery
Wound dehiscence Placement of subcutaneous sutures prior to skin closure
Lymph edema Limit protractor myectomy to the upper eyelid only; avoid aggressive cauterization at the lateral canthus;
apply pressure patch for extended period of time

Table 33.4 Consumables used during surgery

6-0 Prolene, C-1 needle Ethicon #8718
7-0 Vicryl , TG140-8 needle Ethicon #J546G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
6-0 silk suture, TG140-8 needle Ethicon #1732G

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CHAPTER 34
Lower eyelid retraction repair
with porcine acellular dermal
collagen matrix
Bobby S. Korn • Don O. Kikkawa
Table 34.1 Indications for surgery
Lower eyelid retraction without need for significant volume
augmentation
Posterior lamellar and/or middle lamellar shortening
No history of adverse reaction to porcine xenografting
Contraindication or aversion to hard palate or autologous grafting
INTRODUCTION
The use of acellular dermis as a spacer graft for lower eyelid
retraction is similar to dermis fat (Chapter 35) and autologous
hard palate (Chapter 36) with some distinguishing features.
Dermis fat can restore lost orbital volume and provide a large
surface area for posterior lamellar grafting with the benefit of
being autologous, while hard palate supplies only surface area.
SECTION TWO • EYELID AND FACE
Chapter 34 Lower eyelid retraction repair with porcine acellular dermal collagen matrix
234
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Table 34.2 Preoperative evaluation
Quantify amount of eyelid retraction according to MRD2
Manual palpation and elevation of lower eyelid to feel for restriction
within the middle lamella; if supple elevation is possible, spacer
graft may not be required
Assess adequacy of anterior lamella; may need cheek lift or skin
graft if severe shortening
Assess eyelid laxity
Assess globe and inferior orbital rim position for presence of
negative vector
Assess orbicularis strength; weakness on closure may portend high
risk of recurrence
Prior eyelid, facial surgery or trauma
Acellular dermis like hard palate provides posterior lamella but
requires commercial preparation prior to use.
There are two sources of acellular dermis: the first is an
allograft, taken from human cadaveric donors, and the second
is a xenograft from porcine sources. Acellular dermis does not
have a native epithelial layer but does provide a connective
tissue framework for incorporation into host tissues. Conjunc-
tival epithelialization, however, is required from the host.
 Many decisions factor into the choice of posterior lamellar
grafts. If patients are unwilling to have a second incision for an
autologous graft, acellular dermis does provide a suitable
option. Some potential downsides are prolonged inflammation
and conjunctival injection during the epithelialization phase and
the lack of volume that dermis fat provides. One benefit of
acellular dermis and hard palate is no risk of ectopic hair trans-
plantation that can be seen with dermis fat grafting. An addi-
tional benefit of acellular dermis over hard palate is the
consistency of graft thickness and the virtually unlimited size
compared to hard palate.
Conceptually, this chapter and the following two (Chapters
35 and 36) are fundamentally similar. The surgery is performed
through a transconjunctival approach. The lower eyelid cicatrix
is released with an optional subperiosteal midface lift. Orbito-
malar suspension can be performed to elevate the midface and
to recruit additional anterior lamella. The spacer graft is secured
posteriorly and the lower eyelid is tightened. The lower eyelid
is then immobilized with Frost sutures.
For adequate surgical repair, slight oversizing of the graft is
required as there will likely be some shrinkage postoperatively.
Because the posterior lamellar graft can be irritating to the
cornea, particularly if a Frost suture is placed, a collagen shield
or a large-diameter contact lens can be used for comfort. Also
helpful in reducing foreign body sensation are buried knots and
fine, non-braided sutures to secure the graft.

SURGICAL TECHNIQUE

A B

Figures 34.1A and 34.1B Lateral canthotomy and cantholysis

Our preference is to place posterior lamellar grafts from the transconjunctival approach. This prevents postoperative anterior lamellar contraction and
preserves cosmesis. A small, 1 mm lateral canthotomy and inferior cantholysis is performed (Figure 34.1A). Complete release of the inferior crus of the
lateral canthal tendon is performed to loosen any scarring and allow full access to the lower eyelid (Figure 34.1B).

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 A B

C D

Figures 34.2A–D Inferior transconjunctival incision and cicatricial release along inferior orbital rim
Middle lamellar scarring is often a key factor in the development of lower eyelid retraction and fully releasing this cicatrix along the inferior orbital rim is
essential for success. After the lateral canthotomy and inferior cantholysis, an inferior transconjunctival incision with monopolar cautery is performed
6 mm below the lower eyelid margin (Figure 34.2A). This incision is performed 2 mm below the inferior border of the tarsus so that this small flap of
palpebral conjunctiva can be draped over the spacer graft and facilitate subsequent epithelialization. The dissection then continues in the preseptal plane
using a malleable retractor to posteriorly displace orbital fat while a Senn retractor isolates the arcus marginalis at the inferior orbital rim. Cutting cautery
is then used to release the periosteum along the arcus marginalis (Figure 34.2B). At the inferolateral orbital rim, cutting cautery is used to dissect along
the inferolateral orbital rim to release the orbitomalar ligament which has its stoutest attachment to the orbital rim (Figure 34.2C). The zygomaticofacial
foramen is located approximately 5 mm below the inferolateral orbital rim and if bleeding occurs, gentle bipolar cautery should be applied. If significant
lower eyelid retraction (MRD2 >8 mm) and/or severe middle lamellar tethering is present, a subperiosteal midfacial dissection is performed (Figure
34.2D). Care is taken along the inferomedial orbit where the infraorbital nerve emerges 5 mm below the orbital rim. After full release of the cicatrix, the
midface and lower eyelid should freely elevate. If any bands of traction still remain, these are lysed. A cotton-tipped “peanut” sponge on a hemostat can
also be used to release residual attachments to the maxilla and zygoma.

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Chapter 34 Lower eyelid retraction repair with porcine acellular dermal collagen matrix
236
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 A B

Figures 34.3A–C Placement of orbitomalar suspension suture

A suture is then passed through the soft tissues of the cheek for fixation later in the operation. The location of the suture placement is critical. If too
superficial, dimpling may occur. If too deep, bunching may occur. Toothed Adson forceps are used to select an optimal fixation point through the
suborbicularis oculi fat (SOOF) (Figure 34.3A). Once the desired location is selected, 4-0 Vicryl is passed though the SOOF (Figure 34.3B). With
superolateral traction of the suture, the midface should freely elevate without dimpling or bunching of the SOOF and overlying skin. This SOOF lift recruits
additional anterior lamella, which obviates the need for a cosmetically displeasing skin graft (Figure 34.3C).

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 A B

C D

Figures 34.4A–D Retrieval of orbitomalar suspension suture through upper eyelid

Fixation of the orbitomalar suspension is performed at the level of the frontozygomatic suture line. This allows for a high, uniform lift of the midface and
minimizes bunching of tissues at the lateral canthus. A temporal upper eyelid crease incision is created to allow access to this fixation point (Figure
34.4A). A small curved hemostat is used to create a tunnel from the upper eyelid crease incision to communicate with the lower eyelid in a preperiosteal
plane (Figure 34.4B). Care is taken to not disrupt the skin overlying the lateral canthus during the dissection. Once the tunnel is created, the hemostat is
used to deliver the orbitomalar suspension suture through the upper eyelid crease incision (Figure 34.4C). The suspension suture is then elevated
through the upper eyelid to simulate the orbitomalar suspension. The contours of the midface and cheek are then inspected to ensure a smooth
transition from the lower eyelid to the cheek (Figure 34.4D). The suture is tagged with a bulldog clamp and set aside for later fixation.

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Chapter 34 Lower eyelid retraction repair with porcine acellular dermal collagen matrix
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 A B

Figures 34.5A and 34.5B Trimming of inferior edge of spacer graft

In this case, a 1-mm thick porcine acellular dermal matrix graft (ENDURAGen, Stryker Corporation, Kalamazoo, MI) is used as the eyelid spacer (Figure
34.5A). The 1-mm thick graft provides rigid support to stent the retracted lower eyelid and is our preferred acellular dermal graft. This graft is also
sufficiently thick to allow lamellar needle passage to bury sutures away from the ocular surface. At the inferior edge of the graft, a gentle curve is cut to
maintain a square medial border after fixation to the lower eyelid retractors (Figure 34.5B).

A B

C D

Figures 34.6A–D Fixation of inferior edge of spacer graft

The acellular dermal matrix graft does not have an epithelial surface and either side may be used facing the globe. With superior traction on the
conjunctival edge, the lower eyelid retractor band can be seen (Figure 34.6A). As this patient has had prior surgery with lower eyelid retraction, there
may be scarring and fatty infiltration within the middle lamella. Fixation of the graft is achieved using interrupted 6-0 Vicryl sutures that are first placed in
a partial thickness fashion through the inferior edge (Figure 34.6B). The use of a spatulated needle on the 6-0 Vicryl sutures aids in a smooth lamellar
pass through this thick graft. The suture is then anchored medially through the lower eyelid retractors (Figure 34.6C). The graft is then sequentially
anchored laterally with three additional interrupted sutures (Figure 34.6D). In this manner, the knots remain buried away from the ocular surface.

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 A B

C D

Figures 34.7A–D Vertical sizing of spacer graft

Proper vertical sizing of the spacer graft is a key part of the procedure. Commercially available acellular dermal grafts provide a large surface area
compared to hard palate, which is limited by the donor site. The final lower eyelid height is determined largely by physical stenting of the tarsal plate by
the spacer graft, which will rest on the inferior tarsal border, and having a plentiful supply of surface area is key. To vertically size the graft, the
preplaced corneal shield is removed and then the lower eyelid is raised to the desired height and contour (Figure 34.7A). Once satisfactory sizing is
achieved, a mark is made along the graft flush with the eyelid margin (Figure 34.7B). An additional parallel marking is then made 4 mm below the eyelid
margin to account for the height of the inferior tarsal plate (Figure 34.7C). The final markings of the graft are shown schematically in Figure 34.7D.

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Chapter 34 Lower eyelid retraction repair with porcine acellular dermal collagen matrix
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 A B

Figures 34.8A and 34.8B Final trimming of spacer graft

The corneal shield is then replaced prior to trimming the graft. After securing the inferior edge of the spacer graft, the excess is trimmed vertically
starting at the lateral edge (Figure 34.8A). Sharp iris scissors can be used for the excision after vertical sizing has been determined (Figure 34.8B). The
assistant provides countertraction on the graft while the surgeon cuts the graft. Care should be taken to minimize vertical distraction of the graft as this
can disrupt the sutures placed along the lower eyelid retractors. Once the graft has been cut to size, the inferior edge of the graft is rechecked to ensure
than none of the previously placed fixation sutures have loosened.

A B

C D

Figures 34.9A–D Fixation of superior edge of spacer graft

Interrupted 6-0 Vicryl sutures are used to secure the upper edge of the spacer graft. The needle is passed inferior to superior on the anterior face of the
graft in a partial thickness fashion (Figure 34.9A). Again, this buries the knot away from the ocular surface. The second pass of the needle incorporates
the inferior tarsal border and pretarsal orbicularis (Figure 34.9B). When making this second pass, the needle does not incorporate the cut edge of the
palpebral conjunctiva. This allows a 1–2 mm conjunctival cuff to overlap the graft to promote epithelialization of the dermal surface (Figure 34.9C). Three
to four of these interrupted, buried sutures are placed along the superior edge of the graft. To protect the corneal surface while the eyelid is held up on
a Frost suture, a large-diameter (>16 mm) plano bandage contact lens can be placed for comfort (Figure 34.9D).

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 A B

Figures 34.10A and 34.10B Securing orbitomalar suspension suture

After the spacer graft has been secured, the preplaced orbitomalar suspension suture is secured. The needle is passed perpendicular to the superola-
teral orbital rim overlying the frontozygomatic suture line (Figures 34.10A and 34.10B). A deep purchase should be made through the periosteum for
maximal strength. With downward traction on the lower eyelid, there should be resistance owing to the support of the orbitomalar suspension suture.

A B

Figures 34.11A–C Lower eyelid shortening

Lower eyelid shortening is performed last after spacer graft placement and orbitomalar suspension. The spacer graft provides vertical support of the
posterior lamella while the orbitomalar suspension provides anterior lamellar support. The amount of eyelid laxity is assessed by redraping of the tissue
laterally (Figure 34.11A). In this case, mild laxity is present and the eyelid is shortened by excising a 2 mm triangular wedge of tissue (Figure 34.11B). If
significant lower eyelid laxity is present, a tarsal strip procedure can be performed as described in Chapter 25. The cut edge of the lower eyelid will then
be secured to the superior crus of the lateral canthal tendon in the next step (Figure 34.11C).

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Chapter 34 Lower eyelid retraction repair with porcine acellular dermal collagen matrix
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 A B

Figures 34.12A–C Lateral canthal fixation

The canthus is then reconstructed by securing two interrupted 5-0 Vicryl sutures anchoring the lateral tarsus to the superior crus of the lateral canthal
tendon. First, the needle is passed deeply through the superior crus in a posterior to anterior direction (Figure 34.12A). This allows the subsequent knot
to be buried and with this deep pass the lower eyelid will be directed more posteriorly to form a sharp canthal angle. The needle is then passed under
the lower eyelid skin to secure the tarsal plate (Figure 34.12B). The second canthoplasty suture is placed below the first pass (Figure 34.12C). Once
both passes are complete, the superior suture is tied off first, followed by the inferior.

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 A B

Figures 34.13A and 34.13B Placement of canthal angle suture

After lateral canthal fixation, the upper and lower eyelids are examined for alignment (Figure 34.13A). The lower eyelid should fall in line with the upper
eyelid and if the lower eyelid is anteriorly distracted, the lateral canthal fixation sutures should be removed and placed deeper on the superior crus of the
lateral canthal tendon. A buried canthal angle suture can optionally be placed by passing a 7-0 Vicryl suture through the gray lines of the upper and
lower eyelids (Figure 34.13B).

A B

Figures 34.14A–C Skin closure

At the lateral canthus, multiple 6-0 fast-absorbing gut sutures are placed for skin closure (Figure 34.14A). Care is taken to close the skin only and avoid
deeper passes of the needle which may inadvertently cut the previously placed lateral canthoplasty sutures. The upper eyelid crease incision is also
closed with 6-0 fast-absorbing gut sutures (Figures 34.14B and 34.14C).

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Chapter 34 Lower eyelid retraction repair with porcine acellular dermal collagen matrix
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 A B

C D

Figures 34.15A–D Placement of Frost suture

To minimize postoperative wound contraction and assist with healing, one to two Frost sutures are placed for upward traction of the lower eyelid. Double
armed 5-0 Prolene sutures on foam bolsters are placed through the lower eyelid and passed through the gray line (Figure 34.15A). The needle is then
directed through the gray line of the upper eyelid and then fixed superior to the brow (Figures 34.15B and 34.15C). Foam bolsters are placed over the
brow fixation point and tied off (Figure 34.15D). The Frost sutures and any preplaced bandage contact lens are removed in 5–7 days.

BILATERAL LOWER EYELID RETRACTION REPAIR

WITH ACELLULAR DERMAL COLLAGEN MATRIX

Preoperative Postoperative

Figure 34.16 Before and after lower eyelid retraction repair with acellular dermal collagen matrix graft
This 47-year-old female patient presented with foreign body sensation and tearing after aesthetic lower blepharoplasty performed elsewhere. She
underwent lower eyelid retraction repair with placement of acellular dermis with improvement in cosmesis and resolution of her ocular surface
symptoms.

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Table 34.3 Complications
Complications
Delayed epithelialization of graft
Foreign body sensation
Recurrent eyelid retraction
Canthal rounding
Lower eyelid too high
Suggestions to reduce risk
Properly align spacer graft under conjunctival cuff; use topical antibiotic and steroid drops to control
infection and minimize inflammatory reaction
Use of collagen shield or large-diameter bandage contact lens prior to Frost suture placement
Fully release cicatrix; increase graft size; keep Frost suture in place longer; consider antimetabolite
such as 5-FU (flurouracil)
Place deeper canthal fixation sutures; place canthal angle suture; avoid over-shortening of lower eyelid
If not improved after 6 weeks, consider shortening vertical height of spacer graft

Table 34.4 Consumables used during surgery

ENDURAGen (porcine dermal collagen matrix) Stryker #89224
4-0 Vicryl, P-3 needle Ethicon #J494H
5-0 Vicryl, P-3 needle Ethicon #J493H
5-0 Prolene, C-1 needle Ethicon #8725H
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG140-8 needle Ethicon #J556G
Kontur Lens, plano, 16.0–20.0 mm Kontur Kontact Lens Co.

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Chapter 34 Lower eyelid retraction repair with porcine acellular dermal collagen matrix
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 CHAPTER 35
Lower eyelid retraction repair
Table 35.1 Indications for surgery
Lower eyelid retraction with volume loss
Posterior lamellar and/or middle lamellar shortening
Desire for use of autologous grafts
HIV-associated lipoatrophy
Prostaglandin-associated lipoatrophy
Lower eyelid retraction seen in craniofacial syndromes (ie Treacher
Collins syndrome)
INTRODUCTION
The use of dermis fat as a posterior lamellar graft for lower
eyelid reconstruction has several advantages over acellular
dermis and hard palate. Dermis fat can provide a virtually limit-
less amount of volume augmentation and surface area com-
pared to acellular dermis (Chapter 34) and hard palate (Chapter
36). Dermis fat is autologous, which may appeal to patients
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with dermis fat
Bobby S. Korn • Don O. Kikkawa
Table 35.2 Preoperative evaluation
Assess for volume loss/hollowing of lower eyelid
Quantify amount of eyelid retraction according to MRD2
Manual palpation and elevation of lower eyelid to feel for
restriction; if supple elevation is possible, spacer may not be
required
Assess adequacy of anterior lamella; may need cheek lift or skin
graft if severe shortening
Assess eyelid laxity
Assess inferior orbital rim and presence of negative vector
Assess orbicularis strength; weakness on closure may portend high
risk of recurrence
Prior eyelid, facial surgery or trauma
Suitability for donor site of dermis fat (retro/preauricular, hip/
gluteal, flank/periumbilical)
who are adverse to use of xenografts. Hard palate, although
autologous, has more associated donor site morbidity, such as
postoperative pain, difficulty eating, and potential for fistula
formation compared to dermis fat. The use of dermis fat, acel-
lular dermis, and hard palate is technically similar and review
of each of these chapters (Chapters 34–36) should be per-
formed to appreciate the subtle nuances of each graft.
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SURGICAL TECHNIQUE

A B

Figures 35.1A and 35.1B Potential donor site for dermis fat graft
The gluteal and hip region provides excellent surface area for dermis and volume with respect to subcutaneous fat (Figure 35.1A). The donor site should
be hidden under the patient’s undergarment (Figure 35.1B). Even in patients with HIV-associated lipodystrophy, there is often adequate subcutaneous fat
present. When choosing a donor site, a hair-free area should be utilized. The size of the potential donor site should be increased by at least 1.5–2 fold
to account for contraction after harvesting. Other suitable areas for harvesting dermis fat include the periumbilical area and flanks, but these carry the
potential risk of peritoneal perforation. Preauricular or retroauricular grafts may be obtained but these donor sites contain less subcutaneous fat.

A B

C D

Figures 35.2A–D Removal of epithelium from graft

Complete removal of the epithelium from a dermis fat graft is essential to minimize postoperative complications. Vellus hair growth, keratin production,
and mucoid discharge may be seen with incomplete removal of the epithelium. A 4 mm diamond burr rotating at 40,000 rpm can be used for epithelial
removal (Figure 35.2A). As the epidermis is removed, fine pinpoint bleeders can be noted. The dermis is reached when a pale appearance is noted after
the debridement (Figures 35.2B and 35.2C). Lamellar dissection can also be performed with a #15 or #10 blade (Figure 35.2D). One theoretical
advantage of the burr over the blade is the thermal damage that may be directed to the hair follicle base to minimize postoperative hair growth.

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Chapter 35 Lower eyelid retraction repair with dermis fat
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 A B

Figures 35.3A and 35.3B Removal of dermis fat graft

The epithelium should be completely removed from the donor site prior to skin incision. Keeping the surrounding skin intact provides countertraction
when debriding or excising the epithelium. Once the donor site has been prepared, a #15 blade is used to incise the skin slightly inside of the denuded
epithelium to ensure no surface epithelium is transplanted to the eyelid (Figure 35.3A). A residual bed of at least 5 mm thickness of the fat side should
be removed from the donor site (Figure 35.3B). This slight oversizing allows for subsequent trimming when placed into the lower eyelid. The donor site is
closed with a deep 4-0 Vicryl suture followed by a running subcuticular 5-0 Vicryl suture. Alternatively a Monocryl suture may be used for less inflamma-
tory response. The skin should be closed with Steri-Strips for reinforcement and the patient must be instructed to minimize squatting or bending over to
prevent wound dehiscence.

A B

Figures 35.4A and 35.4B Lateral canthotomy and inferior cantholysis

To achieve posterior access to the eyelid, a small 1–2 mm lateral canthotomy followed by an inferior cantholysis (Figures 35.4A and 35.4B). Full release
of the inferior canthal tendon provides complete access to the lower eyelid.

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 A B

Figures 35.5A–C Inferior transconjunctival incision and cicatricial release along inferior orbital rim
An inferior transconjunctival incision is made 6 mm below the inferior tarsal border (Figure 35.5A). This more inferior incision allows deeper placement of
the dermis fat graft and volume augmentation along the inferior orbital rim subsequently. The dissection then continues inferiorly along the arcus
marginalis at the orbital rim to release any cicatricial bands (Figure 35.5B). Careful placement of a malleable inside the orbital rim and inferior traction
with the Senn retractor will isolate the middle lamellar tissues and prevent inadvertent dissection anteriorly or posteriorly into the orbit. At the inferolateral
orbital rim, the dense attachments of the orbitomalar ligament are released. Depending on the degree of lower eyelid retraction, a subperiosteal midface
dissection may also be performed (Figure 35.5C). Care is taken along the inferolateral orbital rim where the zygomaticofacial nerve and artery exit, in
addition to medially at the infraorbital foramen. Further dissection can be performed with cutting cautery or blunt dissection using cotton-tipped
applicators or peanut sponges.

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Chapter 35 Lower eyelid retraction repair with dermis fat
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 A B

C D

Figures 35.6A–D Placement of orbitomalar suspension suture

Orbitomalar suspension is an adjunct during lower eyelid retraction repair which provides midfacial support and anterior lamellar recruitment. Adson
forceps are used to grasp the suborbicularis oculi fat (SOOF) along the lateral cheek (Figure 35.6A). The forceps are drawn upwards to simulate suture
placement while looking for a smooth cheek contour without any bunching or dimpling of skin (Figure 35.6B). Once a satisfactory fixation point is
localized, a 4-0 Vicryl suture is passed through the SOOF (Figure 35.6C). As the suture is drawn superolaterally, the cheek is noted to elevate, recruiting
anterior lamella (Figure 35.6D). In most cases, this cheek lift is sufficient to provide anterior lamella without the use of a full thickness skin graft. The
suture is then left preplaced and attention is focused towards dermis fat graft placement.

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 A B

C D

Figures 35.7A–D Securing inferior border of dermis fat graft

The dermis fat graft is placed in situ with the dermis face towards the ocular surface and the fat side towards the surgical bed (Figure 35.7A). The
dermis side will eventually be covered by conjunctival epithelium. The graft is secured at the nasal aspect first and then subsequently with interrupted
6-0 fast-absorbing gut sutures along the inferior border (Figures 35.7B–D).

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Chapter 35 Lower eyelid retraction repair with dermis fat
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 A B

Figures 35.8A–C Securing the superior border of dermis fat graft

After securing the inferior edge of the graft, the lower eyelid is redraped and the contour of the lower eyelid is evaluated. If excessive fullness is noted in
the inferior orbit, the fat portion of the graft is trimmed. Figure 35.8A shows the improvement in the volume of the right side compared to the hollow
lower eyelid on the left side. A slight overcorrection is desired on the operative side as some of the fat invariably resorbs. At the superior edge of the
graft, the dermis graft is secured 3–4 mm below the inferior tarsal border with interrupted 6-0 fast absorbing gut suture (Figure 35.8B). The dermis graft
is secured lower in the orbit compared to acellular dermis or hard palate, to place the fat portion of the graft closer to the inferior orbital rim. Addition-
ally, the dermis provides less rigid support of the posterior lamella compared to acellular dermis and hard palate. At the superior border of the dermis fat
graft, a conjunctival cuff of 1–2 mm is draped over the dermis to facilitate epithelialization (Figure 35.8C). The conjunctiva may optionally be sutured over
the dermis with several interrupted 7-0 Vicryl sutures.

253
 A B

C D

Figures 35.9A–D Orbitomalar suspension

A temporal upper eyelid crease incision is made and then blunt dissection is performed with a curved hemostat to communicate the upper and lower
eyelid incisions (Figure 35.9A). Through this preperiosteal tunnel, the preplaced 4-0 Vicryl suture is directed through the upper eyelid crease incision
(Figures 35.9B and 35.9C). The suture is fixated to the periosteum at the level of the frontozygomatic suture line (Figure 35.9D). Resistance to downward
traction of the lower eyelid should be noted once the orbitomalar suspension has been completed.

A B

Figures 35.10A and 35.10B Lateral canthoplasty

The lower eyelid is assessed for any laxity (Figure 35.10A). If mild laxity is present, a wedge of the lower eyelid can be excised and reconstructed. If
severe laxity is present, a lateral tarsal strip can be fashioned. Lower eyelid shortening is performed last after spacer graft placement and orbitomalar
suspension. In this case, no laxity is present, and the lateral canthus is simply reconstructed by securing the lower eyelid tarsus to the superior crus of
the lateral canthal tendon with two interrupted 5-0 Vicryl sutures (Figure 35.10B).

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Chapter 35 Lower eyelid retraction repair with dermis fat
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 A B

Figures 35.11A and 35.11B Skin closure

At the lateral canthus, two to three interrupted 6-0 fast absorbing gut sutures are placed for skin closure (Figure 35.11A). Care is taken to close
the skin only and avoid deeper passes of the needle which may cut the previously placed Vicryl sutures. The upper eyelid crease is closed with
6-0 fast-absorbing gut suture (Figure 35.11B).

A B

Figures 35.12A and 35.12B Placement of Frost sutures

At the conclusion of the case, one to two Frost sutures are placed for upward traction of the lower eyelid. Care is taken to ensure that the 5-0 Prolene
sutures are passed through the gray line and not posteriorly where they may abrade the cornea (Figure 35.12A). The Prolene sutures are placed over
foam bolsters for traction and to prevent cheese-wiring through the skin (Figure 35.12B). A pressure patch is placed and the Frost sutures are removed
1 week postoperatively. A large diameter contact lens can be optionally placed to minimize corneal irritation.

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 BILATERAL LOWER EYELID RETRACTION REPAIR
WITH DERMIS FAT GRAFTING

Preoperative Postoperative

Figure 35.13 Before and after lower eyelid retraction repair with dermis fat
This patient presented with foreign body sensation, tearing, and lower eyelid hollowing after blepharoplasty performed elsewhere. She underwent bilateral
lower eyelid retraction repair with lysis of the lower eyelid cicatrix, subperiosteal midface lifting by orbitomalar suspension, and placement of dermis fat
grafts. She notes resolution of her ocular surface symptoms, complete eyelid closure, and improvement in her lower eyelid aesthetics.

Table 35.3 Complications

Complications
Hair growing from graft
Graft too thick
Recurrent eyelid retraction
Canthal rounding
Graft lumpy/irregular
Suggestions to reduce risk
Incomplete removal of epidermis and hair follicles; suggest deeper removal into deep papillary dermis; direct
excision of hair follicles; hyfrecation of follicles
Too much fat left on graft; consider judicious use of fat; consider injection of triamcinolone
Inadequate release of cicatrix; undersized graft; Frost suture removed too early; overcorrection desired in
early postoperative period
Must insert canthal tendon to firm periosteal attachment; consider drill hole for most firm fixation
Consider adjunct steroid and/or 5-FU (fluorouracil) injection

Table 35.4 Consumables used during surgery

4-0 Vicryl, P-3 needle Ethicon #J494H
5-0 Vicryl, P-3 needle Ethicon #J493H
5-0 Prolene, C-1 needle Ethicon #8725H
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG140-8 needle Ethicon #J556G
4 mm round diamond tip burr Stryker #5820-12-40
Kontur Lens, plano, 16.0–20.0 mm diameter Kontur Kontact Lens Co.

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Chapter 35 Lower eyelid retraction repair with dermis fat
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 CHAPTER 36
Lower eyelid retraction repair
Table 36.1 Indications for surgery
Lower eyelid retraction without need for significant volume
augmentation
Posterior lamellar and/or middle lamellar shortening
Desire for use of autologous graft
INTRODUCTION
The indications and clinical assessment for posterior lamellar
grafting with hard palate mucosa are similar to Chapters 34
and 35. The decision to proceed with hard palate mucosa is
made on several factors. Some patients only prefer using an
autologous graft. From a consumable standpoint, there is also
no additional expense of using a commercially prepared
implant. These are personal decisions that should be discussed
with the patient and surgeon. The remote possibility of a trans-
missible agent from either allografts or xenografts should also
be disclosed. Other autologous grafts that can be used as
posterior lamellar grafts are ear cartilage and nasal cartilage.
with hard palate grafting
Bobby S. Korn • Don O. Kikkawa
Table 36.2 Preoperative evaluation
Quantify amount of eyelid retraction according to MRD2
Assess adequacy of anterior lamella; may need cheek lift or skin
graft if severe shortening is present
Assess eyelid laxity
Assess globe and inferior orbital rim position for presence of
negative vector
Assess orbicularis strength; weakness on closure may portend high
risk of recurrence
Prior eyelid, facial surgery or trauma
Examination of oral mucosa and hard palate donor site for history
of prior oral malignancies
Our preference is for hard palate mucosa as this is easy to
harvest, has an epithelial surface and undergoes minimal post
operative contraction.
The greatest downside of hard palate grafting is donor site
morbidity. It can be painful and possible side effects can be
palatal fistulas and oral candidiasis. A preoperative examination
of the hard palate should be performed prior to considering its
use. The presence of atypical lesions, ulceration, bony protru-
sions (torus palatinus) should be noted and, if present, alternate
grafts such as acellular dermal matrix or dermis fat are dis-
cussed (Chapter 34 and 35). Postoperative fitting with a palatal
obturator can reduce discomfort and aid healing. Patients can
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be directed to a dentist or orthodontist for fabrication of an
obturator preoperatively and this is placed immediately after
graft harvesting. Hard palate grafting also provides minimal
volume and a limited amount of surface area and if additional
soft tissue volume and graft size is desired, consideration
should be given to dermis fat.
Surgical principles for all lower eyelid retraction are similar.
Complete release of the retracted eyelid is mandatory. Place-
ment of the posterior lamellar graft with buried fine sutures,
canthoplasty and, in severe cases, midface lifting with mild
overcorrection and use of a Frost suture are necessary
steps.

SURGICAL TECHNIQUE

A B

C D

Figures 36.1A–D Harvesting of hard palate graft

Hard palate serves as an excellent posterior lamellar spacer graft owing to its epithelialized surface and autologous nature. The harvest is best performed
under local anesthesia with IV sedation as the endotracheal tube may interfere with surgical access. The hard palate is marked on either side of the
midline, while avoiding the nasopalatine and anterior palatine neurovascular branches and the soft palate (Figure 36.1A). Local anesthetic is then
infiltrated. A Yankauer suction tip is available on standby to evacuate blood that may irritate the oropharynx. A #69 or #15 blade is used to make the
mucosal incision (Figure 36.1B). A crescent blade is then used to make a lamellar incision along the hard palate to free it from the underlying tissue
(Figure 36.1C). Care is taken to remove the graft intact as the hard palate has limited availability. Hemostasis is then obtained using a combination of
bipolar cautery, fibrin glue, and/or cellulose polymer dressing (Figure 36.1D). A pre-fashioned hard palate obturator is then placed after achieving
complete hemostasis. The graft is inspected, thinned and placed in wrapped saline gauze for subsequent usage.

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Chapter 36 Lower eyelid retraction repair with hard palate grafting
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 A B

Figures 36.2A and 36.2B Lateral canthotomy and inferior cantholysis

A corneal shield is preplaced before the start of surgery. Access to the lower eyelid is facilitated by a small lateral canthotomy and inferior cantholysis
(Figures 36.2A and 36.2B). The inferior crus of the lateral canthal tendon should be completely released to allow full access to the lower eyelid and
midface. Hemostasis is achieved with bipolar cauterization.

A B

C D

Figures 36.3A–D Inferior transconjunctival incision and arcus marginalis release

Cutting cautery is used to create a transconjunctival incision approximately 2–3 mm below the inferior tarsal border (Figure 36.3A). Westcott scissors are
then used to create a pocket under the conjunctiva towards the inferior edge of the tarsal plate, leaving a cuff of conjunctiva intact (Figure 36.3B). The
hard palate graft will be secured at the inferior tarsal border and the conjunctival cuff will be draped over the graft to promote growth of conjunctival
epithelium over the hard palate graft. Although the hard palate graft is covered with oral mucosal epithelium, this layer likely sloughs within days and will
be replaced by conjunctival epithelium. The dissection then continues in a preseptal plane towards the inferior orbital rim (Figure 36.3C). Cutting cautery
is then used to release the periosteum along the arcus marginalis (Figure 36.3D).

259
 A B

C D

E F

Figures 36.4A–F Cicatricial release and subperiosteal dissection

To protect the overlying skin and globe during the dissection, a Senn retractor is used for anterior distraction of the eyelid while a malleable retractor
posteriorly distracts the orbital fat and protects the globe (Figure 36.4A). Any cicatricial bands in the middle lamella are released with cutting cautery.
Along the inferolateral orbital rim, the orbitomalar ligament has stout attachments to the suborbicularis oculi fat (SOOF). Cutting cautery is used to sweep
along the inferolateral orbit rim to release these ligamentous attachments (Figure 36.4B). Approximately 5 mm below the inferolateral orbital rim, the
zygomaticofacial nerve and vessels emerge from the foramen. Care is taken to preserve these structures during the dissection. If bleeding occurs, gentle
bipolar cautery is applied. Once the orbitomalar ligament has been incised, a subperiosteal release is performed to release any residual attachments
using a Freer elevator (Figures 36.4C and 36.4D). If severe lower eyelid retraction is present (MRD2 > 8 mm), then the subperiosteal dissection is
continued to release the entire midface (Figure 36.4E). Once the subperiosteal dissection is complete, the Freer elevator can be freely swept horizontally
along the midface (Figure 36.4F).

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Chapter 36 Lower eyelid retraction repair with hard palate grafting
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 A B

C D

Figures 36.5A–D Placement of orbitomalar suspension suture

Release of the orbitomalar ligament will allow subsequent suspension to a higher level and counteract any forces which may pull the eyelid down
postoperatively. Adson forceps are used to identify the optimal fixation point on the SOOF for orbitomalar suspension (Figure 36.5A). Superior traction on
the SOOF is performed and the lower eyelid and midfacial contour are noted. If excessive lateral canthal bunching and dimpling occurs, the SOOF
purchase is adjusted. Once an optimal fixation point is determined, the SOOF is imbricated with a 4-0 Vicryl suture (Figure 36.5B). The SOOF will
ultimately be fixed to the periosteum overlying the frontozygomatic suture line. Through a small temporal upper eyelid crease incision, a small, curved
hemostat is then used to bluntly dissect an inferior pocket from the upper eyelid crease to the lower eyelid (Figure 36.5C). This inferior pocket is lateral
to the lateral canthal tendon and should be created in the preperiosteal plane. The SOOF suture is then retrieved through this pocket and left preplaced
(Figure 36.5D).

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 A B

C D

Figures 36.6A–D Placement of hard palate graft

The hard palate graft is sized according to the desired elevation of the lower eyelid. In general, for 1 mm of desired lift, we use 2–3 mm of hard palate
to vertically support the retracted eyelid. After the hard palate graft is thinned with Westcott scissors, the tissue is placed into the inferior fornix with
the mucosal side towards the ocular surface (Figure 36.6A). The posterior edge is secured to the lower eyelid retractors with multiple interrupted
6-0 fast-absorbing gut sutures (Figure 36.6B). Along the anterior edge of the graft, a 6-0 fast-absorbing gut suture is used to perform a running
closure securing the graft edge to the inferior edge of the tarsal plate (Figure 36.6C). The 2 mm conjunctival cuff is left to overlap on the graft surface
(Figure 36.6D).

A B

Figures 36.7A and 36.7B Orbitomalar suspension

After placement of the hard palate graft, the orbitomalar suspension suture is secured to the periosteum overlying the frontozygomatic suture line
(Figures 36.7A and 36.7B). This lift supplies anterior lamella from the subperiosteal dissection and provides an aesthetically pleasing midfacial elevation.

SECTION TWO • EYELID AND FACE

Chapter 36 Lower eyelid retraction repair with hard palate grafting
262
 A B

C D

Figures 36.8A–D Lower eyelid tightening

Lower eyelid laxity is invariably associated with lower eyelid retraction. If significant lower eyelid laxity is present, a tarsal strip procedure can be
performed (Chapter 25). In this case, mild lower eyelid laxity was present and the lower eyelid is tightened by removal of a small wedge of the lateral
eyelid (Figure 36.8A). The canthus is then reconstructed by securing two interrupted 5-0 Vicryl sutures anchoring the lateral tarsus to the superior crus
of the lateral canthal tendon (Figures 36.8B–D). The skin overlying the canthus is closed with interrupted 6-0 fast-absorbing gut suture. If the upper and
lower eyelids are not properly aligned, the eyelid is resecured. To reinforce a sharp canthal angle, a buried 7-0 Vicryl suture can optionally be placed
through the gray lines of the upper and lower eyelid.

A B

Figures 36.9A and 36.9B Frost suture placement

At the conclusion of the case, one to two Frost sutures are placed for upward traction of the lower eyelid. Double-armed 5-0 Prolene sutures on a
tapered C-1 needle are passed through the gray line of the lower eyelid and upper eyelid and then secured above the brow (Figure 36.9A). Foam
bolsters can be cut from the suture needle box and placed over the Prolene to prevent cheese-wiring through the skin. A pressure patch is placed and
the Frost sutures are removed 1 week postoperatively (Figure 36.9B).

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 BILATERAL LOWER EYELID RETRACTION REPAIR
WITH HARD PALATE GRAFTING

Preoperative Postoperative

Figure 36.10 Before and after lower eyelid retraction repair with hard palate grafting
This 48-year-old female was referred for treatment of lower eyelid retraction. She underwent transcutaneous lower blepharoplasty 10 years ago
elsewhere and noted foreign body sensation and tearing in both eyes. She underwent lower eyelid retraction repair with lysis of the middle lamellar
cicatrix, orbitomalar suspension, and placement of a hard palate graft. Postoperatively, she has marked improvement in her lower eyelid retraction with
resolution of her ocular surface complaints.

Table 36.3 Complications

Complications
Granuloma in eyelid at graft site
Donor site pain
Recurrent eyelid retraction
Canthal rounding
Bleeding at palatal donor site
Suggestions to reduce risk
Primary intention healing desired; use finer sutures with buried knots
Use of prefabricated palatal obturator
Inadequate release of cicatrix; undersized graft; Frost suture removed too early; overcorrection desired
in early postoperative period
Must insert canthal tendon to firm periosteal attachment; consider drill hole for most firm fixation
(Chapter 28)
Pack donor site with cellulose polymer sheets (Surgicel, between the obturator and hard palate);
application of bipolar cautery in atypical cases; control of pain and blood pressure; use of fibrin glue

Table 36.4 Consumables used during surgery

4-0 Vicryl, PC-1 needle Ethicon #J835G
5-0 Vicryl, PC-3 needle Ethicon #J844G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG140-8 needle Ethicon #J546G
Crescent knife Beaver-Visitec #373807
Kendall Devon Skin Marker Fine Tip #151
Surgicel© absorbable hemostat Ethicon

SECTION TWO • EYELID AND FACE

Chapter 36 Lower eyelid retraction repair with hard palate grafting
264
 CHAPTER 37
Lower eyelid wedge resection
Table 37.1 Indications for surgery
Reconstruction after excision of eyelid neoplasm
Focal trichiasis refractory to epilation or lash follicle destruction
Need for lower eyelid tightening
Repair of traumatic eyelid laceration
Correction of irregular eyelid margin contour (congenital or
secondary to prior surgery such as eyelid margin destruction after
cryotherapy)
INTRODUCTION
Wedge resection of the eyelid can be utilized for removal of
diseased segments of the eyelid from neoplasm and trichiasis
and even for tightening of eyelid laxity. Most commonly, wedge
resection with reconstruction of eyelid is used for reconstruc-
tion after removal of cutaneous malignancies.
Eyelid lesions can range from benign cysts and inflammatory
lesions (hordeolums/chalazions) to malignancies. Although
clinical examination can be extremely helpful in diagnosing
typical eyelid lesions (cysts, nevi, papillomas), other more atypi-
cal lesions are often hard to differentiate by clinical exam alone.
Furthermore, certain conditions such as sebaceous cell carci-
noma can masquerade as a chalazion or chronic blepharitis.
Approximately 10% of all skin malignancies present on
the eyelid. Of these, the highest incidence is basal cell carci-
noma, followed by squamous cell carcinoma, sebaceous cell
and reconstruction
Patrick Yang • Bobby S. Korn
Table 37.2 Preoperative evaluation
History of trauma, prior surgery, cancer
Involvement of punctum/proximal lacrimal drainage system,
particularly for neoplasms and trauma
Biopsy of any suspicious lesions
Anterior/posterior lamellar deficiencies
Associated eyelid malpositions – ectropion/entropion/eyelid
retraction/lagophthalmos
Degree of lower eyelid laxity
carcinoma, and malignant melanoma. Biopsy with pathological
analysis is the only definitive way to determine the etiology of
an unknown eyelid lesion.
Generally, a lesion involving one-third of the eyelid margin or
less can be approached using wedge resection and direct
closure/reconstruction of the eyelid. Defects greater than 50%
may require a semicircular or pedicle-based flap (Chapters
38–43). A complete history is necessary, including the chronic-
ity of a lesion, associated symptoms, discharge, pain, bleeding,
and family history of skin malignancies. In trauma and lacera-
tions, it is important to determine the mechanism of injury and
if the tetanus vaccine status is current. It is also prudent to
determine if the patient is on anticoagulants or has a clotting
disorder.
A complete ocular examination is also necessary. One should
examine the eyelid margins and lesion for size, depth, extent,
involvement of anterior/posterior lamellae, bulbar/palpebral
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conjunctival, punctal, canalicular and lacrimal drainage system.
Furthermore, one should examine for madarosis, trichiasis,
vascularization, irregularities, pigmentation, ulceration, entro-
pion, ectropion, and eyelid laxity. Lymph nodes (including pre-
auricular, submandibular, and cervical nodes) should be
palpated for any evidence of metastases. Photographic docu-
mentation of the eyelid lesion before biopsy, intraoperatively
and postoperatively are highly recommended.
A meticulous, layered closure with restoration of normal
anatomy is essential to maximize form and function after wedge
excision and reconstruction. The eyelid margin is repaired with
silk sutures which provide strength and induce enough inflam-
mation to ensure adequate healing while minimizing irritation of
the ocular surface.

SURGICAL TECHNIQUE

A B

Figures 37.1A and 37.1B Marking of eyelid

This patient presents with a central, ulcerated nodule on the left lower eyelid. A shave biopsy demonstrated basal cell carcinoma. A pentagon-shaped
wedge is marked in the area to be removed to encompass at least 2 mm of normal-appearing tissue (Figure 37.1A). The marking is made obliquely to
facilitate eversion of the lid margin upon reconstruction. As this case involves a basal cell carcinoma, frozen sections are sent from each of the margins
as shown in Figure 37.1B. Frozen section analysis is acceptable for basal cell and squamous cell carcinomas, but melanoma and sebaceous cell
carcinoma requires permanent section and staged reconstruction (Chapter 43). Once margins have been cleared by pathology, eyelid reconstruction
commences. If eyelid reconstruction is to be performed after the Mohs micrographic excision of a tumor, the scalloped defect is converted into a
pentagon for reconstruction.

SECTION TWO • EYELID AND FACE

Chapter 37 Lower eyelid wedge resection and reconstruction
266
 A B

Figures 37.2A–C Wedge resection of eyelid

A large chalazion clamp is placed over the segment for excision (Figure 37.2A). The clamp is useful for manipulation of the eyelid, hemostasis intraop-
eratively and protecting the cornea. Ophthalmic ointment is applied on the backside of the clamp facing the cornea. When excising the inferior eyelid
margin, the vertical height of the marking should extend to 4 mm to account for the vertical height of the tarsal plate. The apex extends 2 mm beyond
the tarsal plate. For excisions of the superior tarsal plate, the upper eyelid should be everted and the height of the segment to be removed is measured.
The height of the marking should take into account the entire vertical dimension of the tarsal plate. The vertical markings are incised full thickness with a
#15 blade (Figure 37.2B). The apex of the pentagon is excised with a straight iris scissor (Figure 37.2C). For neoplasm excision, the instruments used
during the removal are taken from the surgical field during reconstruction to minimize oncologic contamination. In the case of primary excision of a
malignancy, 2 mm margins are sent from each of the cut edges as shown in Figure 37.1B. After excision of the margins, careful bipolar cautery is
applied to the cut edges for hemostasis. Cauterization should not be performed before excision of margins, as the thermal damage to the tissue will
obscure accurate histopathologic examination. Once the margins are reported free of tumor, eyelid reconstruction is performed.

267
 A B

Figures 37.3A–C Reapproximation of mucocutaneous junction

Primary closure is the preferred management after wedge resection of the eyelid. Toothed forceps are used to grasp and approximate the cut edges of
the tarsal plate. If the tarsus can be reapproximated with minimal tension, primary closure is performed. If there is a 2–4 mm deficiency, an internal
lateral cantholysis can be performed to facilitate closure. If a greater than 4 mm deficiency is present, a semicircular flap should be utilized (Chapter 39).
First, the mucocutaneous junction is reapproximated (Figure 37.3A). A 6-0 silk suture on a small G-7 semicircle needle is used for margin reconstruction
(Figure 37.3B). A single surgeon’s knot is placed but the suture is not permanently tied off (Figure 37.3C). Once the remaining margin sutures are
placed, the mucocutaneous junction suture is re-evaluated and adjusted for alignment if necessary. All silk sutures placed in the eyelid margin are left
long and subsequently secured to the adjacent eyelid.

SECTION TWO • EYELID AND FACE

Chapter 37 Lower eyelid wedge resection and reconstruction
268
 A B

C D

Figures 37.4A–D Reapproximation of lash line

Next, a 6-0 silk suture is used to reapproximate the lash line (Figures 37.4A and 37.4B). Deep everting bites are taken through the tarsal plate to ensure
eversion of the eyelid margin (Figures 37.4C and 37.4D). Once the alignment is deemed to be optimal, the suture is permanently tied off. Slight eversion
of the eyelid margin is important, as postoperative wound contraction will result in a smooth eyelid margin. Failure to achieve eversion will result in a
depressed notch in the eyelid, which is aesthetically displeasing.

269
 A B

Figures 37.5A and 37.5B Reapproximation at gray line

The final eyelid margin suture placed is at the gray line (Figures 37.5A and 37.5B). The eyelid margin should be well-aligned at this point and this suture
should further reinforce the eyelid eversion. Once the gray line suture is secured, the silk suture at the mucocutaneous junction is tightened and
permanently tied off.

Figure 37.6 Reapproximation of tarsal plate
Repair of the tarsal defect provides important structural support after the
silk sutures are removed postoperatively. Two interrupted 7-0 Vicryl
sutures are placed through the inferior tarsal plate in a partial thickness
fashion (Figure 37.6). Care is taken to place a lamellar pass through the
tarsus as a full thickness pass will cause corneal irritation. For upper
eyelid reconstructions, three to four sutures are placed to reapproximate
the tarsal plate. The sutures should be spaced 1–1.5 mm from the cut
edges and tied with enough tension to approximate, but not buckle, the
tarsal plate.
Figure 37.7 Reapproximation of conjunctiva and orbicularis
Next, the conjunctiva and orbicularis are reapproximated with interrupted
7-0 Vicryl sutures (Figure 37.7). The conjunctiva is closed deep in the
fornix with an interrupted suture. The forniceal closure is typically deep
enough that the full thickness pass does not cause corneal irritation. The
orbicularis is closed with multiple interrupted sutures in a circular fashion.

SECTION TWO • EYELID AND FACE

Chapter 37 Lower eyelid wedge resection and reconstruction
270
Figure 37.8 Closure of skin
At the inferior edge of the vertical skin closure, a redundant standing cone
deformity (dog ear) may be present. This is conservatively excised with a
Burow’s triangle and then the skin is closed with several interrupted 6-0
Prolene or 6-0 fast-absorbing gut sutures (Figure 37.8).
Figure 37.9 Fixation of silk suture
The long ends of the silk suture are then secured to the lower eyelid away
from the ocular surface. At 1 week postoperatively the Prolene sutures are
removed and at the 2 week postoperative visit the silk sutures are
removed. The patient is instructed to avoid eye rubbing and to wear an
eye shield at night.

LOWER EYELID WEDGE RESECTION AND RECONSTRUCTION

Intraoperative Postoperative

Figure 37.10 Before and after lower eyelid wedge resection and reconstruction
This 64-year-old patient presented with recurrent bleeding and ulceration of the left lower eyelid. A shave biopsy demonstrated basal cell carcinoma. A
wedge excision of the lower eyelid followed by frozen tissue margin clearance was performed. The defect measured at over 50% of the eyelid. Owing to
the patient’s age and eyelid laxity, primary closure was achieved without the need for a lateral cantholysis or semicircular flap.

271
Table 37.3 Complications
Complications
Misalignment of eyelid margin
Eyelid margin notch
Corneal abrasion
Wound dehiscence
Suggestions to reduce risk
Reapproximate tarsal plate along its vertical axis with multiple sutures to ensure structural integrity,
alignment, and healing; consider re-excision of small wedge
Oblique incision of pentagonal wedge will facilitate proper eversion of eyelid margin; consider adjunct
lateral cantholysis if wound is under excessive tension
Ensure that silk sutures are directed away from the ocular surface by securing to the lower eyelid; check
tarsal plate to verify that Vicryl sutures were placed partial thickness; consider placement of bandage
contact lens
Usually due to closure under excessive tension; consider adjunct lateral cantholysis or semicircular flap
advancement to facilitate eyelid repair avoid eye rubbing; place eye shield while sleeping

Table 37.4 Consumables used during surgery

7-0 Vicryl, TG140-8 needle Ethicon #J546G
6-0 silk, G-7 needle Ethicon #765G
6-0 Prolene, C-1 needle Ethicon #8718

SECTION TWO • EYELID AND FACE

Chapter 37 Lower eyelid wedge resection and reconstruction
272
 CHAPTER 38
Lower eyelid reconstruction
with periosteal flap and upper
Table 38.1 Indications for surgery
Lower eyelid defect from skin cancer removal (30–50% defect)
Scarring or notching of eyelid
Focal entropion or madarosis causing functional or aesthetic
concerns
INTRODUCTION
The size and location of eyelid defects typically dictate the
reconstructive options available to the surgeon. Defects that
are less than 25% typically can be closed primarily. The bi-
lamellar anatomical structure of the eyelids allows the surgeon
a multitude of choices to restore structure, function, and
optimal appearance.
Anatomically, the redundant vascular supply permits random
anterior lamellar flaps. A dual vascular arcade supplies the
eyelid, one located at the eyelid margin and the other peripher-
ally along the tarsal border. This has adjacent collateral contri-
butions from the supply of the medial palpebral artery from the
angular and the zygomatico-orbital branch of the superficial
temporal artery. The rich vascular flow to the periocular region
enables creative flap construction that is unparalleled in other
areas of the body.
eyelid rotational flap
Don O. Kikkawa • Bobby S. Korn
Table 38.2 Preoperative evaluation
Size and dimensions of defect
Age of patient
Eyelid laxity and availability of upper eyelid redundancy
History of eyelid, facial surgery or trauma (prior upper
blepharoplasty may limit availability of adjacent tissue flap)
A central continuous lash-bearing segment typically gives the
best aesthetic result. It is less conspicuous if the non-lash-
bearing segment is located laterally and not centrally. For this
reason, with lower eyelid defects greater than 50% of the eyelid
margin not involving the canthus, the semicircular flap is typi-
cally our preferred approach (Chapter 39).
In cases of larger defects with lateral canthal involvement,
several possibilities exist. Some of the options are: tarsocon-
junctival pedicle from the upper eyelid with anterior lamellar flap
(Chapter 40); full thickness skin graft (Chapter 27); Mustardé
cheek rotational flap (Chapter 41); and free posterior lamellar
graft with periocular adjacent anterior lamellar flap (Chapter 43).
If the surgeon is using an upper eyelid pedicle flap, orbicularis
can also be transferred for additional volume.
The periosteum along the lateral orbital rim is unique in that
it provides an anchor point for the medial eyelid remnant and
273
can serve as the posterior lamella. It can be harvested and
shaped to fit a particular-sized defect and provides adequate
vascularity to support a free skin graft if necessary. If an anterior
lamellar flap is used, an additional vascular supply is provided.
The periosteal flap can also be used to reconstruct the inferior
fornix as the palpebral conjunctiva can be advanced superiorly
and secured to the inferior portion of the periosteal flap.
The advantages of the procedure include: the recreation of
the normal bi-lamellar lid structure, an unoccluded visual axis
for use in monocular patients, and an excellent aesthetic
appearance. The disadvantages include: a non-cilia-bearing
reconstructed eyelid segment laterally, and the potential for
notching or scarring at the reconstructed juncture of the native
and advanced eyelid segments.

SURGICAL TECHNIQUE

$ %

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Figures 38.1A–D Excision of eyelid carcinoma

This patient has a biopsy-proven basal cell carcinoma involving the right lower eyelid and lateral canthus. Options for excision include Mohs micrographic
excision or direct excision with intraoperative frozen section controls. This patient opted for direct excision with frozen sections. A skin marker is used to
outline the gross tumor margins with 1–2 mm of additional margins around the circumference of the lesion (Figure 38.1A). This continues to the lateral
aspect of the right lower eyelid extending from the lateral canthal angle. To excise the tumor, the medial aspect of the tumor is first incised with sharp
iris scissors. This is a full thickness incision incorporating skin, orbicularis, tarsus, and conjunctiva. The full vertical height of the tarsus is incised (Figure
38.1B). The incision in the lateral aspect of the tumor margin is then made (Figure 38.1C). From the canthal angle laterally, the incision is made in skin
and muscle. The inferior horizontal incisions are then connected and full thickness incisions are then made. The tumor with appropriate margins is then
removed and sent to pathology. Additional frozen sections of the margins are sent for intraoperative clearance. Reconstruction is delayed until tumor-free
margins are obtained (Figure 38.1D). The resultant defect is approximately 40% of the eyelid.

SECTION TWO • EYELID AND FACE

Chapter 38 Lower eyelid reconstruction with periosteal flap and upper eyelid rotational flap
274
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( )

Figures 38.2A–F Incision of periosteal flap

The lateral rim periosteum is then marked. Typically the flap should measure a minimum of 6 mm in vertical height and the upper edge of the periosteal
flap should be located just at the insertion of the superior crus of the lateral canthal tendon (Figure 38.2A). First, a #15 blade is used to incise the
superior marking down to the level of the bone (Figure 38.2B). The preperiosteal soft tissue can be distracted inferiorly, leaving the firmly adherent
periosteum at the incision line (Figure 38.2C). Westcott scissors are used to clear all residual preperiosteal tissue, leaving the intact periosteum (Figures
38.2D and 38.2E). Care is taken not to incise or injure the periosteal flap. Once dissection is complete and preperiosteal soft tissues have been cleared,
a crescent or #15 blade is used to release the flap posteriorly (Figure 38.2F). It is preferential to allow for a few millimeters of extra horizontal length
rather than to make the flap too short.

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Figures 38.3A–D Elevation of periosteal flap

The periosteal flap is then elevated from its most lateral extent on the zygoma. A Freer elevator is used to gently dissect the periosteal flap off of the
bone (Figure 38.3A). When performing the elevation, it is critical to keep the periosteum intact as a strong continuous band of tissue. The Freer elevator
is used to score the bone in a lateral-to-medial direction with the curved face down towards the bone (Figure 38.3B). This prevents vertical transection of
the periosteal flap if the elevator is inadvertently lifted. As the flap is elevated, it is rotated medially to approximate the tarsal defect. Maintaining the
attachment at the arcus marginalis is critical for vascularization and anchoring of the newly reconstructed eyelid to the lateral orbital rim. Dissection can
continue for several millimeters internally along the lateral orbital rim if necessary for additional length (Figure 38.3C). The periosteal flap should be able
to reach the medial eyelid segment freely and without tension once elevation is complete (Figure 38.3D).

SECTION TWO • EYELID AND FACE

Chapter 38 Lower eyelid reconstruction with periosteal flap and upper eyelid rotational flap
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( )

Figures 38.4A–F Posterior lamellar reconstruction with periosteal flap

First, the cut edge of the tarsal plate is united with the periosteal flap. A 6-0 Vicryl suture is then placed in a partial thickness fashion through both the
medial tarsal remnant and the periosteal flap (Figure 38.4A). A total of two sutures are placed, one at the superior pole of the tarsal plate and one at the
inferior pole (Figures 38.4B and 38.4C). Next, the inferior cul-de-sac is reformed by reinserting the lower eyelid retractors. Several interrupted 6-0 Vicryl
sutures are passed from the cut edge of the lower eyelid retractors to the inferior border of the periosteal flap (Figure 38.4D). Once complete, the inferior
fornix should be formed with nice approximation of the periosteal flap and lower eyelid retractors (Figure 38.4E and 38.4F).

277
 A B

C D

Figures 38.5A–E Elevation of upper eyelid rotational flap

The patient has ample upper eyelid dermatochalasis. Prior to infiltration of local anesthesia, the pinch technique is used to determine the appropriate
amount of skin redundancy. During the skin preparation and surgery, the marking may have faded and needs to be redrawn (Figure 38.5A). Nasally, the
upper mark tapers to join the lid crease mark. Laterally, the two marks are kept parallel and widened slightly to allow for transfer and survival of the
upper eyelid flap. Figure 38.5B shows an overlay with the dual vascular arcade and collateral arterial supply of the eyelid. Laterally based pedicle flaps
have contributions from branches of the superficial temporal artery. A #15 blade is used to incise the skin (Figure 38.5C). The pedicle-based flap is
supplied laterally and both trauma and transection must be avoided in this region. Westcott scissors are used to dissect the flap with both skin and
orbicularis layers being raised in the flap (Figures 38.5D and 38.5E). The orbicularis is left intact to reduce the loss in volume caused by the removal of
the anterior lamellae during the excision of the carcinoma.

SECTION TWO • EYELID AND FACE

Chapter 38 Lower eyelid reconstruction with periosteal flap and upper eyelid rotational flap
278
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Figures 38.6A–E Advancement of upper eyelid rotational flap

After complete dissection with preservation of the lateral flap attachment, the flap should be free to rotate into the lower eyelid defect. If redundant, the
extra skin and orbicularis can be trimmed (Figure 38.6A). The orbicularis muscle is then secured with the use of buried 7-0 Vicryl sutures at several
locations along the superior and inferior aspects of the periosteal flap (Figures 38.6B and 38.6C). Along the upper border of the periosteal flap, buried
7-0 Vicryl sutures should be placed through the periosteal flap and the orbicularis at the superior border of the flap (Figures 38.6D and 38.6E). Once
complete, the flap should rest tension free along the lower eyelid.

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Figures 38.7A–D Skin closure of both upper and lower eyelids

A running 6-0 fast-absorbing gut suture is then used to close the upper eyelid defect (Figure 38.7A). This suturing simulates the blepharoplasty-type
closure. A separate 6-0 fast-absorbing gut running closure is performed along the lower border of the pedicle-based skin flap (Figure 38.7B). Interrupted
6-0 fast-absorbing sutures are used to approximate the medial aspect of the flap and the lateral canthus (Figures 38.7C and 38.7D).

SECTION TWO • EYELID AND FACE

Chapter 38 Lower eyelid reconstruction with periosteal flap and upper eyelid rotational flap
280
 RECONSTRUCTION OF LOWER EYELID WITH
PERIOSTEAL FLAP AND UPPER EYELID ROTATIONAL FLAP

Preoperative Intraoperative

B
Intraoperative Postoperative

Figures 38.8A and 38.8B Before and after lower eyelid and lateral canthal reconstruction
This 72-year-old female has a basal cell carcinoma of her right lower eyelid involving the eyelid margin up to the lateral canthus. The intraoperative view
shows a 40% lower eyelid defect including the lateral canthus (Figure 38.8A). In Figure 38.8B, the immediate intraoperative view is shown on the left
panel and on the right panel, the postoperative view shows an excellent result at 12 months following surgery.

281
Table 38.3 Complications
Complications
Notching of eyelid
Corneal abrasion
Eyelid retraction
Lagophthalmos
Necrosis of flaps
Hemorrhage
Scarring
Wound dehiscence
Suggestions to reduce risk
Careful alignment of periosteal flap and pedicle-based upper eyelid flap to medial lower eyelid remnant
Ensure sutures are passed in a lamellar fashion and not full thickness
Ensure adequate length of both periosteal and upper eyelid flaps
Avoid harvesting too much skin from upper lid and injury to zygomatic branches supplying orbicularis oculi
Avoid excessive trauma when harvesting; keep width of flaps a minimum of 6 mm or more to avoid vascular
insufficiency
Proper hemostasis; cessation of anticoagulant usage prior to surgery
Keep wound tension minimized with layered closure; avoid excessive cautery
Make sure knots tied with appropriate tension with adequate soft tissue incorporation; avoid smoking, lifting, and
bending; use of eye shield; avoid manipulation of wound

Table 38.4 Consumables used during surgery

6-0 Vicryl, double-armed S-29 needle Ethicon #J555G
7-0 Vicryl, TG140-8 needle Ethicon #J546G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G

SECTION TWO • EYELID AND FACE

Chapter 38 Lower eyelid reconstruction with periosteal flap and upper eyelid rotational flap
282
 CHAPTER 39
Lower eyelid reconstruction
with semicircular flap
Table 39.1 Indications for surgery
Upper or lower eyelid defect from skin cancer removal
Scarring or notching of eyelid
Focal entropion or madarosis causing functional or aesthetic
concerns
INTRODUCTION
Reconstruction of eyelid defects requires the surgeon to have an
artistic intuition with regard to balancing structure, function and
aesthetics. Many factors will shape the final decision as to the
type and technique of reconstruction. This is influenced by the
age of the patient, degree of skin and eyelid laxity, visual factors
(monocular versus binocular status), and surgeon preference.
The goals of any eyelid reconstruction should be to recreate
the bi-lamellar structure with a smooth eyelid margin and
contour, preservation of the normal vertical excursion and
appropriate horizontal tension. Depending on the amount of
horizontal laxity, a semicircular flap can be useful in defects
ranging in size from 30 to 60% of the horizontal eyelid length.
Don O. Kikkawa • Bobby S. Korn
Table 39.2 Preoperative evaluation
Size and dimensions of defect
Age of patient
Eyelid laxity
Prior eyelid, facial surgery or trauma
With greater amounts of laxity, even larger defects can be
reconstructed.
Originally described by Tenzel in 1975, the semicircular flap
remains a workhorse in the surgical repertoire for both upper
and lower eyelid reconstruction. The advantages of the pro-
cedure include the re-creation of the normal bi-lamellar eyelid
architecture without the use of grafts, an unoccluded visual
axis for use in monocular patients and optimum cosmesis.
The disadvantages include the potential for scarring in the
soft tissues lateral to the canthus, a non-cilia-bearing recon-
structed eyelid segment laterally, and the potential for notching
at the reconstructed juncture of the native and advanced
eyelid segments.
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SURGICAL TECHNIQUE

$ %

Figures 39.1A and 39.1B Skin marking

The semicircular flap is ideally suited to reconstruct eyelid defects up to 50% (Figure 39.1A). To reconstruct a lower eyelid defect, a superiorly arcing
semicircle is drawn lateral to the lateral canthus (Figure 39.1B). For upper eyelid defects, the arc should be oriented inferiorly. The lateral extent of the
mark should be just inside the brow. It is important to create an arc radius of at least 1.5 cm as the arc will flatten as the semicircular flap is advanced.

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Figures 39.2A and 39.2B Skin incision and flap development

A skin incision is made with a #15 Bard-Parker blade (Figure 39.2A). As the incision travels further away from the canthus, the skin transitions to the
thicker section near the brow. Because of this, the thickness of the flap will vary, being thinner and consisting of only skin and muscle near the canthus
to incorporating the subcutaneous fat plexus near the brow. It is important to raise as thick a flap as possible (Figure 39.2B). The canthal apparatus
should remain intact during flap creation.

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Chapter 39 Lower eyelid reconstruction with semicircular flap
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 A B

C D

Figures 39.3A–D Canthotomy and inferior cantholysis

For the semicircular flap to be rotated and advanced medially, the attachments of the eyelid to the orbital rim via the lateral canthal ligaments must be
released. The lateral canthotomy is first performed to divide the canthal ligament into superior and inferior crura (Figure 39.3A). The inferior cantholysis
is then performed between the layers of the skin and palpebral conjunctiva. It is important to preserve both layers while lysing the inferior crus (Figure
39.3B), as the skin and palpebral conjunctiva will eventually become the anterior and posterior lamellae of the newly created eyelid margin as the
semicircular flap is advanced. It is important to perform the lateral canthotomy and inferior cantholysis to allow the semicircular flap to be rotated
medially. By advancing the semicircular flap medially, any residual attachments can be palpated and lysed (Figure 39.3C). Once lysis of attachments is
complete, tension-free approximation of the flap and the medial eyelid segment can be obtained (Figure 39.3D).

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Figures 39.4A–D Eyelid margin repair

The eyelid margin is then closed surgically in a layered fashion. A 6-0 silk suture is first placed at the mucocutaneous junction (Figure 39.4A). This is
located just posterior to the Meibomian gland orifices. The second suture is placed at the lash line (Figure 39.4B). The third suture is placed at the gray
line (Figure 39.4C). The ends of all three sutures are kept long to fixate on the lower eyelid skin to avoid suture tags from rubbing on the cornea. At the
conclusion of the eyelid margin repair, there should be slight eversion of the wound to account for postoperative contraction (Figure 39.4D).

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Figures 39.5A–C Closure of the anterior and posterior lamellae

Next, the posterior lamella is reapproximated. A 7-0 Vicryl suture is used in a lamellar fashion through edges of the medial and lateral tarsal remnants
(Figure 39.5A). Partial thickness passes are essential to avoid corneal and conjunctival abrasions. The conjunctiva of the inferior fornix is then approxi-
mated, also using 7-0 Vicryl sutures (Figure 39.5B). The orbicularis oculi is then closed. This is performed using 7-0 Vicryl suture with interrupted knots.
The orbicularis closure can be done as a buried interrupted stitch or a circular stitch as depicted (Figure 39.5C). After layered closure, the skin is closed
with 6-0 fast-absorbing sutures. Non-absorbable sutures can also be used and are removed 1 week postoperatively.

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Figures 39.6A–D Flap anchoring and skin closure

Anchoring of the flap to the periosteum of the lateral orbital rim is accomplished with a Vicryl suture. This attachment will create the horizontal stability of
the eyelid and simulate the function of the lateral canthal tendon. The suborbicularis oculi fat is advanced to the periosteum with a 5-0 Vicryl suture
(Figures 39.6A and 39.6B). Layered closure of the flap is then performed. The subcutaneous layer is then approximated with 5-0 Vicryl sutures in an
interrupted fashion with buried knots (Figure 39.6C). The skin is then closed with 6-0 fast-absorbing gut suture in a running fashion (Figure 39.6D).

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Figures 39.7A–D Excision of Burow’s triangle and fixation of silk suture ends
A small amount of skin redundancy may be present at the inferior aspect of the vertical wound closure. This can be removed in a similar fashion to a
Burow’s triangle and closed with an interrupted skin suture (Figures 39.7A and 39.7B). The long ends of the silk suture are then fixated to a looped 6-0
silk suture at the inferior-most aspect of the vertical wound closure (Figures 39.7C and 39.7D). This is performed to avoid corneal irritation and abrasion
from the suture tags.

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Figures 39.8A–C Approximation of anterior and posterior lamellae of the newly reconstructed eyelid margin
An important aspect of the reconstruction is to join the anterior and posterior lamellar layers of the newly reconstructed lateral eyelid segment. This is
accomplished by using a 6-0 fast-absorbing gut suture in a horizontal mattress fashion. The suture starts externally and is passed full thickness through
both anterior and posterior lamellae (Figures 39.8A and 39.8B). The needle is then reversed and passed from posterior to anterior (Figure 39.8C). The
suture is then tied on the skin. Two to three of these sutures are placed.

RECONSTRUCTION OF LOWER EYELID DEFECT WITH SEMICIRCULAR FLAP

Preoperative Postoperative

Figure 39.9 Before and after lower eyelid reconstruction with semicircular flap
This 77-year-old female underwent removal of a lower eyelid squamous cell carcinoma. The resultant defect was approximately 50% and was recon-
structed with a semicircular flap.

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Chapter 39 Lower eyelid reconstruction with semicircular flap
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Table 39.3 Complications
Complications Suggestions to reduce risk
Corneal abrasion Place mucocutaneous suture more anterior; keep suture ends long and secure on anterior lamella to avoid
rubbing on cornea
Depressed segment of newly Keep semicircle radius arched high; harvest thicker semicircular flap
created eyelid margin
Hemorrhage Proper hemostasis; cessation of anticoagulant usage prior to surgery
Eyelid retraction Defect likely too large for procedure choice; reconsider choice of semicircular flap
Notching of eyelid Wound eversion during closure of eyelid margin
Scarring Keep wound tension minimized with layered closure; avoid excessive cautery
Suture granuloma Use non-absorbable sutures, recognize granulomas early, remove suture if symptomatic and treat with
antibiotic/steroid ointment
Wound dehiscence Make sure knots tied with appropriate tension with adequate soft tissue incorporation; avoid smoking,
lifting and bending; use of eye shield; avoid manipulation of wound

Table 39.4 Consumables used during surgery

5-0 Vicryl suture, C-1 needle Ethicon #8718
6-0 silk suture, TG140-8 needle Ethicon #1732G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG140-8 needle Ethicon #J546G

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CHAPTER 40
Lower eyelid reconstruction with
Hughes’ tarsoconjunctival flap
Lee Hooi Lim • Bobby S. Korn
Table 40.1 Indications for surgery
Reconstruction of large full thickness defects of the lower eyelid
INTRODUCTION
Total defects of the lower eyelid often result from wide excision
of lower eyelid malignancies such as melanoma, squamous cell
carcinoma, basal cell carcinoma and Merkel cell carcinoma.
The resultant defects can encompass the entire lower eyelid
and may involve the proximal lacrimal drainage system. Recon-
struction of these defects is guided by the goal of reconstruct-
ing the bi-lamellar nature of the lower eyelid and lacrimal system
if needed.
The size of the defect and degree of lower eyelid laxity
dictate the reconstructive options. Small lower eyelid defects
of less than 33% or slightly larger defects with significant
lower eyelid laxity may be repaired by direct closure (Chapter
37). An adjunctive lateral canthotomy and cantholysis can
be performed to yield an additional 2–3 mm of laxity needed
to close defects primarily. Larger defects greater than 50%
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Chapter 40 Lower eyelid reconstruction with Hughes’ tarsoconjunctival flap
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Table 40.2 Preoperative evaluation
Size and dimensions of lower eyelid defect
Involvement of proximal canalicular system
Eyelid laxity
Prior eyelid, facial surgery or trauma
Evaluation of donor site for full thickness skin graft (upper eyelid,
pre-/retroauricular, supraclavicular, inner arm)
Visual function of both eyes (monocular status)
History of smoking/tobacco use
can be closed with a semicircular flap (Chapter 39). Lower
eyelid defects greater than 80% usually require reconstruc-
tion with a tarsoconjunctival flap with full thickness skin
graft or a Mustardé rotational flap for the anterior lamella
(Chapter 41).
Wendell Hughes originally described reconstruction of the
lower eyelid using an upper eyelid tarsoconjunctival flap that
was split at the eyelid margin. The anterior lamellar deficit was
supplied by advancement of the cheek. At 3 months post-
operatively, the flap was divided and inset. Hughes’ original
tarsoconjunctival flap was complicated by upper eyelid retrac-
tion and entropion after division of the pedicle. Today, most
surgeons perform a modification of Hughes’ original descrip-
tion by raising a tarsoconjunctival flap at least 4 mm from
the eyelid margin and reconstructing the anterior lamella with
a full thickness skin graft or adjacent pedicle-based flap.
Preservation of the inferior 4 mm of the tarsus along with the
eyelid margin maintains structural support of the upper eyelid.
The blood supply for the full thickness skin graft is derived
from the tarsoconjunctival flap of the upper eyelid and this
can be augmented with an adjacent orbicularis flap. The tar-
soconjunctival pedicle is typically separated at 4–6 weeks after
the initial operation. Patients should be strictly advised to stop
smoking.
In patients who are monocular, with the seeing eye on the
reconstructed side, a Hughes’s tarsoconjunctival flap will effec-
tively render the patient blind until the pedicle is severed. A
non-eyelid sharing procedure such as a free tarsal graft with
adjacent tissue flap, for example as a semicircular flap or Mus-
tardé, may be more appropriate. Likewise, children under the
age of 8 should undergo non-eyelid sharing procedures to
minimize risk of occlusion amblyopia.

SURGICAL TECHNIQUE

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Figures 40.1A–D Marking of tarsal plate

This patient has a full thickness lower eyelid defect greater than 80% including the inferior canaliculus after excision of a basal cell carcinoma
(Figure 40.1A). If a scalloped wound is present after Mohs micrographic excision, the edges are squared off to create a rectangular defect. The Hughes’
tarsoconjunctival flap is a suitable technique for the reconstruction of the posterior lamellar defect in this case. For reconstruction of the inferior
canalicular system, refer to Chapter 62 for silicone stent placement using the pigtail catheter. Prior to reconstruction, the upper tarsal plate is everted
with a Desmarres retractor and evaluated for vertical and horizontal adequacy (Figure 40.1B). On average, the tarsal plate is 12 mm in height, as in this
case. In patients with multiple or recurrent periocular neoplasms, prior tarsal splitting procedures may have been previously performed without the
patient’s knowledge. This patient has a virgin tarsal plate. Local anesthetic consisting of 1% lidocaine, 1 : 200,000 epinephrine and 0.25% bupivacaine is
given transcutaneously. A 4 mm mark is made from the central eyelid margin and extended horizontally to encompass the estimated size of the lower
eyelid defect (Figures 40.1C and 40.1D). Leaving the inferior 4 mm of the tarsal plate and keeping the eyelid margin intact significantly minimize the risk
of postoperative eyelid malpositions.

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Figure 40.2A–C Incision of tarsal plate

Prior to tarsal incision, additional local anesthetic can be given in the pretarsal plane for hydrodissection and hemostasis. A #15 blade is used to make a
horizontal incision along the tarsal plate (Figure 40.2A). The tarsus is incised in a full thickness fashion until the pretarsal orbicularis is exposed (Figure
40.2B). With firm retraction of the Desmarres retractor the tarsus will easily separate from the orbicularis. The incision can be extended with Westcott
scissors and use of the #15 blade for multiple tarsal cuts is avoided to prevent bread-loafing of the tarsal edge. Once the horizontal incision is
completed, a vertical incision is made perpendicular to the eyelid margin and extended superiorly towards the fornix (Figure 40.2C).

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Chapter 40 Lower eyelid reconstruction with Hughes’ tarsoconjunctival flap
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 Conjunctiva

Müller’s
muscle

Tarsus

Figures 40.3A–F Dissection of tarsoconjunctival flap

The tarsoconjunctival flap is dissected in a plane between Müller’s muscle and the palpebral conjunctiva at the superior tarsal border, as shown in Figure
40.3A.

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Figures 40.3A–F, cont’d

Although retaining Müller’s muscle and the peripheral vascular arcade will provide robust blood supply to the anterior lamella, Müller’s muscle should be
dissected from the tarsoconjunctival flap as upper eyelid retraction may result postoperatively. After incision of the tarsal plate, fibers of the levator
aponeurosis and pretarsal orbicularis are dissected using blunt tip Westcott scissors (Figure 40.3B). With gentle inferior traction on the tarsal plate from
the surgical assistant, the levator and Müller’s muscle are progressively dissected from the tarsoconjunctival flap (Figure 40.3C). At the superior border,
blunt dissection can be performed laterally under Müller’s muscle (Figure 40.3D). Extreme care should be taken to avoid buttonholing the conjunctiva as
well as tearing the conjunctival flap through the overzealous retraction of the surgical assistant. As the tarsoconjunctival flap is inferiorly retracted,
residual vertical fibers of Müller’s muscle may remain (Figure 40.3E). These fibers are meticulously dissected free using lateral blunt and sharp
dissection until only bare conjunctiva remains (Figure 40.3F). This thin vascularized conjunctiva is sufficient to sustain a full thickness skin graft and
should be carefully handled.

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Figures 40.4A–F Advancement of tarsoconjunctival flap

The tarsoconjunctival flap is advanced to the lower eyelid retractors to recreate the inferior fornix (Figure 40.4A). First, attention is directed towards
anchoring the tarsus medially. If a remnant of the medial tarsal plate is present, interrupted 7-0 Vicryl sutures are used for advancement (Figures 40.4B
and 40.4C). If the medial eyelid including the punctum have been sacrificed to clear tumor margins, the tarsus is secured to remnants of the posterior
limb of the medial canthal tendon using 6-0 Vicryl suture. Bicanalicular or pigtail catheter-assisted stent placement is performed for plastic repair of the
canaliculus (Chapters 60 and 62). At the medial and lateral aspects of the defect, a 1 mm superior overhang of the tarsal flap is created, as shown by
the black arrow (Figure 40.4D). This overhang prevents the development of an eyelid notch after flap severing. Any excess of the new eyelid margin can
be trimmed later during the stage II pedicle separation. The lower eyelid retractors are then secured to the inferior tarsal flap in a buried fashion with
interrupted 7-0 Vicryl sutures (Figures 40.4E and 40.4F).

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Figures 40.5A–F Anterior lamellar reconstruction with full thickness skin graft
Options for anterior lamellar reconstruction include adjacent pedicle-based tissue flaps such as a semicircular flap or Mustardé rotational cheek flap
(Chapters 39 and 41). A full thickness skin graft can also be utilized in cases of insufficient anterior lamellae for rotational flaps. A variety of donor sites
can be used, as discussed in Chapter 1, but the contralateral upper eyelid provides the most aesthetically compatible match (Figure 40.5A). The full
thickness skin graft is thinned down to the rete pegs and the graft is secured with multiple 6-0 fast-absorbing gut sutures (Figure 40.5B). Once the
inferior and lateral borders of the skin graft are secured, the skin is superiorly draped over the tarsus and conjunctiva (Figure 40.5C). To secure the
upper border of the skin graft to the conjunctival flap, n-butyl cyanoacrylate adhesive is used (Figure 40.5D). Placement of full thickness sutures through
the conjunctiva may cause corneal irritation and are subject to tearing, and can result in inferior migration of the skin graft. The adhesive is applied in a
dropwise fashion using a 25-gauge needle on a 1cc tuberculin syringe (Figure 40.5E). The adhesive should remain on the superior border of the skin
and conjunctiva and not subdermal as this will affect plasmatic imbibition between the conjunctival flap and full thickness skin graft. After placement of
the adhesive, any excess is removed as well as any inadvertent adhesions between the upper eyelid and the skin graft (Figure 40.5F). A pressure patch
is placed for 7 days to immobilize the graft and the patient is given oral antibiotic prophylaxis. After 4–6 weeks post surgery, the skin graft is evaluated
for viability and vascular ingrowth and, if satisfactory, stage II release of the pedicle is performed in the clinic setting. When in doubt, additional time can
elapse before pedicle release. The conjunctiva is severed first in the superior fornix and this is followed by trimming at the new eyelid margin. The lower
eyelid margin can be left redundant by approximately 0.5–1.0 mm to account for wound contraction.

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 RECONSTRUCTION OF LOWER EYELID DEFECT
WITH HUGHES’ TARSOCONJUNCTIVAL FLAP

Intraoperative Postoperative

Figure 40.6 Before and after lower eyelid reconstruction with Hughes’ tarsoconjunctival flap
This 43-year-old female presented with an ulcerated lesion of the right lower eyelid that was biopsied as basal cell carcinoma. She underwent excision
with frozen section margin control with a resultant 75% defect of the lower eyelid. Owing to her younger age and lack of eyelid laxity, a tarsoconjunctival
flap was chosen for reconstruction. The anterior lamella was supplied by a full thickness skin graft from the contralateral upper eyelid. Postoperatively,
she has achieved a satisfactory functional and aesthetic outcome (Figure 40.6).

Table 40.3 Complications

Complications
Full thickness skin graft necrosis
Upper eyelid retraction
Keratinization of lower eyelid
Lower eyelid ectropion
Cicatricial entropion
Necrosis of the eyelid margin
Suggestions to reduce risk
Avoid ice packs to eye area after surgery that may compromise blood circulation; no smoking; avoid
eye rubbing to cause shearing of graft; pressure patch for 1 week; no bending, straining or heavy
lifting; avoid buttonholing conjunctival flap; avoid excessive cauterization of conjunctiva
Meticulous separation of Müller’s muscles from the conjunctiva when fashioning the
tarsoconjunctival flap
Debridement of the keratinization with a #15 blade or use of a high-temperature handheld cautery
to shrink tissue
Shorten horizontal width of tarsal plate if ectropion develops after advancement of tarsoconjunctival
flap; consider interval lateral tarsal strip or canthoplasty
Preserve the inferior 4 mm of the tarsal plate and avoid bi-lamellar dissection at the upper eyelid
margin
Keep dissection 4 mm above the eyelid margin to avoid damage to the marginal vascular arcade

Table 40.4 Consumables used during surgery

6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG140-8 needle Ethicon #J546G
Dermabond glue, 0.5 ml ampule Ethicon #AHVM12

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CHAPTER 41
Lower eyelid reconstruction
with Mustardé flap
Richard L. Scawn • Bobby S. Korn
Table 41.1 Indications for surgery
Lower eyelid defects up to 100% total eyelid
Large eyelid–cheek junction skin defects
Large cheek skin defects
INTRODUCTION
Mustardé’s cheek rotational flap is a versatile procedure to
close large defects of the lower eyelid, eyelid–cheek junction
and cheek commonly seen after the removal of cutaneous
malignancies. In addition to supplying ample anterior lamella
for functional reconstructions, Mustardé’s flap can result in a
marked cosmetic improvement over a full or split thickness skin
graft.
When performing a reconstruction of full thickness lower
eyelid defects, the posterior lamella can be provided by an
upper eyelid tarsoconjunctival flap (Chapter 40) or a free tarsal
graft from the contralateral eyelid (Chapter 43) with the anterior
lamella supplied by the Mustardé flap.
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Chapter 41 Lower eyelid reconstruction with Mustardé flap
300
Table 41.2 Preoperative evaluation
History of malignant neoplasm of skin
History of smoking/tobacco use
History of prior facelift or periocular surgery
Presence of lower eyelid malpositions (ectropion, entropion,
retraction, lagophthalmos)
Size and depth of soft tissue defect
The Mustardé flap is performed analogously to the MACS
facelift covered in Chapter 24. A superiorly arcing mark is made
towards the preauricular line and then a subcutaneous flap is
developed. Extensive undermining is performed and the flap is
rotated medially to close defects. At the base of the excision,
a Burow’s triangle is excised to remove a redundant dog ear
of tissue.
Postoperatively, patients are instructed to adhere to the
same restrictions as facelift patients. Strict avoidance of
tobacco is required, as this will cause vasoconstriction and
potential necrosis of the flap. Patients are given postoperative
antibiotic prophylaxis and, in select patients, a drain can be
placed which is removed at 24 hours postoperatively.
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Figures 41.1A–D Skin marking

Figure 41.1A shows an eyelid–cheek junction defect over 40 mm in diameter after excision of a melanoma with permanent tissue margins.
Reconstructive options include full or split thickness skin grafting or an adjacent tissue transfer flap. The disadvantages of the skin graft include color/
textural differences, depression at the site of the graft, donor site morbidity and potential for graft loss. This defect is ideally suited to reconstruction with
a Mustardé flap. Skin incision placement is demonstrated with a superiorly arcing mark from the upper lateral skin defect to the preauricular line (Figure
41.1B). If larger defects are present, the incision can extend posteriorly behind the ear lobe for a more comfortable rotation (Figure 41.1C). When
dissecting posterior to the ear lobe, care is taken to avoid the greater auricular nerve and external jugular vein, which run superficial to the sternocleido-
mastoid muscle. Once the rotational flap is advanced medially, a standing defect will typically be present inferiorly (Figure 41.1D). This can be excised
after the flap is advanced to minimize unnecessary tissue removal.

Figure 41.2 Tumescent anesthesia

The use of tumescent anesthesia provides excellent anesthesia coupled
with a vasoconstricted surgical field. A tumescent solution is prepared by
discarding 50 ml of saline from a 500 ml normal saline IV bag and adding
the components shown in Figure 41.2. This mixture will yield 500 ml of a
dilute anesthetic solution that is liberally infiltrated into the entire flap at
least 10 minutes prior to surgery. The tumescent solution can be given
using a 10 ml syringe and a bent 22-gauge spinal needle. The Mustardé
rotational flap can be performed using monitored anesthesia care or
general anesthesia based on patient and surgeon preference.

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Figures 41.3A–F Raising the Mustardé flap

The surgery is started at least 10 minutes after infiltration of an adequate volume of tumescent solution to achieve maximal hemostasis. A #15 blade is
used to incise the skin from the site of the defect to the superior preauricular mark (Figure 41.3A). Once the cut edge of the flap is elevated, the forceps
are replaced with skin hooks to manipulate the tissue (Figure 41.3B). Repeated crush injury by forceps can lead to maceration and necrosis of the distal
border of the flap. The dissection is then performed in the subcutaneous plane. Blunt-tipped tenotomy scissors are used to start the flap. A combination
of blunt dissection and limited sharp dissection is employed (Figure 41.3C). As the flap is elevated, fine bleeders are controlled with gentle bipolar
cautery. As the flap is developed, blunt-tipped facelift scissors can be used for a more rapid dissection (Figure 41.3D). The blunt tips of the scissors are
directed towards the skin so that a thin and uniform flap can be created and inadvertent deeper dissection through the superficial musculoaponeurotic
system (SMAS) and parotid fascia is prevented. At the same time, care is taken to avoid perforation of the skin flap with a too superficial dissection.
Once the anterior aspect of the flap is elevated and hemostasis is achieved, the preauricular incision is made (Figure 41.3E). Depending on the size of
the defect and the skin laxity, the incision can extend to the ear lobe and even retroauricular if necessary. Along the preauricular line, the facelift scissors
may be used as well as a #10 blade to dissect in the subcutaneous plane (Figure 41.3F). Care is taken to keep the dissection uniform within the
subcutaneous layer. The temporal branch of the facial nerve runs through the parotid gland and within the SMAS to cross the zygomatic arch approxi-
mately 1.8 cm anterior to the helix. By keeping the dissection superficial in this subcutaneous layer, the nerve remains safe.

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Figures 41.4A–D Advancement of flap

Once the flap has been sufficiently undermined, the tissue can be advanced medially (Figure 41.4A). If excessive tension is still present, the inferior base
of the flap is undermined more and the incision is extended in a retroauricular fashion. Once the flap is amenable for advancement, 5-0 Vicryl suture is
used for subcutaneous advancement of the apex (Figure 41.4B). Multiple interrupted sutures are placed along the incision to advance the flap. If there is
excessive tension at the superior border of the flap, several sutures can be placed in the center of the flap and secured to the SMAS to relieve skin
tension (Figure 41.4C). Any irregular edges can be trimmed to fit the defect and these are typically present at the apex and at the superior corner at the
preauricular line (Figure 41.4D). Along the preauricular line, excessive skin may be present, but this should not be excised as this may cause excessive
horizontal tension on the apex of the flap.

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Figures 41.5A–F Excision of standing defect

As the subcutaneous approximation continues, a standing defect can be seen at the base of the excision (Figure 41.5A). A Burow’s triangle excision is
used to flatten this standing defect. The inferior side of the triangle is marked to the apex of the standing defect and then scissors are used to extend
the incision to the base of the mark (Figure 41.5B). The Burow’s triangle is then unfolded inferiorly to identify the redundancy of skin (Figure 41.5C). The
triangular flap of skin is then excised with scissors (Figures 41.5D and 41.5E). At this point, the base of the defect should lay flat with the incision line
(Figure 41.5F). If a residual defect is present, this is conservatively trimmed to achieve a smooth contour. Once a satisfactory result is achieved, 5-0
Vicryl sutures are used for subcutaneous approximation.

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Chapter 41 Lower eyelid reconstruction with Mustardé flap
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Figures 41.6A–C Skin closure

With good subcutaneous suture placement, there should be minimal if any tension on the skin surface. The skin is then closed with 6-0 Prolene suture
in a running fashion (Figure 41.6A). Use of the tapered C-1 needle on the Prolene suture will minimize shearing of vessels and development of a
hematoma under the flap. Prior to final skin closure, any residual blood under the flap can be milked through the preauricular line. This is achieved by
gently sweeping the flap laterally with the index finger lubricated with antibiotic ointment. Closure can be broken into several segments of running suture
(Figures 41.6B and 41.6C). At the base of the ear lobe, care is taken to avoid any excessive inferior traction on the lobe as this may result in a pixie ear
deformity. All non-absorbable sutures are removed at 5–7 days after surgery. In patients with high risk of bleeding, a drain can be placed and removed
after 24 hours if indicated. A facial compression dressing may also be used to minimize hematoma formation.

MUSTARDÉ ROTATIONAL CHEEK FLAP

Preoperative Postoperative
Figure 41.7A and 41.7B
En-face views of right lower eyelid and malar skin defect and subsequent appearance following reconstruction with Mustardé cheek rotation flap
(Figure 41.7A).

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Preoperative Postoperative
Figures 41.7A and 41.7B, cont’d
Oblique views of the same patient demonstrating successful reconstruction with no lower eyelid malposition or donor flap site morbidity (Figure 41.7B).

Table 41.3 Complications

Complications Suggestions to reduce risk
Flap necrosis Maintain tissue depth at flap base; avoid ice in patients with higher risk, e.g. vascular disease; strict
avoidance of tobacco; achieve meticulous hemostasis to prevent hematoma between flap and SMAS; drain
seromas if present postoperatively; pressure pad, drain for high-risk cases; consider hyperbaric oxygen use
for impending necrosis
Burow's triangle Some flap skin excision inevitable: interrupted cardinal flap sutures help with marking correct skin for
excision
Ectropion/eyelid retraction Ensure superiorly arching lateral incision; ensure adequate canthal support and horizontal eyelid; consider
Frost traction suture; adjunct 5-FU injection postoperatively; may need full thickness skin graft (Chapter 27)
Pixie ear deformity Avoid closure under traction of pretragus and lobule skin
Scarring Avoid superficial skin traction; deep closures to relieve skin tension; use silicone scar gel; everted wound
closure with Prolene skin sutures, remove at 1 week

Table 41.4 Consumables used during surgery

4-0 Vicryl, PC-1 needle Ethicon #J835G
5-0 Vicryl, PC-3 needle Ethicon #J844G
6-0 Prolene suture, C-1 needle Ethicon #8718
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G

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Chapter 41 Lower eyelid reconstruction with Mustardé flap
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 CHAPTER 42
Lateral canthal reconstruction
Table 42.1 Indications for surgery
Reconstruction of skin defect at lateral canthus from trauma or
after removal of carcinoma
INTRODUCTION
Cutaneous defects at the lateral canthus often result from
removal of neoplasms such as basal cell and squamous cell
carcinomas. There are a multitude of different options to close
large defects at the lateral canthus and the choice depends on
factors such as the size of the defect, involvement of the eyelid
margin, patient’s skin laxity, age, and surgeon’s preference. A
balance between achieving form and function should be always
considered.
If an upper and/or lower eyelid margin defect is present,
attention should first be directed towards posterior lamellar
reconstruction. This can be achieved with a periosteal flap
(Chapter 38), tarsoconjunctival flap (Chapter 40), hard palate
(Chapter 36) or free tarsal graft (Chapter 43). The anterior
lamellar reconstruction can consist of adjacent tissue transfer
or a free skin graft (Chapter 27). The important principle to
with rhomboid flap
Bobby S. Korn
Table 42.2 Preoperative evaluation
Size and dimensions of defect
Age of patient
Eyelid and skin laxity, entropion, ectropion and lagophthalmos
Prior eyelid, facial surgery, trauma or skin cancers
keep in mind is that one of the lamellae should be pedicle-
based and a free graft should not be placed onto another free
graft.
Although skin grafting can be used to close almost any
anterior lamellar defect, adjacent tissue transfer is our first
preferred option. Skin grafts must be thinned and the recipient
site often has a palpable and visual step off owing to lack of
subcutaneous tissue and muscle. Color and texture match,
as well as graft survival, are other factors to consider with
skin grafting.
Several options for adjacent tissue transfer at the lateral
canthus are available, including a semicircular flap (Chapter 39),
Mustardé rotational flap (Chapter 41) and a Limberg or rhom-
boid flap. At the lateral canthus, the lines of maximal extensibil-
ity (LMEs) and relaxed skin tension lines (RSTLs) are dictated
by contraction of the orbicularis oculi muscle (Chapter 1). Use
307
of the rhomboid flap for lateral canthal defects places more
tension on the horizontal meridians, and minimizes vertical trac-
tion forces that may result in anterior lamellar deficits, while
blending the incisions laterally along the RSTLs to maximize the
aesthetic outcome.
The optimal angles of the rhomboid are 60 and 120° to allow
minimal wound tension upon closure (Figure 42.1). If the area
to be closed is not a pure rhomboid, the edges can be trimmed
to convert the defect into a rhombic configuration. However,
we prefer to minimize removal of normal tissue until the flap
has been advanced and to remove any standing defects at the
time of skin closure. The rhomboid flap can be applied at both
the lateral and medial canthi for a satisfactory functional and
aesthetic outcome.

SURGICAL TECHNIQUE

120°
y

60°

x1

Figures 42.1A–D Rhomboid flap design

The defect is outlined as a Rhomboid with 60° and 120° angles (Figure
42.1A). The primary rhombus is excised and the parallel rhombic donor
flap is undermined (Figure 42.1B). Following flap transposition, a standing
defect is often created which can be excised (Figure 42.1C). The resultant
vector of tension is present at union of X and X1 as shown with the black D
arrows (Figure 42.1D).

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Chapter 42 Lateral canthal reconstruction with rhomboid flap
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Figures 42.2A–D Skin marking

This patient presents with a large lateral canthal defect after Mohs micrographic surgery for basal cell carcinoma (Figure 42.2A). The defect involves only
the skin and spares the posterior lamellae of the eyelid. The defect is approximately 20–25 mm in height and is almost evenly distributed above and
below the level of the lateral canthal tendon. Figure 42.2B shows a proposed rhomboid flap design at the lateral canthus. With advancement of the
rhomboid, the vector forces are predominantly in the horizontal meridians, as shown by the transposition of the X and Y apices and this minimizes
vertical displacement of the brow and eyelids (Figure 42.2C). At the base of the rhomboid, a standing defect may present and can be addressed after
transposition of the flaps (Figure 42.2D). Local anesthetic, consisting of 1% lidocaine, 1:200,000 epinephrine and 0.25% bupivacaine, is given widely
around the rhomboid.

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Figures 42.3A–E Subcutaneous undermining of rhomboid flap

A #15 blade is used to incise the rhomboid as marked (Figure 42.3A). To properly mobilize the flap with minimal tension, the rhomboid and skin defect
should be widely undermined, as highlighted in yellow (Figure 42.3B). Westcott scissors and toothed forceps are used to start the dissection for the first
3–4 mm and then a skin hook is used to provide traction on the subcutaneous side in an effort to minimize trauma to the distal ends of the flap (Figure
42.3C). A combination of sharp and blunt dissection is used to free the flap in the subcutaneous plane (Figure 42.3D). The use of blunt-tipped scissors
for the dissection can minimize the risk of buttonholing through the skin. Care is taken to keep the dissection in the subcutaneous plane. Deeper
dissection through the superficial temporal fascia can result in iatrogenic damage to the temporal branch of the facial nerve which runs 2 cm superior to
the lateral brow. Once the entire bed has been widely undermined, the flap can be transposed (Figure 42.3E). If there is excessive tension, additional
undermining is performed in the area of highest tension.

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Chapter 42 Lateral canthal reconstruction with rhomboid flap
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Figures 42.4A–C Advancement of rhomboid flap

The flap is then advanced with subcutaneous sutures to relieve tension at the skin edge. Interrupted 5-0 Vicryl sutures are used to advance the apices of
the rhomboid (Figures 42.4A and 42.4B). The first bite of each suture is started distal to the skin edge so that the knots are buried away from the skin
surface to avoid exposure of the knots. The leading apex of the flap is then advanced to the lateral canthus (Figure 42.4C). A partial thickness purchase
of the periosteum at the lateral orbital rim can be performed for added strength. Several interrupted sutures are placed in the intervening areas to evenly
distribute wound tension. The position of the brow, as well as the upper and lower eyelids, should be evaluated at this point to ensure no malposition is
created with the advancement.

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Figures 42.5A–C Excision of standing defect

At the base of the rhomboid, a standing defect often results after flap transposition (Figure 42.5A). An oblique back-cut is made and then the Burow’s
triangle is unfolded. This redundant skin and subcutaneous tissue triangle are then excised, allowing the wound edges to flatten (Figure 42.5B).
By releasing this stress point, wound tension is now distributed equally along this arm of the flap. Subcutaneous closure is performed with buried,
interrupted 5-0 Vicryl sutures (Figure 42.5C). The inferior apex should now flatten nicely and, if a residual defect persists, additional tissue is
conservatively removed.

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Chapter 42 Lateral canthal reconstruction with rhomboid flap
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Figures 42.6A and 42.6B Skin closure

Once adequate subcutaneous closure has been completed, there should be minimal skin tension. The skin is closed with 5-0 fast-absorbing gut suture
in a running fashion (Figures 42.6A and 42.6B).

RECONSTRUCTION OF LATERAL CANTHAL

DEFECT WITH RHOMBOID FLAP

Preoperative Postoperative

Figure 42.7 Before and after lateral canthal reconstruction with rhomboid flap
This 46-year-old male presented with an ulcerated lesion at the right lateral canthus. He underwent Mohs micrographic surgery for basal cell carcinoma
and presented with a large defect sparing the eyelid margin. A rhomboid flap was used for closure of the cutaneous defect (Figure 42.7). Note the
position of the brow and eyelid are unchanged after the surgery, with an excellent functional and aesthetic outcome.

313
Table 42.3 Complications
Complications Suggestions to reduce risk
Inferior traction on brow Orient rhomboid flap to direct vector forces in the horizontal meridian; perform more extensive undermining
of tissues
Brow paralysis Keep dissection within subcutaneous tissue plane and avoid deeper dissection through superficial temporal
fascia; mark 2 cm zone above lateral brow to be cognizant of course of temporal (frontal) branch of facial
nerve
Horizontal palpebral fissure Avoid iatrogenic lysis of the lateral canthal tendon; perform lateral tarsal strip or place canthal
narrowing reinforcement sutures if tendon has been compromised
Scarring Keep wound tension minimized with layered closure; avoid excessive cautery
Suture granuloma Use non-absorbable sutures, recognize granulomas early, remove suture if symptomatic and treat with
antibiotic/steroid ointment
Wound dehiscence Make sure knots tied with appropriate tension with adequate soft tissue incorporation; avoid smoking,
lifting and bending; use of eye shield; avoid manipulation of wound

Table 42.4 Consumables used during surgery

5-0 Vicryl C-1 needle Ethicon #8718
5-0 fast-absorbing gut, PC-1 needle Ethicon #1915G

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Chapter 42 Lateral canthal reconstruction with rhomboid flap
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 CHAPTER 43
Upper eyelid reconstruction
with Cutler-Beard flap and free
Table 43.1 Indications for surgery
Reconstruction of large (>80%) full thickness defects of the upper
eyelid
INTRODUCTION
Total defects of the upper eyelid are often the most challenging
to reconstruct. Compared to the lower eyelid, the upper eyelid
has greater vertical excursion, function and dynamic move-
ment. Ideally, the reconstructed upper eyelid should share a
similar purpose with optimum aesthetic appearance.
Complete loss of the upper eyelid can occur due to cutane-
ous malignancy, trauma or developmental anomalies. In
tarsal graft
Bobby S. Korn • Don O. Kikkawa
Table 43.2 Preoperative evaluation
Size and dimensions of upper eyelid defect
Involvement of lacrimal system
Eyelid laxity
Evaluation of donor sites for grafts (contralateral upper eyelid,
ipsilateral lower lid, pre/retroauricular, supraclavicular, inner arm)
History of prior eyelid, facial surgery or trauma
Visual function of both eyes (monocular status)
History of smoking/tobacco use
reconstruction of larger defects, the bi-lamellar architecture of
the eyelid typically requires a combination of flaps and grafts
for the most ideal result. Time-honored grafting principles apply
in that either the anterior or posterior lamella must provide the
vascular supply. Free grafts can be layered on a pedicle-based
flap. If the lacrimal system is involved, canalicular reconstruc-
tion should be performed primarily but creation of a nasolac-
rimal conduit should be deferred in cases of tumor.
315
 Smaller defects of the upper eyelid can be closed using a
variety of techniques. Direct closure (Chapter 37) and the
Tenzel semicircular flap (Chapter 39) work well as non-lid-
sharing techniques, but greater sized defects may require
pedicle-based grafts from the lower eyelid. Direct closure and
the semicircular flap have the advantage of preserving some
eyelashes. The Cutler-Beard procedure was originally described
in 1955 for reconstruction of large upper eyelid defects. The
procedure involves advancing a full thickness (from skin to
conjunctiva) myocutaneous flap from the lower eyelid harvested
inferior to the inferior tarsal border. The flap is then transferred
posteriorly to the preserved lower eyelid margin segment to
reconstruct the upper eyelid. Because there is no tarsus
present in the advancement flap, a free posterior lamellar graft
is typically harvested and placed first in the upper eyelid defect.
Choices for posterior lamellar grafts include free tarsal grafts,
nasal chondral mucosa and hard palate. A posterior lamellar
graft can be omitted but the upper eyelid may be less stable.
As an eyelid sharing procedure, the Cutler-Beard flap needs
to gain vascularity prior to the staged release of the pedicle.
Ideally this should occur from 4 to 6 weeks after stage one. In
monocular patients and in children, eyelid-sharing techniques
should be used cautiously due to the interference with vision
and possible amblyopia.

SURGICAL TECHNIQUE

A B

Figures 43.1A and 43.1B Incisional biopsy of eyelid

This 82-year-old man was referred with a non-resolving chalazion of the right upper eyelid. On examination, the lesion appeared as a firm, yellow mass
disrupting the eyelid margin and with associated madarosis (Figure 43.1). A full-thickness biopsy of the lesion revealed sebaceous cell carcinoma (Figure
43.2). Sebaceous cell carcinoma occurs more frequently on the upper eyelid and presents classically as chronic unilateral blepharitis or chalazion, as in
this case.

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Chapter 43 Upper eyelid reconstruction with Cutler-Beard flap and free tarsal graft
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 A B

C D

E F

Figures 43.2A–F Wedge excision of eyelid lesion

For sebaceous cell carcinoma and melanoma of the eyelid and periorbita, a surgical margin of at least 5 mm should be obtained (Figure 43.2A).
Vertically, the entire tarsal plate should be removed also with a margin of at least 5 mm (Figure 43.2B). The vertical eyelid incisions are made with sharp
iris scissors (Figures 43.2C and 43.2D). At the superior tarsal border, the incision is made with Westcott scissors to remove the entire eyelid wedge
(Figure 43.2E). The tissue is then placed in formalin for permanent section and all instruments used during the excision are removed from the surgical
field to prevent tumor dissemination (Figure 43.2F).

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 A B

C D

Figures 43.3A–D Map biopsy of bulbar and palpebral conjunctiva

Sebaceous cell carcinoma can exhibit Pagetoid or skip lesions with intervening normal areas of tissue. Map biopsies of the conjunctiva survey the entire
ocular surface to determine if local metastasis is present. The bulbar conjunctiva is sampled at six areas around the limbus, as shown in Figure 43.3A.
The palpebral conjunctiva and tarsus are sampled at four areas, as shown in Figures 43.3B and 43.3C. Each individual specimen can be sent in a
separate formalin container wrapped in non-absorbable gauze (Telfa pad) or placed on a sterile sheet of cardboard with the surgical margins marked
(Figure 43.3D). All margins should be sent for rush paraffin-embedded permanent sections. Frozen sections are not sufficient to rule out residual tumor
in either sebaceous cell carcinoma or melanoma.

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Chapter 43 Upper eyelid reconstruction with Cutler-Beard flap and free tarsal graft
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 A B

C D

Figures 43.4A–E Advancement of conjunctiva

The cut edge of the conjunctiva is identified and this is advanced to the skin edge to preserve the cul-de-sac during reconstruction (Figures 43.4A and
43.4B). Interrupted 7-0 Vicryl sutures are used to advance the conjunctiva to prevent retraction deep into the fornix during the postoperative period
(Figures 43.4C and 43.4D). Examination of the upper eyelid shows a greater than 80% defect (Figure 43.4E). Once all margins have been cleared by
permanent sections, the upper eyelid can be reconstructed. If the margins are positive, a wider excision is performed with repeat permanent sections.

319
 A B

C D

Figures 43.5A–D Temporary closure of eyelid

A temporary tarsorrhaphy is performed to close the eyelid while the margin clearance is established. Double-armed 5-0 Prolene sutures are placed over
a foam bolster and directed through the gray line on the lower eyelid (Figure 43.5A). On the upper eyelid, the suture is passed through the orbicularis
muscle nasal and lateral to the cornea (Figure 43.5B). Antibiotic ointment is placed in the fornix and bolsters are placed on the upper eyelid and tied off
(Figures 43.5C and 43.5D). The eyelid is left closed until the time of margin clearance and eyelid reconstruction.

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Chapter 43 Upper eyelid reconstruction with Cutler-Beard flap and free tarsal graft
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 A B

C D

Figures 43.6A–E Marking of Cutler-Beard myocutaneous flap

The patient is brought back to surgery for the first stage of upper eyelid reconstruction after achieving clear margins. The horizontal dimension of the
upper eyelid defect is measured with a caliper (Figure 43.6A). The lower eyelid is marked 5 mm below the eyelid margin to avoid interrupting
the vascular supply of the lower eyelid (Figure 43.6B). Interruption of the vascular supply can lead to necrosis of the free tarsal graft which relies on the
pedicle-based Cutler-Beard flap for survival as well as the integrity of the lower eyelid. The width of the flap is marked to match the upper eyelid defect
and in this case 20 mm (Figure 43.6C). The vertical arms of the flap are extended 10 mm below the horizontal mark (Figure 43.6D). Figure 43.6E shows
the Cutler-Beard flap prior to elevation.

321
 A B

C D

E F

Figures 43.7A–F Harvest of free tarsal graft from contralateral eyelid

The contralateral upper eyelid is everted with a Desmarres retractor and 4 mm is marked from the eyelid margin (Figure 43.7A). The final height of the
tarsal graft depends on the height of the native tarsal plate. Leaving the inferior 4 mm of tarsus lends stability to the donor eyelid as well as preserving
the vascular supply of the eyelid. The width of the marking is matched to the horizontal dimension of the upper eyelid defect (Figure 43.7B). To facilitate
dissection of the tarsus from the orbicularis and for hemostasis, local anesthetic consisting of 1% lidocaine and 1 : 100,000 epinephrine are given
anterior to the tarsal plate (Figure 43.7C). A #15 blade is then used to make a horizontal, full-thickness incision through the tarsal plate only (Figure
43.7D). The tarsus is separated from the orbicularis and levator aponeurosis with a combination of sharp and blunt dissection using blunt tip Westcott
scissors. Once the graft has been reflected off the anterior lamellae, the conjunctiva along the superior tarsal border is excised (Figure 43.7E). Careful
hemostasis is achieved with bipolar cautery at the superior tarsal border. Figure 43.7F shows the free tarsal graft with the conjunctival epithelium intact.
The graft is wrapped in a gauze sponge soaked in normal saline and set aside for subsequent use. The donor site is left to heal by secondary intention.

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Chapter 43 Upper eyelid reconstruction with Cutler-Beard flap and free tarsal graft
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 A B

C D

E F

Figures 43.8A–F Preparation of upper eyelid defect

During the previous operation, the conjunctiva was advanced to the skin edge to prevent retraction and to preserve the cul de sac. The cut edge of the
conjunctiva is then identified (Figures 43.8A and 43.8B). The 7-0 Vicryl advancement sutures are located and removed (Figure 43.8C). The conjunctiva is
then carefully dissected free from the orbicularis, allowing the fornix to deepen (Figure 43.8D). A #15 blade is used to freshen the wound edges by
removing granulated tissue (Figures 43.8E and 43.8F). Finally, the wound is irrigated with balanced salt solution.

323
 A B

C D

E F

Figures 43.9A–F Posterior lamellar reconstruction with free tarsal graft

The free tarsal graft is oriented with the conjunctival epithelial surface directed towards the cornea and with the same vertical orientation as the donor
site (Figure 43.9A). The vertical edges of the tarsal graft are conservatively trimmed with scissors to create a square edge (Figure 43.9B). The graft is
then secured on the lateral edges with two interrupted 6-0 Vicryl sutures on each side. The needle is passed in a partial-thickness fashion through the
donor and host tarsus to prevent corneal abrasion (Figures 43.9C and 43.9D). At the superior border of the graft, 7-0 Vicryl suture is passed partial-
thickness through the tarsus and secured to Müller’s muscle and levator (Figures 43.9D and 43.9F). Three to four interrupted sutures are used to attach
the upper eyelid retractors.

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Chapter 43 Upper eyelid reconstruction with Cutler-Beard flap and free tarsal graft
324
 A B

C D

E F

Figures 43.10A–E Elevation of Cutler-Beard flap

The Cutler-Beard myocutaneous flap is then harvested. A 6-0 silk suture is weaved through the lower eyelid at the gray line (Figure 43.10A). A Jaeger
lid plate is placed in the inferior fornix and then a #15 blade is used to make the horizontal cut on the flap (Figure 43.10B). Care is taken to make the
cut 5 mm below the eyelid margin to preserve the tarsus, vascular arcades and canthal attachments of the lower eyelid margin below the inferior tarsal
border. The full-thickness incision can be completed with Westcott scissors through the conjunctiva to expose the lid plate (Figure 43.10C). The vertical
arms are then incised to include the skin and orbicularis only (Figure 43.10D). A combination of blunt and sharp dissection is performed to dissect the
orbicularis from the orbital septum (Figure 43.10E). The flap is now unrestricted and can now be advanced into the upper eyelid defect (Figure 43.10F).
If any portion of the flap cannot be freely mobilized superiorly, the vertical relaxing incisions can be continued for another 5 mm.

325
 A B

C D

Figures 43.11A–D Elevation of conjunctiva flap

The lower eyelid retractors are then dissected from the conjunctiva with blunt tip Westcott scissors (Figure 43.11A). Vertical relaxing incisions are made
in the conjunctival flap to allow superior advancement through the lower eyelid bridge (Figures 43.11B and 43.11C). Any residual attachments of the
lower eyelid retractors are identified and released to prevent postoperative lower eyelid retraction (Figure 43.11D).

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Chapter 43 Upper eyelid reconstruction with Cutler-Beard flap and free tarsal graft
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 A B

C D

Figures 43.12A–D Advancement of conjunctival flap

Interrupted 7-0 Vicryl sutures are used to advance the conjunctiva to the inferior tarsal border in a partial-thickness fashion (Figures 43.12A and
43.12B). Three to four sutures are used for advancement of the conjunctival flap to the inferior border of the tarsal graft (Figures 43.12C and 43.12D).
The conjunctival flap protects the corneal surface during the first stage of the Cutler-Beard reconstruction, contributes to vascularization of the tarsal
graft, provides a source of conjunctival epithelial cells to repopulate the tarsal graft and will be used to create a mucocutaneous border at stage II of the
reconstruction.

327
 A B

C D

E F

Figures 43.13A–F Advancement of Cutler-Beard flap

The Cutler-Beard flap is now advanced through the lower eyelid bridge and transposed into the defect in the upper eyelid (Figure 43.13A). The orbicula-
ris is secured with several interrupted 6-0 Vicryl sutures (Figures 43.13B and 43.13C). With sufficient dissection of the Cutler-Beard myocutaneous flap
inferiorly, the wound should be under minimal tension and cover the free tarsal graft completely (Figure 43.13D). The skin edges are then closed with
6-0 fast absorbing gut suture in a running fashion (Figures 43.13E and 43.13F). The cut edge of the lower eyelid bridge is allowed to granulate.

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Chapter 43 Upper eyelid reconstruction with Cutler-Beard flap and free tarsal graft
328
 A B

C D

Figures 43.14A–D Stage II Cutler-Beard – division of pedicle

The Cutler-Beard myocutaneous flap is kept intact for 4–6 weeks (Figure 43.14A). If the periocular tissues have undergone prior irradiation, a longer
time period should elapse to ensure complete integration. Once the flap has healed and vascularized, it can be released and the remnant can be inset
back into the lower eyelid. Local anesthetic is infiltrated into the upper and lower eyelids. Westcott scissors are used to divide the flap at the upper eyelid
margin leaving a 1 mm conjunctival cuff (Figures 43.14B and 43.14C). Any residual bleeders are gently coagulated with bipolar cautery (Figure 43.14D).

329
 A B

Figures 43.15A–C Formation of mucocutaneous border

The conjunctival cuff is rotated anteriorly to create a mucocutaneous border for a smooth eyelid margin. 7-0 Vicryl suture is used to advance the
conjunctiva to the skin edge in a buried fashion (Figures 43.15A and 43.15B). Advancement of this mucous membrane prevents eyelid margin keratini-
zation and corneal irritation (Figure 43.15C).

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Chapter 43 Upper eyelid reconstruction with Cutler-Beard flap and free tarsal graft
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 A B

C D

Figures 43.16A–E Insetting of flap

The keratinized lower eyelid margin bridge is excised with Westcott scissors (Figure 43.16A). The lower eyelid retractors are then reinserted onto the
inferior tarsal border with interrupted 7-0 Vicryl sutures (Figures 43.16B and 43.16C). The skin is closed with a running 6-0 fast absorbing gut suture
(Figures 43.16D and 43.16E).

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 RECONSTRUCTION OF UPPER EYELID DEFECT
WITH CUTLER-BEARD FLAP AND FREE TARSAL GRAFT

Intraoperative Postoperative

Figure 43.17 Before and after upper eyelid reconstruction with Cutler Beard flap with free tarsal graft
This 82-year-old underwent excision of a sebaceous cell carcinoma of the right upper eyelid resulting in an 80% defect of the upper eyelid. After margin
clearance by permanent sections, the patient underwent upper eyelid reconstruction with a free tarsal graft and Cutler-Beard myocutaneous flap.
Postoperatively, the patient has achieved a satisfactory functional and aesthetic outcome (Figure 43.17).

Table 43.3 Complications

Complications
Myocutaneous flap necrosis
Lower eyelid margin segment
necrosis
Upper eyelid retraction
Lower eyelid retraction
Cicatricial entropion of upper eyelid
Suggestions to reduce risk
Avoid smoking; avoid harvesting flap too thinly; maintain bulk of orbicularis oculi
Maintain vascular supply of lower lid arcades; harvest flap no closer than 4 mm to lid margin following
parallel distance from eyelid margin across entire flap
Avoid excessive advancement of levator to posterior lamellar graft
Avoid excessive traction of advancement flap; keep flap in position 4–6 weeks or longer to progress
through contractile phase of wound healing; recess lower eyelid retractors from myocutaneous flap
Ensure adequate sizing of posterior lamellar graft to upper eyelid defect size; consider oversizing
slightly

Table 43.4 Consumables used during surgery

6-0 fast absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG1408 needle Ethicon #J546G
6-0 Vicryl, double armed S-29 needle Ethicon #J555G

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Chapter 43 Upper eyelid reconstruction with Cutler-Beard flap and free tarsal graft
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 CHAPTER 44
Table 44.1 Indications for surgery
Suspicion of giant cell arteritis based on temporal headache, jaw
claudication, scalp tenderness, weight loss or fever
Unexplained associated vision loss or pallid optic nerve edema;
may be associated elevation of erythrocyte sedimentation rate
(ESR) and/or C-reactive protein (CRP)
INTRODUCTION
The classic triad of giant cell arteritis (GCA) includes headache,
scalp tenderness, and vision loss. The condition occurs as
a result of granulomatous inflammation in the smaller to
medium-sized vessels in the distribution of the external carotid,
vertebral, ophthalmic, and posterior ciliary arteries. Additional
constitutional symptoms may occur, consisting of jaw claudica-
tion, weight loss, malaise, and fevers. Patients are typically over
50 years of age and laboratory testing, including erythrocyte
sedimentation rate (ESR), is particularly helpful in stratifying risk.
The oculofacial surgeon is frequently called upon to assist
with diagnosis by performing the temporal artery biopsy.
Patients with suspected GCA may be placed on prophylactic
steroids prior to the biopsy; however, if the duration is longer
than 2 weeks, this may interfere with the histopathological
results. The temporal artery biopsy is typically performed
unilaterally. If the first side is histopathologically negative,
Temporal artery biopsy
Don O. Kikkawa • Bobby S. Korn
Table 44.2 Preoperative evaluation
Visual acuity, pupillary reaction, visual field testing, color testing
Palpation of the temporal region for tenderness
Dilated funduscopic examination looking at optic nerve and retinal/
choroidal vascular perfusion
History of prior scalp and facial surgery or trauma
History of rheumatologic conditions, including polymyalgia
rheumatica
Laboratory studies, including ESR, CRP and complete blood count
consideration should be given to performing biopsy of the
contralateral side, as studies have shown that a small per-
centage of cases will be positive on the opposite side. For
continued medical therapy after the biopsy, patients with
GCA should be managed by a neuro-ophthalmologist and
rheumatologist.
The superficial temporal artery (STA) is composed of two
branches: the frontal branch and the parietal branch (Figure
44.1). These vessels are terminal branches of the external
carotid artery. The superficial temporal artery travels in the
plane of the superficial temporal fascia (STF). This layer is just
deep to the subcutaneous layer of the scalp and overlies the
temporalis fascia proper. The frontal branch of the artery is
typically the easiest to access for biopsy and is accessible
through an incision made behind the hairline. The parietal
branch may also be biopsied but this is often behind hair-
bearing skin.
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 Preoperatively, the course of the artery should be palpated
or traced with a Doppler flow detector if not palpable. The
temporal branch of the facial nerve innervates the frontalis
muscle and travels under the STF (Figure 44.2). The course
of the nerve is typically much more anterior and inferior to the
course of the artery, as the nerve crosses the zygomatic arch
at Pitanguy’s line, several centimeters anterior to the tragus.
Approximately 2 cm superior to the lateral brow, the temporal
branch of the facial nerve and frontal branch of the STA may
potentially overlap. Dissection should be avoided in this area
and, if necessary, the dissection should be kept within the
plane of the STF to avoid damage to the nerve. If the dissec-
tion is kept closer to the hairline at the proximal root of the
frontal branch of the STA, risk to the temporal nerve branch
is minimal.

Transverse
facial artery

Parietal branch
of superficial
temporal artery

Maxillary
artery Frontal branch
of superficial
temporal artery

Superficial
temporal
artery

External
carotid artery

Figure 44.1 Diagram of the branches of the external carotid artery.

Note that the superficial temporal artery divides into the frontal and parietal branches. Temporal artery biopsy is performed on one of the terminal ends
of the frontal or parietal branches.

SECTION TWO • EYELID AND FACE

Chapter 44 Temporal artery biopsy
334
 Superficial
temporal fascia

Superficial
temporal
artery
Temporalis
muscle

Temporal branch
of facial nerve

Loose
areolar
tissue

Zygomatic
arch

Subcutaneous
tissue

Parotid
gland

Figure 44.2 Cross-section of superficial temporal artery.

Note course, location and depth of the artery within the superficial temporal fascia, which is superior and more external to the temporal branch of the
facial nerve.

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Figures 44.3A–F Mapping of the frontal branch of the superficial temporal artery
Careful mapping of the frontal branch of the STA is performed first. The STA has two terminal divisions, the parietal and frontal branches (Figure 44.3A).
Either branch can be sent for biopsy and in this case the frontal branch will be obtained. The temporal branch of the facial nerve runs inferior and
anterior to the frontal branch of the STA. The temporal branch of the facial nerve runs within 2 cm superior to the brow and there is potential overlap of
the frontal branch of the STA with the nerve in this area. The frontal branch is often manually palpable unless severely stenotic or diseased (Figure
44.3B). If the artery is not readily identified by palpation, a portable Doppler flow detector can be utilized (Figure 44.3C). A small layer of ultrasonic
transmission gel is applied to the skin for improved sound conduction. Once the artery has been mapped, the course is marked (Figures 44.3D and
44.3E). If hair-bearing skin is present, then a disposable shaver can be used to trim any follicles along the course of the mapped artery. Local anesthetic
consisting of 2% lidocaine with 1 : 100,000 epinephrine is given in the subcutaneous plane a few millimeters above the artery (Figure 44.3F). This helps
to constrict fine, terminal branches of the artery without causing major constriction of the artery itself.

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Chapter 44 Temporal artery biopsy
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Figures 44.4A–D Dissection of the frontal branch of the superficial temporal artery
As the temporal branch of the facial nerve runs 2 cm superior to the brow, the more proximal segment of the frontal branch of the STA should be
obtained (Figure 44.4A). A minimum of 2 cm of artery should be sent for pathology, as GCA is often characterized by skip lesions. A #15 blade is used
to make the skin incision (Figure 44.4B). The subcutaneous fat layer is exposed after incising the epidermis and dermis. Both blunt and sharp dissection
is used to divide the subcutaneous fat to expose the superficial temporal fascia. The superficial temporal artery lies in this plane and if properly mapped
will be readily identified (Figure 44.4C). If exposure of the temporalis fascia proper occurs, the surgeon has gone too deep and needs to dissect in a
more superficial plane to avoid potential damage to the temporal branch of the facial nerve. Once the artery has been identified, blunt dissection is
performed along the plane of the superficial temporal fascia to expose the vessel (Figure 44.4D). Typically, the artery is tortuous and may pulsate. The
thicker adventitial layer distinguishes the artery from the vein.

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Figures 44.5A–F Ligation of the frontal branch of the superficial temporal artery
After the artery has been identified, it is isolated and smaller branches can be tied off with 6-0 silk sutures. First, the proximal end of the frontal branch
of the STA is ligated (Figure 44.5A). Care is taken to place sufficient tension on the knot to tie off the vessel while not cheese-wiring through the artery
itself. Figure 44.5B shows the frontal branch of the STA as it runs along the STF. At the distal end of the artery, 6-0 silk is used to ligate the vessel
(Figure 44.5C). At least 2 cm should be obtained as diagnostic accuracy increases at this length (Figure 44.5D). An additional 6-0 silk is placed at the
proximal end to ensure hemostasis in case the first suture breaks. A second 6-0 silk is placed at the distal end and this will be used for gentle traction
of the vessel during removal. At the distal end, the artery is severed between the two silk ties (Figure 44.5E). Finally, the artery is carefully dissected
from the superficial temporal fascia. Care is taken to avoid directly grasping the artery with forceps as crush artifact may be induced into the specimen,
potentially complicating the pathologic interpretation. Figure 44.5F shows a 2.5 cm segment of the frontal branch of the STA which is placed in formalin
for pathology. An experienced ocular pathologist should interpret the specimen and elastin stains should be requested to examine the internal elastic
lamina of the vessel, which can be disrupted with GCA as well as atherosclerosis.

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Chapter 44 Temporal artery biopsy
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Figures 44.6A and 44.6B Skin closure

The subcutaneous layer is closed with multiple buried 5-0 interrupted Vicryl sutures (Figure 44.6A). Tension-free wound closure should be obtained. The
skin is then closed with 6-0 fast-absorbing suture in a running fashion. (Figure 44.6B).

Table 44.3 Complications

Complications Suggestions to reduce risk
Inability to locate superficial temporal Use Doppler flow preoperatively to track course of vessel; keep dissection in the plane of the
artery superficial temporal fascia; consider biopsy of contralateral side
Damage to temporal branch of facial Dissection too far anterior and inferior; avoid 2 cm zone above brow during dissection; avoid
nerve dissection under superficial temporal fascia; cautious use of bipolar cautery; avoid use of
monopolar cautery for hemostasis
Damage to hair follicles and loss of hair Avoid excessive cautery and trauma during retraction of wound edges
Wound dehiscence Well-approximated, tension free layered closure; consider placement of sterile adhesive strips for
reinforcement

Table 44.4 Consumables used during surgery

6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
5-0 Vicryl, P-3 needle Ethicon #J493G

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CHAPTER 45
Conjunctival pillar tarsorrhaphy
Bobby S. Korn

Table 45.1 Indications for surgery Table 45.2 Preoperative evaluation

Paralytic lagophthalmos Presence of Bell’s phenomenon
Exposure keratopathy Degree of lagophthalmos
CN VII palsy Corneal epithelial staining
Failing/exposed corneal transplant Orbicularis strength
Neurotrophic cornea Anterior or posterior lamellar shortage
Recalcitrant corneal infections Prior eyelid, facial surgery or trauma
Debilitating corneal pain History of head and neck cancer treatment, especially involving
facial nerve
Corneal sensation
History of thyroid eye disease/proptosis

INTRODUCTION suited for conjunctival pillar tarsorrhaphy. The conjunctival pillar

A conjunctival pillar tarsorrhaphy is suitable for treating corneal
exposure that is refractory to medical management. The size
and location of the conjunctival pillar can be customized for the
degree of corneal exposure. Exposure of the medial cornea, in
particular, is difficult to treat with permanent tarsorrhaphy
(Chapter 46) without significantly constricting the horizontal
palpebral aperture. A conjunctival pillar tarsorrhaphy can be
rapidly reversed in the clinical setting and is cosmetically supe-
rior to permanent lateral tarsorrhaphy.
Patients with a history of impending failure or recurrent pen-
etrating keratoplasty with corneal exposure are particularly
continually lubricates the corneal graft with blinking and routine
eye movements while maintaining a normal vertical aperture to
allow for instillation of topical medications and slit lamp exami-
nation. Recurrent corneal infections, viral, bacterial or proto-
zoal, may be considered after failed medical management.
Acquired or heritable causes of neurotrophic corneas are other
indications for treatment.
The surgery involves raising a tarsoconjunctival flap from the
upper eyelid and fusing this to the lower eyelid. The pillar can
easily be severed in the clinical setting with topical anesthesia
and no disfiguring sequela.

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Chapter 45 Conjunctival pillar tarsorrhaphy
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Figures 45.1A and 45.1B Assessment of corneal exposure

Examination of this patient discloses lagophthalmos. Her history is significant for upper eyelid blepharoplasty performed elsewhere resulting in an anterior
lamellar deficiency (Figure 45.1A). This corneal exposure resulted in ulceration and perforation necessitating a penetrating keratoplasty. With elevation of
the upper eyelid, there is dense corneal vascularization and thinning of the inferonasal cornea (Figure 45.1B). With the insufficiency of anterior lamella,
placement of an upper eyelid weight would not be expected to improve the corneal exposure and the patient did not favor a cosmetically displeasing
permanent medial tarsorrhaphy.

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Figures 45.2A and 45.2B Marking of lower eyelid

The tarsal portion of the conjunctival flap is anchored to the lower eyelid. A mark is made 4 mm below the inferior eyelid margin to correlate with the
inferior border of the tarsal plate (Figure 45.2A). The location and width of the marking varies depending on the desired coverage of the cornea (Figure
45.2B). In this case, the inferomedial cornea is exposed and the mark is appropriately made.

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Figures 45.3A–D Marking of the upper tarsus

The height of the upper tarsal plate ranges from 8 mm to 12 mm. In this patient, the upper tarsal plate measures 9 mm (Figure 45.3A) and this is more
than enough tarsus for use as a donor pedicle. The desired width of the donor tarsal pedicle is marked on the eyelid margin (Figure 45.3B). In general, a
3–4 mm wide conjunctival flap is enough to protect the corneal surface. If the flap is too thin, the risk of severing is higher, and if the flap is too wide, it
will interfere more with vision. A 2 mm tall tarsal flap is more than sufficient to anchor the conjunctival flap inferiorly and this is marked from the upper
tarsal border (Figure 45.3C). Figure 45.3D shows the upper tarsal plate prior to incision. At least 5 mm of vertical tarsus will be remaining after raising
the flap and this will have minimal impact on the stability of the upper eyelid.

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Chapter 45 Conjunctival pillar tarsorrhaphy
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Figures 45.4A–C Incision of tarsus

A Desmarres retractor is used to evert the upper eyelid. With countertraction on the retractor, a #15 blade is used to make the horizontal tarsal incision
(Figure 45.4A). The incision continues until the tarsus is incised full thickness, exposing the underlying pretarsal orbicularis muscle (Figure 45.4B). Care
is taken to avoid incision of the orbicularis, as this will incite bleeding. The incision is completed medially and laterally as marked. Next, the vertical tarsal
incisions are made. With gentle inferior traction on the tarsal plate, the levator aponeurosis is dissected free (Figure 45.4C).

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Figures 45.5A and 45.5B Raising tarsoconjunctival flap

Vertical incisions are made in the conjunctiva and the flap is inferiorly rotated. Müller’s muscle is tightly adherent to the palpebral conjunctiva and these
fibers are seen as vertical bands with inferior traction on the tarsal plate (Figure 45.5A). Müller’s muscle should be removed from the conjunctival flap to
prevent eyelid retraction. Using a 0.3 forceps, the residual Müller’s muscle fibers are dissected away using blunt tip Westcott scissors (Figure 45.5B).
Extreme care is taken to avoid buttonholing or severing the conjunctival flap as Müller’s muscle is dissected free.

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Figures 45.6A and 45.6B Full thickness inferior blepharotomy

The tarsal flap from the upper eyelid is anchored to the lower eyelid through a full thickness inferior blepharotomy. A large chalazion clamp is placed
over the lower eyelid at the previously marked recipient site for the tarsal flap (Figure 45.6A). The chalazion clamp provides traction on the lower eyelid
and hemostasis during the incision as well as protecting the cornea. A #15 blade is used to make the horizontal incision through the skin and orbicularis
4 mm below the inferior eyelid margin. The inferior tarsal border is identified and then the #15 blade is used to make a full thickness incision to expose
the chalazion clamp (Figure 45.6B). Once the button hole is created, the conjunctiva is open medially and laterally. The chalazion clamp is then loosened
and any point bleeders are controlled with bipolar cautery.

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Chapter 45 Conjunctival pillar tarsorrhaphy
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Figures 45.7A–D Advancement of tarsoconjunctival flap

The tarsus is drawn through the inferior blepharotomy incision (Figure 45.7A). Prior to securing the tarsal flap, the corneal coverage by the flap is
evaluated. If the flap does not adequately cover the cornea, the fixation point is adjusted or a larger tarsoconjunctival flap is raised. As the tarsus is
drawn inferiorly, the conjunctival pillar may be noted as being anchored superiorly. Any tethering is carefully lysed, allowing the flap to settle inferiorly
without pulling the upper eyelid down (Figure 45.7B). The inferior tarsal plate is then secured to the cut edge of the lower eyelid retractors with three
interrupted 6-0 Vicryl sutures (Figures 45.7C and 45.7D). With this small 2 mm tarsal remnant, we have not observed any chalazion or cyst formation
even with this tissue buried within the eyelid.

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Figures 45.8A and 45.8B Skin closure

The skin is then closed with a running 6-0 fast-absorbing gut suture (Figures 45.8A and 45.8B). The patient is instructed to avoid eye rubbing as this
can result in severing of the conjunctival pedicle.

Table 45.3 Complications

Complications Suggestions to reduce risk
Dehiscence of tarsorrhaphy Increase size of tarsal flap; increase width of conjunctival pillar; avoid rubbing; anchor tarsal plate to
lower eyelid retractors with 6-0 Vicryl suture; place more Vicryl anchoring sutures; careful dissection of
Müller’s muscle from conjunctiva
Hemorrhage Meticulous hemostasis during procedure; ice packs postoperatively; cessation of anticoagulants
Infection Perform procedure after sterile preparation; use of topical antibiotic ointment; be cognizant of
immunosuppressed states
Continued corneal exposure Revision of tarsorrhaphy to improve coverage of cornea

Table 45.4 Consumables used during surgery

6-0 Vicryl, S-29 needle Ethicon #J556G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G

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Chapter 45 Conjunctival pillar tarsorrhaphy
346
 CHAPTER 46
Table 46.1 Indications for surgery
Paralytic lagophthalmos
Exposure keratopathy
CN VII palsy
Symptomatic dry eye
INTRODUCTION
Permanent tarsorrhaphy may be considered when maximal
medical therapy has failed to treat corneal exposure. Paralysis
of the facial nerve and, specifically, the zygomatic branch of
cranial nerve 7 (CN VII) results in denervation of the orbicularis
oculi muscle which is essential for eyelid closure and mainte-
nance of a healthy and clear ocular surface.
Possible causes of CN VII palsy include infections, trauma,
skin cancers, salivary gland carcinomas, and other head and
neck cancers. Occasionally, the facial nerve will be intentionally
sacrificed during the excision of malignant head and neck
cancers. Unknown causes should be investigated with assist-
ance from primary care and/or neurologic consultation.
Lateral tarsorrhaphy
Bobby S. Korn • Honglei Liu
Table 46.2 Preoperative evaluation
Presence of Bell’s phenomenon
Degree of lagophthalmos
Corneal epithelial staining
Orbicularis strength
Anterior or posterior lamellar shortage
Prior eyelid, facial surgery or trauma
History of head and neck cancer treatment, especially involving
facial nerve
Corneal sensation
History of thyroid-related orbitopathy/proptosis
Non-paralytic indications for tarsorrhaphy include lower
eyelid retraction secondary to thyroid-related orbitopathy (TRO)
and post-blepharoplasty surgery. Stability of the exophthalmos
and optic nerve status should be evaluated before considering
tarsorrhaphy in a patient with TRO as progressive disease can
increase intraorbital pressure and may preclude auto-decom-
pression. Ideally, management of TRO should include consid-
eration of orbital decompression (Chapter 64) and eyelid
retraction repair (Chapter 17) if indicated. For the cosmetic
patient, lateral tarsorrhaphy is the least favorable choice, and
lower eyelid retraction repairs should be considered first (Chap-
ters 34–36).
Prior to considering tarsorrhaphy, initial management
should consist of frequent ocular surface moisturization with
347
lubricating drops and ointments, taping of the eyelids and use
of moisture chambers. The presence of corneal anesthesia
(cranial nerve 5; CN V) in conjunction with CN VII palsy puts
the patient at significant risk of rapid corneal decompensation
and warrants more aggressive management.
If the facial nerve paralysis is permanent and the ocular
surface is compromised, several surgical options are available.
The first consideration is upper eyelid loading with a weight
(Chapter 19). Placement of an eyelid weight provides a good
balance between function and form. A conjunctival pillar tarsor-
rhaphy (Chapter 45) can be fashioned to protect the ocular
surface, particularly when a penetrating keratoplasty was previ-
ously performed. Finally, permanent tarsorrhaphy may be con-
sidered in recalcitrant cases. Lateral tarsorrhaphy of one-third
of the eyelid provides excellent protection of the ocular surface,
but at the cost of obstructing portions of the lateral visual field
as well as the aesthetic changes to the eyelid. In patients with
poor visual potential and non-compliance with ocular lubrica-
tion and eyelid taping, lateral tarsorrhaphy can be very protec-
tive of the ocular surface. Tarsorrhaphy may also be considered
for debilitated patients as a protective measure. The surgery
can be performed medially, but this causes more significant
vertical palpebral shortening and conjunctival pillar tarsorrhaphy
may be more appropriate.
The surgery involves dividing the anterior and posterior
lamellar of the upper and lower eyelids, followed by fusion
of the tarsal plates and anterior lamella. To allow for revers-
ibility, a segment of epithelialized eyelid margin is kept intact
at the lateral canthus. When severing the tarsorrhaphy, this
can be performed sequentially with 1–2 mm increments at
a time while carefully monitoring corneal status. After sever-
ing, the eyelid margin epithelizes well with minimal aesthetic
consequences.

SURGICAL TECHNIQUE

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Figures 46.1A–C Eyelid marking

When marking for permanent lateral tarsorrhaphy, the eyelid margin at the lateral canthus is spared (Figure 46.1A). If the tarsorrhaphy is reversed, the
original horizontal palpebral aperture can be restored. The determination of how much eyelid to fuse depends on the degree of corneal exposure and
compromise. A balance must be established between the degree of eyelid closure, preserving the visual field and aesthetic changes. In this case, the
medial marking is at the level of the lateral corneal limbus. Corresponding markings are made on the upper and lower eyelids (Figures 46.1B and
46.1C).

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Chapter 46 Lateral tarsorrhaphy
348
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Figures 46.2A and 46.2B Incision of eyelid margin

A large chalazion clamp is placed over the operative eyelid for stability and hemostasis (Figure 46.2A). The use of a chalazion clamp is preferred over
using a hemostat as this causes less crush damage and potential harm to the ocular surface. Lubricating ointment is placed between the ocular surface
and the chalazion clamp. A #15 blade is used to make an incision at the gray line to separate the anterior and posterior lamellae (Figure 46.2B). If
excessive bleeding is present, the chalazion clamp is further tightened.

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Figures 46.3A–D Division of anterior and posterior lamellae

The anterior lamella, consisting of the skin and orbicularis, is dissected from the tarsal plate for at least 2 mm vertically using sharp dissection (Figure
46.3A). The vertically oriented Meibomian glands provide a good landmark for the tarsal plate. Care should be taken to avoid lamellar dissection within
the tarsal plate to provide a healthy platform for subsequent fusion of the tarsal plates. Transection of the eyelash follicles is also carefully avoided. A
1 mm vertical relaxing incision may be optionally made medial and lateral to the marking, allowing for separation of the anterior and posterior lamellar
flaps (Figures 46.3B–46.3D). This also minimizes the risk of eyelash misdirection, which can comprise an exposed cornea.

349
Figure 46.4 Trimming of eyelid margin
Creation of a raw tarsal border by trimming the mucous membrane lining
at the posterior eyelid margin is essential for successful tarsorrhaphy. This
mucosal lining is carefully thinned with Westcott scissors in a smooth
horizontal cut. This freshened surgical edge will facilitate fusion of the
corresponding tarsal plate. Care should be taken to minimize removal of
any of the tarsal plate, particularly in the lower eyelid where the vertical
height is only 4 mm.

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Figures 46.5A and 46.5B Fusion of posterior lamella

The chalazion clamp is then removed and hemostasis is obtained with bipolar cautery. The identical procedure is then repeated on the opposing eyelid
(Figure 46.5A). Multiple Vicryl sutures are used to unite the tarsal plates in an interrupted fashion. When a thicker and more robust tarsal plate is
present, 6-0 Vicryl can be used, but in thinner, more attenuated tarsal plates, 7-0 Vicryl suture is used. The needle should be of the spatulated variety to
minimize damage to the tarsal plate with each pass. To prevent corneal abrasion, the suture is passed in a partial thickness fashion through the tarsal
plate (Figure 46.5B). When tying off the knots, the tarsal plates should be brought into apposition but not tied off so tight that tarsal kinking occurs.

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Figures 46.6A and 46.6B Fusion of anterior lamella

The skin and orbicularis flaps are then united with 6-0 fast-absorbing gut sutures. Horizontal mattress suture placement allows for outward rotation of
the eyelashes (Figures 46.6A and 46.6B). The eyelashes should be carefully directed outwards and not buried into the wound. The skin and muscle flaps
are then closed in a horizontal mattress fashion using 6-0 fast-absorbing gut suture.

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Chapter 46 Lateral tarsorrhaphy
350
Table 46.3 Complications
Complications Suggestions to reduce risk
Corneal abrasion Careful placement of Vicryl sutures in a partial thickness fashion through the tarsal plate
Dehiscence of tarsorrhaphy May be secondary to cheese-wiring of sutures through tarsal plate; sutures should be placed within
Meibomian glands and not too anteriorly in tarsal plate; careful dissection between anterior and posterior
lamellae; placement of sufficient number of tarsal sutures; complete removal of epithelium at mucous
membrane lining of tarsus; avoid eye rubbing; use of eye shield
Hemorrhage Meticulous hemostasis during procedure; ice packs postoperatively; cessation of anticoagulants
Infection Perform procedure after sterile preparation; use of topical antibiotic ointment; be cognizant of
immunosuppressed states
Continued corneal exposure Revision of tarsorrhaphy to improve coverage of cornea

Table 46.4 Consumables used during surgery

7-0 Vicryl, TG140-8 needle Ethicon #J546G
6-0 Vicryl, RD-1 needle Ethicon #J446G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G

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CHAPTER 47
Autologous fat transfer to
the tear trough
Morris Hartstein • Bobby S. Korn

Table 47.1 Indications for surgery Table 47.3 Tumescent anesthetic solution
Deep tear trough, skeletonization of the inferior orbital rim, malar Component Concentration Amount
depression Normal saline 0.9% 450 ml
Lidocaine (plain) 1% 50 ml

Table 47.2 Preoperative evaluation Epinephrine 1 : 1000 (1 mg/ml) 0.5 ml

Grade tear trough, skeletonization of inferior rim, cheek or malar Sodium bicarbonate 8.4% 5 ml
hollowness, lower lid fat prominence, lower lid laxity, lower lid
excess skin, festoons, “V” deformity
History of ventral abdominal or umbilical hernia (potential donor
sites for autologous fat)

INTRODUCTION
The majority of our aesthetic oculofacial surgical procedures
involve the excising and lifting of redundant and descended
tissues. In recent years, the role of volume loss in the aging
process has received more focus and there is an increasing
awareness of how restoring volume in the face can address
this process. Adding autologous volume enhancement to our
surgical armamentarium can be a tremendously useful adjunct.
Autologous fat transfer is not a new concept but advances
by Dr. Sidney Coleman have made the procedure more effec-
tive and safer. Instead of injecting harvested fat as a bolus
where it will likely not survive owing to insufficient blood supply,
the fat is placed as multiple droplets. This maximizes uptake of
the transfer and is less likely to produce palpable nodules.
The donor site for autologous fat should be discussed with
the patient before surgery. The patient should be counseled
that the donor site will not result in a therapeutic contouring
of adipose beds as seen with traditional lipoaspiration. Suit-
able locations include the abdomen and outer thigh. In women,
the outer thigh usually has a good supply of fat, whereas in
men the abdomen may be a more fruitful donor site. A history
of abdominal hernia should direct harvesting from the outer
thigh. Care is taken with abdominal harvesting to avoid peri-
toneal perforation. Tumescent anesthesia solution is given at
the donor site as described in Table 47.3. The total amount
of lidocaine given is far below the toxic dose, which is greater
than 50 mg/kg of lidocaine. Triamcinolone, which is often
included in standard tumescent solutions, is intentionally
omitted for fat transfer as this may result in adipose cell
death.
After harvesting, blood, tumescent anesthetic, lysed adi-
pocytes and free fatty acids must be separated from the fat

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Chapter 47 Autologous fat transfer to the tear trough
352
pearls to be grafted. There are several methods for separation
and these are all performed under aseptic and relative anaero-
bic conditions including passive sedimentation, filtration, and
centrifugation. Our preferred technique is passive sedimenta-
tion followed by removal of the supranatant and infranatant by
gently rolling the fat over a non-adherent dressing (Telfa pad).
The fat is emulsified and transferred to 1 ml syringes for
transfer.
While autologous fat transfer can be performed as a stand-
alone procedure, large quantities of fat are required as well as
a prolonged recovery and potentially less predictable uptake of
the tissue. However, when performed as a surgical adjunct to
aesthetic surgery, this can be a powerful tool to address the
limitations of lifting and tightening alone. In particular, autolo-
gous fat transfer can be used to volumize the inferior orbital
rim, malar depressions and to blend the eyelid–cheek junction
during lower blepharoplasty. Patients are increasingly aware of
the benefits of autologous fat transfer and are readily accepting
of this technique.
Fat transfer, although autologous, is not without complica-
tions. The most feared complication is death resulting from fat
emboli causing ischemic stroke. Blindness can result from
central retinal artery occlusion similar to hyaluronic acid gel
fillers. Fat emboli can also cause regional necrosis of the face,
depending on the arterial supply that is interrupted. More
common complications of fat transfer are related to the plane
of the injection. Fat transfer more superficially can be unforgiv-
ing with the thin periocular skin leading to lumps, bulges,
depressions, and persistent edema at the injection site. Man-
agement is conservative, consisting of local steroid injection
and possibly 5-fluorouracil. Surgical excision, if contemplated,
should be delayed by at least 6 months.

SURGICAL TECHNIQUE

A B

Figures 47.1A–E Harvest of autologous fat

In this female patient, abundant adipose tissue is present in the outer thighs. The donor site is fully prepped and draped in the usual sterile fashion. A
stab incision is made with a #15 or #11 blade at the desired entry site (Figure 47.1A). Tumescent anesthetic solution is prepared (Table 47.3) and given
with a 22-gauge spinal needle into the harvest site (Figure 47.1B).

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 C D

Figures 47.1A–E, cont’d

At least 10 minutes should elapse after infiltration of tumescent to allow for maximal effect. One gram of intravenous cefazolin should be given prior to
fat harvesting as antimicrobial prophylaxis. The deeper layers of fat are harvested manually using a 10cc luer lock syringe attached to a harvesting
cannula using a bimanual technique (Figure 47.1C). Several cannulas are available for harvesting, both disposable and non-disposable, with port sizes
varying from 0.5 mm to 3 mm. A blunt tipped Tonnard cannula or standard Coleman straight tip is used for harvesting. While the larger port sizes allow
more rapid harvesting, we have personally found that smaller ports yield healthier fat grafts. Harvesting is performed by applying 3–4 cc of negative
pressure in the plunger and by using the non-dominant hand to stabilize the harvest site as the cannula is passed back and forth (Figure 47.1D). Care
should be taken to not be too superficial as this may cause skin dimpling postoperatively. If redirecting the cannula, it should be withdrawn until almost
exiting and then repositioned for the next passes. The surgeon should always have an awareness of the location of the cannula’s tip to avoid donor site
complications. When approximately 10 cc of fat has been harvested, the syringe is removed, capped and placed aside in a vertical stand (Figure 47.1E).
The harvesting cannula can be left in the tissue bed while a new syringe is attached for additional harvesting. The entry site is self-sealing but can be
closed with a 5-0 fast-absorbing gut suture if desired. A sterile adhesive dressing (Steri-strip) can be placed for additional strength.

SECTION TWO • EYELID AND FACE

Chapter 47 Autologous fat transfer to the tear trough
354
 A B

C D

E F

Figures 47.2A–F Preparation of fat for transfer

Preparation of the fat must be performed in a sterile fashion typically on the surgical back table. The fat is left to stand vertically during the harvest for
passive sedimentation and then the fat is overlaid on a large Telfa pad (Figure 47.2A). The fat is then is purified by gently rolling the tissue over the Telfa
pad using the blunt handle of an Adson forceps, blade holder or malleable retractor to remove the supranatant and infranatant (Figure 47.2B). While
rolling the fat, excessive pressure is avoided as this may rupture adipocytes. After several passes, the blood, anesthetic, and free fatty acids have been
absorbed by the Telfa and the fat is placed in a 10cc syringe and the plunger reattached (Figure 47.2C). The 10cc syringe is then attached to one end
of a straight transfer device (Tulip) to standardize the texture of the fat (Figure 47.2D). The fat is then transferred to a 1cc luer lock polycarbonate
syringe on the other side (Figure 47.2E). Multiple 1cc syringes are filled to volume of 0.8cc and then a 0.9 mm x 5 cm microinjector is placed in a stand
until ready for use (Figure 47.2F). The face can be marked along the inferior orbital rim and any other depressed areas that are to be filled. Also, a mark
can be made at the intersection of a line drawn from the alar groove and the mid lateral orbital rim. Standard local anesthetic is infiltrated along the
inferior rim, nasolabial fold, and cheek.

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 A B

C D

Figures 47.3A–D Fat transfer to medial cheek

In this case, fat transfer is used as an adjunct to lower blepharoplasty with fat redraping (Figure 47.3A). The target for the fat transfer is the deep medial
cheek fat as shown in yellow (Figure 47.3B). At the completion of the blepharoplasty procedure, a stab incision is made with an 18-gauge needle within
the nasolabial fold and the microinjector is inserted (Figure 47.3C). Beginning with the entry site in the nasolabial fold, the microinjector cannula is
inserted into the deep medial cheek fat pad while a finger rests on the medial inferior orbital rim (Figure 47.3D). The fat is slowly injected with the
non-dominant hand on the inferior rim to ensure the cannula is beneath the rim. Approximately 1–3 cc can be injected into the medial cheek fat pad.
Blunting of the medial tear trough and nasolabial folds can be seen as the fat is injected.

SECTION TWO • EYELID AND FACE

Chapter 47 Autologous fat transfer to the tear trough
356
 A B

C D

Figures 47.4A–D Fat transfer to lateral cheek

The next site of injection is on the cheek. An 18-gauge needle is used to make a stab incision at the midpoint of the maxilla below the inferior orbital rim
(Figure 47.4A). The cannula is inserted deeply and used to fill approximately 0.3–0.5cc of fat along the inferiorly orbital rim (Figure 47.4B). The cannula
is then directed laterally to fill along the inferolateral orbital rim (Figure 47.4C). Again, a small amount of fat (0.3–0.5cc) is given. Finally, the cannula is
inserted into the cheek entry site at 90°, in a preperiosteal plane and 0.5cc is injected. The fat is then digitally molded over this site and along the
inferior orbital rim and helps to volumize the cheek (Figure 47.4D)

357
 AUTOLOGOUS FAT TRANSFER TO DEEP MEDIAL AND LATERAL CHEEK FAT PAD AND LOWER
BLEPHAROPLASTY WITH FAT REDRAPING

Before After

Figure 47.5 Before and after fat transfer to tear trough

This 47-year-old female underwent transconjunctival lower blepharoplasty with fat redraping and autologous fat transfer to the deep medial cheek fat
and lateral cheek. Postoperatively, she has effacement of the tear trough deformity with smooth blending of the eyelid–cheek junction as well as fullness
of the lateral cheek and blunting of the nasolabial fold (Figure 47.5).

Table 47.4 Complications

Complications
Visible lumps and bumps and
irregular contour
Fat embolus/central retinal artery
occlusion
Peritoneal perforation
Skin dimpling at donor site
Regression of fat graft
Persistent edema
Suggestions to reduce risk
Keep injections deep and along inferior orbital rim; avoid injection over thin preseptal skin; consider
steroid injection to resolve surface irregularities versus surgical excision if still present after 6 months
Slow injection; pull back on plunger prior to injections; retrograde injection of fat
Avoid abdominal donor site with history of hernias and restrict to outer thigh
Limit lipoaspiration to deeper layers
Use smaller cannula for harvesting; wait until blepharoplasty is performed and harvest and purify fat
last; careful purification and separation of fat from contaminants; consider regrafting of new fat versus
hyaluronic acid gel filler to supplement (Chapter 48)
Avoid fat transfer in patients with malar mounds/festoons; consider topical, injected or systemic
steroid use

Table 47.5 Consumables and instrumentation used during surgery

Tonnard and standard Coleman harvester Tulip Medical
0.7 mm × 4 cm microinjector (periorbita) Tulip Medical
0.9 mm × 5 cm microinjector (periorbita, midface and temple) Tulip Medical
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG140-8 needle Ethicon #J546G

SECTION TWO • EYELID AND FACE

Chapter 47 Autologous fat transfer to the tear trough
358
 CHAPTER 48
Hyaluronic acid gel filler to
Table 48.1 Indications for surgery
Lower eyelid hollows without skin laxity or festoons
INTRODUCTION
Injection of hyaluronic acid gel (HAG) filler to the infraorbital area
is a common treatment patients seek for non-surgical rejuvena-
tion of the lower eyelids. The infraorbital region is a non-
forgiving area, as the thin eyelid skin overlying bone cannot
mask contour irregularities and lumps and predisposes to blue
discoloration, hydrophilic reaction, and excessive bruising and
swelling. In addition, while treatment of the infraorbital hollows
is generally safe, intravascular complications can occur, and
care should always be taken during injections.
Each class of HAG filler has a different biochemical composi-
tion (concentration, percent cross-linking, etc.) and unique flow
characteristics (viscosity, G’, etc.) yielding specific and distinct
clinical manifestations. As such, the appropriate selection of
HAG product for different facial areas is essential for success.
This is especially true for the very delicate area of the eyelids
and associated periorbita. In the infraorbital area, the single
injection technique, the use of a cannula versus a needle, and
a multidirectional entry point, can be important features for
successful application of filler and avoidance of injection-related
the inferior periorbita
Guy G. Massry
Table 48.2 Preoperative evaluation
Use of anticoagulants
Prior fillers and neurotoxin use
Assessment for lower eyelid malposition and dermatochalasis
History of prior facial surgery
complications. The use of HAGs is ideal for the infraorbital
region as they are readily reversed with hyaluronidase should
complications arise.
For deeper, infraorbital injections, a stiffer (higher G’) and
more viscous product such as Restylane (Galderma) can
provide a three-dimensional tissue expansion (lift and fill), while
a less robust and viscous product such as Belotero Balance
(Merz) can better efface more superficial irregularities. In my
experience, deep injection of Belotero, has less capacity three
dimensionally to fill and a shorter clinical duration compared to
Restylane. Postoperative oral antibiotics are not routinely given
unless a tapering course of oral steroids (Medrol dose pack) is
added for swelling. After completion of injection, patients are
observed for 15 minutes to assure the absence of skin blanch-
ing or mottling which may signify an intravascular injection of
the gel. A slow and low pressure injection technique, aspiration
on the plunger of the syringe prior to injection, and retrograde
delivery of the gel can minimize intravascular complications that
can lead to skin necrosis or blindness. Every office should have
hyaluronidase, nitropaste (controversial), heat packs and aspirin
on hand in case complications arise.
359
SURGICAL TECHNIQUE

A B

Figures 48.1A–C Periorbital nerve blocks

Hyaluronic acid gel fillers are considered implants by the US FDA and, as such, at least semi-sterile technique should be used. The skin is prepped with
a chlorhexidine solution (Hibiclens) and isopropyl alcohol wipe prior to injection. Regional local nerve blocks are given with a 0.3 ml bolus of 1% lidocaine
to the infraorbital and zygomaticofacial nerves (Figures 48.1A and 48.1B). The anesthetic should be given over the nerve bundle but the needle should
not be placed directly into the foramen. The injected areas are massaged to distribute the fluid as not to mask local depression. I prefer a cannula for
filler injection as this minimizes bruising and potentially the risk of intravascular complications. An entry point below the central orbital rim in the upper
malar tissue is selected for injection. Through this single entry port, the entire infraorbital hollow can be addressed. This area is injected with a small
wheal of 1% lidocaine (Figure 48.1C) prior to creating a skin puncture for the blunt cannula.

SECTION TWO • EYELID AND FACE

Chapter 48 Hyaluronic acid gel filler to the inferior periorbita
360
 A B

C D

E F

Figures 48.2A–F Injection of filler into infraorbital hollows

A 22-gauge needle is used to nick the skin and create an entry port to facilitate cannula placement (Figure 48.2A). A
25-gauge 112 inch cannula is placed on the hyaluronic acid gel syringe for entry. In this case, Restylane-L (Galderma) is used.
The use of smaller caliber cannulas obviate the advantage of avoiding needle injections (they are more like needles) and I find
them more flimsy and less precise. This longer cannula allows for injection along the entire lower eyelid hollows from one entry
site. The filler can be placed pre-periosteally, below the orbicularis, or in very small amounts subcutaneously depending on the
anatomic deficit present and clinical needs. Retrograde injection after aspirating the plunger should theoretically reduce the
risk of intravascular penetration. The tear trough is usually first injected by placing the cannula along the inferior orbital rim
using a bimanual technique (Figure 48.2B). The filler is injected in a retrograde fashion and digital massage is performed to
contour the gel along the bony rim (Figure 48.2C). The periorbita is examined after each bolus for consistency. On the treated
side, effacement of the tear trough can be seen compared to the untreated side (Figure 48.2D). The lateral hollows can be
addressed through the same injection port. Using the blunt tip of the cannula, deep subcision of the soft tissues along the
lateral orbital rim is performed, allowing the gel to fill this space (Figure 48.2E). Digital massage is again performed over bone
to allow even dispersion of the gel (Figure 48.2F).

361
Figure 48.3 Postinjection evaluation
The injected side is carefully evaluated and additional filler is given if
necessary. The patient can be given a mirror to visualize the changes and
provide input if needed. In this case, there is effacement of the tear
trough, lateral orbital hollows and nice blending of the eyelid and cheek
junction (Figure 48.3).

HYALURONIC ACID GEL FILLER TO INFERIOR PERIORBITA, BROW AND TEMPLES

Before After

Figure 48.4 Before and after injection of hyaluronic acid gel to the infraorbital hollows
This 42-year-old female underwent injection of Restylane-L to the infraorbital hollows. After injection, there is a marked improvement in the tear trough
deformity and a more continuous, youthful and aesthetic continuous blending of the eyelid–cheek junction (Figure 48.4).

SECTION TWO • EYELID AND FACE

Chapter 48 Hyaluronic acid gel filler to the inferior periorbita
362
Table 48.3 Complications
Complications Suggestions to reduce risk
Tyndall effect Consider use of Belotero Balance
Asymmetry/nodules Reassurance; massage; consider hyaluronidase
Edema Reassurance; consider hyaluronidase; consider short course of oral steroids
Granuloma/ Consider local or oral steroid treatment; hyaluronidase
hypersensitivity
Infection Sterile prep of skin; oral antibiotics directed at culture/sensitivity of pathogen; hyaluronidase
Skin necrosis Hyaluronidase; nitropaste; warm compresses
Blindness Use cannulas; retrograde injection with low pressure pull back on plunger to verify placement

Table 48.4 Consumables used during surgery

Restylane-L Galderma
Belotero Balance Merz Aesthetics
Hyaluronidase/Vitrase Bausch and Lomb
25-gauge 1 12 (38 mm) inch cannula Merz Aesthetics REF 9013M1X20

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CHAPTER 49
Botulinum toxin treatment for
lateral canthal rhytids (crow’s feet)
Michael S. McCracken • Eric M. Hink
Table 49.1 Indications for treatment
Lateral canthal lines (“crow’s feet”) with smiling; lines are mostly or
entirely gone in repose
Inferior pretarsal orbicularis bunching (“jelly roll”) and narrowing of
the palpebral fissure (squinting) with smiling
INTRODUCTION
Botulinum toxin injections are the most frequently performed
cosmetic procedure in the United States. The injections have
a high satisfaction rate and offer the advantages of minimal risk
and minimal downtime. Botulinum toxin injections are often
sought out by patients who may not yet be candidates for
cosmetic surgery.
Botulinum toxin injections are most effective when used to
treat dynamic wrinkles (wrinkles present with animation) rather
than static wrinkles (wrinkles present at rest). Static wrinkles
may respond at least partially to botulinum toxin injections, but
often require treatment with dermal fillers or laser skin resurfac-
ing. Botulinum toxin injections work by blocking the release of
SECTION TWO • EYELID AND FACE
Chapter 49 Botulinum toxin treatment for lateral canthal rhytids (crow’s feet)
364
Table 49.2 Preoperative evaluation
Lateral canthal lines mostly when patient smiles. Some patients will
have asymmetry in the prominence or location of the lines. Often
the lines are more prominent on the side that gets sun exposure
when driving (the left in the United States)
Evaluation for inferior pretarsal bunching with smiling or squinting
with smiling
acetylcholine at the neuromuscular junction. The effect of botu-
linum treatment may take 1–2 weeks to fully manifest, and the
effect lasts 3–4 months.
Currently there are three FDA-approved brands of botulinum
toxin type A: onabotulinumtoxinA (Botox®), abobotulinum-
toxinA (Dysport®), and incobotulinumtoxinA (Xeomin®). Our
dosing recommendations apply to Botox® and not necessarily
other toxins.
The crow’s feet are a very commonly treated area, with a
high rate of patient satisfaction. Although essentially similar, not
all toxins have the same FDA-approved indications for treat-
ment. Please consult the packaage insert for each respective
toxin to determine on-labelled indications.
SURGICAL TECHNIQUE

Figure 49.1 Preoperative evaluation at rest

Lateral canthal rhytids or “crow’s feet” are caused by repeated contraction
of the orbicularis oculi muscle. Chemodenervation with botulinum toxin is
the mainstay of treatment. Soft tissue fillers play a very limited role in the
treatment of crow’s feet. At the lateral canthus, orbicularis fibers run
vertically, causing the development of horizontal rhytids (Figure 49.1).
At rest, these rhytids may not be readily noticed. Note, this patient is
undergoing subcutaneous filler placement in the nasolabial folds and has
topical anesthetic cream applied.

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Figures 49.2A and 49.2B Preoperative evaluation of dynamic rhytids

When the patient smiles, lateral canthal rhytids are readily visible (Figure 49.2A). Furthermore, with smiling this patient has excessive contraction and
bunching of the inferior pretarsal orbicular muscle or “jelly roll”, leading to narrowed palpebral fissures with orbicularis contraction (Figure 49.2B). The
patient should be counseled preoperatively to inform him or her that the dynamic and not static rhytids will have the most significant improvement with
treatment.

Figure 49.3 Preinjection anesthesia

Adequate preinjection anesthesia is an important determinant in overall
patient satisfaction with botulinum toxin treatment. Several options exist
including local application of ice for several seconds prior to injection
(Figure 49.3). Alternatively, topical anesthetic creams such as lidocaine
2.5% and prilocaine 2.5% (EMLA cream) can be applied for at least 15
minutes prior to injection. The advantages of ice treatment include its
cost-effectiveness as well the reduced chance of postinjection ecchymosis
from vasoconstriction.

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Figures 49.4A and 49.4B Injection planning

Injections for lateral canthal rhytids should be performed outside the lateral rim to prevent orbital complications (Figure 49.4A). Two to four sites are
typically injected at 2.5 to 5.0 units per injection site with a total of 5.0 to 20.0 units per side (Figure 49.4B). Note that these dosages are for the
Botox ® Cosmetic (Allergan, Inc.) formulation. The potencies for other commercially available formulations of botulinum toxin vary, so please consult the
package insert for full details. Careful drawings on the patient’s paper or electronic chart should document the location and dosage given to guide future
treatment.

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&

Figures 49.5A–C Botulinum toxin injection for lateral canthal rhytids

The injections are given with a 32-gauge needle on a 1 ml syringe. The needle is injected in the immediate subdermal plane to generate a small wheal.
Care should be taken to direct the needle away from the globe to minimize the chance for ocular perforation with patient movement (Figure 49.5A).
Injections are given in a small volume with 0.1 ml aliquots per site (Figure 49.5B). This small volume of injection minimizes migration of the toxin. For
many experienced toxin patients, the use of the fine 32-gauge needle may obviate the needle for topical anesthesia. When giving injections, make every
effort to avoid any visible subdermal blood vessels (Figure 49.5C).

SECTION TWO • EYELID AND FACE

Chapter 49 Botulinum toxin treatment for lateral canthal rhytids (crow’s feet)
366
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Figures 49.6A and 49.6B Inferior pretarsal orbicularis injection

For patients with symptomatic palpebral fissure narrowing with orbicularis contraction, treatment of the pretarsal orbicularis can be considered. The
patient is asked to look up while 1.0–2.5 units of botulinum toxin are delivered (Figure 49.6A). While injecting, the lower eyelid should be pulled slightly
down to minimize the risk of globe perforation (Figure 49.6B). Appropriate preoperative counseling should be performed with the patient to include the
possibility of ectropion, lagophthalmos, and epiphora from impaired tear pumping.

BOTULINUM TOXIN TREATMENT FOR LATERAL CANTHAL RHYTIDS

Before treatment After treatment

Figure 49.7 Before and after botulinum toxin

This 29-year-old female was displeased with lateral canthal rhytids with smiling, as well as narrowing of her vertical palpebral apertures. She received
20 units of botulinum toxin A (Botox ® Cosmetic) to the lateral orbicularis oculi on each side as well as 2 units to the inferior pretarsal orbicularis muscle.
With smiling, there is marked improvement in the dynamic rhytids at the lateral canthus as well as widening of the vertical palpebral aperture after
treatment.

367
Table 49.3 Complications
Complications Suggestions to reduce risk
Bruising Preinjection application of ice; avoidance of visible blood vessels; injection into the dermis or subdermal layer
followed by massage (rather than into muscle)
Pain Preinjection icing; longer incubation with local anesthetic cream; acetaminophen
Diplopia Injection 1 cm from orbital rim (for crow’s feet); injection in the direction opposite the orbital rim
Lower eyelid ectropion Keep injections outside of the lateral orbital rim; start with low dosage of botulinum toxin; rule out pre-
existing lower eyelid laxity and tighten eyelid if necessary
Upper eyelid ptosis Keep injections outside of the lateral orbital rim; injection subdermally only to minimize retroseptal migration

Table 49.4 Consumables used during surgery

Braun Injekt 1 ml syringe 4F16048
32-gauge needle, TSK Laboratory PRE-32013
OnabotulinumtoxinA (Botox®) Allergan
AbobotulinumtoxinA (Dysport®) Ipsen
IncobotulinumtoxinA (Xeomin®) Merz

SECTION TWO • EYELID AND FACE

Chapter 49 Botulinum toxin treatment for lateral canthal rhytids (crow’s feet)
368
 CHAPTER 50
Botulinum toxin treatment for
Table 50.1 Indications for treatment
Glabellar rhytides (“frown lines” or “elevens”) with animation
INTRODUCTION
The glabellar complex was the first site approved by the US
FDA for treatment of cosmetic rhytids. All currently available
FDA-approved neurotoxins have an on-label indication for
treatment of this area. Patient satisfaction is often reported as
SURGICAL TECHNIQUE
glabellar rhytids
Michael S. McCracken • Eric M. Hink
Table 50.2 Preoperative evaluation
Glabellar rhytids when the patient frowns
Height and configuration of brows
Presence of upper eyelid malposition – dermatochalasis, eyelid
ptosis, brow ptosis
the highest for the treatment of glabellar rhytids. Deeper rhytids
that persist after chemodenervation may be treated with
hyaluronic acid fillers, but used cautiously as ischemic necrosis
has been reported in this region.
Figure 50.1 Preoperative evaluation at rest
Without activation of the brow depressors, this patient has minimal vertical
rhytids in her forehead, and she is therefore an excellent candidate for
botulinum toxin treatment of her brow depressors (Figure 50.1). For
patients with deep, visible rhytids at rest, reasonable expectations should
be given and a discussion of the risks, benefits, and alternatives of dermal
filler injections for residual vertical rhytids is undertaken. Photographic
documentation in the resting and contracting state should be performed.
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Figures 50.2A–D Preoperative evaluation of dynamic rhytids

With contraction of the brow depressors, this patient exhibits deep vertical furrows or “eleven lines” in the glabella (Figure 50.2A). The predominant brow
depressors include the midline procerus muscle (yellow), which is located superficial to the paired corrugator supercilii (green) and depressor supercilii
muscles (green) (Figure 50.2B). The two supercilii muscles have a curvilinear configuration and, with contraction, they act to bring the brows in closer
approximation, leading to vertical furrows (Figure 50.2C). The vertically oriented procerus muscle causes downward contraction of the brow that leads to
transverse furrows across the nasal bridge (Figure 50.2D). Note that the corrugator often extends past the mid pupillary line, where it inserts into the
superficial dermis. Also, the vertical portion of the orbicularis oculi muscle exerts a downward vector on the brow.

Figure 50.3 Preinjection anesthesia

Many techniques for anesthesia have been employed, including topical
anesthetic, cryogen spray, and ice. Local application of ice is preferable
because it is readily available, cost-effective, and gives the added benefit
of vasoconstriction to reduce the risk of bruising (Figure 50.3). Lidocaine/
prilocaine (EMLA) cream, if used, should be applied for at least
10 minutes, with care taken to avoid ocular surface exposure of
the medication.

SECTION TWO • EYELID AND FACE

Chapter 50 Botulinum toxin treatment for glabellar rhytids
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Figures 50.4A–E Injection of botulinum toxin to the glabellar complex

The pattern shown is a commonly used treatment of the brow depressors (Figure 50.4A). A facial injection diagram should be used for all patients to
indicate location and dosage given to ensure consistency. Four to six injection sites at a concentration of 2.5 to 5.0 units are given per injection site for
a total of 20 to 40 units. Note that these dosages are for the Botox ® Cosmetic (Allergan, Inc.) formulation. The potencies for other commercially available
formulations of botulinum toxin vary, so please consult the package insert for full details. The patient is asked to activate and relax the brow depressor
several times to pinpoint the sites. The muscles are pinched between the thumb and forefinger to aid in injecting the mid-depth of the muscle (Figure
50.4B). Injections are never given down to the level of the periosteum as this can result in levator infiltration (Figure 50.4C). Injection too far superiorly
above the supercilii muscles may lead to inadvertent paralysis of the central frontalis muscles and lead to the mephisto or “Mr. Spock” appearance with
temporal peaking of the brows (Figure 50.4E).

371
 BOTULINUM TOXIN INJECTION TO THE GLABELLAR COMPLEX

Preinjection Postinjection

Figure 50.5 Before and after injection of botulinum toxin to the glabellar complex
This 47-year-old female noted an angry appearance due to deep vertical furrows in the glabellar region. She has no history of neurotoxin injection. A
total of 20 units of botulinum A toxin (Botox® Cosmetic) was given to the corrugator and depressor supercilii muscles. An additional 5 units was given to
the procerus muscle. Postinjection, she has relaxation of the brow depressors. Residual vertical furrows still remain owing to long-standing depressor
activation. The patient was pleased with the outcome and deferred filler injection in the glabella because of the risk of ischemic necrosis.

Table 50.3 Complications

Complications Suggestions to reduce risk
Bruising Preinjection application of ice; avoidance of visible blood vessels; injection into the dermis or
subdermal layer followed by massage (rather than into muscle)
Pain Preinjection icing; longer incubation with local anesthetic cream; acetaminophen
Upper eyelid ptosis and/or diplopia Avoid deeper injection to the level of the periosteum as the toxin may diffuse into the levator and
even the superior rectus; consider topical naphazoline/pheniramine (Naphcon-A) to elevate the
eyelid via Müller’s muscle; consider Fresnel prisms for induced diplopia or eye patching
Mephisto / “Mr. Spock” appearance Avoid injecting the frontalis muscle above corrugator and depressor supercilii; consider injection of
the frontalis muscle above the lateral eyebrows to counteract the brow arching

Table 50.4 Consumables used during surgery

Braun Injekt 1 ml syringe 4F16048
32-gauge needle, TSK Laboratory PRE-32013
OnabotulinumtoxinA (Botox®) Allergan
AbobotulinumtoxinA (Dysport®) Ipsen
IncobotulinumtoxinA (Xeomin®) Merz

SECTION TWO • EYELID AND FACE

Chapter 50 Botulinum toxin treatment for glabellar rhytids
372
 CHAPTER 51
Botulinum toxin treatment for
Table 51.1 Indications for treatment
Horizontal forehead rhytids that worsen with eyebrow elevation
Lack of underlying brow ptosis, eyelid ptosis, or upper eyelid
dermatochalasis
INTRODUCTION
The forehead is an off-label indication for all the FDA-approved
brands of botulinum toxin type A. The forehead requires caution
in treatment, as overtreatment in this area can lead to several
undesirable outcomes. It is advisable to treat this area
SURGICAL TECHNIQUE
forehead rhytids
Michael S. McCracken • Eric M. Hink
Table 51.2 Preoperative evaluation
Rule out underlying brow ptosis
Rule out underlying upper eyelid ptosis or upper eyelid
dermatochalasis
Excessively deep rhytids may require additional treatment with
dermal fillers or laser skin resurfacing
conservatively and have patients return for additional treatment
if necessary. Particular caution must be taken not to treat
patients whose rhytids are due to compensation for underlying
brow ptosis, eyelid ptosis, or upper eyelid dermatochalasis.
Figure 51.1 Preoperative evaluation at rest
Without frontalis muscle activity, this patient has no horizontal forehead
rhytids and she demonstrates no brow ptosis, upper eyelid ptosis, or upper
eyelid dermatochalasis (Figure 51.1). She is, therefore, an excellent
candidate for botulinum toxin treatment of her frontalis muscle.
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Figures 51.2A and 51.2B Preoperative evaluation of dynamic rhytids

With contraction of the brow elevator, this patient exhibits deep horizontal furrows in the forehead (Figure 51.2A). The principal brow elevator is the
frontalis muscle that is responsible for the horizontal forehead rhytids (Figure 51.2B). In most patients, the frontalis muscle is a paired structure that is
localized over both brows. In a minority of patients, frontalis muscle fibers are present centrally and this has implications for treatment.

Figure 51.3 Preinjection anesthesia

Many techniques for anesthesia have been employed, including topical
anesthetic, cryogen spray, and ice. Local application of ice is preferable
because it is readily available, cost-effective, and gives the added benefit
of vasoconstriction to reduce the risk of bruising (Figure 51.3).

SECTION TWO • EYELID AND FACE

Chapter 51 Botulinum toxin treatment for forehead rhytids
374
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Figures 51.4A–C Botulinum toxin injection to the frontalis muscle

When designing an injection pattern for a given patient, a number of factors must be considered. These include the vertical height of the frontalis, the
presence of frontalis function in the superior portion of the central forehead, and the overall strength of the frontalis. Undertreatment of the temporal
forehead near the eyebrow may cause residual upward movement of the temporal eyebrow with attempted frontalis activity. Caution must be used when
injecting patients who require frontalis function to compensate for visually significant upper eyelid dermatochalasis, upper eyelid ptosis, or brow ptosis.
Eight to ten injection sites are typically injected at 2.5 to 5.0 units per site with a total of up to 40 units (Figure 51.4A). Note that these dosages are for
the Botox ® Cosmetic (Allergan, Inc.) formulation. The potencies for other commercially available formulations of botulinum toxin vary, so please consult
the package insert for full details. To minimize the risk of brow ptosis, injections should only be performed above the most inferior horizontal rhytid
(Figure 51.4B). The injections are performed deep within the body of the frontalis muscle (Figure 51.4C).

375
 BOTULINUM TOXIN INJECTION TO THE FOREHEAD

Before treatment After treatment

Figure 51.5 Before and after botulinum toxin injection to the frontalis muscle
This 27-year-old female complained of cosmetically displeasing horizontal forehead rhytids with brow elevation. With activation of the frontalis muscle,
she has deep rhytids (left panel, Figure 51.5). She underwent treatment with 30 units of Botox ® Cosmetic (Allergan, Inc.) with marked improvement of
her forehead rhytids even with attempted brow elevation (right panel, Figure 51.5). Preoperatively, this patient had brow asymmetry, with the left side
lower than the right side.

Table 51.3 Complications

Complications Suggestions to reduce risk
Brow ptosis Do not inject below the most inferior horizontal rhytid
Loss of compensatory brow elevation in patients Careful preoperative evaluation and patient selection; may require upper blepharoplasty
with brow ptosis, eyelid ptosis, or upper eyelid or ptosis repair first
dermatochalasis
Mephisto (Mr. Spock) appearance Multiple causes – undertreatment of the lateral frontalis, leaving residual elevation of
the temporal brow, treatment of the lateral orbicularis oculi (eyelid protractor), or
injecting glabellar complex too far superior to include central frontalis muscle fibers;
treat by injecting the lateral aspect of the overacting frontalis muscle
“Frozen look” Conservative treatment with patient returning for additional injections if needed

Table 51.4 Consumables used during surgery

Braun Injekt 1 ml syringe 4F16048
32-gauge needle, TSK Laboratory PRE-32013
OnabotulinumtoxinA (Botox®) Allergan
AbobotulinumtoxinA (Dysport®) Ipsen
IncobotulinumtoxinA (Xeomin®) Merz

SECTION TWO • EYELID AND FACE

Chapter 51 Botulinum toxin treatment for forehead rhytids
376
 CHAPTER 52
Thermal conjunctivoplasty
Table 52.1 Indications for surgery
Symptomatic conjunctivochalasis affecting tear film and lacrimal
outflow
Non-resolving chemosis after eyelid surgery
INTRODUCTION
Conjunctivochalasis is characterized by redundant conjunctival
tissue analogous to dermatochalasis of the eyelids. This condi-
tion is generally benign and age-dependent. Advanced con-
junctivochalasis of the inferior bulbar conjunctiva can rest on
the lower eyelid margin, cause ocular discomfort, tear film
instability and obstruct lacrimal outflow (Figure 52.1, left panel).
With blinking, the redundant inferior bulbar conjunctiva is con-
tinually chafed by the lower eyelid margin and becomes hyper-
emic (Figure 52.1, right panel). Conjunctivochalasis should be
distinguished from chemosis, which is swelling of the conjunc-
tiva associated with exudative fluid.
In the preoperative evaluation, diseases associated with cica-
trizing conjunctivitis should be ruled out and, if appropriate,
referred to an ocular surface specialist. Redundant conjunctiva
Bobby S. Korn
Table 52.2 Preoperative evaluation
History of cicatrizing conjunctivitis (Stevens–Johnson syndrome/
toxic epidermal necrolysis, mucous membrane pemphigoid, linear
IgA disease, drug-induced)
History of any lower eyelid surgery (functional or cosmetic with
details of the surgical approach)
History of thyroid-related orbitopathy or any orbital process causing
proptosis
History of previous ocular medications used
Evaluation of ocular surface and tear film
Snap-back and eyelid distraction tests to assess lower eyelid laxity
Presence of punctal ectropion and stenosis
Lacrimal irrigation to rule out outflow obstruction
of the caruncle and inferior bulbar conjunctiva can be seen
with thyroid-related orbitopathy as well as any condition that
causes proptosis. Lower eyelid surgery, in particular transcon-
junctival blepharoplasty, can be complicated by persistent
chemosis. This condition is usually self-limited as the exudate
resolves as the postsurgical inflammation diminishes. In a lax
lower eyelid where tightening has been performed with undi-
agnosed conjunctivochalasis, this redundant conjunctiva may
spill over onto the eyelid margin, causing ocular surface symp-
toms. Epiphora may be the result of conjunctivochalasis
obstructing the inferior punctum. Canalicular irrigation should
be performed to rule out lacrimal outflow obstruction even in
the presence of conjunctivochalasis. Corneal examination may
show inferior staining from irritation by the redundant conjunc-
tiva with blinking.
377
 There are numerous techniques that have been described
for the treatment of conjunctivochalasis. Medical management
consisting of ocular lubrication is the initial treatment. Topical
antihistamines, cyclosporine and steroids may be used judi-
ciously. For refractory cases of conjunctivochalasis, our pre-
ferred treatment is thermal conjunctivoplasty. This technique
uses a hand-held, battery-powered, high-temperature cautery
tip to thermally contract the redundant conjunctiva. Treatment
at the limbus is spared to avoid damage to the stem cells.
Refractory chemosis after eyelid surgery can also be treated
with thermal conjunctivoplasty. Performing cauterization on the
palpebral conjunctiva is avoided as symblepharon may result.
Finally, this procedure should not be carried out in patients with
a history of cicatrizing conjunctivitis.

INFERIOR BULBAR CONJUNCTIVOCHALASIS

Figure 52.1A–B B Inferior conjunctivochlasis

On clinical examination, this patient has conjunctivochalsis along the lower eyelid margin (Figure 52.1A). With supraduction of the globe, the chronically
irritated bulbar conjunctiva can be appreciated (Figure 52.1B).

SECTION TWO • EYELID AND FACE

Chapter 52 Thermal conjunctivoplasty
378
SURGICAL TECHNIQUE

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Figures 52.2A–C Infiltration of local anesthetic

This patient has inferior bulbar conjunctivochalasis that obstructs the puncta and causes symptomatic foreign body sensation and epiphora (Figure
52.2A). On slit lamp examination, the conjunctivochalasis that rests over the punctum impairs lacrimal outflow. Local anesthetic consisting of 1%
lidocaine with 1 : 200,000 epinephrine is given to the inferior half of the bulbar conjunctiva (Figures 52.2B and 52.2C). A 27-gauge or 30-gauge needle
is used to deliver the anesthetic. Prior to injection, topical proparacaine or tetracaine is given to minimize discomfort from the subconjunctival injection.
The local anesthetic also balloons the conjunctiva away from Tenon’s capsule and highlights the areas of redundancy. Use of the epinephrine will
facilitate hemostasis but usually results in pupillary dilation which the patient should be alerted to.

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Figures 52.3A–D Thermal conjunctivoplasty

A high-temperature battery powered handpiece is used for the thermal contraction of the conjunctiva. The low-temperature cautery handpiece does not
heat sufficiently and conjunctiva tends to stick to the tip after each application. The cautery tip is then bent by 30° inferiorly towards the patient, for a
more ergonomic treatment in a controlled fashion. With the base of the palm against the patient’s cheek, precise control of the cautery is always present
and will minimize inadvertent corneal burns if the patient’s head moves. If using the unbent cautery tip, the probe must be directed perpendicular to the
conjunctiva surface, which can put the patient at unnecessary risk if there is movement. Thermal cauterization is started 2 mm away from the limbus to
minimize damage to stem cells. The spots should also be separated by 2 mm (Figure 52.3A). The tip should only contract the conjunctiva and spare the
underlying Tenon’s capsule (Figure 52.3B). This is aided by a small layer of local anesthetic in the subconjunctival space and additional solution can be
injected if needed. Two to three rows of cautery are usually given, depending on the degree of conjunctivochalasis. The treatment can be given from the
3 o’clock to 9 o’clock position (Figure 52.3C). Special care is taken to avoid any cauterization of the palpebral conjunctiva as this may induce sym-
blepharon in the inferior cul-de-sac (Figure 52.3D).

SECTION TWO • EYELID AND FACE

Chapter 52 Thermal conjunctivoplasty
380
 INFERIOR THERMAL CONJUNCTIVOPLASTY

Preoperative Postoperative

Preoperative Postoperative
Figures 52.4A and 52.4B Before and after thermal conjunctivoplasty
This 67-year-old female presented with tearing and foreign body sensation in both eyes. Medical management with ocular lubricants and anti-inflamma-
tories was unsuccessful. Preoperatively, the patient’s inferior conjunctivochalasis with redundant conjunctiva resting on the eyelid margin and covering
the puntum is shown in Figure 52.4A (left panel). After three rows of inferior thermal conjunctivoplasty, there is resolution of the conjunctivochalasis
(Figure 52.4A, right panel). With upgaze, there is resolution of the inferior hyperemia seen in the preoperative state (Figure 52.4B).

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Table 52.3 Complications
Complications Suggestions to reduce risk
Persistent conjunctivochalasis Consider surgical resection if thermal cautery is insufficient to reduce conjunctivochalasis
Symblepharon Do not apply thermal cautery to palpebral conjunctiva; rule out conditions associated with cicatrizing
conjunctivitis; medical treatment if cicatrizing conjunctivitis is diagnosed; consider symblepharon
lysis with fornix reconstruction using amniotic membrane; consider conjunctival biopsy
Limbal stem cell deficiency Avoid thermal cautery at limbus; maximize ocular surface lubrication; autologous serum; consider
limbal stem cell transplantation
Corneal scarring Cautious application of thermal cautery; perform in operative room with IV sedation; sufficient
subconjunctival anesthetic use; bend cautery tip to allow the hand to rest on cheek and control
facial movements
Continued epiphora Complete re-evaluation of ocular surface health and tear film; rule out lacrimal outflow obstruction

Table 52.4 Consumables used during surgery

High-temperature cautery, fine tip Bovie Medical AA01

SECTION TWO • EYELID AND FACE

Chapter 52 Thermal conjunctivoplasty
382
 SECTION THREE LACRIMAL SYSTEM

CHAPTER 53
Endoscopic
dacryocystorhinostomy
Bobby S. Korn • Don O. Kikkawa

Table 53.1 Indications for surgery

Acquired nasolacrimal duct obstruction (NLDO) associated with:
• Epiphora
• Mucocele
• Dacryocystitis (acute or chronic)
Congenital NLDO failed probing and silicone stent placement
Functional or partial NLDO that has failed silicone stent placement
Recurrent symptomatic dacryoliths

Table 53.2 Preoperative evaluation

Elicit for history of:
• Sinus disease and prior endoscopic sinus surgery
• Trauma, particularly naso-orbital fractures
• Inflammatory disease, such as sarcoidosis, granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis)
• Lacrimal plug placement, particularly intracanalicular
• Radioactive iodine used to treat thyroid carcinoma (higher dose than for Graves' disease)
• Sinus neoplasm
• Cardiac history to determine tolerance for nasal decongestion and vasoconstrictors
Characteristics of epiphora:
• Tears run down cheek
• Associated mucoid discharge
• Hemorrhagic punctal discharge (concerning for lacrimal sac neoplasm)
• Associated cutaneous erythema and swelling over lacrimal sac (dacryocystitis)
• Mattering of eyelids and eyelashes, particularly in morning
Continued

383
 Table 53.2 Preoperative evaluation – cont’d
Evaluation:
• Jones I and Jones II test
• Dye disappearance test
• Slit lamp examination
• External examination of periorbita
• Canalicular probing and irrigation
• Evaluation for punctal disease (atresia, stenosis, supranumerary puncta, slit, canaliculitis)
• Evaluation for pseuodoepiphora (tear meniscus, breakup time, corneal/conjunctival staining, Schirmer I testing, foreign body sensation
improved with artificial tears, intermittent epiphora, lack of tear overflow onto cheek)
• Nasal endoscopy (septal deviation or defects, scarring from prior surgery, concha bullosa, size of naris
• Contrast dacryocystography and dacryoscintigraphy
• CT/MRI of the orbit and sinuses
Preoperative considerations to maximize hemostasis:
• Stop supplements, vitamins, foods with natural anticoagulant activity
• Stop aspirin, clopidrogel (Plavix), dabigatran (Pradaxa), dipyridamole, rivaroxaban (Xarelto), ticlopidine after consultation with primary
care physician and cardiologist
• Maximize control of allergic rhinitis (intranasal steroids)
• Maximize blood pressure control
Intraoperative considerations to maximize hemostasis:
• Preoperative oxymetazoline spray
• Hypotensive anesthesia
• Head of bed elevated
• Nasal packing with 1 : 10,000 epinephrine (with no cardiac contraindication)

INTRODUCTION holding area with inhaled oxymetazoline. Intraoperatively, intra-

Nasolacrimal duct obstruction with symptomatic epiphora and
associated mucoid discharge is the most common indication
for dacryocystorhinostomy (DCR) (Table 53.1). First described
by Toti in 1904 as an external procedure, DCR has undergone
several modifications throughout the years. While external DCR
has been described as the “gold standard,” modern endonasal
techniques approach the same success rate without a skin
incision and more rapid recovery.
The decision to perform endoscopic DCR depends on
several factors. The procedure requires different technical skills
and proficiency compared to the external approach. The pre-
operative intranasal exam is useful to determine if a patient is
a suitable candidate for endoscopic DCR. Septal deviations,
masses, scarring and other nasal pathology should be identi-
fied preoperatively and a decision is made to proceed with an
external versus endoscopic approach. Since general anesthe-
sia is usually performed, some elderly patients may be more
suited for the external approach under local anesthesia with
sedation. Finally, if tumor is suspected, the external approach
is preferred if possible dacryocystectomy is indicated.
Several preoperative and operative aspects must be consid-
ered (Table 53.2). Achieving maximal hemostasis is vital for
success of endoscopic DCR. Proper preparation begins in the
nasal packing should be placed immediately after induction of
general anesthesia to allow for maximal absorption. The choice
of vasoconstriction varies with surgeons and patient condition.
Some surgeons still prefer 4% cocaine, but cardiac toxicity
may preclude its use in high risk patients. Our preference is
for cottonoids soaked in epinephrine at a concentration
of 1 : 10,000. Other surgeons prefer oxymetazoline-soaked
packing.
After prepping and draping, the packing is removed and the
endoscope is inserted. Additional anesthetic consisting of 1%
lidocaine with epinephrine 1 : 100,000 is injected submucosally
in the region overlying the lacrimal sac. Packing with vasocon-
striction is then replaced for 5 minutes to allow for additional
hemostasis. Additional adjunct measures include placing the
bed in reverse Trendelenburg and hypotensive anesthesia if the
patient’s medical condition permits.
Knowledge of the anatomy of the lacrimal sac and its relation
to the turbinates and lateral nasal wall is paramount. The lac-
rimal sac typically lies just anterior to the middle turbinate and
the nasolacrimal duct courses slightly posteriorly and medially
to open beneath the inferior turbinate. For nascent surgeons,
localization of the lacrimal sac can be obtained by using a
vitreoretinal light pipe or fracture of the lacrimal bone with a

SECTION THREE • LACRIMAL SYSTEM

Chapter 53 Endoscopic dacryocystorhinostomy
384
Bowman probe through the superior canaliculus; however,
experienced surgeons may not find this to be necessary. The
area of bone removal extends from the posterior lacrimal crest,
anterior past the maxillary line to the anterior lacrimal crest of
the maxilla. Superiorly it should not extend beyond the frontal
bone due to proximity of the cribriform plate and the risk of
cerebrospinal fluid leakage.
Numerous techniques of endonasal procedures have been
described. All procedures have as the common goal the crea-
tion of a mucosally lined opening from the lacrimal sac to the
nasal mucosa. This chapter and the following (Chapters 54–58)
demonstrate the different techniques for both primary and revi-
sion endoscopic DCR using various instrumentation for bony
removal and adjuncts during the procedure. In this case and
in Chapter 55, primary endoscopic DCR is performed using
Kerrison rongeurs. Chapter 54 demonstrates the use of an
osteotome to facilitate bone removal. Some surgeons prefer
intranasal flap creation with suturing and this is described in
Chapter 57. We routinely perform biopsy of the lacrimal sac in
all cases of endoscopic DCR to rule out unsuspected pathol-
ogy; however, this is not considered to be standard of care
(Chapter 55). The reader is encouraged to view each of these
procedures to experience the variation in anatomy and
technique.
Failure rate in DCR ranges between 5% and 10%. Re-
operation may be necessary if the ostium is inadequate in size
(Chapter 56) or if there is common canalicular obstruction,
where balloon dacryoplasty is indicated (Chapter 58). Finally,
conjunctivodacryocystorhinostomy with Jones tube may be
considered as an ultimate option (Chapter 59).

Figure 53.1 Anatomy of nasolacrimal system

Figure 53.1 shows a schematic of a probe placed into the nasolacrimal duct. The probe passes in a posterior and lateral direction into the nasolacrimal
duct where it opens under the inferior turbinate. On the endonasal view, the probe can be seen inside the nasolacrimal sac, as shown in green shading.
Anatomically, the nasolacrimal duct courses anterior to the middle turbinate and this is an important landmark when planning the initial osteotomy site
during endoscopic dacryocystorhinostomy.

385
SURGICAL TECHNIQUE

A B

C D

Figures 53.2A–D Endonasal anatomy and surgical planning

The ideal scope for use in endonasal dacryocystorhinostomy is a 4-mm wide 30° scope. This particular endoscope allows for a wide surgical view
without excessive obstruction of the nares. In this endoscopic view, the middle turbinate can be clearly visualized (Figures 53.2A and 53.2B). The nasal
mucosa has been adequately decongested with cottonoids soaked in 1 : 10,000 epinephrine. Directly anterior to the middle turbinate is the course of the
lacrimal sac, as shown in yellow (Figure 53.2C). The initial osteotomy site will be performed in this area (Figure 53.2D). By using the middle turbinate as
a surgical landmark, the use of a retinal light pipe through the upper canaliculus is not necessary.

A B

Figures 53.3A and 53.3B Injection of local anesthetic

Maximal nasal decongestion is essential for optimal results with endoscopic dacrocystorhinostomy. The surgery is typically performed under general
anesthesia. After induction of general anesthesia, the surgical bed is placed in a reverse Trendelenburg configuration. After removal of the preplaced
cottonoids, further hemostasis is promoted by direct infiltration of 1% lidocaine with 1 : 100,000 epinephrine into the site of the initial osteotomy using a
22-gauge, 3 inch spinal needle (Figures 53.3A and 53.3B). The nasal mucosa can be repacked with 1 : 10,000 epinephrine for an additional 5 minutes.

SECTION THREE • LACRIMAL SYSTEM

Chapter 53 Endoscopic dacryocystorhinostomy
386
 Figures 53.4A–C Creation of osteotomy
with Kerrison rongeur
The 4 mm Kerrison rongeur is small enough to
use in almost all cases of endoscopic DCR
including pediatric DCR cases (Figure 53.4A). The
5 mm Kerrison rongeur can be used in larger
nares for more rapid bone removal. The footplate
of the Kerrison rongeur is used to infracture the
thin lacrimal bone of the posterior lacrimal crest
while the thick maxillary bone of the anterior
lacrimal crest is removed (Figure 53.4B). Our
preference is to remove both the nasal mucosa
and bone as a single unit instead of elevating a
mucosal flap (Figure 53.4C). Care should be
A
taken to avoid traumatizing the nasal septum or
surrounding mucosa during all endonasal
manipulations as this bleeding will obscure
visualization for the remainder of the case.
Lacrimal Superior
gland canaliculus
Common
canaliculus

Lacrimal sac

Maxillary-lacrimal suture

Kerrison
rongeur
Inferior
canaliculus

Posterior lacrimal crest

(lacrimal bone)
Anterior lacrimal crest
B Nasolacrimal duct (maxillary bone)

387
 A B

C D

Figures 53.5A–D Exposure of lacrimal sac

The osteotomy is continually enlarged laterally and vertically to expose the lacrimal sac (Figures 53.5A and 53.5B). Gentle external palpation over the
lacrimal sac can facilitate its identification. Bone is meticulously removed until the entire length of the lacrimal sac is visualized, as shown in Figures
53.5C and 53.5D. In this patient, a 10 mm exposure of the lacrimal sac can be seen. Removing bone higher to the level of the internal common
punctum becomes increasingly difficult owing to narrowing of the nasal passage as well as placement of a standard upbiting Kerrison rongeur high in the
naris. The use of a 2 mm 45° or a downbiting 4 mm Kerrison rongeur can facilitate removal of this difficult-to-reach bone. Alternatively, an osteotome
can be used as described in Chapter 54.

SECTION THREE • LACRIMAL SYSTEM

Chapter 53 Endoscopic dacryocystorhinostomy
388
 A B

C D

Figures 53.6A–D Fenestration of lacrimal sac

A sterile, disposable sickle knife is used to fenestrate the lacrimal sac (Figure 53.6A). A Bowman lacrimal probe is placed through the upper system and
used to tent out the lacrimal sac. With the lacrimal sac under tension, the sickle knife is used to fenestrate it, starting superiorly through its entire length
(Figure 53.6B). Figure 53.6C shows the lacrimal sac fully fenestrated with the Bowman probe at its highest point. The ruggae of the lacrimal sac can be
appreciated in Figure 53.6D. This sac is removed and sent for routine histopathology if any atypica is suspected (Chapter 55).

389
 A B

Figures 53.7A and 53.7B Retrieval of silicone stents

The silicone stents are retrieved by directing the guidewire through the suction tip (Figure 53.7A). After both silicone stents are retrieved through the
osteotomy, fluorescein can be irrigated through the upper canalicular system to demonstrate patency (Figure 53.7B). We routinely place silicone stents in
all cases of endoscopic DCR and remove these at the 3-month postoperative visit.

A B

C D

Figures 53.8A–D Packing of osteotomy site

An absorbable gelatin sponge is soaked in triamcinolone acetonide 40 mg/ml (Figure 53.8A). Then, the steroid-soaked gelatin sponge is placed through
both ends of the stent guidewire and directed to the site of the osteotomy (Figures 53.8B and 53.8C). The guidewire is removed and the stent is tied
together with four square knots. The end of the loop is secured to the lateral vestibule of the nares with a single 5-0 Prolene suture.

SECTION THREE • LACRIMAL SYSTEM

Chapter 53 Endoscopic dacryocystorhinostomy
390
Table 53.3 Complications
Complications
Epiphora with scarring of
dacryocystorhinostomy (DCR)
ostium
Epiphora with patent DCR ostium
(prelacrimal causes)
Epiphora with patent DCR ostium
Sump syndrome
Pseudoepiphora – patent DCR
ostium
Reflex of air with nose blowing or
sneezing
Intraoperative epistaxis
Table 53.4 Consumables used during surgery
22-gauge, 3 inch spinal needle
Sickle knife
23-gauge silicone stent
5-0 Prolene, C-1 needle
Suggestions to reduce risk
Revision DCR surgery (Chapters 56 and 58); enlarge osteotomy; sutured flaps (Chapter 57);
use of mitomycin-C at osteotomy site; placement of double silicone stent; rule out obstruction
secondary to mass lesion with lacrimal biopsy (Chapter 55)
Rule out lower eyelid ectropion/entropion; punctal ectropion, punctal stenosis;
conjunctivochalasis; treatment malposition accordingly
Insufficient ostium; enlarge osteotomy (see above)
Diagnose endoscopically or with dacryocystogram; revision of surgery with extension of the
osteotomy to eliminate inferior sump
Likely related to dry eye (diagnose with dye disappearance test and Schirmer’s test); use
artificial tears and ointments; placement of punctal plugs
Observation and reassurance; placement of punctal plugs; silicone stent intubation of lacrimal
system
Injection of nasal mucosa with local anesthetic containing epinephrine; packing of naris with
oxymetazoline or 1 : 10,000 epinephrine; cautious use of suction cautery; application of silver
nitrate; use of fibrin glue; hypotensive anesthesia; keep head of bed elevated
Becton Dickinson #405171
Surgistar #38-7300H
Eagle Labs #180-23
Ethicon #8725H
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CHAPTER 54
Endoscopic dacryocystorhinostomy
with osteotome
Bobby S. Korn

INTRODUCTION Kerrison ronguer, the 6 mm osteotome is directed vertically to

In this chapter, endoscopic dacryocystorhinostomy (DCR) with
the use of an osteotome is presented. For indications and
preoperative evaluation, refer to Chapter 53. The osteotome is
a useful adjunct during endoscopic DCR to rapidly remove the
difficult-to-reach bone at the superior portion of the lacrimal
sac fossa. Once the lacrimal sac has been exposed using the
fracture the frontal process of the maxilla along the lacrimal sac
fossa. Once the vertical osteotomy has been completed, the
osteotome is rotated horizontally to fracture the remaining thin
lacrimal bone. The entire maxillary–lacrimal complex encom-
passing the lacrimal sac fossa can often be removed as a single
unit.

SECTION THREE • LACRIMAL SYSTEM

Chapter 54 Endoscopic dacryocystorhinostomy with osteotome
392
SURGICAL TECHNIQUE

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Figures 54.1A–D Endonasal anatomy and surgical planning

In this endoscopic view, the middle turbinate can be clearly visualized (Figures 54.1A and 54.1B). Adequate nasal decongestion has been performed as
evidenced by the appearance of the mucosa. Directly anterior to the middle turbinate is the course of the lacrimal sac, as shown in yellow (Figure
54.1C). The initial osteotomy site will be performed in this area (Figure 54.1D).

Figure 54.2 Injection of local anesthetic

Nasal decongestion is facilitated by packing neurosurgical cottonoids
soaked in a 50/50 mixture of 4% lidocaine and oxymetazoline solution or
1 : 10,000 epinephrine (no cardiac contraindications) into the middle
meatus. Further hemostasis is achieved by direct infiltration of lidocaine
with epinephrine into the site of the initial osteotomy along the maxillary
line using a 22-gauge, 3 inch spinal needle (Figure 54.2).

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Figures 54.3A and 54.3B Creation of osteotomy

A 4 mm Kerrison ronguer is used to create the initial osteotomy. Care should be taken to avoid traumatizing the nasal septum or surrounding mucosa
during all endonasal manipulations (Figure 54.3A). Nasal mucosa and bone overlying the lacrimal fossa are removed en-bloc. The footplate of the
Kerrison ronguer should be squarely placed in a “toe-in” configuration to slightly infracture the lacrimal bone and to firmly engage the thicker maxillary
bone within the lacrimal sac fossa (Figure 54.3B).

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Figures 54.4A–C Exposure of lacrimal sac

The osteotomy is enlarged laterally until the lacrimal sac is seen (Figures 54.4A and 54.4B). Gentle external palpation over the lacrimal sac can facilitate
identification of the sac. Figure 54.4C shows a visualization of the superior extension of the lacrimal sac. Typically, the maxillary–lacrimal bone is
removed mid height along the lacrimal sac fossa. Care is taken to preserve the lacrimal sac mucosa.

SECTION THREE • LACRIMAL SYSTEM

Chapter 54 Endoscopic dacryocystorhinostomy with osteotome
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Figures 54.5A–C Osteotome-assisted bone removal

A 6 mm osteotome and mallet are used for the subsequent bone removal (Figure 54.5A). First, the osteotome is oriented vertically and parallel to the
lacrimal sac (Figure 54.5B). The second fracture is performed with the osteotome rotated 90° in an effort to transect the bone overlying the superior half
of the lacrimal sac (Figure 54.5C). Extreme care should be taken to avoid excessive superior migration of the osteotome as dural perforation can occur.

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Figures 54.6A and 54.6B Removal of lacrimal sac fossa

A Takahashi nasal forcep is used to remove the loosened bone (Figure 54.6A). In this case, a 10 mm segment of bone, consisting of the lacrimal sac
fossa, is removed en-bloc (Figure 54.6B).

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Figures 54.7A and 54.7B Exposure of lacrimal sac

After removal of the lacrimal and maxillary bone of the lacrimal fossa, the lacrimal sac can be seen in its entirety (Figures 54.7A and 54.7B).

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Figures 54.8A and 54.8B Fenestration of lacrimal sac

A Bowman probe is passed through the superior canaliculus and used to tent out the lacrimal sac (Figure 54.8A). Then, a sickle blade is used to
fenestrate the lacrimal sac from its most superior position to an inferior one (Figure 54.8B). The anterior and posterior lacrimal sac flaps can be excised
and sent for histologic analysis if neoplasm is suspected.

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Chapter 54 Endoscopic dacryocystorhinostomy with osteotome
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Figures 54.9A–C Retrieval of silicone stents

In this view, the silicone stent is visible at the internal common punctum (Figures 54.9A and 54.9B). The silicone stents are retrieved by directing the
guidewire through the suction catheter tip. After both silicone stents are retrieved through the osteotomy, fluorescein is irrigated through the upper
canalicular system to demonstrate patency (Figure 54.9C).

397
 Table 54.3 Complications
Complications Suggestions to reduce risk
Cerebrospinal fluid leak May occur if osteotome extends fracture
superiorly into intracranial space;
measure height of osteotome placement
and extrapolate outside of nose to
ensure that tip does not extend above
level of medial canthal tendon; hammer
with two gentle taps per session
See Chapter 53 for general endoscopic DCR complications.

Figure 54.10 Packing of steroid and gelatin sponge

An absorbable gelatin sponge is soaked in triamcinolone acetonide
40 mg/ml. This steroid-soaked gelatin sponge is placed through both ends
of the stent guidewire and directed to the site of the osteotomy. The
guidewire is removed and the stent is tied together with four square knots.
The end of the loop is secured to the lateral vestibule of the nares with a
single 5-0 Prolene suture.

SECTION THREE • LACRIMAL SYSTEM

Chapter 54 Endoscopic dacryocystorhinostomy with osteotome
398
 CHAPTER 55
Endoscopic
dacryocystorhinostomy with
lacrimal sac biopsy
Bobby S. Korn • Masashi Mimura

ronguer for the bony osteotomy. The medial portion of the

INTRODUCTION lacrimal sac is also removed and sent for routine histopathol-
In this chapter, endoscopic dacryocystorhinostomy (DCR) is ogy. For indications, preoperative evaluation, and complica-
performed using an up-biting and down-biting 4 mm Kerrison tions refer to Chapter 53.

SURGICAL TECHNIQUE

$ %

Figures 55.1A and 55.1B Injection of local anesthetic

Preoperative nasal decongestion is maximized as described in Chapter 53. Figure 55.1A shows the maxillary line, which is the mucosal projection of the
maxillary–lacrimal suture line comprising the lacrimal crest. Local anesthetic containing 1% lidocaine and 1 : 100,000 epinephrine is injected into the
nasal mucosa overlying the lacrimal sac at the maxillary line (Figure 55.1B).

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( )

Figures 55.2A–F Creation of osteotomy

A Freer elevator is used to reflect the medial turbinate medially (Figure 55.2A). This creates room for the Kerrison ronguer to later engage the lacrimal
fossa bone. The Freer elevator is then used to infracture the posterior lacrimal crest posterior to the maxillary line (Figure 55.2B). A 4 mm Kerrison
ronguer is used to medially reflect the middle turbinate and the footplate is placed in a “toe-in” position through the infractured lacrimal bone (Figure
55.2C). Nasal mucosa and bone are removed en-bloc at the initial osteotomy site (Figure 55.2D). Care should be taken to avoid traumatizing the nasal
septum or surrounding mucosa during all endonasal manipulations to minimize bleeding and postoperative scarring. External compression over the skin
helps to identify the lacrimal sac (Figure 55.2E). The lacrimal sac is kept intact while bone is progressively removed superiorly. At the most superior level
of the lacrimal sac, a down-biting 4 mm Kerrison ronguer can be used to remove this difficult-to-remove bone (Figure 55.2F).

SECTION THREE • LACRIMAL SYSTEM

Chapter 55 Endoscopic dacryocystorhinostomy with lacrimal sac biopsy
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Figures 55.3A–E Lacrimal sac fenestration and biopsy

After exposure of the lacrimal sac, the naris is repacked with 1 : 10,000 epinephrine for 5 minutes (Figure 55.3A). The tissues should be decongested at
this point, exposing the full extent of the lacrimal sac (Figure 55.3B). The medial half of the lacrimal sac, exposed by the osteotomy, is then removed and
sent for histopathology. First, a vertical cut is made along the lateral nasal wall (Figure 55.3C). Next, two horizontal incision are made at the most
superior and inferior extents (Figure 55.3D). Takahashi forceps are then used to avulse the exposed flap and this is placed in formalin (Figure 55.3E).

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Figures 55.4A–C Placement of silicone stents

Bicanalicular silicone stents are placed to ensure patency of the DCR fistula. Figure 55.4A shows exposure of the bone at the most superior aspect of
the lacrimal sac at the level of the internal common punctum. Both stents are retrieved by directing the 23-gauge guidewire through the suction tip. The
stent is secured to the lateral nasal wall with 5-0 Prolene suture after four square knots are tied at the end of the stent. For cases at high risk of
rebleeding, aerosolized fibrin glue is used to promote hemostasis (Figure 55.4B). Gelfoam soaked in triamcinolone 40 mg/mL is packed at the osteotomy
site for additional hemostasis and antifibrosis (Figure 55.4C). At 3 months postoperatively, the silicone stents are removed in the clinical setting if tearing
has resolved subjectively and objectively with lacrimal irrigation.

Table 55.1 Consumables used during surgery

23-gauge silicone stent Eagle Labs
#180-23
5-0 Prolene, C-1 needle Ethicon #8725H
Gelfoam Pfizer
Evicel 2 mL kit Ethicon 3902
Flexible tip aerosol set Ethicon 3909

SECTION THREE • LACRIMAL SYSTEM

Chapter 55 Endoscopic dacryocystorhinostomy with lacrimal sac biopsy
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 CHAPTER 56
Endoscopic revision of failed
dacryocystorhinostomy
Table 56.1 Indications for surgery
Symptomatic epiphora secondary to failed
dacryocystorhinostomy
History of acute dacryocystitis
Excessive mucoid discharge secondary to chronic
dacryocystitis
Sump syndrome after DCR surgery
INTRODUCTION
Recurrent epiphora after prior dacryocystorhinostomy (DCR) is
uncommon but presents the patient and lacrimal surgeon with
a challenging dilemma. Patients should be observed for at least
6 months after surgery to allow for complete healing prior to
considering any further intervention. If symptoms are improved
compared to the preoperative state, observation may be the
most prudent approach. If symptoms are similar or worse, then
a consideration could be given to re-operation. If atypical
symptoms are present with an abnormal exam, neoplasm
Don O. Kikkawa • Bobby S. Korn
Table 56.2 Preoperative evaluation
Elicit prior surgical history; method of prior DCR –
endonasal or external; stent placement; any surgical
complications; any relief of symptoms prior to
recurrence
Probing and irrigation of canaliculi – determine location of
obstruction
Look for canalicular slitting from prior stent placement
External pressure to assess presence of mucoid reflux;
mucoid discharge indicates a sac remnant and a
relatively good prognosis if repeat DCR is performed
Nasal exam to assess prior ostium site, presence of
scarring, adhesions; rule out intranasal pathology and
septal deviation
If epiphora is present with patent irrigation, consider
dacryocystogram to rule out sump syndrome
If any medial canthal or intranasal masses detected or
bloody tears present, orbital and paranasal sinus
imaging should be performed to rule out neoplasm
should be considered and ruled out with imaging and biopsy
of suspicious masses.
There are many possible causes of failure after prior DCR.
Pre-lacrimal causes such as eyelid malposition and punctal
stenosis should be ruled out and addressed (Chapters 25, 26
and 63). Common causes of DCR failure include the bony
ostium being of inadequate size, common canalicular obstruc-
tion, and intranasal adhesions between the nasal septum and
ostium site. Other less common causes include occult tumor,
lacrimal sump syndrome and canalicular slitting from silicone
stents tied excessively tight.
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 After the appropriate work-up has been performed, as out-
lined in Table 56.2, a detailed discussion should be undertaken
with the patient regarding expectations, goals, and potential
complications. If significant canalicular obstruction exists,
CDCR with Jones tube should be considered (Chapter 59). The
SURGICAL TECHNIQUE
Figure 56.1 Injection of local anesthetic
Tolerance for systemically absorbed vasoconstrictors should be discussed
with the anesthesiologist prior to surgery, particularly if the patient has a
cardiac history. Excellent nasal decongestion is generally obtained with
the use of nasal packing soaked in 0.05% oxymetazoline and direct
submucosal infiltration of 1% lidocaine with epinephrine 1 : 100,000
overlying the site of the ostium with a 22-gauge spinal needle being used
to inject the anesthetic (Figure 56.1). While intranasal cocaine can be
used if necessary, there is a general tendency to avoid its use due to the
potential for cardiac effects. If desired, additional nasal decongestion can
be obtained with the use of nasal packing soaked in epinephrine at a
concentration of 1 : 10,000.
SECTION THREE • LACRIMAL SYSTEM
Chapter 56 Endoscopic revision of failed dacryocystorhinostomy
404
patient should be cautioned that any revisional surgery may
also be unsuccessful. In our opinion, the endoscopic approach
provides the best method to revise failed lacrimal
procedures.
Figure 56.2 Endonasal anatomy and surgical planning
Both visible and manual intranasal examination of the failed ostium site is
critical for surgical planning. The site of the scarred ostium is clearly
visible on the lateral nasal wall (Figure 56.2). The surgeon must inspect
the area for any evidence of tumors or septal adhesions. Using a 3-0
Bowman probe, manual palpation of the medial wall of the lacrimal
apparatus allows the surgeon to determine several key aspects that will
help guide the surgical revision. First, if residual bone is present, it can be
felt with the probe. The extent of the bone should be assessed while
moving the probe in all directions. Second, by examining the lateral
intranasal aspect of the lacrimal apparatus while the probe is advanced
and retracted, the surgeon can determine if a residual lacrimal sac
remnant or common canalicular obstruction is present.
 A B

Figures 56.3A–C Incision and removal of scarred nasal mucosa

The first step is removal of the superficial portion of the scarred nasal mucosa. With a Bowman probe displacing the soft tissue obstruction, a sickle
blade is used to make a vertical incision in the area of the scarred nasal mucosa (Figure 56.3A). The scar tissue is incised until the tip of the Bowman
probe becomes visible (Figure 56.3B). Additional scarred nasal mucosa is excised with a Kerrison rongeur (Figure 56.3C).

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 A B

C D

Figures 56.4A–D Enlargement of the ostium

Upon removal of the tissue overlying the scarred ostium, residual bone along the anterior lacrimal crest is evident (Figure 56.4A). Indeed, creation of an
inadequate bony ostium likely leads to scarring and increased rates of DCR failure. The Kerrison rongeur is used to progressively remove the maxillary
bone along the anterior lacrimal crest (Figure 56.4B). A 2 mm 45° Kerrison rongeur is used to enlarge the superior ostium (Figure 56.4C). The ostium is
enlarged with several bites circumferentially around the lacrimal sac. Along the posterior lacrimal crest, a remnant of the lacrimal bone remains and this
is removed with Takahashi forceps (Figure 56.4D).

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Chapter 56 Endoscopic revision of failed dacryocystorhinostomy
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 A B

C D

E F

Figures 56.5A–F Exposure to internal common punctum

After enlargement of the bony ostium, the medial lacrimal sac remnant is visible and this is removed with Takahashi forceps (Figures 56.5A and 56.5B).
Upon removal, a small portion of the lumen of the lacrimal sac is now exposed (Figure 56.5C). The sickle blade is used to fenestrate the lacrimal sac
superiorly (Figure 56.5D). This superior flap is then removed with Takahashi forceps (Figure 56.5E). If there is suspicion of lacrimal sac pathology, these
flaps can be sent for histopathology. A Bowman probe is then introduced and the internal aspect of lacrimal sac is then fully exposed, with removal of all
surrounding scar tissue. The internal common punctum is clearly identified and this should be the endpoint of tissue removal (Figure 56.5F).

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 A B

Figures 56.6A–C Mitomycin C application to ostium site

To lessen the risk of additional scarring and maintain patency, antimetabolites can be applied to the ostium site. Mitomycin C 0.04% is soaked on the
tip of a long cotton swab. It is then introduced intranasally, protected within the sleeve of the spinal needle that is used for the anesthetic injection
(Figure 56.6A). The applicator is then advanced through the sleeve and applied directly over the ostium site for 2 minutes (Figure 56.6B). Copious
irrigation with saline is then used to rinse away the antimetabolite (Figure 56.6C).

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Chapter 56 Endoscopic revision of failed dacryocystorhinostomy
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 A B

Figures 56.7A and 56.7B Placement of silicone stents

Silicone stents are then placed through the upper and lower canaliculi and are retrieved through the internal common punctum (Figure 56.7A). A small
piece of Gelfoam soaked in triamcinolone 40 mg/ml is then placed directly over the ostium site (Figure 56.7B). Postoperatively, the patient is instructed
to use aerosolized nasal steroids and antibiotic steroid drops twice daily. The patient is seen in the office 3–5 days later and nasal debridement is
performed if necessary. Silicone stents are removed in 3 months.

Table 56.3 Complications

Complications Suggestions to reduce risk
Failure of repeat DCR Incomplete osteotomy and scar tissue removal; ensure adequate bony removal and identify internal common
puncta; consider use of antimetabolite
Nasal hemorrhage Ensure adequate nasal decongestion; consider nasal packing postoperatively

Table 56.4 Consumables used during surgery

23-gauge probe with silicone stents Eagle Labs 180-23
Absorbable gelatin compressed sponge Pfizer, Gelfoam

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CHAPTER 57
Endoscopic
dacryocystorhinostomy with
intranasal flap suturing
Nattawut Wanumkarng

Table 57.1 Indications for surgery Table 57.2 Preoperative evaluation

Symptomatic epiphora from nasolacrimal duct obstruction Endonasal examination to identify cause of DCR failure:
• Scarring at site of osteotomy
Primary dacryocystorhinostomy (DCR) failure
• Septal deviation
• Middle meatal synechiae
• Polyps
• Concha bullosa
• Atypical masses
Lacrimal probing and irrigation

INTRODUCTION flap suturing is particularly challenging owing to poor surgical

Suturing of the nasal mucosal and lacrimal sac flaps is routinely
performed during external dacryocystorhinostomy (DCR). The
open approach afforded by the external skin incision and direct
visualization allows meticulous suturing of these flaps. However,
within the narrow field provided by the endoscopic approach,
access. In this chapter, flap suturing during endonasal DCR is
presented. While this may be considered as an optional adjunct
during primary endonasal DCR, flap suturing may be more
appropriately applied for cases of failed external or endonasal
DCR.

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Chapter 57 Endoscopic dacryocystorhinostomy with intranasal flap suturing
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SURGICAL TECHNIQUE

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Figures 57.1A–D Endonasal anatomy and surgical planning

Achieving maximal nasal decongestion is crucial to successful endoscopic DCR with nasal flap suturing (refer to Chapter 53 for full discussion). The
nasal mucosa is packed preoperatively with pledgets soaked with 1 : 10,000 epinephrine. Intranasal flap suturing is considered in this case as the nasal
septum is deviated towards the surgical side (Figures 57.1A and 57.1B). Anatomically, the course of the lacrimal sac is observed to run anterior to the
middle turbinate as highlighted in blue and this is where the initial osteotomy will be performed to expose the lacrimal sac (Figure 57.1C). The maxillary
line is the mucosal projection that represents the maxillary–lacrimal suture line that unites the anterior and posterior lacrimal crest (Figure 57.1D). This
important landmark is where the initial osteotomy is performed.

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Figures 57.2A and 57.2B Elevation of nasal mucosal flap

Prior to elevation of the nasal mucosal flap, local anesthetic containing 1% lidocaine and 1 : 100,000 epinephrine is injected into the nasal mucosa
overlying the lacrimal sac. Next, the nasal mucosa overlying the lacrimal sac is scored with a Freer elevator (Figure 57.2A). The elevator is then used to
dissect the mucosa from the bone in an anterior to posterior direction. Takahashi nasal forceps are used to remove the mucosal flap (Figure 57.2B). This
exposes bone underlying the maxillary line. Care is taken to avoid trauma to the adjacent nasal septum or middle turbinate.

Figure 57.3 Creation of osteotomy

Once the nasal mucosal flap overlying the maxillary line is exposed, a
4 mm Kerrison rongeur is used to create the initial osteotomy. The
footplate of the Kerrison rongeur is placed deeply along the midpoint of
the maxillary line and firm pressure is required to engage this bone. Often,
the thin lacrimal bone must be slightly infractured with the Kerrison
rongeur to engage the thicker maxillary bone. At least 1 cm of bone is
removed along the maxillary line. Care should be taken to remove only
bone with the rongeur and to preserve the lacrimal sac, as this will be
used for flap suturing. Localization of the lacrimal sac can be aided by
external palpation along the inferomedial orbit.

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Chapter 57 Endoscopic dacryocystorhinostomy with intranasal flap suturing
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Figures 57.4A–D Fenestration of the lacrimal sac

After the osteotomy has exposed a 1 cm vertical window, the lacrimal sac should be fully exposed (Figures 57.4A and 57.4B). Conceptually, the lacrimal
sac will be fenestrated in an “H”-shaped configuration to create a superior and inferior flap. These vertical flaps will then be sutured to the adjacent
nasal mucosa. Careful preservation and creation of the flap is paramount to success. First, the lacrimal sac is slit horizontally, midway between the
superior and inferior extent of the osteotomy (Figure 57.4C). The horizontal fenestration can be achieved with a variety of instruments, including a
Westcott scissors, #15 blade, 3 mm keratome or sickle blade. The vertical cuts are then made in a similar fashion (Figure 57.4D).

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Figures 57.5A–D Suturing of inferior flaps

Suturing in the tight confines of the naris can be technically challenging. The S-24 needle on a 6-0 Vicryl suture is an 8.0 mm, 14 circle needle that can
be bent into a semicircle for easier flap suturing. Figures 57.5A and 57.5B show the inferior flap of the lacrimal sac. The lacrimal sac is secured first
with the bent S-24 needle and retrieved and reloaded outside of the naris (Figure 57.5C). Finally, the nasal mucosa is sutured and three to four square
knots are gently placed (Figure 57.5D). The knots are tied externally and then walked down carefully into the naris.

SECTION THREE • LACRIMAL SYSTEM

Chapter 57 Endoscopic dacryocystorhinostomy with intranasal flap suturing
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Figures 57.6A–D Suturing of superior flaps

The superior lacrimal sac flap is then rotated upwards (Figures 57.6A and 57.6B). The 6-0 Vicryl on the bent S-24 needle is used to secure the lacrimal
sac flap to the nasal mucosa (Figures 57.6C and 57.6D). Securing the superior flap is more technically challenging than the lower flap. To facilitate
passage of the needle, a backhanded position should be used to pass the needle inferior to superior through the lacrimal flap. Three knots are tied
externally similar to the inferior flap. The knots should be cut on the knot to minimize suture burden. After securing the superior and inferior flaps, the
lumen of the lacrimal sac should be fully exposed.

415
Figure 57.7 Placement of silicone stent
Bicanalicular placement of the silicone stents is performed and retrieved
through the osteotomy. The guide wire of the silicone stent can be directed
through the suction tip or removed with Takahashi forceps. The silicone
stent is then tied with four square knots and secured to the lateral
vestibule of the nares using a 5-0 Prolene suture. Stents are left in place
for at least 3 months or longer with failed DCR cases. A triamcinolone-
soaked Gelfoam sponge is placed at the osteotomy site.

Table 57.3 Complications

Complications Suggestions to reduce risk
Granulomas at Pack osteotomy site with triamcinolone and Gelfoam sponge at end of case; use postoperative nasal steroids;
osteotomy site remove Vicryl sutures; minimize suture burden by cutting Vicryl knots short
DCR failure Create larger osteotomy; keep stents in place longer; consider mitomycin C treatment at osteotomy site
Damage to lacrimal Carefully remove bone with Kerrison rongeur and don’t incorporate lacrimal sac each bite; use external compression
sac flaps at medial canthus to identify lacrimal sac

Table 57.4 Consumables used during surgery

23-gauge silicone stent Eagle Labs #180-23
6-0 Vicryl, S-24 needle Ethicon #J552G
5-0 Prolene, C-1 needle Ethicon #8725H

SECTION THREE • LACRIMAL SYSTEM

Chapter 57 Endoscopic dacryocystorhinostomy with intranasal flap suturing
416
 CHAPTER 58
dacryocystorhinostomy with
Don O. Kikkawa • Suk-Woo Yang • Bobby S. Korn
Table 58.1 Indications for surgery
Symptomatic epiphora with failed prior dacryocystorhinostomy
Common canalicular obstruction
INTRODUCTION
Balloon dacryoplasty is a useful adjunct in failed dacryocystorhi-
nostomy secondary to common canalicular obstruction. In
these cases, bone removal is adequate and there is no lacrimal
sac remnant present. Typically, recurrent epiphora without
mucoid discharge is the primary symptom.
Endoscopic
balloon dacryoplasty
Table 58.2 Preoperative evaluation
Elicit prior surgical history; method of prior DCR – endonasal or
external; stent placement; any surgical complications; any relief of
symptoms prior to recurrence
Probing and irrigation of canaliculi – determine that obstruction is
at level of common canaliculus
Nasal exam to assess prior ostium site, presence of scarring,
adhesions; rule out intranasal pathology and septal deviation
Consider dacryocystogram (DCG) to determine the presence of
residual lacrimal sac remnant
Probing should confirm the presence of a canalicular obstruc-
tion. Dynamic probing with intranasal endoscopic visualization
aids in the diagnosis. Prognosis for success is typically less for
common canalicular stenosis compared to failed DCR with a
sac remnant. Combined balloon dacryoplasty and antimetabo-
lite therapy will likely increase the chances of success.
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SURGICAL TECHNIQUE

A B

Figure 58.1A and 58.1B Endonasal anatomy and dynamic probing

Intranasal examination is essential for proper surgical planning. The scarred ostium is seen on the lateral nasal wall and the middle turbinate cannot be
easily distinguished (Figure 58.1A). Dynamic probing with a 3-0 Bowman probe helps to define the common canalicular obstruction (Figure 58.1B). If the
obstruction is too dense to bypass, a lacrimal trephine (0.80 mm, Beaver–Visitec) may be used. The probe is also used to palpate for residual bone.

Figure 58.2 Submucosal injection of local anesthetic
Nasal decongestion is generally obtained preoperatively with nasal packing
soaked in 0.05 % oxymetazoline. Direct submucosal infiltration of 1 %
lidocaine with epinephrine 1 : 100,000 is then injected overlying the site of
the ostium with a 22 gauge spinal needle (Figure 58.2). The protective
plastic sheath that comes with the spinal needle is kept for later use in
the case.
Figure 58.4 Balloon dacryoplasty
The 3 mm LacriCATH balloon is then introduced into the lacrimal system
(Figure 58.4). The balloon sits within the common canaliculus and
connected to the inflation device and inflated to 4 ATM for 90 seconds.
A second repeat inflation can be performed if desired. The balloon is then
withdrawn.

A B

Figure 58.3A and 58.3B Incision and removal of scarred nasal mucosa
Removal of the superficial portion of the scarred nasal mucosa is performed with a sickle blade. The mucosa is enlarged in a semicircular fashion (Figure
58.3A). The Bowman probe is the introduced and additional scarred nasal mucosa is identified and excised (Figure 58.3B). Superior scar tissue is
removed with a 45° Kerrison ronguer or Takahashi forceps.

SECTION THREE • LACRIMAL SYSTEM

Chapter 58 Endoscopic dacryocystorhinostomy with balloon dacryoplasty
418
 A B

Figure 58.5A–C Mitomycin C application to ostium site

A long cotton tip applicator soaked in mitomycin C (0.04%) is placed within the plastic sheath that accompanies the 22 gauge spinal needle (Figure
58.5A). This protective sleeve prevents inadvertent contact with normal nasal mucosa while applying the mitomycin C. The mitomycin C soaked cotton tip
is then introduced intranasally and applied directly over the internal common puncta for two minutes (Figure 58.5B). Keeping the Bowman probe in
position during the mitomycin C placement helps to ensure proper location. Copious irrigation with normal saline is performed after the incubation with
mitomycin C (Figure 58.5C).

A B

Figure 58.6A and 58.6B Placement of silicone stents

Silicone stents are then introduced and are retrieved through the internal common punctum (Figure 58.6A). A small piece of gelfoam soaked in
triamcinolone 40 mg/cc is then placed directly over the ostium site (Figure 58.6B). The stents are kept in place for six months.

419
 Table 58.3 Complications
Complications Suggestions to reduce risk
Recurrent common canalicular obstruction Ensure that false passage is not created; consider use of canalicular trephine if obstruction
cannot be bypassed; consider conjunctivodacryocystorhinostomy if all else fails (Chapter 59)
Slitting of canaliculi Stent too tight; reduce tension when tying stent
Note: See Chapter 53 for general complications of Endoscopic DCR

Table 58.4 Consumables used during surgery

Lacricath 3 mm DCP balloon catheter Quest Medical DCP213
Inflation device Quest Medical AQL 1015
23 gauge probe with silicone stents Eagle Labs 180-23
Absorbable gelatin compressed sponge Pfizer, GELFOAM
22 gauge spinal needle, 3.00 in 0.70 x 75 mm Becton Dickinson #405171
Lacrimal trephine (Sisler), 0.80 mm x 38 mm Becton Dickinson #585031

SECTION THREE • LACRIMAL SYSTEM

Chapter 58 Endoscopic dacryocystorhinostomy with balloon dacryoplasty
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 CHAPTER 59
conjunctivodacryocystorhinostomy
Don O. Kikkawa • Kanjana Leelapatranurak •
Table 59.1 Indications for surgery
Symptomatic epiphora secondary to canalicular obstruction or
canalicular atresia
Intractable epiphora in the setting of failed prior lacrimal bypass
procedures
Intractable epiphora in the setting of facial paralysis and poor
lacrimal pump function
INTRODUCTION
Conjunctivodacryocystorhinostomy (CDCR) with Jones tube is
an operation performed for symptomatic epiphora secondary
to canalicular obstruction untreatable by other means. It should
not be undertaken lightly and must be viewed as a procedure
that requires long-term follow-up and maintenance. CDCR can
also be useful in some situations of multiple prior failed lacrimal
bypass procedures and intractable epiphora secondary to
facial nerve (CN VII) palsy. In cases of symptomatic isolated
canalicular obstruction, a thorough discussion should be
undertaken with the patient of other options available, such as
canalicular trephination and silicone stent placement prior to
proceeding with CDCR.
Endoscopic
Bobby S. Korn
Table 59.2 Preoperative evaluation
Probing and irrigation of canaliculi to determine location of
obstruction
Ocular surface examination including caruncle and plica semilunaris
to determine optimal location for Jones tube
Nasal exam to rule out intranasal pathology and septal deviation
that may interfere with Jones tube placement
Assess orbicularis strength and cranial nerve (CN) VII function
Assess eyelid laxity
Inspection of puncta to identify stenosis or atresia
CDCR with placement of the Jones tube can be performed
either through an external or endoscopic approach. Our prefer-
ence is for the endoscopic approach, which provides direct
intranasal visualization during the operation. Preoperative eval-
uation should include probing of the canaliculi to determine the
location of the obstruction, examination of the ocular surface,
and intranasal exam. For preoperative considerations for endo-
scopic surgery, please see Chapter 53.
For optimum function, placement of the Jones tube should
be as vertically oriented as possible. The location on the ocular
surface should be at the junction of the plica semilunaris and
caruncle. Although varying versions of the original glass tube
have been fabricated, we prefer the straight Jones tube with
421
4.0 mm diameter flange and fixation hole. Fixation of the tube
is performed with an 8-0 Vicryl suture to the surrounding con-
junctiva. Intranasal location of the Jones tube should be just
anterior and inferior to the origin of the middle turbinate. The
tube should not abut the nasal septum or middle turbinate.
Occasionally partial middle turbinectomy of the anterior tip is
required to provide a clear unobstructed pathway for the tube.
Patients should be advised that extrusions and clogging of
the tube can occur and regular maintenance is required. Daily
“sniffing” through the tube with closed nostrils helps to clear
the tube and ensure patency. Periodic removal with cleaning
and replacement of the tube may be required. A porous
polyethylene-coated tube can be used in cases of repeated
extrusion. Despite complications and continued symptoms that
may occur in up to 25% of patients in some published series,
many patients experience complete relief of epiphora.

SURGICAL TECHNIQUE

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Figures 59.1A–D Endonasal anatomy and surgical planning

Endoscopic visualization offers many advantages over “blind” Jones tube placement. With direct visualization, any intranasal process that may obstruct
tear flow can be addressed. In this endoscopic view, the middle turbinate can be clearly visualized (Figures 59.1A and 59.1B). Concha bullosa or middle
turbinate pneumatization may obstruct the outflow of the Jones tube and can be vertically incised and removed. If severe nasal septal deviation is
present and prevents middle turbinate visualization, septoplasty may be required first or may be performed together with CDCR. Directly anterior to the
middle turbinate is the course of the lacrimal sac within the lacrimal sac fossa, as shown in yellow (Figure 59.1C). The initial osteotomy site will be in
this area similar to routine endoscopic DCR surgery as described in Chapter 53 (Figure 59.1D).

SECTION THREE • LACRIMAL SYSTEM

Chapter 59 Endoscopic conjunctivodacryocystorhinostomy
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Figures 59.2A and 59.2B Injection of local anesthetic

Endoscopic CDCR is typically performed under general anesthesia. Immediately after the patient is asleep, nasal decongestion is facilitated by preopera-
tive packing with neurosurgical cottonoids soaked in a 50/50 mixture of 4% lidocaine and oxymetazoline solution into the middle meatus or 1 : 10,000
epinephrine if no cardiac contraindication exists. The vasoconstrictive effect is achieved during the time when the patient is prepped and the surgeon
prepares for surgery. Refer to Chapter 53 for a more complete discussion of maximizing nasal decongestion. Once the surgery begins, the packing is
removed and additional local anesthetic containing 1% lidocaine with 1 : 100,000 epinephrine is infiltrated along the maxillary line using a 22-gauge
spinal needle (Figure 59.2A). Blanching of the mucosa can be observed immediately after the solution is injected owing to fluid distention of the tissues
(Figure 59.2B). Additional nasal packing with cottonoids soaked in epinephrine can be performed for 5 minutes for additional nasal decongestion.

Figure 59.3 Creation of osteotomy

After suitable nasal decongestion has been achieved, attention is directed
towards creation of the osteotomy in the lacrimal sac fossa. The middle
turbinate is reflected nasally and a 4 mm Kerrison rongeur is used to firmly
secure the frontal process of the maxilla at the maxillary line (Figure 59.3).
En-bloc removal of bone and mucosa is performed. As the tissues are
removed, the lacrimal sac will become visible. A window of bone approxi-
mately twice the width of the 4 mm Kerrison rongeur is created. While
performing endonasal manipulations, care is taken to avoid trauma to the
nasal septum or surrounding mucosa which may induce fibrosis that may
obstruct the Jones tube postoperatively. The osteotomy measures
approximately 8–10 mm in height and can be enlarged during subsequent
steps if needed.

423
 A B

C D

Figures 59.4A–D Creation of conjunctival fistula

The desired placement of the Jones tube is marked on the conjunctiva. This corresponds to an area 2.5 mm posterior to the medial commissure, located
at the junction of the caruncle and the plica semilunaris (Figure 59.4A). An 18-gauge needle is then used to create a communication from the conjuncti-
val side to the right nasal cavity, aiming towards the osteotomy created previously (Figure 59.4B). The angle of entry into the nasal cavity is kept as
vertical as possible (Figure 59.4C). Using intranasal visualization with the endoscope, the sharp end of the 18-gauge hypodermic needle is visualized as
it enters the right nasal cavity and care is taken to avoid trauma to the nasal septum during needle entry (Figure 59.4D).

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Figures 59.5A and 59.5B Placement of guidewire

Once the fistula has been created, a 23-gauge stainless steel guidewire is threaded into the lumen of the 18-gauge needle (Figure 59.5A). The straight
stainless steel guidewire that is used for bicanalicular stent placement was used in this case. The guidewire remains in the fistula while the 18-gauge
needle is removed. Figure 59.5B shows the endoscopic view of the guidewire within the lumen of the 18-gauge needle. Simultaneous endoscopic
visualization allows careful placement of the 23-gauge guidewire while preventing the 18-gauge needle from perforating the nasal septum.

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Chapter 59 Endoscopic conjunctivodacryocystorhinostomy
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Figures 59.6A and 59.6B Measuring length of desired Jones tube

With endoscopic guidance, the optimal size and length of the Jones tube can be selected. Under direct visualization, the 18-gauge needle is then
adjusted such that there is no contact with the nasal septum and it is oriented into as vertical a position as possible (Figure 59.6A). The tip of the
18-gauge needle will correspond to the intranasal projection of the Jones tube and the needle is advanced or withdrawn to the desired length. Once a
satisfactory position is achieved, a hemostat is externally clamped at the level of the caruncle to correspond to the Jones tube flange (Figure 59.6B). The
18-gauge needle with the hemostat attached is carefully removed while the 23-gauge guidewire remains in place.

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Figures 59.7A and 59.7B Selection of Jones tube

The distance between the clamped hemostat and tip of the needle is then measured using a caliper (Figure 59.7A). The appropriate Jones tube is
selected based on this measurement (Figure 59.7B). Since a vertical orientation is desired, the tube length tends to be longer, often in the 20–25 mm
range. For diameter, our preference is to use a 4.0 mm flange with suture hole fixation. If a Jones tube set is not available, a range of different sized
tubes should be made available prior to the start of surgery.

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Figures 59.8A–C Insertion of Jones tube

A 15-gauge is then passed over the guidewire to widen the conjunctival tract prior to Jones tube placement (Figure 59.8A). Simultaneous endoscopic
visualization is performed when widening the fistula to avoid iatrogenic intranasal trauma. If the 15-gauge needle cannot be easily passed, the Kerrison
rongeur can be used to enlarge the osteotomy. After removal of the 15-gauge needle, the pre-selected Jones tube is then passed over the guidewire
(Figure 59.8B). Ophthalmic ointment is placed around the Jones tube to facilitate easier passage. Care is taken to gently direct the tube into the fistula.
Excessive pressure can cause fracture of the Jones tube, leaving shards of glass on the ocular surface and intranasally. Figure 59.8C shows endoscopic
visualization of the Jones tube in excellent position with a near vertical orientation and not abutting the nasal septum. The tip of the Jones tube also has
clearance from the middle turbinate.

Figure 59.9 Inspection of Jones tube

The final external view shows the Jones tube in an excellent position in
medial conjunctiva (Figure 59.9). Saline irrigation into the medial canthus
should show capillary drainage into the nares. Any blood or debris is
removed intranasally with the suction tip. The flange of the Jones tube is
threaded with a 8-0 Vicryl suture through the predrilled hole and this is
secured to the conjunctiva. If a predrilled hole is not present in the Jones
tube, a lasso is tied around the neck and secured to the conjunctiva.

SECTION THREE • LACRIMAL SYSTEM

Chapter 59 Endoscopic conjunctivodacryocystorhinostomy
426
Table 59.3 Complications
Complications Suggestions to reduce risk
Tube extrusion Incomplete osteotomy and soft tissue clearance; make larger osteomy and enlarge soft tissue tract with 15-gauge
needle; consider porous polyethylene-coated tube in cases of multiple extrusion; replace Vicryl anchoring suture to
conjunctiva
Tube occlusion Keep tube placement vertical to avoid abutting nasal septum; perform daily sniff test; periodically clean biofilm and
protein buildup; replace tube if necessary
Conjunctival or corneal Advance Jones tube deeper; consider revision surgery with reorientation of tube or replacement with a smaller
irritation from tube flange

Table 59.4 Consumables used during surgery

Jones tube Gunther Weiss Scientific Glass Blowing
Company, Portland, Oregon
8-0 polyglactin, Ethicon #J547G
TG140-8 needle

427
CHAPTER 60
Bicanalicular intubation with
silicone stent
Bobby S. Korn
Table 60.1 Indications for surgery
Functional nasolacrimal duct obstruction
Partial nasolacrimal duct obstruction
Congenital nasolacrimal duct obstruction (after failed probing)
After removal of lesion overlying punctum
For reconstruction of the eyelid after removal of the proximal
lacrimal system from cancer surgery
To promote healing of the lacrimal system after repair of eyelid
laceration including the canalicular system
Prophylaxis against canaliculus stenosis while on chemotherapy
(docetaxel)
INTRODUCTION
Silicone stent intubation of the nasolacrimal duct has a role in
both children and adults and each warrants a separate discus­
sion. In children, a membranous lining over the valve of Hasner
is associated with congenital nasolacrimal duct obstruction.
The vast majority of these cases resolve spontaneously as this
membrane perforates. Initial management of congenital naso­
lacrimal duct obstruction includes digital massage over the
lacrimal sac with occasional topical antibiotics for the associ­
ated mucoid discharge. Probing of the nasolacrimal duct is
considered between 9 and 12 months and has a high rate of
success. After failed probing, nasolacrimal duct intubation can
SECTION THREE • LACRIMAL SYSTEM
Chapter 60 Bicanalicular intubation with silicone stent
428
Table 60.2 Preoperative evaluation
Detailed history of tearing – frequency, mucoid discharge,
dacryocystititis
Medication history – chemotherapy for breast cancer (docetaxel),
radioactive iodine for thyroid carcinoma, glaucoma medications,
anti-herpes simplex/zoster virus drops
History of prior lacrimal surgery – nasolacrimal duct probing, stent
placement, DCR (external/endonasal)
Probing and irrigation of canaliculi
Presence of punctal stenosis
Presence of lower eyelid malposition – ectropion, entropion, punctal
ectropion, eyelid retraction
Work-up for dry eye (pseuoepiphora)
be considered. This is often performed in conjunction with
fracturing of the inferior turbinate towards the nasal septum.
The stent is left in place for a minimum of 3 months. If tearing
recurs after stent removal, then dacryocystorhinostomy may be
the only remaining option (Chapters 53–58).
In adults, there are several indications for stenting of the
nasolacrimal duct. Any trauma to the lower eyelid involving
the canaliculus requires early stenting to prevent scarring of the
proximal lacrimal drainage apparatus. Similarly, lesions that
occlude the punctum may be removed, followed by silicone
stenting. An alternative to bicanalicular intubation with unilateral
pathology is the monocanalicular stent.
 Lacrimal obstruction can also occur by iatrogenic causes as
well. Extended treatment with docetaxel for breast carcinoma
is associated with proximal lacrimal obstruction and prophylac­
tic stenting is advised in such cases. Short-term treatment with
docetaxel is not primarily indicated. Radioactive iodine for the
treatment of thyroid carcinoma has also been associated with
nasolacrimal duct obstruction and stenting may be considered
in select cases.
Silicone stent intubation for epiphora remains the most
common indication. Partial and functional nasolacrimal duct
obstruction on lacrimal irrigation may be considered for stent­
ing. Failed stenting for partial or functional nasolacrimal duct
obstruction should proceed to dacryocystorhinostomy.
Silicone stenting of the nasolacrimal system is typically per­
formed in the operating room with intravenous sedation or
general anesthesia, with the latter a requirement in children. An
infraorbital block (Chapter 1) can be performed to minimize
discomfort. Local anesthetic is infiltrated around the upper and
lower punctum as well as the lateral vestibule of the naris.
Oxymetazoline and 2% lidocaine can be mixed and used for
nasal packing for decongestion and anesthesia. The stent is
left in the nasolacrimal system for a variable amount of time but
generally for at least 2 months’ duration.

SURGICAL TECHNIQUE

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Figures 60.1A and 60.1B Dilation of punctum

A punctal dilator is used to enlarge the punctum (Figure 60.1A). When dilating the punctum, the ampulla is entered 2 mm perpendicular to the eyelid.
Once the tip is in the ampulla, the dilator is rotated parallel to the eyelid and with lateral distraction of the eyelid, the instrument is directed deeper. The
dilator should glide smoothly into the canaliculus and if there is resistance, a false passage may have been created. A gentle 30° bend is placed in the
27-gauge Crawford-style olive tip stent (Figure 60.1B). This stent is less likely to cause a false passage owing to its olive tip design but it is more
difficult to place in a tight punctum. If the punctum is stenotic, a snip punctoplasty can be performed at this time (Chapter 63).

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Figures 60.2A–C Bicanalicular intubation

The upper canaliculus should be intubated first in case trauma occurs during the procedure; the inferior canaliculus will likely still be preserved. The olive
tip is first placed in line with the ampulla, perpendicular towards the eyelid margin. Once inside the ampulla, firm lateral traction is applied to the upper
eyelid and then, the probe is passed parallel towards the common canaliculus (Figure 60.2A). The firm lateral traction that is placed on the eyelid
prevents kinking of the stent and minimizes the chance of creating a false passage. The probe is directed until a hard stop is reached against the
lacrimal bone (Figure 60.2B). After the hard stop is reached, the probe is directed posterior and lateral to enter the nasolacrimal sac (Figure 60.2C). As
the probe is directed into the nasal passage, a final hard stop will be noted when the floor of the naris is encountered. The probe should be gently
passed down the nasolacrimal duct as the nasal floor is sensitive upon contact with the olive tip.

SECTION THREE • LACRIMAL SYSTEM

Chapter 60 Bicanalicular intubation with silicone stent
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Figures 60.3A–D Retrieval of silicone stent from nasolacrimal duct

Retrieval of the olive tip can be frustrating for the nascent surgeon. This technique is often performed “blind” by feel rather than under direct observa-
tion. When initially performing retrieval, an endoscope may be used for guidance. A common misconception is that the nasolacrimal duct opens deep in
the naris when in fact the opening in the inferior meatus is very anterior and lateral. The Crawford hook is ideal for retrieving the olive tip. The hook is
directed laterally and the instrument itself often has a flat platform to help with orientation of the end (Figures 60.3A and 60.3B). The hook is then gently
swept along the floor of the nose anteriorly until metal on metal contact is noted. Once the hook has engaged the olive tip, the stent is extracted from
the naris (Figures 60.3C and 60.3D). If the stent is difficult to extract, antibiotic ointment can be applied to the guidewire to ease passage. Alternatively,
a nasal speculum and headlight can be used to identify the olive tip below the inferior turbinate.

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Figures 60.4A and 60.4B Fixation of silicone stent

Once both ends of the stent are retrieved through the nose, the tension of the stent should be checked at the puncta. Approximately 4 mm of slack should
be left at the punctum to prevent cheese-wiring postoperatively. Both ends of the stent are then tied over a locking needle holder with four square knots
(Figure 60.4A). A 5-0 Prolene suture is used to anchor the stent to the lateral vestibule of the naris (Figure 60.4B). Postoperatively, the patient is given a
combination antibiotic–steroid drop twice daily for 2 weeks. The stents are kept in place for at least 2 months and then removed in the clinic.

431
Table 60.3 Complications
Complications
Cheese-wiring of punctum
Pyogenic granuloma at punctum
Prolapse of stent onto ocular surface
Ocular surface irritation/abrasion
Table 60.4 Consumables used during surgery
5-0 Prolene suture, P-3 needle
27-gauge olive tip silicone stent
SECTION THREE • LACRIMAL SYSTEM
Chapter 60 Bicanalicular intubation with silicone stent
432
Suggestions to reduce risk
Leave 4 mm of slack in the stent before fixation; loosen nasal fixation suture if tension is
noted at the punctum during postoperative visits; consider early stent removal
Often seen with chronic stent placement; consider topical steroids; earlier stent removal
Instruct patients to not rub eyes or clean naris; replace Prolene fixation suture in naris;
consider removal if stent cannot be reposited in the clinical setting
Fixate stent deeper in naris if too loose; use lubricating drops and ointments; earlier stent
removal
Ethicon #8698G
Eagle Labs #180-27T
 CHAPTER 61
Table 61.1 Indications for surgery
Primary canaliculitis resistant to medical management (digital
massage, warm compresses, targeted topical or oral antimicrobials,
and repeated irrigation)
Secondary canaliculitis resistant to plug removal and irrigation
Punctal stenosis or canalicular obstruction associated with
canaliculitis
Recurrent primary or secondary canaliculitis
INTRODUCTION
Canaliculitis is an infection of the canaliculus and the proximal
lacrimal ducts. It classically presents with epiphora, medial
eyelid swelling, conjunctivitis, and a characteristically elevated
pouted punctum with mucopurulent discharge (Figure 61.1A).
Canaliculitis is often confused with chalazia but is distinguished
by its centration about the punctum where the meibomian
glands are not present.
Classically, concretions or sulfur granules are expressed from
the punctum by retrograde massage and are associated with
infection by Actinomyces spp., a filamentous Gram-positive
rod. Infection or co-infection with Streptococcus and Staphy-
lococcus are also seen.
Canaliculitis can be primary or secondary to instrumentation
such as lacrimal intubation or plug insertion. Intracanalicular
occlusion by the SmartPlug and Herrick plug has been associ-
ated with secondary canaliculitis. These intracanalicular devices
cause tear stasis and act as a nidus for infection and can be
Treatment of canaliculitis
Ramzi M. Alameddine • Bobby S. Korn
Table 61.2 Preoperative evaluation
History of prior intracanalicular plug (SmartPlug, hydrogel, silicone,
or collagen)
History of prior head and neck malignancy (squamous cell
carcinoma, inverting papilloma, etc.)
Check for patency of the lacrimal drainage system by irrigation
posteriorly dislodged further down the lacrimal system by irriga-
tion. With more distal obstruction and scarring, an open surgi-
cal approach is often necessary for removal. Permanent
scarring of the common canaliculus may necessitate conjunc-
tivodacryocystorhinostomy (Chapter 59).
Primary canaliculitis is treated conservatively with warm com-
presses, retrograde digital massage, along with topical and oral
antibiotics. Repeated irrigation of the lacrimal system with anti-
biotics has also been advocated as an alternative to surgical
treatment.
Once the canaliculus becomes impacted by progressively
larger concretions, medical management gives way to definitive
surgical intervention. The procedure begins with a canalic-
ulotomy to expand the posterior aspect of the punctal ring and
then meticulous expression and curettage of impacted concre-
tions. Antibiotic irrigation of the lacrimal system can also be
performed as an adjunctive procedure. Recurrent canaliculitis
warrants histopathology and cultures to rule out neoplasm and
resistant organisms.
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SURGICAL TECHNIQUE

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Figures 61.1A and 61.1B Injection of local anesthetic

Figure 61.1A shows the classic appearance of primary canaliculitis with a dilated, pouted punctum with associated mucoid discharge. As the pericanal-
icular tissues are inflamed, further manipulation is delayed until adequate anesthesia can be instituted. Cotton-tipped applicators soaked in topical 4%
lidocaine solution are applied to the conjunctiva posterior to the punctum for several minutes. A local anesthetic mixture consisting of 2% lidocaine with
1 : 200,000 epinephrine is injected in the conjunctiva posterior and medial to the punctum (Figure 61.1B). If cultures are desired, these are obtained
prior to instillation of povidone-iodine 5% drops.

Figure 61.2 Posterior canaliculotomy

Punctal dilation is often unnecessary with canaliculitis, as the opening is
often wide and further probing may dislodge any material deeper into the
proximal lacrimal system. Westcott scissors are used to perform a single
posteriorly directed canaliculotomy for 2 mm (Figure 61.2). The incision
should not be made medially as the punctal sphincter ring may expand
postoperatively and develop into a slit canaliculus. No punctal tissue should
be excised.

SECTION THREE • LACRIMAL SYSTEM

Chapter 61 Treatment of canaliculitis
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Figures 61.3A–D Expression of concretions

Using a pair of cotton-tipped applicators, the medial-most aspect of the canaliculus is expressed from a nasal to temporal direction (Figure 61.3A). With
persistence, canalicular concretions are expressed from the punctum using a retrograde massage movement (Figure 61.3B). Multiple, large concretions
can be removed from the proximal lacrimal system and these are sent for histopathology and culture if indicated (Figure 61.3C). The canalicular massage
is repeated with the cotton-tipped applicators until no more concretions are expressed (Figure 61.3D). If the concretions are too large to expunge from
the punctum, the canaliculotomy can be increased by 1 mm.

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Figures 61.4A and 61.4B Canalicular curettage

A fine 2 mm curette is then used to gently sweep the canaliculus for any residual granules that may have escaped retrograde massage (Figures 61.4A
and 61.4B). Care should be taken with the curette to avoid damaging the canaliculus or creating a false passage. Thorough removal of all residual
concretions should minimize recurrence.

435
Figure 61.5 Lacrimal irrigation with antibiotic
As a final step, the lacrimal system is irrigated to flush microscopic debris
through the lacrimal system and to confirm patency. Sterile saline or an
antibiotic solution (e.g. penicillin G) can be flushed through the canaliculus
using a blunt tip lacrimal cannula.

TREATMENT OF CANALICULITIS

Preoperative Postoperative

Figure 61.6 Before and after treatment of canaliculitis

The patient presented with primary canaliculitis and failed medial management with warm compresses and topical antibiotic therapy. He underwent
vertical canaliculotomy and removal of concretions. Histopathology and cultures were consistent with infection by Actinomyces israelii. His symptoms
resolved completely following surgical intervention.

Table 61.3 Complications

Complications
Recurrence of canaliculitis
Tearing with patent lacrimal
system with slit canaliculus
Canalicular fistula formation
Canalicular luminal narrowing or
scarring
Suggestions to reduce risk
Meticulous curettage to all residual concretions; injection of antibiotic solution; obtain histopathology to rule
out occult neoplasm; obtain cultures and sensitivity to rule out resistant organisms such as methicillin-
resistant Staphylococcus aureus; consider silicone stent intubation as an adjunct (Chapter 60)
Avoid large excisions of the punctal sphincter or a three-snip punctoplasty as this may lead to impairment
of lacrimal pump; use a small single-snip canaliculotomy; consider suture closure of a large punctum after
canaliculotomy
Avoid extensive canaliculotomy, greater than 2 mm; consider silicone stent placement; consider suturing of
the marsupalized canaliculus
Avoid silver nitrate cauterization or thermal cauterization

SECTION THREE • LACRIMAL SYSTEM

Chapter 61 Treatment of canaliculitis
436
 CHAPTER 62
Silicone stent intubation with
Table 62.1 Indications for surgery
After removal of lesion overlying punctum
For reconstruction of the eyelid after removal of the proximal
lacrimal system from cancer surgery
To promote healing of the lacrimal system after repair of eyelid
laceration involving the canalicular system
Prophylaxis against canalicular stenosis while on chemotherapy
(docetaxel)
INTRODUCTION
Silicone stent intubation of the proximal lacrimal system is typi-
cally done as a prophylactic measure to prevent scarring
from a variety of causes. As the nasolacrimal duct (NLD) is
not intubated in this technique, there is no role for proximal
pigtail probe
Bobby S. Korn
Table 62.2 Preoperative evaluation
Detailed history of tearing – frequency, mucoid discharge,
dacryocystititis
Medication history – chemotherapy for breast cancer (docetaxel),
radioactive iodine for thyroid carcinoma, glaucoma medications,
anti-herpes simplex/zoster virus drops
History of prior lacrimal surgery – nasolacrimal duct probing, stent
placement, DCR (external/endonasal)
History cutaneous malignancies, prior photographs of eyelid lesion
at punctum
History of trauma to eyelid involving canalicular system, timing and
associated symptoms
Probing and irrigation of canaliculi
Presence of punctal stenosis
Presence of lower eyelid malposition – ectropion, entropion, punctal
ectropion, eyelid retraction
Workup for dry eye (pseudoepiphora)
intubation for epiphora secondary to NLD obstruction. Common
indications include reconstruction of the puncta and canaliculi
after excision of cutaneous malignancies and during eyelid
laceration repair involving the canaliculus. Excision of lesions
at the punctum may cause scarring and prophylactic stent
437
placement is protective. Canalicular stenosis induced by chem-
otherapeutic medications such as docetaxel may be prevented
by proximal stenting but bicanalicular stent placement through
the NLD is more advisable (Chapter 60).
The pigtail catheter is used to facilitate proximal intubation of
the lacrimal system. The primary complication with the pigtail
catheter is iatrogenic damage to the common canalicular
system. Care is taken to minimize lateral traction with the cath-
eter in place. Finally, certain manufacturers have erroneously
created large diameter pigtail probes. These should be com-
pletely avoided as they induce a high rate of common canalicu-
lar disinsertion that may necessitate Jones tube placement
(Chapter 59).

SURGICAL TECHNIQUE

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Figures 62.1A and 62.1B Placement of pigtail probe

The pigtail probe is useful for circular intubation of the upper and lower canalicular system. When there is any suspicion of common canalicular damage
or compromise, the pigtail probe should not be used and instead bicanalicular intubation should be performed (Chapter 60). In this case, removal of a
basal cell carcinoma of the lower eyelid included the inferior punctum. Proximal canalicular intubation was performed to allow for reconstruction of the
inferior canaliculus. The pigtail probe has two distinct ends corresponding to the upper or lower puncta. The probe is delicately threaded into either
punctum while avoiding any lateral traction (Figures 62.1A and 62.1B). Placement of ophthalmic ointment on the catheter will facilitate passage.

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Figure 62.2A and 62.2B Placement of suture guide wire

Once the probe has been successfully placed, a 6-0 Prolene suture is threaded into the eye of the pigtail probe (Figure 62.2A). The probe is then gently
removed, guiding the suture through the upper canalicular system (Figure 62.2B). This suture will serve as a guide for the placement of the silicone stent
to complete the circle.

SECTION THREE • LACRIMAL SYSTEM

Chapter 62 Silicone stent intubation with pigtail probe
438
 Figure 62.3 Determining size of silicone stent
A silicone stent is then cut to the appropriate size based on patient age. In
children, the proximal canalicular system averages 20 mm while in adults
it averages 25 mm (Figure 62.3). In this case, the silicone stent from a
27-gauge olive tip stent is used.

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Figures 62.4A and 62.4B Placement of silicone stent

The stent is then directed into the superior punctum while a locking needle holder places traction on the distal end of the stent (Figure 62.4A). In this
manner, the stent and suture are passed as a single unit into the canaliculus (Figure 62.4B). Use of antibiotic ointment will facilitate passage of the stent
around the common canaliculus. If the punctum is stenotic, dilation and punctoplasty can be performed to improve passage (Chapter 63).

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Figures 62.5A and 62.5B Securing stent

The Prolene suture is then tied with three square knots with attention not to excessively kink the silicone stent (Figure 62.5A). The suture is cut close to
the knot and the suture is then rotated to direct the knot away from the ocular surface (Figure 62.5B).

439
Table 62.3 Complications
Complications
Cheese wiring of punctum
Pyogenic granuloma at punctum
Prolapse of stent onto ocular surface
Ocular surface irritation/abrasion
Suggestions to reduce risk
Appropriately size silicone stent for age of patient; replace with longer stent if Prolene suture is
under tension after tying knots; consider early stent removal but balance with risk of canalicular
stenosis
Often seen with chronic stent placement; consider topical steroids; earlier stent removal
Ensure stent is cut to appropriate length; shorten stent if necessary; instruct patients to not rub
eyes; consider removal of stent
Ensure Prolene knot is rotated towards the common canaliculus; knot may spontaneously rotate
towards ocular surface and may require re-rotation; use lubricating drops and ointments; earlier
stent removal

Table 62.4 Consumables used during surgery

5-0 Prolene suture, C-1 needle Ethicon #8890H
27 gauge olive tip silicone stent Eagle Labs #180-27T

SECTION THREE • LACRIMAL SYSTEM

Chapter 62 Silicone stent intubation with pigtail probe
440
 CHAPTER 63
Table 63.1 Indications for surgery
Punctal stenosis
Symptomatic epiphora
INTRODUCTION
Punctal stenosis often occurs in conjunction with punctal ectro-
pion. Punctal stenosis may be one of the first signs of the
spectrum of lower eyelid ectropion, which first begins with the
medial aspect of the eyelid and then involves the entire margin.
Punctal stenosis also may occur as part of conjunctival cicatriz-
ing disorders. Ocular cicatricial pemphigoid, Stevens–Johnson
syndrome, and pseudo-pemphigoid can all affect the puncta
and may cause progressive stenosis that is difficult to manage.
In patients with isolated punctal stenosis, snip puncto-
plasty can be performed as an in-office procedure or in
Snip punctoplasty
Don O. Kikkawa • Bobby S. Korn
Table 63.2 Preoperative evaluation
Probing and irrigation of canaliculi and lacrimal system
Assess for co-existent punctal ectropion
Rule out any conjunctival cicatrizing disorder
Assess lower eyelid laxity
Prior eyelid, facial surgery or trauma
conjunction with other lower eyelid procedures. Our pre-
ferred approach is to use a Kelly Descement punch to
perform the punctoplasty. This allows more precise and
controlled enlargement compared to the classic three-snip
punctoplasty. Placement of silicone stents at the time of
punctal stenosis can also improve long-term patency (Chapter
60). Canalicular stenosis and nasolacrimal duct stenosis,
however, may be co-existent and, if present, should be
also addressed appropriately. After dilation of the puncta,
probing and irrigation are essential to diagnose and treat
associated lacrimal obstructions.
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SURGICAL TECHNIQUE

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Figures 63.1A–C Dilation of punctum

Prior to the start of surgery, local anesthetic is given through the conjunctiva posterior to the punctum. If the procedure is performed in the clinic setting,
the conjunctiva around the punctum can be soaked with 4% lidocaine on cotton-tipped applicators prior to injection to minimize discomfort. The eyelid is
slightly everted manually to examine the punctum and, in this case, stenosis is clearly seen (Figure 63.1A). The upper eyelid should also be everted to
rule out a co-existent upper punctal stenosis as well. Punctal dilation is necessary before punctoplasty can be performed. A tapered, pointed small-
caliber dilator is useful for severely stenotic puncta. The dilator is first inserted vertically for 1–2 mm to follow the anatomic orientation of the punctum
prior to it joining the horizontally oriented canaliculus (Figure 63.1B). After vertical insertion, the punctal dilator is reoriented horizontally as the eyelid is
manually distracted laterally with gentle countertraction (Figure 63.1C). This facilitates keeping the dilator within the native canaliculus and helps to avoid
creation of a false passage.

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Figures 63.2A and 63.2B Punctoplasty with Kelly punch

The Kelly punch, used for trabeculectomy, provides an excellent platform for precise enlargement of the stenotic punctum. The medial ring of the
ampulla should remain intact and the targeted area for removal with the Kelly punch is the posterior and posterior-lateral aspect of the ampulla (Figure
63.2A). Medial punctoplasty can lead to a slit punctum, which inefficiently conducts tears through the lacrimal apparatus. Upon completion of the
punctoplasty, redilation is performed in a similar manner to that described above (Figure 63.2B). This may be repeated several times. Topical antibiotic
and steroid drops are given twice daily for 1 week postoperatively.

SECTION THREE • LACRIMAL SYSTEM

Chapter 63 Snip punctoplasty
442
 RIGHT INFERIOR PUNCTOPLASTY

Preoperative Postoperative

Figure 63.3 Before and after punctoplasty

This patient underwent right inferior punctoplasty with resolution of epiphora.

Table 63.3 Complications

Complications Suggestions to reduce risk
Inadequate punctal opening Inadequate primary opening with Kelly punch; consider 2-3 bites to ensure adequate size
Slit puncta Avoid removal of medial punctal ampulla
Re-stenosis Reassess for any evidence of conjunctival cicatrizing disorder; use topical steroid drops postoperatively;
consider placement of silicone stent (Chapter 60)

Table 63.4 Instrumentation used during surgery

Kelly Descemet punch Storz E2798

443
 SECTION FOUR ORBIT

CHAPTER 64
Three wall orbital
decompression
Bobby S. Korn • Don O. Kikkawa

Table 64.1 Indications for surgery Table 64.3 Algorithm for average proptosis reduction by degree
of bone removal
Disfiguring proptosis
Area of decompression Proptosis reduction
Compressive optic neuropathy unresponsive to maximally tolerated
medical therapy Orbital fat 2 mm
Exposure keratopathy unresponsive to maximally tolerated medical Orbital fat and lateral wall 4 mm
therapy Orbital fat, lateral wall, and medial wall 6 mm
Preparation for strabismus surgery with large angle deviation Orbital fat, lateral wall, medial wall, 8 mm
Deep aching pain and pressure from proptosis and floor
Orbital fat, lateral wall, medial wall, 10 mm
Table 64.2 Preoperative evaluation floor, and lateral rim removal
Exophthalmometry readings
Extraocular muscle movements and primary deviation
MRD1, MRD2, degree of upper and lower eyelid retraction,
lagophthalmos
Optic nerve function – relative afferent pupillary defect (RAPD),
color perception, visual field testing, optic nerve head examination
CT scan – sinus relationships, muscle size and bone volume
Thyroid status including thyroid function tests

primarily occurs in the extraocular muscles; however, some

INTRODUCTION
Thyroid-related orbitopathy (TRO) is the most common cause
of proptosis in adults. TRO is caused by an autoimmune
process that leads to deposition of extracellular matrix in the
orbital soft tissues that attracts water, causing swelling. This
patients have activation of orbital fat, leading to adipogenesis
and fat hypertrophy. As with most autoimmune diseases,
women have a 6 : 1 predilection for the disease. Factors associ-
ated with worsening disease include smoking, but tobacco use
is not causal.

SECTION FOUR • ORBIT

Chapter 64 Three wall orbital decompression
444
 The most common eye manifestation is eyelid retraction, but
other findings include: proptosis, restrictive strabismus, chem-
osis, conjunctival injection, eyelid edema, eyelid erythema, and
optic neuropathy in severe cases. Approximately 90% of
patients with eye findings are hyperthyroid, with the remaining
10% being either euthyroid or hypothyroid. CT imaging can
reveal enlarged extraocular muscles (type II disease) and/or
enlarged fat compartments (type I disease) in the orbit. The
most commonly enlarged extraocular muscles in decreasing
order are: inferior, medial, superior and lateral rectus muscles.
The tendon insertions are typically spared from enlargement
compared to myositis seen with idiopathic orbital inflammation.
Treatment is based on symptoms and severity of disease.
Patients with optic neuropathy require urgent medical treat-
ment followed by orbital decompression if resistant. In patients
requiring elective surgical intervention, a staged approach is
recommended (with not all stages being required) in order:
orbital decompression, strabismus surgery, and eyelid surgery.
The decision to perform orbital decompression depends on
many factors. The most common indication is disfiguring prop-
tosis (Table 64.1). The orbital aspect of the autoimmune
process is self-limited and many patients have spontaneous
improvement once the active inflammatory phase ends. Elec-
tive surgical rehabilitation should occur in the quiescent phase.
Orbital decompression is an effective operation to help restore
the proptosis to the pre-disease state. The preoperative evalu-
ation must include measurement of exophthalmos and imaging
(Table 64.2). Symptoms of deep ache and pressure often
resolve after orbital decompression. Our algorithm for decom-
pression is seen in Table 64.3.

Superior orbital fissure Optic foramen

A Inferior orbital fissure B

Figures 64.1A and 64.1B Preoperative surgical planning

Figure 64.1A shows an anatomic representation of bone removal during orbital decompression. The lateral wall is depicted in “A” shaded yellow, medial
wall in “B” shaded blue, and floor in “C” shaded red. Removal of the lateral orbit rim is covered in Chapter 65. Access to the lateral wall is achieved
through a temporal upper eyelid crease incision (Figure 64.1B, “A”). Medial wall decompression is achieved through a transcaruncular incision (Figure
64.1B, “B”). Access to the orbital floor is achieved via a lateral canthotomy and inferior transconjunctival incision (Figure 64.1B, “C”).

445
 A

Figures 64.2A and 64.2B Preoperative orbital imaging

High-resolution CT scanning of the orbit in both the axial and coronal planes is essential for preoperative planning. The use of the “bone window” allows
for more accurate determination of bone volume available for decompression. In the axial view, several features should be noted: the amount of bone
present in the greater wing of the sphenoid, the amount of intraconal fat present, the size of the extraocular muscles (type I vs. II orbitopathy), and the
position and size of the sphenoid sinus (Figure 64.2A). In the coronal view, attention is directed towards the assessment of the ethmoid and maxillary
sinuses, the location of the skull base during medial wall decompression, and crowding of the orbital apex (Figure 64.2B).

SECTION FOUR • ORBIT

Chapter 64 Three wall orbital decompression
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Figures 64.3A–D Dissection down to deep lateral orbit

A temporal eyelid crease incision is marked and a #15 Bard-Parker blade is used to make the incision. A subperiosteal dissection plane is created and a
malleable retractor is used to expose the deep lateral wall (Figure 64.3A). At this level of reflection, the superior orbital fissure is demarcated and the
bone overlying the greater wing of the sphenoid is exposed for decompression (Figures 64.3B and 64.3C). Figure 64.3D shows a schematic representa-
tion of the surgeon’s view.

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Figures 64.4A–F Lateral wall decompression

Bony decompression of the deep lateral wall is achieved using a high-speed diamond tip burr rotating at 60,000 rpm (Figure 64.4A). This high speed,
combined with the fine cutting diamond tip, causes minimal bleeding due to thermal coagulation even within the marrow space of the sphenoid. Drilling
is performed with the dominant hand while the other hand holds a Frazier suction tube (8 or 10 French size) to remove particulate bone. Frequent breaks
in the drilling is performed with normal saline irrigation to cool the bone and surrounding orbital apex soft tissues. Saline is not typically irrigated during
the actual bony decompression as this obscures the view and may lead to inadvertent penetration into the intracranial space. The heat generated by
decompressing the marrow space accounts for the thermal coagulative effect. In this first step, a safe depth of decompression is established and
corresponds to the scan shown in Figure 64.4B. Once this level has been established, further decompression continues superiorly and inferiorly. The end
point of decompression is best noted by the pale appearance of the decompressed bone. While still in the marrow space, the bone has a darker
appearance, from the coagulated blood (Figures 64.4C and 64.4D).

SECTION FOUR • ORBIT

Chapter 64 Three wall orbital decompression
448
 ( )

Figures 64.4A–F, cont’d

Once the inner table of the greater wing of the sphenoid bone has been reached, the bone has a more pale appearance, as shown in Figures 64.4E and
64.4F. After bony decompression is complete, a #12 Bard-Parker blade is used to fenestrate the periorbita to allow orbital fat to prolapse into the newly
created space. Conservative fat decompression can be performed in this area of approximately 2–4 ml.

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Figures 64.5A and 64.5B Isolation of inferior oblique muscle

For isolated medial wall decompression without orbital floor decompression, a transcaruncular incision is performed (Chapter 69). When access to both
the floor and medial wall are required, lateral canthotomy, inferior cantholysis, and transconjunctival incisions are performed. The inferior oblique muscle
is imbricated and disinserted for maximal access to the floor and medial wall (Figures 64.5A and 64.5B). A 6-0 double-armed Vicryl suture is passed in
a double-locked whip stitch and the muscle is disinserted close to its origin on the maxillary bone.

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Figures 64.6A–D Medial wall decompression

After disinsertion of the inferior oblique, a subperiosteal dissection plane is created along the orbital floor and communicated to the medial wall at the
level of the frontoethmoidal suture line and deeply corresponding to the posterior ethmoidal air cell (Figures 64.6A and 64.6B). Along the frontoethmoidal
suture line, the anterior and posterior ethmoidal arteries may be noted. This vessels may be cauterized towards the orbital side with gentle bipolar
cautery. Takahashi forceps and Kerrison rongeurs are then used to remove all bone overlying the ethmoid bone (Figure 64.6C). The anterior, middle, and
posterior ethmoidal air cells are sequentially removed. The most posterior ethmoidal air cell should be fully removed in cases of compressive optic
neuropathy for maximal decompressive effect. Care should also be taken to avoid excessive removal of air cells cranially as the skull base is adjacent.
The sinus mucosa along the skull base should be kept intact and the anatomy should be well known from the CT scans (Figure 64.2B). The end point of
the decompression is the sphenoid sinus, which can be noted in Figure 64.6D. Exquisite attention should be paid to avoiding trauma in this area, as the
internal carotid artery is located close to this position.

SECTION FOUR • ORBIT

Chapter 64 Three wall orbital decompression
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Figures 64.7A–D Creation of ethmoid sinusotomy

To prevent development of sinusitis and facilitate drainage of hemorrhage, a sinusotomy between the ethmoid and nares is performed. The sinusotomy
will be created under the middle turbinate and posterior to the lacrimal sac fossa (Figures 64.7A and 64.7B). A Freer elevator is used to create the
sinusotomy intranasally (Figure 64.7C). The tip of the Freer elevator should be clearly visible from the orbital side (Figure 64.7D). Residual bone is
removed around the elevator to ensure a patency. This sinusotomy allows blood to exit the naris and minimizes orbital accumulation.

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Figure 64.8A–D Fenestration of medial periorbita

The medial periorbita is then isolated with a malleable retractor (Figures 64.8A and 64.8B). A #12 Bard-Parker blade is then used to fenestrate the
periorbita in a “U-shaped” configuration allowing fat to prolapse into the ethmoidal space (Figures 64.8C and 64.8D). Conservative fat decompression
can be performed in this area of approximately 1–2 ml. Care is taken to avoid laceration of the medial rectus and associated ciliary vessels during the
periosteal fenestration.

SECTION FOUR • ORBIT

Chapter 64 Three wall orbital decompression
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Figures 64.9A–D Orbital floor decompression

A malleable retractor is used to superiorly reflect the periorbita overlying the floor (Figure 64.9A). The maxillary bone and infraorbital nerve are visualized
with superior retraction (Figure 64.9B). Only the posterior half of the orbital floor is decompressed, staying medial to the infraorbital nerve to prevent
postoperative globe ptosis (Figure 64.9C). Kerrison rongeurs and Takahashi forceps are used for bony decompression (Figure 64.9D). To prevent globe
ptosis, the anterior half of the maxillary-ethmoidal strut should be kept intact.

453
 Bilateral 3 Wall Orbital Decompression
and Upper Eyelid Retraction Repair

Preoperative Postoperative
Figures 64.10 Before and after orbital decompression
This patient presented with severe bilateral exophthalmos and upper eyelid retraction secondary to thyroid-related orbitopathy. He underwent bilateral 3
wall orbital decompression and upper eyelid retraction repair with marked improvement.

Table 64.4 Complications

Complications Suggestions to reduce risk
Residual proptosis Incomplete removal of bone or opening into sinuses; carefully review preoperative imaging and correlate with
intraoperative anatomy to insure adequate bony removal; fully fenestrate periorbita; consider augmenting with
orbital fat removal
Hypesthesia Avoid injury to infraorbital and zygomatic temporal nerves during lateral wall decompression; may also counsel
patients that sensation often returns; avoid injury to infraorbital nerve during orbital floor decompression
Sinusitis Keep middle meatus patent to ensure egress of sinus secretions; keep anterior orbital floor intact and bone
just behind the lacrimal sac along the medial wall to keep ostiomeatal complex patent
Diplopia Avoid extraocular muscle trauma; consider balanced decompression of medial and lateral walls; counsel
patients that diplopia is a possibility and may require strabismus surgery
Retrobulbar hemorrhage Stop preoperative anticoagulation with coordination from primary care physician; ensure hemostasis if fat is
removed during orbital decompression; apply bone wax to residual marrow bleeding
Cerebrospinal fluid leak Careful bone removal and observation of color change going from bone marrow (dark) to inner table (pale);
seal dural breaks with bone wax, fibrin glue, or dural seal system (DuraSeal) with fat patch
Epistaxis Preoperative nasal decongestion; cauterize anterior and posterior ethmoidal arteries during medial wall
decompression; pack ethmoid sinus with thrombin-soaked Gelfoam; apply fibrin glue to ethmoid mucosa

Table 64.5 Consumables used during surgery

6-0 Vicryl double-armed S-29 needle Ethicon #J555G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
4 mm round diamond tip burr Stryker #5820-12-40

SECTION FOUR • ORBIT

Chapter 64 Three wall orbital decompression
454
 CHAPTER 65
Table 65.1 Indications for surgery
Maximal orbital decompression
Need for access to the intraconal space
In combination with a medial and lateral orbitotomy approach for
lesions near the orbital apex
INTRODUCTION
Marginotomy of the lateral orbital rim is performed to improve
access to the retrobulbar space and in cases of maximal orbital
decompression for severe thyroid-related orbitopathy (TRO).
Improved visualization and approach to intraconal lesions is
facilitated with removal of the lateral orbital rim. For medial
masses, the lateral rim can be removed to allow the globe to
rotate laterally, which allows for more space medially.
Our preferred skin incision is the lateral upper eyelid crease
incision. Through this incision, osteotomy is performed in two
locations; one at the frontozygomatic suture and the other
inferior bone cut is made just above the zygomatic arch. Pre-
drilled holes allow for ease of replacement with sutures.
Lateral orbitotomy with
rim removal
Bobby S. Korn • Don O. Kikkawa
Table 65.2 Preoperative evaluation
Complete ophthalmic examination with attention to optic nerve
status
Orbital imaging studies – CT, MRI, angiography when indicated
Exophthalmometry readings
Extraocular muscle movements and primary deviation
MRD1 and MRD2
Photographic documentation of eye movements and worm’s eye view
In most instances the orbital rim is temporarily removed for
access and then replaced. In the case of orbital decompres-
sion, the rim is typically removed and not replaced (see Table
64.3, Chapter 64). The thin lateral orbital wall and deeper
marrow space of the greater wing of the sphenoid is removed
to allow for maximal decompressive effect. The zygomatico-
temporal nerve should be preserved to avoid a small area of
hypesthesia just lateral to the brow in the temple region. We
have found that removing the lateral orbital rim and leaving it
off in cases of maximal decompression causes minimal
cosmetic deformity and improves the decompressive effect
significantly.
455
SURGICAL TECHNIQUE

Superior orbital fissure Orbital foramen

A Inferior orbital fissure B

Figures 65.1A–B Surgical planning

Lateral orbitotomy with removal of the rim can be performed when deep access to the orbital apex is required for both diagnostic and therapeutic cases.
If rim replacement is desired, preplaced drill holes are made before the start of the osteotomy. In some cases, the lateral orbital rim is permanently
removed to achieve a maximum orbital decompression. This typically yields an additional 2–3 mm of proptosis reduction when performed in conjunction
with three wall orbital decompression (Chapter 64). Figure 65.1A shows a schematic of the area of bone removed after rim removal. The upper eyelid
crease approach is the preferred method of access to the lateral rim (“A” in Figure 65.1B). Alternatively, a lateral canthus splitting Berke-style incision
can be performed, but this affords little benefit over the upper eyelid crease incision and disrupts the lateral canthus (“B” in Figure 65.1B).

SECTION FOUR • ORBIT

Chapter 65 Lateral orbitotomy with rim removal
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 6XSHULRURUELWDOILVVXUH 2UELWDOIRUDPHQ

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Figures 65.2A–D Creation of superior osteotomy

Prior to the start of surgery, 2% lidocaine with 1 : 200,000 epinephrine is infiltrated along the temporalis muscle overlying the lateral rim for hemostasis.
After dissection to the superolateral orbital rim, the periosteum inside and outside of the rim is dissected with a Freer elevator (Figure 65.2A). The
superior osteotomy site will be created slightly above the level of the frontozygomatic suture line and can be marked with cutting cautery or a surgical
marker (Figure 65.2B). The plane of the osteotomy should be directed approximately 15° caudally to avoid intracranial entry. An average cutting,
medium-sized oscillating saw blade is used for creating the osteotomy (Figure 65.2C). An appropriately sized malleable retractor is placed in the orbit to
protect the globe. Using foot control, the oscillating blade is activated before actual contact with bone to maximize control (Figure 65.2D). Once the blade
penetrates the thin bone overlying the temporalis muscle, less resistance is noted and further posterior sawing should cease.

$ %

Figures 65.3A and 65.3B Creation of inferior osteotomy

The inferior osteotomy is made at a plane parallel to the floor of the orbit, slightly above the level of the zygomatic arch (Figure 65.3A). For both superior
and inferior sites, the osteotomy should be communicated medially and laterally to facilitate subsequent removal (Figure 65.3B). Once the inferior
osteotomy has been completed, the lateral rim should be freely mobile, with only residual attachments from the temporalis muscle.

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Figures 65.4A and 65.4B Removal of lateral orbital rim

After the osteotomy has been performed, a Freer elevated or cutting cautery is used to free up residual lateral attachments of the temporalis muscle to
the rim. A large rongeur can be used for traction (Figure 65.4A). Residual bleeding from the temporalis muscle is easily controlled with bipolar bayonet
forceps. Bleeding from the marrow space of the sphenoid bone can be stopped with digital application of bone wax. Figure 65.4B shows the lateral orbit
and rim removal. Residual bone overlying the temporalis muscle can be removed piecemeal with a rongeur or high-speed diamond drill. If the rim is to
be replaced, 5-0 Prolene suture is threaded through the predrilled holes and tied off. The knots are rotated into the marrow space to avoid palpability.

RIGHT THREE WALL ORBITAL DECOMPRESSION WITH LATERAL RIM REMOVAL

Preoperative Postoperative
Figure 65.5 Before and after lateral rim removal during three wall orbital decompression
This 55-year-old female presented with severe unilateral right exophthalmos of 29 mm and binocular diplopia secondary to thyroid-related orbitopathy.
After disease quiescence, the patient underwent three wall decompression and permanent removal of the lateral orbital rim followed by strabismus
surgery and upper eyelid retraction repair. Postoperatively, the patient has marked functional and cosmetic improvement.

SECTION FOUR • ORBIT

Chapter 65 Lateral orbitotomy with rim removal
458
Table 65.3 Complications
Complications
Palpable step off
Masticatory oscillopsia
Hypesthesia near temple
Cerebrospinal fluid leak
Suggestions to reduce risk
Careful realignment of rim fragment during replacement
Keep temporalis intact; keep thin rim of bone in lateral wall intact
Avoid injury to zygomaticotemporal nerves
Careful removal of bone at greater wing of sphenoid after rim removal; repair defect with bone wax, fibrin
glue, or fat plug with dural sealant (DuraSeal)

Table 65.4 Consumables used during surgery

Average cutting, medium-sized blade 25.0 mm, 9.0 mm Stryker Surgical
#2296-3-111
5-0 Prolene suture, P-3 needle Ethicon #8698G

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CHAPTER 66
Inferior orbitotomy for
cavernous hemangioma
Bobby S. Korn
Table 66.1 Indications for surgery
Diagnosis of unknown orbital mass
Removal of orbital mass causing optic neuropathy
INTRODUCTION
Successful orbital surgery requires: a detailed knowledge of
orbital anatomy and orbital disease pathology; careful preop-
erative planning with orbitofacial imaging, optimal manage-
ment of anticoagulants, aesthetically minded incision design;
and careful and meticulous surgical technique to maximize
exposure, lighting and hemostasis with appropriate
instrumentation.
Multiple orbital imaging modalities can be employed to
provide information about suspected lesions. CT imaging is
readily available at almost all centers and is useful for evaluation
of trauma, infection, foreign bodies, paranasal sinuses, orbital
lesions and fine details of the bony orbit. A contrast agent may
be used for evaluation of vascular malformations, infections and
suspected orbital masses, but in the acute trauma setting or
SECTION FOUR • ORBIT
Chapter 66 Inferior orbitotomy for cavernous hemangioma
460
Table 66.2 Preoperative evaluation
Visual acuity, pupillary reaction, automated visual fields, color
testing
Slit lamp examination
Exophthalmometry
Clinical photographs
Orbital imaging (contrast-enhanced CT or MR)
Anticoagulant status
Communication with pathologist – suspected lesions requiring
immunohistochemistry or special stains/preparations
as a primary screen tool it is often unnecessary. MR imaging
is superior for delineation of orbital soft tissues, but it provides
poor resolution of bone. Dynamic vascular MR angiographic
imaging is particularly useful for vascular lesions of the orbit.
MR imaging is contraindicated for suspected metallic foreign
bodies, while CT imaging is contraindicated in pregnancy and
should be avoided when possible in children.
Orbitotomy is performed for diagnostic and therapeutic indi-
cations. For diagnosis of unknown orbital lesions, the decision
should be made to perform an excisional versus an incisional
orbitotomy. A careful history, clinical examination and orbital
imaging allow formulation of a differential diagnosis to guide
surgical decision making.
Excisional biopsy is performed to completely remove
an orbital lesion and is appropriate for well-circumscribed
lesions on orbital imaging. Examples of such lesions include a
cavernous hemangioma, hemangiopericytoma, fibrous histio-
cytoma or schwannoma. Encapsulated lesions of the lacrimal
gland such as pleomorphic adenoma should also be removed
in completion to minimize the potential for malignant
degeneration.
Incisional biopsy partially removes an orbital mass for his-
topathologic study. Communication between the orbital
surgeon and pathologist is critical to assure proper handling of
precious orbital tissues. Suspected lesions such as lymphoma
may be sent fresh for immunohistologic markers instead of
default placement in formalin solution. Meticulous handling of
orbital specimens is also carried out as crush artifact or exces-
sive cauterization may disrupt tissue architecture.
Orbital surgery requires specialized instrumentation that
should be made available before the start of surgery. Des-
marres and Senn retractors are used for skin and eyelid distrac-
tion. Malleable retractors of multiple widths as well as
neurosurgical cottonoids are critical to retract orbital fat. Freer
periosteal elevators and peanut sponges are useful for blunt
Superior orbit
Medial Optic
extraconal nerve
Medial
intraconal
Inferior
orbit
Figures 66.1 Zones of the orbit
Surgical approaches to orbital lesions are dictated by location as
elucidated by imaging. Figure 66.1 shows four zones of the orbit where
lesions may reside. With modern advances in oculofacial techniques,
orbital surgery may be approached through incisions that remain
aesthetically pleasing while providing excellent exposure.
dissection. A drill and bone saw should be available for creating
osteotomies when needed. A cryoprobe is useful for stabiliza-
tion and traction of orbital masses. A skilled surgical assistant
is invaluable to provide exposure and retraction for the primary
orbital surgeon. A fiberoptic or LED headlight with magnifying
loupes is essential to provide illumination within the deep orbit.
The operating microscope can be used but often impedes full
access to the surgical field. We reserve the use of the micro-
scope for finer operations such as optic nerve sheath fenestra-
tion (Chapter 71).
General anesthesia is preferred, particularly for dissection
within the retrobulbar space. A sequential compression device
is placed on both legs to prevent deep venous thrombosis and
the surgery is performed in a hypotensive environment when
possible and with the head in reverse Trendelenburg position.
Throughout the operation, frequent breaks are taken when
performing orbital retraction in order for the pupillary reactions
to be examined.
Figures 66.2 Oculofacial incisions
Using classic oculofacial incisions, the majority of orbital lesions can be
accessed through an anterior approach. Selected lesions in the deep,
superior orbital apex may require neurosurigcal exposure. Lesions in the
superior and lateral orbit (Figure 66.1 – blue) can be approached through
an upper eyelid crease incision (Figure 66.2 – Incision A) and can
be combined with lateral orbital rim removal for larger lesions in the
intraconal space (Chapters 64, 65, 70). Medial extraconal approach
to the orbit (Figure 66.1 – green) can be approach through a
transcaruncular incision (Figure 66.2 – Incision B and Chapter 69).
For surgical access to the medial intraconal space (Figure 66.1 – yellow),
a medial upper eyelid crease approach can be performed (Chapter 71).
Access to the inferior orbit (Figure 66.1 – red) can be achieved through
an inferior transconjunctival approach (Figure 66.2 – Incisions C and D)
with or without a lateral canthotomy approach (Chapters 66, 67, 68).
Further exposure can be afforded to the inferomedial orbit with
disinsertion of the inferior oblique muscle (Chapters 64 and 68).
461
 LEFT AXIAL PROPTOSIS

CT IMAGING OF ORBIT

B
Axial Coronal

Figures 66.3A and 66.3B Clinical examination

This patient presents with progressive pain and pressure in the left eye. On clinical examination, there is left lower eyelid retraction and 3 mm of
proptosis (arrow, Figure 66.3A). CT imaging of the orbit shows a large, well circumscribed intraconal mass that displaces the optic nerve medially (Figure
66.3B, left panel). Contrast enhancement shows stippled filling of the lesion that is most consistent with a low flow vascular malformation such as a
cavernous hemangioma (Figure 66.3B, right panel). The orbital mass is at least 18 mm in diameter and causes choroidal folds on dilated fundoscopic
examination. The patient also reports diplopia upon left gaze. The patient was presented with two surgical options: removal of the lateral orbital rim with
disinsertion of the lateral rectus muscle through an upper eyelid crease incision or an inferior transconjunctival approach. The patient elected for the
inferior transconjunctival approach as will be presented in this case.

SURGICAL TECHNIQUE

A B

Figures 66.4A and 66.4B Placement of bridle sutures

To facilitate superonasal rotation of the globe, bridle sutures are placed. The conjunctiva and Tenon’s capsule are grasped at least 6.5 mm from the
inferior limbus and then a 6-0 silk suture is gently passed under the inferior rectus muscle (Figure 66.4A). The needle should pass gently under the
muscle and any resistance suggests scleral engagement and should be avoided. A second traction suture is placed 7 mm posterior to the limbus for
the lateral rectus bridle suture (Figure 66.4B). Both sutures are tied off and rotated superonasally. Antibiotic ophthalmic ointment is placed on the cornea
for protective measures.

SECTION FOUR • ORBIT

Chapter 66 Inferior orbitotomy for cavernous hemangioma
462
 Figure 66.5 Lateral canthotomy and inferior cantholysis
A lateral canthotomy and inferior cantholysis is performed with Westcott
scissors (Figure 66.5). This allows for additional exposure after the
transconjunctival incision. Any bleeding from the lateral canthus is carefully
controlled with bipolar cautery.

A B

C D

Figures 66.6A–D Inferior transconjunctival approach

A Senn retractor is placed on the lower eyelid and a malleable retractor is used to protect the ocular surface and to isolate the conjunctiva. Cutting
cautery is used to create a transconjunctival incision 4 mm below the inferior tarsal border and carried to the caruncle (Figure 66.6A). Dissection
continues in the preseptal space with cautery. The arcus marginalis along the inferolateral orbital rim is then exposed and incised with cautery (Figure
66.6B). Care is taken along the medial orbit where the inferior oblique originates. As this orbital mass will be approached through the inferolateral space,
the inferior oblique is left intact. A subperiosteal dissection is carried out with a Freer elevator and then the periosteum between the inferior and lateral
rectus muscles is incised with a #12 blade (Figures 66.6C and 66.6D).

463
 A B

C D

E F

Figures 66.7A–F Dissection of orbital mass

Once the periosteum has been incised, a blunt dissection is performed with a Freer elevator between the inferior and lateral rectus muscles (Figure
66.7A). If the lesion is large enough, finger palpation can be used to localize the mass. Using a hand-over-hand technique with two malleable retractors,
the orbital fat is dissected away from the mass. The anterior face of the mass has a dark red vascular appearance most consistent with the preoperative
diagnosis of a cavernous hemangioma (Figure 66.7B). If the orbital fat begins to obscure visualization, 12 × 3 inch neurosurgical cottonoids can be
placed behind the malleable retractors to keep the fat away from the mass. As this lesion has the classic appearance of a cavernous hemangioma, an
18-gauge needle can be used to exsanguinate the mass (Figure 66.7C). This process shrinks the size of the mass and allows for safer removal through
this smaller incision approach. Once the anterior face of the mass has been exposed, the use of a straight tip cryoprobe can facilitate traction during the
dissection (Figure 66.7D). The mass is meticulously dissected along its capsular surface from the surrounding orbital attachments with a Freer elevator
and blunt dissection using the malleable retractors (Figure 66.7E). Separation of the posterior attachments of the mass is often the most difficult and
time consuming and patience and gentle dissection are a must to minimize complications. Periodically, all tension should be relaxed from the retractors
and the pupillary reactions are examined (Figure 66.7F). Reversible pupillary dilatation is often seen once the malleable retractors are released.

SECTION FOUR • ORBIT

Chapter 66 Inferior orbitotomy for cavernous hemangioma
464
 A B

C D

Figures 66.8A–D Removal of mass

Once all adhesions to the encapsulated mass have been freed, the lesion may be carefully delivered from the orbit using the cryoprobe (Figure 66.8A).
Blunt dissection should always be used and blind cuts should never be performed with scissors. After partial exsanguination, the lesion is smaller than
on the preoperative imaging (Figure 66.8B). Establishing hemostasis after removal of the lesion is next. Bipolar forceps with fine tips are used for
pinpoint coagulation of any orbital fat bleeding. Saline is used to irrigate the orbit and fine bleeders can be identified and cauterized (Figures 66.8C and
66.8D). Thrombin solution can be used to facilitate hemostasis, but Gelfoam and microfibrillar collagen should be avoided as these can induce orbital
adhesions and expand postoperatively.

465
 A B

C D

Figures 66.9A–D Closure of conjunctiva and canthal reconstruction

The conjunctiva is reapproximated with a running 6-0 fast-absorbing gut suture. The knot is buried away from the ocular surface and the conjunctiva is
secured on posterior cut edge first (Figure 66.9A). The suture is then run across the length of the incision (Figure 66.9B). At the lateral canthus two 5-0
Vicryl sutures are used to secure the cut edge of the tarsus to the superior crus of the lateral canthal tendon (Figure 66.9C). Careful reapproximation and
realignment of the gray lines of the upper and lower eyelids will result in a sharp canthal angle (Figure 66.9D). The skin overlying the canthus is closed
with interrupted 6-0 fast-absorbing gut sutures.

SECTION FOUR • ORBIT

Chapter 66 Inferior orbitotomy for cavernous hemangioma
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 LEFT INFERIOR ORBITOTOMY FOR
CAVERNOUS HEMANGIOMA

Preoperative Postoperative

Figure 66.10 Before and after left inferior orbitotomy for cavernous hemangioma
This 28-year-old patient presented with progressive pressure and proptosis of the left globe. On clinical examination, the patient exhibited left axial
proptosis of 3 mm (Figure 66.10, left panel). CT scanning showed a well-circumscribed intraconal mass lateral to the optic nerve (Figure 66.3B). An
inferior orbitotomy approach using a lateral canthotomy and inferior transconjunctival incision was performed to remove the lesion. Histopathology
confirmed suspicion of a cavernous hemangioma. Postoperatively, the patient has a return of normal left globe position with full vision, motility and no
optic neuropathy (Figure 66.10, right panel).

Table 66.3 Complications

Complications Suggestions to reduce risk
Vision loss/optic Frequent intraoperative pupillary checks, relaxation of orbital retractors, avoid overzealous and blind dissection of
neuropathy tumors attached to or near optic nerve; avoid all cautery near optic nerve
Retrobulbar Careful cessation of all anticoagulants (pharmacologic and dietary); meticulous and cautious hemostasis with bipolar
hemorrhage cauterization; consider adjunct use of thrombin or fibrin glue
Diplopia Avoid excessive traction on extraocular muscles; caution along inner one-third of extraocular muscle where cranial
nerves enter
Ptosis Avoid excessive superior traction
Pupillary dilation/ Avoid cauterization/excessive trauma/retraction to optic nerve, particularly posterior segment on lateral side
irregularity
Xerophthalmia May occur as expected complication after removal of lacrimal gland masses; caution near lacrimal gland and palpebral
lobe where ductules enter fornix

Table 66.4 Consumables used during surgery

Neurosurgical cottonoids, 1
2 × 3 inches Codman – Surgical Patties

6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G

7-0 Vicryl, TG140-8 needle Ethicon #J546G
5-0 Vicryl, P-3 needle Ethicon #J493H
6-0 silk, G-7 needle Ethicon #765G

467
CHAPTER 67
Orbital fracture repair
Don O. Kikkawa • Bobby S. Korn
Table 67.1 Indications for surgery
Enophthalmos (>2 mm)
Extraocular muscle entrapment with diplopia
Hypoglobus
Oculocardiac reflex
Large floor fracture (>50%)
INTRODUCTION
Bony and soft tissue injury can occur with any trauma to the
orbit. The clinical presentation and treatment vary, based on
the cause, findings, and symptoms. Fractures comprise the
majority of bone injuries. Several types of fractures involve the
orbit with blow-out fractures being the most common. Other
fractures include zygomaticomaxillary complex (tripod) frac-
tures, Le Fort fractures, and nasoethmoidal fractures. Orbital
apex fractures involving the optic canal may result in optic
neuropathy with vision loss.
Blow-out fractures occur when an object strikes the orbital
entrance. Two theories are postulated: (1) the indirect hydraulic
theory in which posterior pressure in the orbit causes a blow-
out; and (2) the direct buckling theory in which direct pressure
along the inferior orbital rim causes deformation along the floor.
Symptoms may include diplopia from entrapment of the inferior
SECTION FOUR • ORBIT
Chapter 67 Orbital fracture repair
468
Table 67.2 Preoperative evaluation
Exophthalmometry readings
Extraocular muscle movements and primary deviation
Measure globe dystopia
CT scan, axial and coronal views with thin cuts
Check infraorbital nerve sensation
Palpation for bony step off, trismus and signs of
zygomaticomaxillary complex fracture (tripod)
Vital signs – heart rate, blood pressure; history of nausea/
lightheadedness from oculocardiac reflex
Rule out globe injury; perform dilated fundoscopic exam
rectus muscle, enophthalmos, infraorbital nerve hypesthesia,
and hypoglobus. CT imaging with axial and coronal thin cuts
is essential for diagnosis, treatment and decision making in
fracture repair.
Urgent indications for fracture repair include the “white-eyed”
blow out fracture in children where the fracture site incarcerates
the rectus muscle causing possible ischemia, and the oculo-
cardiac reflex resulting from muscle entrapment. Other indica-
tions vary but most surgeons will repair fractures within 2
weeks if one or more of the following criteria are met: diplopia
within 30° of primary gaze associated with a positive forced
duction test, clinically significant enophthalmos greater than
2 mm, and a fracture size greater than 50% of the orbital floor.
Repair is typically via a transconjunctival approach with com-
plete reduction of the orbital contents from the fracture site and
placement of an alloplastic implant.
 Tripod fractures can also be associated with orbital floor
fractures but with a different mechanism. The zygoma is frac-
tured along the fronto-zygomatic, zygomatic-maxillary, and
zygomatic-temporal suture lines with possible soft tissue
entrapment.
Our preference for implant choice depends on the loca-
tion and amount of enophthalmos. For isolated orbital floor
fractures, our preferred implants are thin porous polyethylene
sheets or nylon foil. For fractures with significant enoph-
thalmos, thicker barrier channel porous polyethylene is used.
For combined medial and floor fractures, titanium-coated
porous polyethylene is useful to precisely configure the
implant to fit the desired shape. The use of bare titanium
mesh or absorbable floor implants may increase risk of
delayed orbital restriction.
Complications include implant infection, extrusion, hemor-
rhage into the implant capsule, persistent hypesthesia of the
infraorbital nerve, and eyelid malposition. Although excellent
anatomic bony correction may be obtained, significant soft
tissue injury may still be present. Residual enophthalmos, con-
tinued extraocular muscle imbalance, eyelid malposition, and
traumatic ptosis all may necessitate additional surgery.

RIGHT ORBITAL FLOOR FRACTURE

A
Hypoglobus Enophthalmos

Figures 67.1A and 67.1B Preoperative examination

Clinically significant orbital blow-out fractures present with enophthalmos and, possibly, hypoglobus, as shown in Figure 67.1A. Photographs of the nine
gazes and worm’s eye views should be taken at all clinical encounters. Documentation of any diplopia, ocular motility disturbance, and hypesthesia of the
infraorbital nerve should also be recorded. High-resolution CT imaging of the orbit with thin cuts in the axial, coronal, and sagittal planes is essential for
preoperative planning. Figure 67.1B, left panel, shows a coronal image with a large orbital flow blow-out fracture (greater than 50%) with significant
prolapse of the orbital soft tissues into the maxillary sinus. Figure 67.1B, right panel, is a sagittal CT image of the same patient showing the extent of the
fracture from anterior to posterior. The axial images give the least amount of information of the orbital floor but better images of lateral and medial walls of
the orbit.

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SURGICAL TECHNIQUE

Figure 67.3 Lateral canthotomy and cantholysis

Exposure of the inferior orbit is assisted by a lateral canthotomy and
cantholysis (Figure 67.3). Inferior cantholysis combined with a transcon-
Figure 67.2 Intraoperative forced ductions
junctival incision allows exposure of the entire orbital floor. In patients with
Forced ductions can be performed in the office setting to confirm muscle significant lower eyelid laxity, a lateral canthotomy and inferior cantholysis
entrapment, but should be repeated in the operating room. Fracture repair may be unnecessary to achieve suitable visualization.
is optimally performed under general anesthesia. Using toothed forceps,
the globe is grasped and moved both vertically and horizontally (Figure
67.2). Restriction to movement should be documented. Repeat forced
ductions should be performed again after implant placement to ensure
that any restriction is freed and that the implant itself is not causing
restriction due to improper placement. The patient depicted here had
recent trauma causing a right orbital floor blow-out fracture as well as an
associated right upper eyelid laceration.

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Figures 67.4A and 67.4B Transconjunctival incision

The lower eyelid is retracted with a Desmarres retractor. The monopolar cautery with the cutting needle tip is then used to make a transconjunctival
incision 3–4 mm beneath the inferior tarsal border (Figure 67.4A). The dissection plane occurs anterior to the orbital fat to directly expose the inferior
orbital rim (Figure 67.4A). The periosteum is incised along the rim (Figure 67.4B).

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Chapter 67 Orbital fracture repair
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Figures 67.5A–D Subperiosteal dissection and reduction of orbital tissues

The subperiosteal dissection begins at the inferior orbital rim (Figure 67.5A). A hand over hand dissection technique is used with a Freer elevator and
malleable retractor to gently reduce the fracture. Release of entrapped orbital soft tissues can also be facilitated with the use of a peanut sponge. The
dissection should proceed from the intact area of bone (known) to the fractured area (unknown) (Figure 67.5B). The infraorbital nerve is identified and
avoided (Figure 67.5C). The orbital contents are delicately elevated and reduced from the bony fracture site (Figure 67.5D). Most fracture sites occur
medially to the infraorbital nerve and posteriorly to the equator of the globe in the thinnest portion of the orbital floor. Any free bone fragments can be
removed carefully from the orbit. In cases of a greenstick fracture associated with pediatric injuries, the orbital floor may require infracturing to fully
reduce entrapped orbital soft tissues.

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Figures 67.6A and 67.6B Implant configuration

The orbital implant is then sized appropriately. A template can be used prior to configuring the final implant shape. Alternatively, a Mayo scissor (Figure
67.6A) can be used to trim freehand the barrier channel implant that should be shaped more broadly anteriorly, tapering posteriorly (Figure 67.6B). The
barrier side of the porous polyethylene is placed towards the orbital soft tissues, with the porous side toward the bone to allow fibrovascular ingrowth.

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Figures 67.7A–D Confirmation of proper implant placement

While elevating the inferior orbital soft tissues, the orbital implant (barrier side up) is then placed in the subperiosteal space covering the bony defect
(Figure 67.7A). Several aspects of implant placement are important. First, the implant should be adequately supported on all sides to prevent instability
and possible displacement. Posteriorly, it should abut the edge of the floor remnant; often this consists of only the palatine bone at the apex of the
orbital floor (Figure 67.7B). Second, all soft tissues should be above the implant to avoid possible restriction of the inferior rectus muscle. Here an
endoscope is used to visualize beneath the implant and, medially, residual soft tissue is seen (Figure 67.7C) and the implant is repositioned (Figure
67.7D). Lastly, the anterior edge of the implant should not extend beyond the inferior orbital rim to avoid being palpable. Porous polyethylene implants
can be shaved down with a #10 blade after rigid fixation if the implant is still palpable anteriorly.

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Figures 67.8A and 67.8B Intraoperative assessment

After placement of the orbital implant, the globe position is then checked intraoperatively. Repeat forced duction testing is also performed to ensure free
movements (Figure 67.8A). Vertical globe position is examined as well as the degree of correction of the enophthalmos. Symmetry is examined and
confirmed (Figure 67.8B).

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Chapter 67 Orbital fracture repair
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Figures 67.9A–C Fixation of orbital floor implant

Not all orbital floor implants need rigid fixation. Smaller implants that fit securely behind the orbital rim do not need fixation. For larger implants, rigid
fixation is recommended. An 8 mm stopped drill bit is used to create a pilot hole in the orbital implant and bone in the desired location behind the
inferior orbital rim (Figure 67.9A). A 1.0 mm by 6 mm screw is then used to rigidly fixate the orbital implant in position (Figure 67.9B). The edge of the
implant should remain behind the inferior orbital rim (Figure 67.9C). We have not found it necessary to close the periorbita directly. The conjunctiva is
then closed with a running 6-0 fast-absorbing gut suture. The canthus is reinserted with a 6-0 Vicryl suture and the skin overlying the canthus with 6-0
fast-absorbing gut suture.

473
 RIGHT ORBITAL FLOOR FRACTURE REPAIR

Preoperative Postoperative

Preoperative Postoperative

Figures 67.10A and 67.10B Before and after blow-out fracture repair
This 28-year-old female presented with right enophthalmos and hypoglobus secondary to a right orbital floor blow-out fracture. She underwent right
orbital fracture repair with implant placement with excellent globe position postoperatively (Figures 67.10A and 67.10B).

SECTION FOUR • ORBIT

Chapter 67 Orbital fracture repair
474
Table 67.3 Complications
Complications
Residual enophthalmos
Hypesthesia
Hyperglobus
Diplopia
Optic neuropathy
Implant displacement
Retrobulbar hemorrhage
Cicatricial entropion
Cicatricial ectropion
Suggestions to reduce risk
Incomplete reduction of orbital soft tissues; ensure circumferential exposure of the fracture site with
complete reduction of orbital soft tissue; consider thicker orbital implant if any evidence of continued
enophthalmos despite complete reduction of soft tissues; ensure implant has rigid support at orbital apex
along palatine bone
Avoid unnecessary injury and trauma to infraorbital nerve
Orbital implant riding too high; reduce vertical height
Avoid extraocular muscle trauma during dissection; ensure complete freedom of muscle entrapment and
orbital fat before placing orbital implant; avoid use of absorbable implants and bare titanium mesh along
orbital floor
Implant too large and possibly abutting orbital apex; keep anterior to posterior dimensions of orbital implant
between 35 and 40 mm maximum from inferior orbital rim; examine for pupillary dilation intraoperatively, a
sign of optic nerve compression
Consider rigid fixation if implant is unstable
Ensure hemostasis during orbital floor dissection; gentle cautery of feeder vessels arising from orbital floor
Ensure careful reapproximation of conjunctiva during closure; avoid shortening/excision of conjunctiva during
surgery; consider recession of lower eyelid retractors if entropion is present upon wound closure; avoid
excessive retraction and damage to conjunctiva from retractor
Perform transconjunctival approach to orbital fractures, as this complication is more common with
transcutaneous approach; avoid removal of skin during incision; consider use of sterile adhesive strips
postoperatively but balance the risk of masking vision-threatening retrobulbar hemorrhage

Table 67.4 Consumables used during surgery

Porous polyethylene barrier channel orbital implant Stryker #9529
1.0 mm by 6 mm titanium screw Stryker #400.506
0.7 mm by 8 mm drill bit Stryker #316.08
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
6-0 Vicryl suture, PC-3 needle Ethicon #J843G

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CHAPTER 68
Orbital floor reconstruction in
silent sinus syndrome
Bobby S. Korn
Table 68.1 Indications for surgery
Enophthalmos caused by orbital floor resorption in silent sinus
syndrome
Secondary volume augmentation after enucleation/evisceration or
orbital fracture repair
INTRODUCTION
Silent sinus syndrome describes an indolent and chronic
disease characterized by atelectasis of the maxillary sinus due
to obstruction of the ostium. The resultant collapse of the maxil-
lary sinus is associated with inferior bowing of the orbital floor
that increases the effective orbital volume. Clinically, this is
manifested by enophthalmos, hypoglobus, and a superior
sulcus deformity. The condition is described as silent owing to
little or no signs of sinusitis or nasal congestion.
Primary treatment is aimed towards aeration of the sinus by
enlarging the native maxillary ostium with functional endoscopic
sinus surgery. Microbial cultures of the sinus aspirate are
typically sterile in nature and antimicrobial therapy has no role
in the management of silent sinus syndrome. In a small
SECTION FOUR • ORBIT
Chapter 68 Orbital floor reconstruction in silent sinus syndrome
476
Table 68.2 Preoperative evaluation
History of orbital trauma, sinus disease, breast cancer or other
malignancies
Exophthalmometry
Ocular ductions, cover/uncover testing
Photographs documenting eye movements in nine fields and
worm’s eye views
Examination by otolaryngology
CT scan of orbit and sinuses
percentage of patients who have underwent endoscopic sinus
surgery alone, the orbital floor can re-expand, improving the
enophthalmos but rarely to the pre-disease state. Treatment of
the globe malposition is achieved by augmenting the orbital
volume with alloplastic implants in a fashion similar to repair of
an orbital fracture (Chapter 67).
A variety of implants have been described, including autolo-
gous bone, porous polyethylene, hydroxyapatite, and titanium
mesh. Our preference is to use a porous polyethylene enoph-
thalmos wedge along the floor defect and covered by a thin
barrier sheet of porous polyethylene with or without embedded
titanium mesh. The surgery is carried out using a transconjunc-
tival approach and can be performed simultaneously with
endoscopic sinus surgery to address the maxillary sinus
disease.
 RIGHT SILENT SINUS SYNDROME

Figures 68.1A and 68.1B Preoperative examination

Figure 68.1A shows a patient with the classic findings of silent sinus syndrome: hypoglobus, enophthalmos, superior sulcus deepening and upper eyelid
retraction. Chronic obstruction of the maxillary ostium results in sinus opacification and atelectasis of the walls of the maxillary sinus on CT scanning
(Figure 68.1B). These radiographic changes are virtually pathognomonic for silent sinus syndrome. With long-standing disease, maxillary hypoplasia can
occur, resulting in significant midfacial hypoplasia as seen in Figure 68.1B. Restoration of sinus ventilation is achieved through endoscopic enlargement
of the maxillary ostium and orbital reconstruction.

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SURGICAL TECHNIQUE

Figure 68.2 Lateral canthotomy and cantholysis

A lateral canthotomy and inferior cantholysis facilitates wide exposure of
the inferior orbit when combined with a transconjunctival incision (Figure
68.2). In patients with pre-existing lower eyelid laxity, a lateral canthotomy
and inferior cantholysis may not be necessary.

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Figures 68.3A and 68.3B Transconjunctival incision

A transconjunctival incision is made 3–4 mm below the inferior tarsal border with cutting cautery (Figure 68.3A). Exposure and retraction are facilitated
with the use of a Desmarres retractor on the lower eyelid and a malleable retractor to protect the globe and to isolate the inferior orbit. The dissection
continues in a preseptal plane to expose the arcus marginalis along the inferior orbital rim (Figure 68.3B). Care is taken near the medial eyelid where
inadvertent damage to the inferior punctum can occur during cauterization.

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Chapter 68 Orbital floor reconstruction in silent sinus syndrome
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( )

Figures 68.4A–F Disinsertion of inferior oblique muscle

The inferior oblique muscle originates along the inner aspect of the orbital rim at the medial one-third of the orbit (Figure 68.4A). When dissecting along
the arcus marginalis, care is taken near this origin to avoid transecting the muscle. Although optional, disinsertion of the inferior oblique muscle can
provide a wide, panoramic view of the orbital floor and the medial wall of the orbit. This is particularly useful for repair of combined floor and medial wall
fractures as well as three wall orbital decompression. In this case, disinsertion of the inferior oblique muscle allows for placement of the large
floor implants needed to restore orbital volume. A Green or Von Graefe muscle hook is used to isolate the inferior oblique muscle and cotton-tipped
applicators are used to strip off the orbital fat and fascia to expose the muscle fibers (Figure 68.4B). A double-armed 6-0 Vicryl suture is used to
imbricate the muscle by a partial thickness pass through two-thirds of the muscle width (Figure 68.4C). At the terminal end, a full thickness locking bite
is placed (Figure 68.4D). The other arm of the suture is passed in a similar fashion to complete the double-locking whip stitch (Figure 68.4E). Once the
suture has been passed, the muscle is disinserted close to its origin, leaving a 2–3 mm stump (Figure 68.4F). The muscle is then tagged with a bulldog
clamp for subsequent reinsertion.

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Figures 68.5A–C Subperiosteal dissection

The periosteum along the arcus marginalis is scored with the cautery tip and then a subperiosteal dissection plane is initiated inside the inferior orbital
rim (Figure 68.5A). Compared to an orbital floor fracture, the tissue planes should be intact and careful preservation of the periosteum will minimize
prolapse of orbital fat. The dissection is continued medially with the Freer elevator and malleable retractor using a hand-over-hand technique. Along the
medial aspect of the orbital rim, the inferior oblique origin can be seen and this muscle stump is left intact (Figure 68.5B). With the wide exposure
afforded by the disinsertion of the inferior oblique muscle, the inferiorly bowed orbital floor can be fully appreciated once the periosteum has been
elevated (Figure 68.5C). Along the orbital floor, any fine bleeders should be noted and these are carefully coagulated with a bipolar forceps, taking care
to avoid damage to the infraorbital nerve.

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Chapter 68 Orbital floor reconstruction in silent sinus syndrome
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Figures 68.6A–E Sizing of template

A nylon foil sheet can be used as a template for sizing and placement of the actual implant. A notch is cut out of the template at the medial side to
facilitate passage of the inferior oblique muscle stump (Figure 68.6A). The smooth nylon implant is then placed along the orbital floor in the subperiosteal
plane (Figure 68.6B). As the template is placed in the orbit, the dimensions are inspected and the material is trimmed as needed. Along the inferior
orbital rim, the implant should be not palpable (Figure 68.6C). Once satisfactory, the corneal shields are removed and the globes are inspected for
position and symmetry (Figure 68.6D). Throughout all aspects of the case the two eyes should be evaluated and force duction testing performed on the
surgical side to confirm free movements. With the template in place, the physiologic position of the orbital floor, pre-disease, is noted as well as the
dead space below from the inferior bowing of the floor (Figure 68.6E). This dead space should be eliminated as serosanguineous fluid can collect and
serve as a nidus of infection.

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Figures 68.7A–E Sizing of alloplastic implant

The dead space created by the bowing of the orbital floor can be bridged with multiple options. Hydroxyapatite wedges or bone paste can be placed
along the orbital floor but our preference is to use stacked sheets of porous polyethylene or an enophthalmos wedge. Use of a porous implant allows for
fibrovascular ingrowth and minimizes movement to promote bio-integration. The enophthalmos wedge is trimmed to size with Mayo scissors and thinned
carefully using a #10 blade. The implant is then placed below the nylon template and the globe positions are reassessed (Figure 68.7A). This process is
repeated until the wedge has been contoured to the desired shape with restoration of normal globe position. As the wedge is porous on all sides, a
barrier surface must be placed between the orbital soft tissues and the wedge itself to prevent restriction of eye movements. If a commercially available
nylon foil implant (Supramid) is used as the template, this can be permanently implanted. Other options include a barrier sheet of polyethylene (MEDPOR
BARRIER sheet) or barrier polyethylene-covered titanium mesh (MEDPOR TITAN). The nylon foil template is then traced over the desired implant and this
is cut to size (Figure 68.7B). Using the smooth nylon template to protect the orbital tissues, the polyethylene titanium mesh implant can be smoothly
glided into position with the barrier side directed towards the orbital soft tissues (Figures 68.7C and 68.7D). With the barrier implant in place, the nylon
template can be permanently removed (Figure 68.7E).

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Chapter 68 Orbital floor reconstruction in silent sinus syndrome
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Figures 68.8A and 68.8B Intraoperative forced duction testing

After placement of the orbital implants, the globe position is rechecked for symmetry and correction of enophthalmos. Forced duction testing is per-
formed in all gazes and any restriction is noted (Figures 68.8A and 68.8B). If restriction is noted, the orbit is inspected for any entrapped soft tissue
under the implant and this is released. If hyperglobus is present, the wedge should be trimmed to normalize vertical globe position.

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Figures 68.9A and 68.9B Fixation of orbital floor implant

Every implant need not be secured, but with the combination of two implants along the orbital floor, our preference is to secure the implant to the orbital
rim. The implant is best secured at the lateral aspect of the inferior orbital rim, away from the course of the infraorbital nerve (Figure 68.9A). A predrilled
self-tapping screw or self-drilling titanium screw can be used. In this case, a 1.5 mm × 6 mm self-drilling screw is used to fixate the porous polyethyl-
ene and titanium mesh implant securely to the inferior orbital rim (Figure 68.9B). Forced duction testing and globe inspection are performed again after
fixation.

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Figures 68.10A and 68.10B Reinsertion of inferior oblique

The inferior oblique stump is then directed through the cut out in the implants. The tagged muscle is then sutured to the stump, keeping the orientation
of the original suture placement the same (Figures 68.10A and 68.10B). This ensures that the muscle will not have torsional stress after the suture is
tied off. A simple way to keep the orientation straight is to keep the lateral suture longer and the medial suture shorter. Care should also be taken to
ensure no orbital fat is incarcerated during the reinsertion of the inferior oblique.

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Figures 68.11A–E Conjunctiva and lateral canthal closure

The conjunctiva is closed with a buried, running 6-0 fast-absorbing gut suture (Figures 68.11A and 68.11B). The conjunctiva is meticulously closed,
end-to-end, without any shortening or incorporation of orbital fat or septum. At the lateral canthus, a 5-0 Vicryl suture is passed through the tarsus and
secured to the superior crus of the lateral canthal tendon (Figures 68.11C and 68.11D). The skin overlying the canthus is closed with interrupted 6-0
fast-absorbing gut sutures (Figure 68.11E).

SECTION FOUR • ORBIT

Chapter 68 Orbital floor reconstruction in silent sinus syndrome
484
 RIGHT ORBITAL FLOOR RECONSTRUCTION FOR SILENT SINUS SYNDROME

Preoperative Postoperative

Preoperative Postoperative

Figures 68.12A and 68.12B Before and after right orbital floor reconstruction
This 51-year-old male presented with a 5-year history of 5 mm of enophthalmos and 3 mm of hypoglobus of the right eye. His CT scan showed silent
sinus syndrome (Figure 68.1B) and this was treated by endoscopic enlargement of the maxillary ostium. Simultaneously, the patient underwent right
orbital floor reconstruction with porous polyethylene enophthalmos wedge and barrier titanium sheet. Postoperatively, he has marked improvement in
globe position and fullness of the superior sulcus (Figures 68.12A and 68.12B).

485
Table 68.3 Complications
Complications
Residual enophthalmos
Hypesthesia
Hyperglobus
Diplopia
Optic neuropathy
Implant displacement
Retrobulbar hemorrhage
Cicatricial entropion
Cicatricial ectropion
Suggestions to reduce risk
Insufficient volume augmentation; consider placement of additional porous polyethylene sheets under
barrier implant vs. observation; ensure maxillary sinus remains aerated by nasal endoscopy and CT
scanning
Avoid injury and trauma to infraorbital nerve
Excessive volume augmentation; consider removal of implant volume
Avoid extraocular muscle trauma during dissection; ensure complete freedom of muscle entrapment and
orbital fat before securing orbital implant; ensure orbital soft tissues not exposed to porous side of implant;
consult strabismus specialist if globe position is symmetric and diplopia does not resolve after 3 months
Implant too large and abutting orbital apex; keep anterior to posterior dimensions of orbital implant
between 35 mm and 40 mm maximum from inferior orbital rim; examine for pupillary dilation
intraoperatively, a sign of optic nerve compression
Consider rigid fixation if implant is unstable
Ensure hemostasis during orbital floor dissection; gentle cautery of feeder vessels arising from orbital floor
Ensure careful reapproximation of conjunctiva during closure; avoid shortening/excision conjunctiva during
surgery; consider recession of lower eyelid retractors if entropion is present upon wound closure
Perform transconjunctival approach to orbital fractures, as this complication is more common with
transcutaneous approach; avoid removal of skin during incision; consider use of sterile adhesive strips
postoperatively but balance the risk of masking vision-threatening retrobulbar hemorrhage

Table 68.4 Consumables used during surgery

Porous polyethylene barrier sheet Stryker #8305
Porous polyethylene enophthalmos wedge Stryker #9541 (left) or #9542 (right)
Porous polyethylene titanium sheet Stryker #81026 (MTB)
Nylon foil sheet 1 mm S. Jackson Inc. (Suprafoil)
1.0 mm by 6 mm titanium screw Stryker #400.506
0.7 mm by 8 mm drill bit Stryker #316.08
1.5 mm by 6 mm self-drilling titanium screw Synthes 04.503.226.05
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
5-0 Vicryl suture, PC-3 needle Ethicon #J844G

SECTION FOUR • ORBIT

Chapter 68 Orbital floor reconstruction in silent sinus syndrome
486
 CHAPTER 69
Transcaruncular approach to
ethmoidal artery ligation
Table 69.1 Indications for surgery
Intractable recurrent epistaxis secondary to:
• Coagulopathy
• Vascular malformations such as hereditary hemorrhagic
telangiectasia (Osler–Weber–Rendu syndrome)
• Neoplasm
• Naso-orbital trauma
INTRODUCTION
Epistaxis is a very common and often self-limiting condition that
the majority of the population has experienced in their lifetime.
Even in young healthy patients without pre-existing medical
conditions, recurrent epistaxis can occur. Recurrent and intrac-
table epistaxis can occur with heritable coagulopathies, vascu-
lar malformations such as hereditary hemorrhagic telangiectasia
(Osler–Weber–Rendu syndrome), neoplasms, and the result of
naso-orbital trauma. While most treatment is aimed at packing
and cautery of bleeding vessels, recalcitrant cases may neces-
sitate adjunct procedures.
There is a rich vascular supply of the orbits, nose, and
paranasal sinuses. Both internal and external carotid arteries
supply this important area of the head and neck region. The
anterior and posterior ethmoidal arteries arise as branches
Don O. Kikkawa • Bobby S. Korn
Table 69.2 Preoperative evaluation
History of coagulopathy
Anticoagulant medications
Nasal endoscopy
Vascular imaging of orbit, nose, and sinuses (magnetic resonance
or catheter angiography)
Hematologic and systemic evaluation, including laboratory
coagulation testing
off the ophthalmic artery, which arises from the internal carotid
artery (Figure 69.1A). They pass medially through the anterior
and posterior ethmoidal foramina, to supply the lateral nasal
wall and nasal septum (Figure 69.1B). The sphenopalatine
artery, a branch of the external carotid artery, together with
the anterior ethmoidal artery form Kiesselbach’s plexus, which
perfuses the anteroinferior part of the nasal septum (Figure
69.1B). Over 90% of nosebleeds occur at Kiesselbach’s
plexus.
In severe cases of recalcitrant nasal hemorrhage, particularly
with hereditary hemorrhagic telangiectasia, ligation of the ante-
rior and posterior ethmoidal arteries may be a useful adjunct
to reduce the incidence and severity of epistaxis. Medial orbi-
totomy through a trancaruncular approach provides the best
and most direct access to the ethmoidal vessels, which can
then be clipped under direct visualization.
487
 Anterior
ethmoidal
artery

Posterior
ethmoidal
artery

Lacrimal
artery

Ophthalmic
artery

Internal
carotid artery

Figure 69.1A and 69.1B Anatomy of the ethmoidal arteries

Axial view of the vascular supply of the orbit. Note the origin of the ethmoidal arteries from the ophthalmic artery (Figure 69.1A).

SECTION FOUR • ORBIT

Chapter 69 Transcaruncular approach to ethmoidal artery ligation
488
 Anterior
ethmoidal
artery

Posterior Ophthalmic
ethmoidal artery
artery Sphenopalatine
artery
Kiesselbach’s
Maxillary
plexus
artery

Internal
carotid
artery
External
B carotid
artery
Figures 69.1A and 69.1B, cont’d
Sagittal view of the lateral nasal wall from inside the nasal cavity showing entry of the ethmoidal vessels at the frontoethmoidal suture line
(Figure 69.1B). Note Kiesselbach’s plexus (shaded area) along the anteroinferior aspect of the septum.

SURGICAL TECHNIQUE

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Figures 69.2A and 69.2B Placement of traction suture

To assist with exposure, traction sutures are placed. A 6-0 silk traction suture is placed through the gray line of the medial left upper (Figure 69.2A) and
left lower (Figure 69.2B) eyelids. With retraction of the lids, the entire region of the medial conjunctiva, plica semilunaris, and caruncle are visualized.
Care is taken to avoid trauma to the punctum and ampulla during needle passage.

489
 A B

C D

E F

Figures 69.3A–F Transcaruncular approach

The incision line is then marked just posterior to the caruncle, extending superiorly and inferiorly for approximately 2 cm (Figure 69.3A). Cutting cautery
is used to make the conjunctival incision just posterior to the caruncle. The thicker Tenon’s fascia and orbital septum are then incised with sharp
dissection in this avascular plane (Figure 69.3B). A Desmarres retractor is placed on the posterior lacrimal crest and is used to retract Horner’s muscle
and protect the lacrimal sac, while a malleable retractor is used to retract the globe to expose the medial orbital wall (Figure 69.3C). The periorbita is
then incised just posterior to the posterior lacrimal crest using cutting cautery (Figure 69.3D). A Freer elevator is used to carefully dissect a subperiosteal
plane along the medial orbital wall (Figure 69.3E). Approximately 24 mm behind the anterior lacrimal crest, the anterior ethmoidal artery is visualized
(Figure 69.3F). Both anterior and posterior ethmoidal foramina lie along the frontoethmoidal suture line.

SECTION FOUR • ORBIT

Chapter 69 Transcaruncular approach to ethmoidal artery ligation
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 A B

C D

Figures 69.4A–E Ligation of ethmoidal arteries

Under direct visualization, small titanium vascular clips are placed both proximally and distally along the anterior ethmoidal artery. The proximal clip is
placed closest to the periorbita (Figure 69.4A) and the distal clip is placed just outside the bony foramina (Figure 69.4B). The vessel is then severed
between the two clips (Figure 69.4C). After severing the anterior ethmoidal artery, the same dissection plane is continued for approximately 12 mm
(Figure 69.4D) until the posterior ethmoidal vessel is identified (Figure 69.4E). The posterior vessel can then be clipped and severed in a similar fashion.
The conjunctiva is then closed with a running 6-0 fast-absorbing suture.

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Table 69.3 Complications
Complications Suggestions to reduce risk
Unable to identify ethmoidal vessels Maintain subperiosteal plane and hemostasis; identify frontoethmoidal suture line; measure
distance from anterior lacrimal crest
Continued epistaxis Possible recanalization; need to ensure proper clipping and severing of artery, not just
cauterization; angiography to look for redundnant vascular supply
Orbital hemorrhage Inadvertent dislodging of vascular clip; ensure tight placement of clip and minimal disruption after
placement
Epiphora Carefully isolate posterior lacrimal crest with Desmarres retractor to prevent damage during
dissection; careful placement of traction sutures and avoid trauma/cauterization to punctum; avoid
disinsertion of Horner’s muscle around lacrimal sac

Table 69.4 Consumables used during surgery

6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
6-0 silk suture, G-7 needle Ethicon #765G
Titanium vascular clips – small Weck Hemoclip #523835

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Chapter 69 Transcaruncular approach to ethmoidal artery ligation
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 CHAPTER 70
Table 70.1 Indications for surgery
Discomfort over lateral orbit
Cosmetically displeasing lateral fullness
Rule out lacrimal gland malignancy/pathology
INTRODUCTION
Prolapse of the lacrimal gland is generally considered a benign,
senescent change. The presentation may vary from lateral full-
ness of the upper eyelids on physical examination or an inci-
dental finding during upper blepharoplasty. Patients will often
present with cosmetically displeasing lacrimal gland prolapse
noted on external examination. Palpation along the superola-
teral orbital rim may disclose a palpable nodule that spontane-
ously prolapses despite manual retroplacement.
A history of pain and paresthesias over the lateral orbit should
prompt consideration of malignant lacrimal pathology such as
adenoid cystic carcinoma, particularly for unilateral cases. A
history of autoimmune disease and dry eye may also be associ-
ated with lacrimal gland prolapse as is trauma or prior facial
surgery. Pain, redness, and mucoid discharge may suggest
infectious dacryoadenitis.
Reposition of prolapsed
lacrimal gland
Bobby S. Korn • Don O. Kikkawa
Table 70.2 Preoperative evaluation
History of pain and/or paresthesia over lateral orbit suggestive of
lacrimal gland malignancy
History of autoimmune disease and dry eye
Presence of upper eyelid dermatochalasis, ptosis or
blepharochalasis syndrome
History of trauma
History of prior facial surgery
Consider orbital imaging
The upper eyelid should be everted whilst looking for pro-
lapse of lacrimal gland tissue. Exophthalmometry and globe
position should be measured to rule out an orbital mass lesion.
Ductions should be measured and slit lamp examination and
tear function studies should be performed to rule out dry eye.
If there is any suspicion of a neoplasm, orbital imaging should
be obtained prior to surgery.
Lacrimal gland prolapse is generally treated by repositing the
gland into the orbit through placement of several non-absorb-
able sutures. An incisional biopsy of the lacrimal gland should
be considered in all cases to rule out occult neoplasm. Com-
monly, non-specific inflammation will be noted in the lacrimal
gland. A concurrent blepharoplasty may be performed to
address dermatochalasis at the time of lacrimal gland reposi-
tioning. Care should be taken to minimize removal of tissue to
prevent dry eye.
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Figures 70.1A and 70.1B Preoperative evaluation

This patient presents with cosmetically displeasing bilateral fullness of the superolateral orbits (Figure 70.1A). She notes firm nodules that are palpable
against the superolateral orbital rim. Preoperative evaluation was unremarkable. With elevation of the upper eyelid, the palpebral lobe of the lacrimal
gland is visible in the superior fornix (Figure 70.1B). Surgery of the palpebral lobe is not recommended as the risk of damage to the lacrimal ductules
increases significantly.

SURGICAL TECHNIQUE

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Figures 70.2A and 70.2B Temporal eyelid crease approach

If upper eyelid dermatochalasis is present, a concurrent upper blepharoplasty should be discussed with the patient. The skin marking for blepharoplasty
should take into account the skin redundancy after the gland is posteriorly reposited. If a blepharoplasty will not be performed, then an upper eyelid
crease incision over the temporal third is marked (Figure 70.2A). Local anesthetic consisting of 1% lidocaine, 0.25% bupivacaine with 1 : 200,000
epinephrine is given subdermally and along the superolateral orbital rim. The skin incision is made with a #15 blade (Figure 70.2B).

SECTION FOUR • ORBIT

Chapter 70 Reposition of prolapsed lacrimal gland
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Figures 70.3A and 70.3B Preperiosteal dissection

After the skin incision, the orbicularis is tented up and dissection is performed through this layer. The superolateral orbital rim is identified and isolated
with Desmarres and malleable retractors (Figure 70.3A). Then, using cutting cautery, an incision is carefully made along the superolateral orbital rim in a
preperiosteal fashion (Figure 70.3B). The dissection should not proceed down to the level of the bone as this will disrupt the periosteum along the arcus
marginalis. The periosteum must remain intact along the rim, as this will be the tissue used for repositioning of the gland.

Figure 70.4 Identification of prolapsed lacrimal gland
As the orbital septum is opened along the superolateral orbital rim, the
orbital lobe of the lacrimal gland can be noted. Identification of the gland
may be facilitated by gentle pressure on the eyelid with a malleable
retractor (Figure 70.4). The lacrimal gland should be distinguished from
the preaponeurotic fat pad. The lacrimal gland has a white appearance
with lobules often grossly visible. The preaponeurotic fat has an orange-
colored appearance and can easily be dissected free from the lacrimal
gland. If significant redundancy of the fat pad is present, this may be
cautiously excised after dissection free from the lacrimal gland.
Figure 70.5 Biopsy of orbital lobe of lacrimal gland
The lacrimal gland is grossly inspected to rule out any irregularities. We
routinely perform an incisional biopsy of the lacrimal gland (Figure 70.5) to
rule out malignancy or other lacrimal gland pathology. The most anterior
portion of the orbital lobe of the lacrimal gland is shaved with a #15
blade. If there is patient discomfort as the gland is grasped with 0.5
forceps, additional local anesthetic is given into the gland itself. A large
resection/biopsy of the gland should be avoided to prevent dry eye unless
there is suspicion of lymphoma or other neoplasm (white, gelatinous
appearance of gland). In the latter case, a larger biopsy should be
obtained and the tissue should be sent for fresh tissue analysis and the
incision closed without further manipulation. The patient should be
referred for oncological work-up, pending results of the lacrimal gland
biopsy. Commonly, non-specific inflammation of the lacrimal gland will be
noted after biopsy. After obtaining tissue, meticulous hemostasis should
be achieved as the lacrimal gland is richly vascularized.

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Figures 70.6A–C Reposition of orbital lobe of lacrimal gland

For reposition of a prolapsed lacrimal gland, multiple permanent sutures are used to retroplace the gland into the deeper orbit. A 5-0 Prolene suture on
a tapered C-1 needle will minimize damage to fine vessels and this is used to purchase the anterior aspect of the lacrimal gland (Figure 70.6A). The
orbital rim is exposed and then the needle is passed deeply into the periosteum over the superolateral orbital rim (Figure 70.6B). If the orbit is tight, then
the C-1 needle can be slightly bent to facilitate deeper suture placement. Several interrupted sutures can be placed to reposit the gland back into the
orbit as needed (Figure 70.6C).

SECTION FOUR • ORBIT

Chapter 70 Reposition of prolapsed lacrimal gland
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Figures 70.7A–C Final inspection

Once a sufficient number of sutures have been placed, the orbital lobe of the lacrimal gland should be noted as being flush with the orbital rim (Figure
70.7A). The sutures are cut short and the knots are then rotated so that the ends are buried in the lacrimal gland tissue. Final hemostasis is achieved
with gentle bipolar cautery (Figure 70.7B). Elevation of the upper eyelid shows reduced prolapse of the palpebral lobe of the lacrimal gland (Figure
70.7C). The orbicularis is closed with interrupted 7-0 Vicryl suture and the skin closed with a running 6-0 fast-absorbing gut or 6-0 Prolene suture.

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 BILATERAL REPOSITION OF PROLAPSED LACRIMAL GLAND

Preoperative Postoperative

Figure 70.8 Before and after reposition of lacrimal gland

This 27-year-old patient underwent bilateral lacrimal gland reposition. Incisional biopsy revealed non-specific inflammation of the lacrimal gland. After
reposition of the prolapsed lacrimal gland, there is reduction of the lateral upper eyelid fullness bilaterally.

Table 70.3 Complications

Complications Suggestions to reduce risk
Recurrence of lacrimal gland Careful dissection to preserve periosteum over rim; place additional sutures for repositioning; rule out
prolapse neoplasm; consider judicious removal of anterior portion of gland while weighing the risks of dry eye
Disruption of periosteum during Use sharp dissection with scissors instead of cautery followed by blunt dissection with cotton-tipped
dissection applicators; consider placement of drill holes along orbital rim for fixation; be careful of penetration to
frontal sinus or intracranial cavity
Dry eye Avoid excessive removal of lacrimal gland tissue; minimize cautery of gland; do not biopsy palpebral lobe
Upper eyelid ptosis Avoid deeper dissection in the orbit as the lateral horn of the levator aponeurosis is located between the
orbital and palpebral lobes of the lacrimal gland

Table 70.4 Consumables used during surgery

5-0 Prolene suture, C-1 needle Ethicon #8725H
6-0 Prolene suture, C-1 needle Ethicon #8718
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG140-8 needle Ethicon #J546G

SECTION FOUR • ORBIT

Chapter 70 Reposition of prolapsed lacrimal gland
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 CHAPTER 71
Optic nerve sheath fenestration
Table 71.1 Indications for surgery
Vision-threatening papilledema refractory to maximal medical
therapy
INTRODUCTION
Optic nerve sheath fenestration (ONSF) is most commonly
performed for vision-threatening papilledema associated with
idiopathic intracranial hypertension (IIH). Other conditions
where ONSF may be performed include optic nerve sheath
hemorrhage, cryptococcal meningitis with papilledema, dural
sinus thrombosis, and cancer-associated intracranial hyperten-
sions with papilledema.
The work-up of papilledema associated with IIH first involves
a detailed medication history to identify possible associations.
Signs and symptoms of IIH should be elicited and docu-
mented. Automated visual field testing and optic nerve
Bobby S. Korn • Don O. Kikkawa
Table 71.2 Preoperative evaluation
History of medication use associated with idiopathic intracranial
hypertension (IIH) – oral contraceptives, antibiotics,
chemotherapeutics, steroids, and acne medications
Dandy’s criteria for increased intracranial pressure (ICP) –
headaches, nausea, vomiting, transient visual obscurations,
papilledema, non-localizing unilateral or bilateral abducens palsy
Documentation of body habitus and gender
History of prior therapy for IIH – weight loss, carbonic anhydrase
inhibitors, CSF shunts
Magnetic resonance imaging of the brain, orbits as well as MRA/
MRV
Lumbar puncture with documentation of chemistries and opening
pressure
Prior visual field testing if available
photographs should be obtained and then MR imaging is
performed to rule out a mass effect causing the increased
intracranial pressure (ICP) as well as vascular studies to rule
out sinus thrombosis. Once imaging is deemed normal, atten-
tion is focused towards lumbar puncture to establish the
opening pressure, which is elevated over 20 cm H2O in non-
obese and over 25 cm H2O in obese patients. Infectious
meningitis should be ruled out by normal chemistries and
cultures if indicated.
Weight reduction and oral acetazolamide therapy is the main-
stay of treatment for IIH. Patients with severe headaches are
candidates for peritoneal shunts and should be referred to
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neurosurgery or interventional radiology. Vision-threatening
papilledema is addressed by ONSF.
ONSF can be performed through a medial orbitotomy
approach with disinsertion of the medial rectus, lateral orbit-
otomy with or without bone removal or through a superomedial
eyelid crease incision. The latter technique is our preferred
approach owing to its rapid, minimally invasive access to the
medial optic nerve sheath. The surgery can be performed with
a microscope or headlight and with optimal exposure can be
performed under 30 minutes.

SURGICAL TECHNIQUE

Figure 71.1 Medial upper eyelid crease approach

A variety of approaches for optic nerve sheath fenestration have been
described. In this case, the medial upper eyelid crease approach is
described. This approach is safe and direct with minimal complications.
The case is typically performed under general anesthesia, although
monitored anesthesia care with local anesthetic can be utilized in select
cases. A standard upper eyelid crease is marked in the medial aspect
(Figure 71.1). The operating microscope used for cataract and retina
surgery provides excellent visualization and illumination during ONSF.

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Figures 71.2A and 71.2B Dissection through orbital septum

After skin incision, cutting cautery is used for deeper dissection. After dissection through the orbicularis and orbital septum, the nasal and central fat
pads are identified (Figures 71.2A and 71.2B). The trochlea serves as an important landmark separating these two fat pads.

SECTION FOUR • ORBIT

Chapter 71 Optic nerve sheath fenestration
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Figures 71.3A–C Blunt dissection in the posterior and medial orbit

Once the fat pads are identified, curved, blunt-tipped tenotomy scissors are then used to perform blunt dissection between the nasal and central fat pads
while the medial horn of the levator aponeurosis is reflected laterally (Figures 71.3A and 71.3B). The dissection is also directed inferiorly to avoid
damage to the superior oblique tendon (Figure 71.3C). As the tips of the scissors are opened, a Senn retractor or malleable retractor is inserted between
the blades and used to bluntly dissect deeper in the orbit. The dissection should be performed in an inferolateral direction to hug the globe.

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Figures 71.4A and 71.4B Identification of sclera

The next landmark to be identified is the sclera. Once the sclera is identified, blunt dissection can be performed using two small–medium-sized
malleable retractors to mobilize fat while following the scleral vessels in a posterior and medial direction (Figures 71.4A and 71.4B). The dissection is
also guided by following the scleral vessels posteriorly.

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Figures 71.5A and 71.5B Isolation of optic nerve

As the dissection continues with the malleable retractors, the optic nerve will be identified during the posteromedial scleral dissection. Two additional thin
malleables (10 mm width) can be used to provide oblique retraction. If excessive orbital fat prolapses into the surgical field, neurosurgical cottonoids can
be used for traction. Often, the posterior ciliary vessels can be seen coursing along the nerve and can serve as another surgical landmark for identifica-
tion of the nerve (Figures 71.5A and 71.5B). Retraction should be performed gently in the intraconal space to avoid trauma to the nearby insertions of
cranial nerve III branches. Throughout the exposure of the optic nerve and previous dissections, the pupil should be periodically evaluated to look for
dilatation. If this occurs, tension on the retractors should be relaxed immediately.

SECTION FOUR • ORBIT

Chapter 71 Optic nerve sheath fenestration
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Figures 71.6A–C Fenestration of optic nerve sheath

The optimal location for optic nerve sheath fenestration is within 1 cm of the posterior globe on the medial side and away from the ciliary ganglion
located on the lateral side. Fenestration greater than 1 cm from the optic nerve insertion site risks damage to the central retinal artery and vein.
A 19-gauge microvitreal retinal (MVR) blade is used to incise the dural sheath. The MVR blade is ideally suited because of its sharp tip as well as its
small profile in the orbit (Figure 71.6A). Often a burst of CSF is noted with the incision of the dural sheath, but if no fluid egress is noted the arachnoid
may require incision (Figure 71.6B). A Sinskey hook is then used to tent up the dural/arachnoid sheath from the underlying layers (Figure 71.6C). With
significantly elevated ICP, the optic nerve often appears grossly dilated with a bluish hue.

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Figures 71.7A–C Creation of dural window

After the dural/arachnoid sheath has been tented up, a Kelly punch is used to create the window (Figure 71.7A). The shielded tip of the Kelly punch
protects the underlying optic nerve fibers from incidental trauma and is more adept at tissue incision in the deep orbit compared to standard ophthalmic
scissors. A window of approximately twice the width of the Kelly punch is created in the dural sheath. Figures 71.7B and 71.7C show the appearance of
the completed dural window. Skin closure is performed in a standard fashion.

SECTION FOUR • ORBIT

Chapter 71 Optic nerve sheath fenestration
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Table 71.3 Complications
Complications Suggestions to reduce risk
Vision loss Frequent checks of pupil during surgery; minimize traction on optic nerve; avoid creating
window greater than 1 cm from insertion site which may affect central retinal artery; avoid
prolonged episodes of hypotension during surgery (communicate with anesthesiologist)
Cranial nerve palsy Gentle traction/exposure with malleable retractors; take frequent retraction breaks during
procedure; avoid cautery in posterior orbit
Ciliary ganglion damage (anisocoria) Avoid creating dural/arachnoid window on lateral aspect of optic nerve

Table 71.4 Consumables and instrumentation used during surgery

Kelly Descemet membrane punch Storz E2798
Sinskey iris hook Storz E0545
19-gauge MVR blade Alcon Laboratories
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
7-0 Vicryl, TG140-8 needle Ethicon #J546G

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CHAPTER 72
Evisceration with orbital
implant placement
Bradford W. Lee • Don O. Kikkawa • Bobby S. Korn

Table 72.1a Indications for surgery Table 72.2 Preoperative evaluation

Blind, painful eye
Intractable endophthalmitis or corneal ulceration with no visual
potential
Anterior ruptured globe with no visual potential
Table 72.1b Contraindications for surgery
Significant phthisis bulbi with contracture of the sclera
Panophthalmitis with infection of posterior sclera
History of necrotizing scleritis
Known intraocular malignancy or inability to rule out occult
intraocular malignancy
History of prior eye diseases, trauma, or surgeries
Prior medical management for blind painful eyes or endophthalmitis
Overall medical health and surgical risk profile
Psychological status of patient (particularly for younger patients)
Complete examination of both the surgical eye AND the fellow eye
to evaluate for visual potential, pathology, and occult malignancies
(including ophthalmic ultrasound and/or CT or MRI imaging if
fundoscopic examination is limited)
Pupillary response (reverse testing if globe and pupil are
degenerated)
Motility
Eyelid and superior sulcus
Conjunctiva and fornices
Orbit (volume)
Intraocular pressure

SECTION FOUR • ORBIT

Chapter 72 Evisceration with orbital implant placement
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INTRODUCTION
Evisceration surgery is performed in end-stage blind, painful
eyes or infected eyes for which medical management has failed
and there is no visual potential. The surgery involves removing
the intraocular contents entirely and oftentimes the cornea and
portions of the anterior sclera as well.
During the preoperative evaluation, it is critical to perform a
complete dilated exam on both eyes. Visual potential and any
concomitant ocular pathology should be evaluated fully. In
cases of trauma, structural integrity of the injured eye should
be evaluated to determine if any useful vision could be regained.
In cases where the posterior pole cannot be adequately exam-
ined on fundoscopy, ophthalmic ultrasound, with or without CT
or MRI imaging, should be performed to rule out occult intraoc-
ular tumors. Patients are strongly advised to wear protective
eyewear at all times to preserve the fellow eye.
The decision between evisceration and enucleation (Chapter
73) varies by surgeon. With cases of known or suspected
intraocular malignancy, enucleation is the standard of care, not
only to avoid seeding the intraocular malignancy into the orbit
but also to allow for complete pathologic examination with
implications toward prognosis and treatment.
One of the main advantages of evisceration surgery is that
there is less disruption of the orbital structures, such as the
extraocular muscles, optic nerve, and orbital fat. This often
results in improved cosmesis, ocular motility, and orbital volume
preservation. Moreover, evisceration surgery is faster and can
be more comfortably performed with a retrobulbar block if the
patient is not a good surgical candidate due to medical co-
morbidities. Additionally, in the case of endophthalmitis from a
perforated corneal ulcer, the infected intraocular tissues are
less likely to spill deep into the orbit causing a potential implant
infection, orbital cellulitis, or meningitis.
The main disadvantages of evisceration surgery are the risks
of sympathetic ophthalmia and occult malignancy. Unlike in
enucleation surgery, in which the total intraocular contents are
removed, it is impossible to remove all the pigmented uveal
melanocytes during evisceration since some will inevitably
remain in the emissary channels of the sclera. With the advent
of modern immunomodulatory medications, sympathetic oph-
thalmia can be more effectively treated than in the past, but
remains an important and serious condition that deserves dis-
cussion during the preoperative evaluation. As such, some
ophthalmologists feel that an extensive history of intraocular
surgeries and/or ocular traumas is a relative contraindication to
evisceration.
Occult intraocular malignancy is another important risk with
evisceration. Trauma or intraocular pathology often causes
media opacities that prevent a detailed fundoscopic examina-
tion of the eye in question. In these cases, evaluation by oph-
thalmic ultrasonography and/or CT or MRI imaging is advisable
to rule out any readily apparent tumors. Nonetheless, diffuse
choroidal melanomas are characterized by minimal choroidal
thickening and can be missed on echography. If there is any
concern or doubt about the presence of an intraocular malig-
nancy, enucleation should be favored over evisceration.
Restoring orbital volume after evisceration is essential to
achieving optimal aesthetic and functional outcomes. A multi-
tude of different orbital implants have been described over the
past 50 years. As compared to enucleation surgery, there is
relative orbital volume preservation with evisceration due to
preservation of the sclera and optic nerve and minimal trauma-
induced atrophy to surrounding orbital tissues.
The volume of the implant placed is limited by the size of the
sclera and whether the corneal button and any surrounding
sclera are removed during the operation. Typically, a size 14- or
16-mm spherical implant can be placed. In order to place a
larger implant in the socket to prevent a superior sulcus deform-
ity, a posterior scleral window can be created. This allows a
larger implant to be placed such that its posterior portion
extends deep into the orbit through the scleral window. With
this modification, an 18-, a 20-, or even a 22-mm spherical
implant can be placed. When available, our preference is to
use a 20-mm conical implant (equivalent in volume to a 22-mm
spherical implant) when possible, as this allows the tapered
end of the implant to project beyond the posterior sclera in the
same cone-shaped configuration as the orbit.
Complications related to evisceration include superior sulcus
deformity, upper eyelid ptosis, and lower eyelid malpositions.
Socket contracture is a surgical condition that is challenging to
treat, and meticulous surgical technique at the time of eviscera-
tion can help prevent this condition.
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Figures 72.1A–C Conjunctival peritomy

Evisceration can be performed under general anesthesia or with a retrobulbar/peribulbar block with intravenous sedation. Prior to induction of anesthesia,
a surgical “time-out” is performed by all members of the team and the patient to confirm the correct eye for evisceration. If the correct eye to be
eviscerated is not obvious by external examination, dilation can be performed to visualize the intraocular pathology that warrants evisceration. A corneal
shield is placed on the fellow eye for protection. A retrobulbar injection provides maximal anesthesia and facilitates posterior hemostasis. For anterior
hemostasis, local anesthetic containing 1 : 100,000 epinephrine is given in a subconjunctival fashion around the limbus. A wire eyelid speculum is placed
to facilitate exposure. A 360° limbal peritomy is performed with Westcott scissors (Figures 72.1A and 72.1B). During the peritomy, care should be taken
to preserve the maximum amount of conjunctiva to ensure an adequate cul-de-sac postoperatively. The blunt tips of the scissors are directed towards
the sclera to prevent damage to the conjunctiva. The conjunctiva should be recessed approximately 5 mm from the limbus (Figure 72.1C).

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Chapter 72 Evisceration with orbital implant placement
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Figures 72.2A–D Creation of a 360° sclerotomy

Once the peritomy has been completed, a #67 blade is used to create a full-thickness incision of the sclera approximately 2 mm posterior to the limbus
and scleral spur in a circumferential fashion (Figure 72.2A). A cyclodialysis spatula is inserted in the suprachoroidal space and swept 90° from a radial
posterior orientation toward the leading edge of the scleral incision (Figure 72.2B). It is important to maintain constant pressure on the sclera to stay in
the suprachoroidal space. Once the choroid has been dissected from the sclera in front of the leading edge of the incision, Westcott scissors are used to
advance the leading edge of the sclerotomy in a sequential fashion until the 360° sclerotomy is complete (Figures 72.2C and 72.2D).

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Figures 72.3A and 72.3B Posterior delineation of the suprachoroidal space using an evisceration spoon
A small evisceration spoon is used to delineate the suprachoroidal plane posteriorly (Figure 72.3A). This is performed in multiple passes with anterior-to-
posterior radial sweeps at each clock-hour (Figure 72.3B). In this manner, the uveal contents are completely released from the sclera, except for the final
posterior attachment around the optic nerve. An alternate maneuver is to sweep the spoon in a circumferential fashion, starting from the anterior sclera
and spiraling downward posteriorly.

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Figures 72.4A–C Posterior release and removal of the uvea

Once the suprachoroidal plane has been well delineated posteriorly, a large evisceration spoon can be used to release the final posterior attachment of
the choroid at the lamina cribrosa of the optic nerve head (Figure 72.4A). The uveal contents with cornea attached are then lifted out of the eye and sent
for permanent pathological analysis (Figure 72.4B). Maintaining the scleral spur and its attachments at the limbus allows complete removal of the
intraocular contents as a single unit (Figure 72.4C).

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Chapter 72 Evisceration with orbital implant placement
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Figures 72.5A–C Cleansing and denaturing of uveal contents with ethanol

To mitigate the risk of sympathetic ophthalmia, cotton-tipped applicators are used to meticulously remove any residual uveal tissues adherent to the
sclera (Figure 72.5A). Gentle bipolar cautery can be applied as needed to any bleeding vessels, such as the vortex veins. Absolute or 70% ethanol is
then applied to fill the entire sclera and denature residual uveal contents that cannot be grossly removed (Figure 72.5B). Care is taken to avoid spilling
the ethanol outside the scleral confines, as this will cause chemical injury to the conjunctiva and orbital contents. After multiple ethanol cleanses, suction
and balanced salt solution are used to cleanse the sclera of residual ethanol (Figure 72.5C).

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Figures 72.6A and 72.6B Creation of anterior scleral relaxing incisions

Radial scleral relaxing incisions are created at the 3 and 9 o’clock meridians with Westcott scissors. The relaxing incisions should be 3–6 mm in length
and will facilitate insertion of the orbital implant (Figures 72.6A and 72.6B). A thin triangular flap can be alternatively excised to facilitate later closure if
desired.

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Figures 72.7A and 72.7B Creation of a posterior scleral window

Westcott scissors are used to perform a circular posterior sclerotomy that creates a scleral window centered on the optic nerve with a diameter of
10–15 mm (Figure 72.7A). This will allow placement of a larger orbital implant that extends deep into the orbital apex through the posterior scleral
window (Figure 72.7B). This also allows fibrovascular ingrowth through the scleral window to promote biointegration of the implant and minimize the risk
of implant extrusion.

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Figures 72.8A and 72.8B Placement of the orbital implant

Placement of the largest implant possible typically yields the best post-surgical outcome. Trial spheres come in a variety of sizes up to 24 mm. In most
cases, a 20-mm conical implant (equivalent to a 22-mm spherical implant) can be placed while still allowing Tenon’s capsule to be closed without
tension (Figures 71.8A and 71.8B). If orbital sizers are not available, the spherical size of the implant can be determined by subtracting 2 mm from the
axial length of the fellow eye using the Kaltreider–Lucarelli formula. For porous orbital implants, air contained within the implant is removed, and a dilute
antibiotic solution is infused into the porous channels for antimicrobial prophylaxis. The implant is placed in a 60 ml syringe filled with approximately
30 ml of dilute gentamicin solution if there are no drug allergies. The plunger is withdrawn to create negative pressure and this simultaneously draws air
out of the porous implant and infuses antibiotic solution into the implant (Chapter 73). With the plunger still withdrawn, the negative pressure is released
at the tip of the syringe, and the air is expelled from the syringe. This process is repeated several times to maximally draw antibiotic solution into the
implant.The implant should be placed deeply within the orbital socket to maximize retention (Figure 72.8A). The assistant provides anterior countertrac-
tion on the anterior sclera with Adson forceps. The implant is placed within a Carter sphere introducer and the prongs are placed deep into the socket
before the plunger is depressed. The anterior scleral flaps should easily overlap with minimal tension (Figure 72.8B).

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Figures 72.9A–D Primary scleral closure

A double-layered scleral closure is performed anteriorly to help prevent implant extrusion. A double-armed 6-0 Vicryl suture is sewn in-to-out on the
inferior scleral flap and then in-to-out on the superior scleral flap (Figures 72.9A–C). This is tied in a horizontal mattress fashion and results in the
creation of a double-layered scleral “envelope”. This is performed a total of three times across the sclerotomy to cover the implant, and any redundant
sclera can be trimmed or tacked down to create a smoother contour of the anterior sclera. The sclera should overlap by approximately 2 mm in the first
layer of closure (Figure 72.9D).

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Figures 72.10A–D Secondary scleral closure

The final layered closure is performed by suturing the anterior overlapping sclera to the adjacent sclera with interrupted 6-0 Vicryl suture (Figures
72.10A–D). Several of these interrupted sutures are placed across the width of the sclera.

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Figures 72.11A–D Closure of Tenon’s capsule

Meticulous closure of Tenon’s capsule provides the greatest protection against implant extrusion. Multiple buried interrupted 5-0 Vicryl sutures are used
to close Tenon’s capsule, and large bites of Tenon’s capsule are taken when possible to provide a robust closure (Figures 72.11A–C). When finished, no
sclera should be visible on examination (Figure 72.11D). During closure of Tenon’s capsule, conjunctiva should not be incorporated, as this may lead to
subsequent socket and/or fornix contracture. If delineation between Tenon’s capsule and the conjunctiva is not readily apparent during closure, Tenon’s
capsule can be hydrated with balanced salt solution resulting in a whitening of the Tenon’s capsule but without change to the conjunctiva.

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Figures 72.12A and 72.12B Closure of conjunctiva

The layered closure is finished by reapproximation of the conjunctiva. A running 6-0 fast-absorbing gut suture can be used to close the conjunctiva
(Figure 72.12A). The conjunctival edges should be everted to avoid postoperative epithelial inclusion cyst formation (Figure 72.12B).

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Figures 72.13A–C Placement of a conformer and temporary tarsorrhaphy

The largest conformer that will comfortably fit in the fornix is then placed with antibiotic ointment (Figure 72.13A). This helps to maintain the fornices for
eventual placement of an ocular prosthesis. The eyelids are temporarily closed in a horizontal mattress fashion through the gray line of the upper and
lower eyelid margins using 5-0 or 6-0 fast-absorbing gut suture (Figures 72.13B and 72.13C). This helps to keep the conformer in place and helps
prevent extrusion of the conformer in the event of a postoperative orbital hemorrhage or prolonged chemosis. If the patient is on blood thinners or at high
risk for an orbital hemorrhage, a more robust temporary tarsorrhaphy can be performed using double-armed 5-0 Prolene suture and foam bolsters.

Figure 72.14 Injection of postoperative anesthetic

Postoperative pain is a common complaint following evisceration surgery.
This can be ameliorated initially by administering an injection of 0.5%
bupivacaine in a peribulbar fashion at the end of the surgery (Figure
72.14). No more than 3 ml of anesthetic should be given, as this increases
posterior pressure on the orbital implant and may compromise the anterior
closure. Patients should be warned that the local anesthetic will wear off
after several hours, and their subsequent pain should be controlled with
oral analgesics. A pressure patch is applied to the operative side to help
prevent postoperative bleeding and drainage. This is maintained until the
patient is seen in follow-up approximately 5–7 days after surgery.

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 RIGHT EVISCERATION WITH ORBITAL IMPLANT

Preoperative Postoperative

Figure 72.15 Before and after right evisceration

This 58-year-old female presented with a blind and painful right eye. She previously underwent two retinal detachment repairs followed by glaucoma
surgery and developed intractable pain and had no light perception vision. She underwent right evisceration with placement of a 20-mm conical porous
polyethylene implant (Figure 72.15).

Table 72.3 Complications

Complications
Sympathetic ophthalmia
Orbital hemorrhage
Pain
Implant extrusion
Inadequate volume
Contracted fornices
Superior sulcus defect
Anophthalmic ptosis
Depression
Suggestions to reduce risk
Careful and meticulous mechanical removal and chemical denaturing of uvea
Meticulous hemostasis; pressure patch; management of anticoagulants where possible
Peribulbar block with bupivacaine performed at the end of the operation; oral analgesics
Double-layered scleral closure; meticulous layered closure of Tenon’s capsule; temporary tarsorrhaphy; widen
posterior scleral aperture
20 mm diameter or greater implant in most patients; determine appropriate implant size with sizing spheres;
consider volume augmentation with floor implants (Chapter 68)
Preserve as much conjunctiva as possible; avoid tight suturing of Tenon’s capsule and conjunctiva; avoid
cauterization of conjunctiva and Tenon’s capsule; early referral to ocularist for custom conformer placement in
high-risk cases
Caused by inadequate orbital volume; consider implant exchange; placement of orbital volume along floor with
stacked implants; injection of filler or free fat grafts (Chapter 47); placement of dermis fat graft (Chapter 75)
Maximize orbital volume; adjustment of prosthesis; ptosis repair by external levator advancement (Chapter 11);
avoid posterior approach ptosis repair due to risk of causing socket contracture
Psychological screening and counseling

Table 72.4 Consumables used during surgery

5-0 Vicryl, PC-1 needle Ethicon #J843G
6-0 Vicryl, TG100-8 needle Ethicon #J544G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
Porous polyethylene orbital implant Stryker Surgical

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CHAPTER 73
Enucleation and orbital implant
placement
Jeremiah Tao • Bobby S. Korn
Table 73.1 Indications for surgery
Blind and painful eye
Sympathetic ophthalmia prophylaxis after uveal prolapse
Intraocular malignancy (e.g. choroidal melanoma, retinoblastoma)
Phthisis bulbi with disfigurement and blind eye from multiple
causes (post-traumatic, retinal detachment, end-stage glaucoma,
endophthalmitis)
INTRODUCTION
Enucleation is one of the oldest ophthalmic procedures and
involves removal of the entire globe and portions of the optic
nerve. The indications include blind and painful eye from a
variety of causes, intraocular malignancy, and sympathetic
ophthalmia prophylaxis after severe ocular trauma.
Importantly, the loss of an eye – especially a seeing eye – is
strongly associated with depression and other psychological
disturbances and, accordingly, referral to mental health profes-
sionals is often indicated.
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Table 73.2 Preoperative evaluation
Vision potential of eye
Pupillary response (reverse testing if globe and pupil are
degenerated)
Motility
Eyelid and superior sulcus
Conjunctiva and fornices
Orbit (volume)
Intraocular pressure
Complete examination of fellow eye
Timing of injury
Oncologic work-up for cases of intraocular malignancy
Psychological status of patient (particularly for younger patients)
During the evaluation, a careful examination is performed
of the eye to be enucleated. The visual potential should be
fully assessed, particularly in traumatic cases where some
usable vision may remain. In cases where no view of the
posterior pole is possible, a B-scan ultrasound should be
performed to rule out occult intraocular tumor. The fellow
eye must also be carefully evaluated and any pathology
treated as the patient will be monocular. Patients are strongly
advised to wear protective eyewear at all times to preserve
the fellow eye.
 The preference for evisceration (Chapter 72) or enucleation
varies between surgeons. With cases of known or suspected
intraocular malignancy, enucleation is the standard of care, as
complete pathologic examination is necessary. Obtaining a
long optic nerve segment is particularly important in the man-
agement of retinoblastoma as this malignancy can spread via
the optic nerve. Furthermore, a systemic oncologic evaluation
should be performed in cases of intraocular malignancy.
Restoring orbital volume after enucleation is paramount to
achieving the best aesthetic and functional outcomes. A multi-
tude of different orbital implants have been described over the
past 50 years. The generally accepted consensus is to place
the largest possible implant at the time of surgery. Currently
used alloplastic implant materials at the time of writing include
porous polyethylene (Medpor, Stryker Surgical, Kalamazoo, MI),
hydroxyapatite (Bio-Eye, IOI, San Diego, CA) silicone, acrylic,
and aluminum oxide bioceramic (FCI, Cedex, France).
Fibrovascular integration of orbital implants lessens the
chance of implant extrusion. Implants may also be wrapped
with tissue such as fascia, autologous or donor sclera or bovine
pericardium to decrease the risk of extrusion and to facilitate
attachment of the extraocular muscles. The newer implants
such as porous polyethylene do not require wrapping and the
extraocular muscles can be directly attached to the implant.
Pegging of the implant can be performed to improve motility
of the prosthetic but the high complication rates with this modi-
fication have largely limited its widespread use. Other complica-
tions related to enucleation include superior sulcus deformity,
upper eyelid ptosis, and lower eyelid malpositions. Socket con-
tracture is a challenging surgical condition and meticulous sur-
gical technique at the time of enucleation can minimize this
problematic condition.

SURGICAL TECHNIQUE

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Figures 73.1A and 73.1B Injection of local anesthetic

Enucleation is best performed under general anesthesia. Prior to the start of surgery, a “time out” is performed by all members of the team to confirm
the correct eye for enucleation. Removal of the wrong eye is an unacceptable complication. If necessary, dilation can be performed to visualize
intraocular pathology, particularly if there is no gross pathology evident on external examination of the globe. A corneal shield is placed on the fellow eye
for protection. A retrobulbar injection provides maximal anesthesia and can facilitate hemostasis. To maximize hemostasis anteriorly, local anesthetic
containing 1 : 100,000 epinephrine is given in a subconjunctival fashion around the limbus (Figures 73.1A and 73.1B). This local anesthesia also helps to
hydrodissect the conjunctiva from Tenon’s capsule during the conjunctival peritomy.

Figure 73.2 Conjunctival peritomy

A wire eyelid speculum is placed to facilitate exposure. A 360° limbal
peritomy is performed with Westcott scissors. During the peritomy, care
should be taken to preserve the maximum amount of conjunctiva to ensure
an adequate cul-de-sac postoperatively (Figure 73.2). The blunt tips of the
scissors are directed towards the sclera to prevent damage to the
conjunctiva. In traumatic cases with gross disruption of normal anatomy,
every effort should be made to preserve viable conjunctiva and avoid
creating buttonholes in the tissues. Occasionally, scleral ruptures may be
noted and these should be closed with 6-0 silk to minimize uveal extrusion
and to maintain globe pressure during subsequent steps. Any dark, uveal
tissues should be removed and irrigated away to lessen the theoretic risk
of sympathetic ophthalmia.

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Figures 73.3A and 73.3B Exposure of extraocular muscles

Once the peritomy has been completed, Tenon’s capsule is dissected from the underlying sclera. Curved, blunt-tipped tenotomy scissors are placed with
the closed tips hugging the sclera in the oblique quadrants (Figure 73.3A). The scissors are then spread widely as the instrument is withdrawn, bluntly
widening Tenon’s capsule (Figure 73.3B). This is repeated multiple times in each oblique quadrant. Care is taken to not sever any of the extraocular
muscle during the blunt dissection. Adequate dissection will facilitate exposure of the extraocular muscles in the subsequent step.

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Figures 73.4A–D Isolation and imbrication of medial rectus

After freeing conjunctiva and Tenon’s capsule from the underlying sclera, the rectus muscles are sequentially isolated and secured. Wide platform
instruments such as the Von Graefe and Green muscle hooks are used to isolate the rectus muscles. In a non-traumatic eye, the medial rectus can be
isolated first. When isolating the muscle, the hook is widely swept to ensure complete purchase of the entire muscle width. Once the muscle has been
hooked, a cotton-tipped applicator is used to strip away the muscular capsule and expose the rectus fibers (Figure 73.4A). The muscles are secured with
double-armed 6-0 Vicryl suture on a spatulated needle, passed in two-thirds width bite in a partial thickness fashion (Figure 73.4B). The terminal end of
the suture is then passed full thickness and locked in a double whip stitch fashion (Figures 73.4C and 73.4D). Once the muscle is secured, scissors are
used to disinsert the rectus muscle from sclera. When severing the rectus muscles, it is useful to leave a 2 mm stump of tendon so that a forceps,
hemostat, or 5-0 silk suture can be placed for globe traction. The double-armed suture is then temporarily secured with a bulldog serrefine clamp.

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Figures 73.5A–D Isolation and imbrication of vertical rectus muscles

The vertical rectus muscles are isolated after disinsertion of the medial rectus. To isolate the inferior rectus, the muscle hook is passed from a lateral-to-
medial direction (Figure 73.5A). The globe is rotated superiorly to ensure complete capture of the muscle and if the globe resists rotation or if the
insertion site is not clearly identified, the inferior oblique may have been inadvertently hooked and the rectus should be re-isolated. The muscle is then
secured with double locking bites as previously described and disinserted (Figure 73.5B). Next, the superior rectus is isolated with a lateral-to-medial
sweeping motion. The superior rectus, like the inferior rectus, has a wide horizontal base of attachment to the globe (Figure 73.5C). The muscle is
imbricated and disinserted with scissors (Figure 73.5D).

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Figures 73.6A and 73.6B Disinsertion of oblique muscles

The oblique muscles are not typically anchored to the orbital implant and can be severed after isolation. In cases of trauma with globe disruption and
loss of some of the rectus muscles, the obliques may be imbricated and sutured to the implant for additional support. The inferior oblique runs below the
course of the inferior rectus and is isolated by passing a Stevens muscle hook in a deep medial-to-lateral sweeping motion (Figure 73.6A). The muscle is
then severed with scissors. Similarly, the superior oblique tendon is isolated in a medial-to-lateral motion with the Stevens hook (Figure 73.6B). The
oblique is disinserted and allowed to retract back into the orbit.

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Figures 73.7A–D Isolation and imbrication of lateral rectus

The lateral rectus muscle is then isolated and imbricated with 6-0 Vicryl suture (Figures 73.7A and 73.7B). The muscle can be disinserted, leaving a
2 mm stump for placement of a 5-0 silk suture that passes through the tendon’s stumps at the rectus insertion site. Alternatively, the silk suture can be
passed through the sclera in a partial thickness fashion to provide traction (Figure 73.7C). However, for cases of suspected intraocular malignancy,
scleral passes should not be used for traction as this may seed the tumor. With anterior traction on the silk suture, enucleation scissors are used to
perform blunt dissection within the deep orbit to release Tenon’s capsule posteriorly (Figure 73.7D). This is a key part of the procedure and is critical for
obtaining the longest possible segment of optic nerve. This blunt dissection is performed in a 360° fashion to release residual attachments to the globe.
At this point, the only major attachment to the globe should be at the optic nerve. The globe can also be noted to freely rotate about the axis of the optic
nerve once freed.

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Figures 73.8A and 73.8B Transection of the optic nerve

With gentle traction on the globe, the enucleation scissors are placed deep within the lateral orbit. The tips of the scissors are kept in the closed position
and the instrument is used to strum and localize the optic nerve. After the nerve has been localized, the scissor tips are opened, the optic nerve is
engaged and, with firm upward traction on the globe and downward pressure on the scissors, the optic nerve is transected (Figure 73.8A). Alternatively,
an enucleation snare can be placed around the optic nerve for 5 minutes to constrict blood flow and improve hemostasis prior to severing the nerve.
Residual attachments to the globe are often present after optic nerve transection and these are cut while carefully avoiding the extraocular muscles
(Figure 73.8B). Removal of orbital fat should not be performed, as this will decrease the effective orbital volume.

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Figures 73.9A and 73.9B Achieving orbital hemostasis

A well-executed retrobulbar block with dilute epinephrine will maximize hemostasis. Prior to transecting the optic nerve, several saline-soaked gauzes are
set aside for packing the orbit. Immediately after enucleation, these moist gauzes are deeply packed into the orbit while the assistant provides anterior
traction on the superior and inferior leaflets of Tenon’s capsule (Figure 73.9A). Firm pressure is applied to the orbit for at least 5 minutes (Figure 73.9B).
The gauze pads are slowly extracted from the orbit and point bleeding can be controlled with a bayonet bipolar forceps. Monopolar cautery should not be
used for hemostasis as this can theoretically conduct energy down the optic nerve stump to the chiasm.

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Figures 73.10A and 73.10B Inspection of enucleated globe

After enucleation, the globe is grossly inspected for any anatomic abnormalities, such as extrascleral extension of tumor (Figure 73.10A). The optic nerve
is also measured with a caliper (Figure 73.10B). In this case, a 18-mm optic nerve segment is obtained which is particularly important for the staging of
intraocular malignancies that may spread via the optic nerve. If genetic testing is desired for intraocular tumors, fine needle aspiration can be performed
through the mass and sent for the relevant diagnostic studies. Otherwise, the globe is placed in formalin for subsequent histopathologic analysis.

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Figures 73.11A–D Orbital implant sizing

Placement of the largest possible implant in the orbit will yield the best postsurgical result. Trial spheres come in a variety of sizes up to 24 mm. In this
case, a 22 mm sphere fits well in the orbit and allows Tenon’s capsule to close without tension (Figures 73.11A and 73.11B). If a spherical orbital
implant is to be used, the same diameter implant is selected. If a conical implant is to be used, the size is reduced by 2 mm. Figure 73.11C shows the
equivalent volumes of a spherical and conical implant. If orbital sizers are not available, the spherical size of the implant can be determined by
subtracting 2 mm from the axial length of the fellow eye using the Kaltreider–Lucarelli formula. For porous orbital implants, a dilute antibiotic solution is
impregnated for antimicrobial prophylaxis. The implant is placed in a 60-ml syringe filled with dilute gentamicin solution, as long as the patient has no
drug allergies. The plunger is withdrawn to create negative pressure, drawing antibiotic solution into the implant (Figure 73.11D). This process is
repeated several times to maximally draw fluid into the implant.

Figure 73.12 Placement of orbital implant

The implant should be placed deeply within the orbital socket to maximize
retention. The assistant should provide anterior countertraction on Tenon’s
capsule with Adson forceps. The implant is placed within a Carter sphere
introducer and the prongs are placed deep into the socket before the
plunger is depressed (Figure 73.12). The implant can optionally be coated
with a viscoelastic to act as a lubricant to facilitate deep placement of the
implant in the anophthalmic socket. Care should be taken to not drag
Tenon’s capsule deeper into the orbit while placing the implant. Once the
implant is in place, Tenon’s capsule is pulled anteriorly to stretch out any
laxity that may have occurred during placement.

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Figures 73.13A–D Attachment of extraocular muscles

Proper attachment of the extraocular muscles to the orbital implant will facilitate movement and fibrovascular ingrowth, and will serve as a barrier to
implant extrusion. In this case using a porous polyethylene implant, the rectus muscles are sutured directly to the implant without the need for wrapping.
The needles of the Vicryl suture are gently glided through one of the many pores of the implant and carefully tied off (Figure 73.13A). We routinely
secure the rectus muscles in close approximation to the anterior face of the implant to provide additional protection against extrusion (Figure 73.13B).
The muscles are inserted as opposing pairs one set at a time (horizontal and vertical). As more muscles are secured, traction on the implant may
become difficult. A 18-gauge needle on a 10-ml syringe can be used to pierce the center of the anterior surface. This will provide a landmark about
which the muscles can be attached as well as providing traction on the implant without disturbing the extraocular muscles (Figure 73.13C). Upon
completion, the extraocular muscles are seen to be in close approximation (Figure 73.13D). This provides a strong barrier against anterior extrusion as
well as promoting vascular ingrowth.

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Figures 73.14A–C Closure of Tenon’s capsule

Meticulous closure of Tenon’s capsule provides the greatest protection against implant extrusion. Several interrupted 5-0 Vicryl sutures are used to close
Tenon’s capsule (Figures 73.14A and 73.14B). During closure of Tenon’s capsule, conjunctiva should not be incorporated as this may lead to
subsequent socket and/or fornix contracture. Tenon’s capsule is closed until no implant is visible (Figure 73.14C)

Figure 73.16 Injection of postoperative anesthetic

Figure 73.15 Closure of conjunctiva
The layered closure is finished by reapproximation of the conjunctiva.
A running 6-0 fast-absorbing gut suture can be used to close the
conjunctiva (Figure 73.15). The conjunctival edges should be everted to
avoid postoperative cyst formation.
Postoperative pain is a common complaint after enucleation. This can be
ameliorated with an injection of 0.5% bupivacaine, which is given in a
peribulbar fashion in the orbit after the conjunctiva (Figure 73.16). No
more than 3 ml of anesthetic should be given, as this places excessive
posterior pressure on the orbital implant and may compromise the anterior
closure.

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Figures 73.17A and 73.17B Placement of conformer

An appropriately sized conformer shell is placed in the fornix to resist socket contracture (Figure 73.17A). A temporary suture tarsorrhaphy may also be
placed at the time of surgery. The socket is firmly pressure patched at the end of the case (Figure 73.17B).

RIGHT ENUCLEATION WITH ORBITAL IMPLANT

Preoperative Postoperative

Figure 73.18 Before and after right enucleation

This 45-year-old female suffered trauma to the right eye resulting in a ruptured globe. Her eye became painful and there was no light perception vision.
She underwent right enucleation with placement of a 20-mm conical porous polyethylene implant (Figure 73.18).

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Table 73.3 Complications
Complications
Orbital hemorrhage
Pain
Implant extrusion
Inadequate volume
Contracted fornices
Superior sulcus defect
Anophthalmic ptosis
Depression
Suggestions to reduce risk
Meticulous hemostasis; use of an enucleation snare
Additional anesthesia blocks to supratrochlear and other periorbital nerves
Wrapping implant; meticulous layered closure of Tenon’s capsule; overalp extraocular muscles insertions at
anterior face of implant
20 mm diameter or greater implant in most patients; determine proper implant with sizing sphere; augment
volume with secondary orbital implant (Chapter 68)
Preserve as much conjunctiva as possible; avoid tight suturing of Tenon’s capsule and conjunctiva; avoid
cauterization of conjunctiva and Tenon’s capsule; early referral to ocularist for custom conformer placement
in high-risk cases
Caused by inadequate orbital volume; consider implant exchange; placement of orbital volume along floor
with stacked implants; injection of filler; placement of dermis fat graft (Chapter 75)
Maximize orbital volume; adjustment of prosthesis; ptosis repair by external levator advancement (Chapter
11); avoid posterior-approach ptosis repair as this may contract socket
Psychological screening and counseling

Table 73.4 Consumables used during surgery

5-0 Vicryl, PC-1 needle Ethicon #J843G
6-0 Vicryl, TG100-8 needle Ethicon #J544G
6-0 fast-absorbing gut, PC-1 needle Ethicon #1916G
Porous polyethylene implant Stryker Surgical

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 CHAPTER 74
Table 74.1 Indications for surgery
Malignant primary orbital tumors
Malignant eyelid and ocular adnexal tumors with orbital extension
Malignant orbital tumors extending from the cranium or paranasal
sinuses
Malignant intraocular tumors with extrascleral extension
Sino-orbital invasive fungal infections
Orbital metastatic disease or advanced orbital disease as palliative
therapy
INTRODUCTION
Orbital exenteration is an operation that must be reserved for
life-threatening or severely progressive disease that is not ame-
nable to alternative treatment. It is a disfiguring operation that
can extend survival, relieve pain and improve appearance in
certain circumstances but should not be contemplated without
considerable deliberation and extensive discussion with the
patient and family.
Common indications for exenteration include primary orbital
malignancy, orbital extension of adnexal tumors (including skin
cancers and sinus tumors), extrascleral extension of primary
ocular tumors, intractable pain, life-threatening infection, and
extensive ocular surface malignancy. Orbital exenteration can
be surgically tailored in response to the indication with more
extensive orbital tissue removal being desired when surgical
cure is the goal and more limited removal when palliation or
pain control is desired.
Multidisciplinary tumor board involvement is critical in the
management of complex orbital malignancies. Colleagues with
Orbital exenteration
Bobby S. Korn • Don O. Kikkawa
Table 74.2 Preoperative evaluation
Definitive pathologic diagnosis of malignancy
Systemic oncologic workup to include orbitofacial imaging
Neurosensory examination (ophthalmic V1 and maxillary V2)
Lymph node examination
Discussion of expectations of surgery, rehabilitation, psychological
impact
Sinonasal evaluation if extension into sinuses or fungal etiology
expertise in radiation and chemotherapy should be readily
available for consultation as needed during adjunct therapy.
Sometimes radical surgery is not the best option and input
from other services is essential to help manage difficult tumor
cases.
There are different types of exenteration. Total exenteration,
involves removal of all orbital tissue including the eyelids, globe,
orbital soft tissues and periorbita. Adjacent bone and the
sinuses may also be included in the removal. A limited or sub-
total exenteration involves globe removal with the sparing of
some orbital soft tissue, limiting the excision to the anterior
orbit. Either total or subtotal exenteration may be combined
with sparing of the eyelids, which allows for faster healing and
results in less disfigurement.
Reconstruction of the exenterated socket can be accom-
plished in several ways. Secondary intention with granulation
typically takes weeks and involves frequent dressing changes
and prolonged discomfort. Split-thickness skin grafts allow for
more rapid healing of the socket but harvesting of skin must
be from a secondary donor site. If eyelid skin can be preserved,
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the residual skin can be used to line the orbit for the most rapid
healing. A myocutaneous free flap can be used if additional
volume is desired, but this typically precludes use of an exenter-
ation prosthesis and may obscure tumor recurrence. An addi-
tional option includes the use of a vascularized temporalis flap
that is tunneled through the lateral orbital rim and can be used
to support a variety of grafts, including autologous dermis fat.
Provided there is adequate space, good cosmesis can be
achieved with a custom orbital exenteration prosthesis that
includes a globe and non-functioning eyelids. Large frame
glasses can be fitted to help camouflage the prosthetic rim.
Osseointegration with retaining posts can be implanted into the
orbit to facilitate retention of a prosthesis with a difficult-to-fit
orbit. Alternatively a patch can be used.

SURGICAL TECHNIQUE

Figure 74.1 Skin marking Figure 74.2 Infiltration of local anesthetic

The eyelids can be sutured together with 4-0 silk suture if no obvious Local anesthetic consisting of 2% lidocaine with 1 : 100,000 epinephrine
eyelid pathology is present. Three sutures are placed in a horizontal is given around the skin marking (Figure 74.2). A retrobulbar block is not
fashion through the gray line and are tied, keeping the lids closed. These placed as this exenteration is performed for an orbital malignancy. The
sutures are used for traction during removal of the specimen and also to naris is packed with oxymetazoline on neurosurgical cottonoids prior to
keep the globe and conjunctiva intact during removal. In this case, the incision.
patient presented with biopsy proven squamous cell carcinoma that
involved the entire eyelid, precluding the use of an eyelid traction suture
(Figure 74.1). At least 10 mm of normal-appearing tissue is marked
circumferentially around the orbit. For patients with secondary orbital
spread of primary cutaneous malignancy, adequate margins should be
obtained to completely excise the skin component. An ulcerated lesion
present on the patient’s superior brow is removed separately. Following
the primary excision, intraoperative frozen tissue margins are sent for this
squamous cell carcinoma.

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Chapter 74 Orbital exenteration
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 A B

C D

Figures 74.3A–D Skin incision

A #15 blade is used to incise the skin and subcutaneous tissues (Figure 74.3A). The dissection then proceeds along the postorbicularis fascia to the
orbital rim. This dissection is then continued circumferentially to expose the entire aspect of the orbital margin (Figures 74.3B–D). The skin incision is
performed with a #15 blade instead of cutting cautery, as this causes less tissue destruction, particularly when intraoperative margin control is required.
At this point, surgical margins are excised and sent for frozen sections and hemostasis is achieved with bipolar cautery.

531
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C D

Figures 74.4A–D Periosteal incision

Cutting cautery is used to incise the periosteum external to the arcus marginalis (Figures 74.4A and 74.4B). Near the superomedial orbit, the supraorbital
and supratrochlear nerves are severed (Figure 74.4C). Prior to surgery, it is explained that numbness beyond the supraorbital is an expected result of the
surgery. The medial canthal tendon is lysed with cutting cautery (Figure 74.4D). Depending on the location of the infraorbital foramen, it may be possible
to spare the nerve and preserve sensation. If perineural spread of tumor is suspected, the nerve can be excised and sent as a surgical margin.

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Chapter 74 Orbital exenteration
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 A B

Figures 74.5A–C Subperiosteal dissection

A subperiosteal dissection plane is then created inside the orbit using a Freer elevator to dissect along each orbital wall to the orbital apex (Figure
74.5A). Laterally, the canthal attachments are released with the Freer elevator or with cutting cautery. Superomedially, the attachment of the trochlea is
released (Figure 74.5B). The supraorbital nerve is identified and transected. Depending on where the infraorbital nerve enters the orbital floor, it may be
possible to preserve the nerve. The lacrimal sac should be transected and removed from the lacrimal sac fossa (Figure 74.5C). The sac may be sewn
onto itself with a 5-0 Vicryl suture as a “turnover” flap to minimize fistula formation or plugged with fat. The subperiosteal dissection space should now
be continuous surrounding the entire orbit and remain anchored only at the orbital apex.

533
 A B

C D

Figures 74.6A–E Removal of orbital contents

A 4-0 silk traction suture is placed through normal appearing skin and then the orbital contents are lifted anteriorly (Figure 74.6A). A long angled
hemostat can be placed as far posteriorly in the orbital apex as possible for hemostasis. Alternatively, a snare can be placed around the orbital apex and
slowly tightened until the tissues are transected. A long enucleation or curved Mayo scissors is used to transect the tissues at the orbital apex (Figure
74.6B). The orbital contents are then delivered and sent to pathology. A frozen section can be taken from the residual tissue at the orbital apex for
sampling if indicated. The socket is packed with saline soaked gauze for 5 minutes for hemostasis (Figure 74.6C). Bipolar cautery is then used for
hemostasis at the orbital apex (Figure 74.6D). Monopolar cautery should not be used as this may transmit energy to the optic chiasm. The exenterated
socket is then grossly inspected for any residual tumor and to check the integrity of each of the walls (Figure 74.6E).

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Chapter 74 Orbital exenteration
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 A B

C D

E F

Figures 74.7A–F Harvest of split thickness skin graft

A non-hair-bearing donor site is selected on the anterior or inner aspect of the thigh (Figure 74.7A). Local anesthetic consisting of 0.5% lidocaine and
1 : 400,000 epinephrine is liberally infiltrated at the donor site. The skin is then coated generously with mineral oil (Figure 74.7B). The dermatome is set
to 0.3 mm thickness and then with firm and constant pressure, the split thickness skin graft is harvested (Figure 74.7C). Forceps are used to guide the
skin away from the cutting blade during removal. A Xeroform gauze is used to completely cover the donor site and the thigh is wrapped with a Kerlix roll
(Figure 74.7D). The Xeroform gauze is not disturbed and is allowed to fall off on its own. The skin graft is then passed through a 1.5 : 1 ratio mesher to
allow for greater surface area coverage and to allow for drainage of serosanguinous fluid from the orbit (Figures 74.7E and 74.7F).

535
 A B

Figures 74.8A and 74.8B Placement of skin graft

The split thickness skin is then carefully inset into the socket (Figure 74.8A). At the orbital apex, 6-0 Vicryl suture can be used to anchor the graft to soft
tissue remnants at the orbital apex. At the anterior edge, the graft is secured to residual eyelid skin with 5-0 plain gut sutures. Xeroform gauze soaked in
antibiotic ointment is then packed into the orbit and 4-0 silk is used to secure the dressing to the overlying skin (Figure 74.8B). A pressure patch is
applied for 7 days. After the 7 days, the xeroform gauze is removed, and wet to dry dressing changes are initiated. The socket is cleaned with hydrogen
peroxide, dilated 1 : 1 with normal saline. By 3 months, the socket should be fully epithelialized.

RIGHT TOTAL EXENTERATION

Preoperative Postoperative

Figure 74.9 Before and after right orbital exenteration

This 69-year-old female developed metastatic breast carcinoma to the right orbit. The patient’s right eye lost light-perception vision and developed
intractable pain. She elected to undergo palliative right orbital exenteration. After 3 months, the orbit was fitted with a right orbital prosthesis
(Figure 74.9).

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Chapter 74 Orbital exenteration
536
Table 74.3 Complications
Complications
Orbital bleeding
Paranasal sinus fistulas
Nasolacrimal duct fistula
Numbness in V1 and/or V2 distribution
Breakdown of split thickness skin graft
Tumor recurrence
Cerebrospinal fluid leak
Inability to retain prosthetic
Table 74.4 Consumables used during surgery
4-0 silk suture, PC-5 needle
Petrolatum dressing
7-0 Vicryl, TG1408 needle
5-0 plain gut suture, PC-3 needle
Suggestions to reduce risk
Preoperative cessation of anticoagulants; intraoperative use of bipolar cautery; use of bone wax
at orbital apex
Careful preservation of orbital floor and medial wall during subperiosteal dissection; careful
lining of socket with split thickness skin graft
Consider obliteration with fat or muscle; consider suturing lacrimal sac onto itself (turnover flap)
Reassurance that postoperative numbness is expected with resection of these respective nerves
Avoid scratching/mechanical irritation; consider hyperbaric oxygen (balance theoretic risk of
tumor proliferation with high oxygen tension environment)
Careful surgical margin control with intraoperative frozen and permanent sections depending on
type of malignancy; multidisciplinary management with medical and radiation oncology
Careful dissection along orbital roof; close small defects with bone wax; application of
n-butyl-cyanoacrylate; consider neurosurgical consultation for larger defects; consider closure
of socket with vascularized free flap
Consider use of osseointegrated implants to anchor prosthetic
Ethicon #1984G
Kendell – Xeroform
Ethicon #J546G
Ethicon 1915G
537
CHAPTER 75
Orbital implant exchange
with dermis fat graft
Bobby S. Korn
Table 75.1 Indications for surgery
Implant extrusion, not amenable for repair with patch graft
Enophthalmos and superior sulcus deformity from insufficient orbital
volume
Socket contracture
Primary implant in the growing orbit of a child
INTRODUCTION
A healthy anophthalmic socket consists of an intact conjuncti-
val surface with deep fornices that allows for retention of an
ocular prosthesis, symmetric upper and lower eyelid positions,
and a buried orbital implant of sufficient volume. Socket
complications can result from deficiencies of any of these
features.
A detailed history of the events leading up to the anophthal-
mic socket is important. The type of surgery (enucleation vs.
evisceration), implant used, and any intraoperative findings
should be elicited from the patient and the operative report if
available. Enucleation for intraocular tumors may be associated
with irradiation, which can result in socket contraction and/or
ischemia. A phthsical eye resulting from multiple surgeries may
have conjunctival shortening. Trauma and loss of the globe
may be associated with occult orbital fractures and lost
extraocular muscles during surgery. The prosthetic should be
evaluated for size, fit, and surface irregularities. With the pros-
thetic in place, evaluation is directed towards: position of the
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Chapter 75 Orbital implant exchange with dermis fat graft
538
Table 75.2 Preoperative evaluation
History of socket irradiation
Details about enucleation/evisceration; type of implant used
Depth of fornices and presence of socket contraction
Implant motility (suggests extraocular muscle attachment)
upper and lower eyelids, vertical excursion of the eyelids,
volume of the superior sulcus, presence of lower eyelid malpo-
sitions, and exophthalmometry. After removal of the prosthetic,
the socket should be evaluated for: depth of the fornices,
conjunctival shortening/symblepharon, signs of breakdown of
the conjunctiva/exposure of the orbital implant, and signs of
infection or inflammation of the conjunctival surface.
Implant extrusion can be a consequence of multiple factors
including: insufficient coverage of the implant with Tenon’s
capsule, placement of too large an orbital implant, implant
infection, a poorly fitting prosthetic causing pressure necrosis
of the conjunctival surface, after placement of a peg for
improved motility, and a complication related to the type of
orbital implant used. Medical management consists of antibi-
otic therapy, but implant extrusion is managed definitively with
surgery. Small and early extrusions can be managed with a
patch graft over the exposed implant with autologous tempo-
ralis fascia or donor sclera, provided sufficient conjunctiva is
present to completely cover the exposure. The success rate of
patch grafts is variable and depends on several factors includ-
ing: size of the defect, degree of microbial contamination of the
implant, and viability of the conjunctiva. For larger and late
extrusions with possible infection of the implant, our preference
is to remove the infected orbital foreign body implant and
replacement with an autologous dermis fat graft.
A dermis fat graft has many advantages including that it:
is an autologous tissue with no risk of extrusion, provides
surface area for contracted sockets, and can grow in the
developing child. The main disadvantages are: donor site
morbidity and the variable rate of absorption of the fat
component.

SURGICAL TECHNIQUE

A B

Figures 75.1A–C Anterior dissection of orbital implant

This patient presents with mucoid discharge and pain from the left socket. He previously underwent enucleation for a traumatically ruptured globe.
External examination shows a porous polyethylene implant exposed at the anterior surface (Figure 75.1A). The patient elected to undergo implant
exchange with a dermis fat graft. Local anesthetic consisting of 1% lidocaine and 1 : 100,000 epinephrine is given in the sub-Tenon’s plane along the
surface of the implant for analgesia and vasoconstriction (Figure 75.1B). A wire-eyelid speculum is placed and then Westcott scissors are used to dissect
Tenon’s capsule from the anterior aspect of the implant using a combination of sharp and blunt dissection (Figure 75.1C).

539
 A B

C D

Figures 75.2A–D Imbrication of extraocular muscles

Identification and attachment of the extraocular muscles to the edge of the dermis fat graft will impart limited motility as well as providing additional
blood supply to the graft. Depending on the prior surgery, the muscles may not be anchored to the implant in their physiologic location but every attempt
should be made to locate them to improve the outcome of the dermis fat grafting. A muscle hook is used to sweep along the implant at the respective
rectus muscle site and, once captured, the muscle is imbricated with a double-locking 6-0 Vicryl whip stitch (Figures 75.2A–D). Once each rectus
muscle has been imbricated, the muscle is disinserted from its attachment to the implant with sharp dissection. The superior and inferior oblique
muscles may also be anchored to the implant but our preference is to disinsert these and leave them unattached. The sutures are each tagged with a
bulldog clamp for later attachment.

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Chapter 75 Orbital implant exchange with dermis fat graft
540
 A B

C D

Figures 75.3A–D Removal of exposed orbital implant

After imbrication of the extraocular muscles, the exposed implant is ready for removal. A 4-0 silk suture is passed through the anterior face of the
implant and this is used for traction (Figure 75.3A). If necessary, a small 1–2 mm relaxing incision can be made horizontally through conjunctiva and
Tenon’s capsule to facilitate implant removal. The sharp end of a Freer elevator is then used to dissect adherent orbital tissues to the implant (Figure
75.3B). Curved tenotomy scissors are used to cut all residual attachments to the most posterior aspect of the implant (Figure 75.3C). Care should be
taken to minimize removal of orbital tissues as this will lead to unnecessary volume loss in the socket. A smooth pseudocapsule often remains,
particularly with non-porous implants such as polymethylmethacrylate or silicone, and this is removed to facilitate fibrovascular ingrowth into the fat graft.
Upon removal of the implant, saline-soaked gauze is firmly packed in the orbit for at least 5 minutes to achieve hemostasis (Figure 75.3D). The implant
is inspected and cultures may be obtained if indicated and the implant is sent to pathology for gross examination.

541
 A B

C D

Figures 75.4A–D Attachment of extraocular muscles to fornix

Each of the tagged extraocular muscles is attached to Tenon’s capsule at the anterior border of the conjunctiva (Figures 75.4A–D). The dermis fat graft
will also be secured to Tenon’s capsule, putting the muscles in approximation with the graft to further improve vascular ingrowth and retention.
Alternatively, the muscles can be directly secured to the dermis fat graft after implantation.

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Chapter 75 Orbital implant exchange with dermis fat graft
542
 A B

C D

E F

Figures 75.5A–F Placement of secondary orbital implant

Multiple secondary implant options exist but in the case of an exposed implant with possible microbial seeding, use of an autologous graft such as
dermis fat theoretically has a lower chance of infection and rejection compared to an alloplastic implant. For details of harvesting the dermis fat graft,
please refer to Chapter 35. The graft should be stripped of the epithelial layer and oversized initially prior to implantation (Figure 75.5A). The graft is
anchored to Tenon’s capsule using four cardinal 5-0 Vicryl sutures in the medial, superior, inferior, and lateral positions (Figure 75.5B). The anchoring
sutures are placed adjacent to the rectus muscles to provide vascular support and impart motility to the graft (Figure 75.5C). As the cardinal sutures are
placed, the excess fat is debulked to prevent pressure necrosis of the tissue (Figure 75.5D). Additional sutures are placed around the entire graft
circumference (Figure 75.5E). At the conclusion of the dermis graft placement, the tissue should be slightly domed outwards to account for postoperative
tissue contraction (Figure 75.5F). An ocular conformer covered with antibiotic and steroid ointment should be placed at the end of the case to keep the
fornices intact and minimize adherence of the non-epithelialized surface of the graft to the eyelids. A gentle pressure patch is placed as well.

543
 LEFT ORBITAL IMPLANT EXCHANGE WITH DERMIS FAT GRAFT

Preoperative Postoperative

LEFT ORBITAL IMPLANT EXCHANGE WITH DERMIS FAT GRAFT

1 year postoperative visit

Figures 75.6A and 75.6B Before and after left orbital implant exchange with dermis fat graft
This 24-year-old patient required enucleation after developing a blind and painful eye after trauma to the left globe. He underwent placement of a
presumed porous polyethylene orbital implant and presented with 2 weeks of mucoid discharge in the left socket. On examination, the patient was noted
to have an exposed left orbital implant with mucoid discharge at the conjunctival–implant interface (Figure 75.6A, left panel). He underwent removal of
the exposed orbital implant and placement of a dermis fat graft. At 1 year postoperatively his socket remains healthy with minimal loss of orbital volume
(Figure 75.6A, right panel). With a prosthetic in place, there is excellent cosmesis (Figure 75.6B).

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Chapter 75 Orbital implant exchange with dermis fat graft
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Table 75.3 Complications
Complications Suggestions to reduce risk
Socket contracture Careful surgical technique; minimize use of cautery; provide large dermis surface to
maximize surface area; placement of largest possible conformer size at end of surgery
Continued volume deficit May be caused by pressure necrosis of fat graft or, if undersized, insufficient fat volume
– aim for slight doming of the dermis after implantation; consider secondary volume
augmentation with free fat transfer (Chapter 47), permanent filler injection, subperiosteal
placement of enophthalmos wedge (Chapter 68)
Pyogenic granuloma Topical steroid use initially; consider excision if no response to steroids
Anophthalmic ptosis Consider external levator advancement after prosthetic fit has been maximized (Chapter 11)
Lower eyelid ectropion/prosthetic instability Consider lateral tarsal strip or lateral canthoplasty (Chapters 25 and 29)

Table 75.4 Consumables used during surgery

5-0 Vicryl, PC-1 needle Ethicon #J843G
6-0 Vicryl, TG100-8 needle Ethicon #J544G
4-0 silk, PC-5 needle Ethicon #1984G

545
CHAPTER 76
Multidisciplinary management
of orbital varix
Jack Rootman
Table 76.1 Indication for surgery
Removal of a residual and retro-trochlear varix in the anterior orbit
INTRODUCTION
Varices are a challenge surgically since they are thin walled,
may be deflated (making them hard to find) and can be rup-
tured easily during surgery. Rupture can be avoided by
mapping, which is facilitated percutaneously by inflating the
lesion and placing a needle in the varix. Co-localization with CT
scan in the radiology suite has added accurate visualization
intraoperatively to facilitate this process. If this facility is not
available, superficial lesions can be identified and cannulated.
This process is easily aided by intraoperative inflation of the
varix through raising the thoracic pressure in order to identify
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Chapter 76 Multidisciplinary management of orbital varix
546
Table 76.2 Preoperative evaluation
Clinical evaluation with emphasis on identifying the character of
filling (rapid-slow) and deflation of the lesion during and following a
Valsalva maneuver
Diagnostic imaging requires dynamic arterial and Valsalva-
augmented venous multidetector imaging (CT DP–MDCTA)
the lesion for placement of the cannula and for the mapping
and gluing of the varix. Deeper lesions can also be identified
by careful exposure using periodic Valsalva to recognize and
isolate the anterior surface as shown in the following retro-
trochlear varix.
Once cannulated, the lesion can be mapped to define its
limits and to determine the outflow, which can be through
single or multiple vessels. The strategy for gluing is to block the
outflow carefully with the first injection of glue (either Onyx or
N-butyl-cyanoacrylate) and then backfilling the lesion. This may
require multiple injections through the same cannula.
SURGICAL TECHNIQUE

A B

Figures 76.1A and 76.1B Preoperative evaluation

Preoperative imaging is essential for planning orbital varix mapping, gluing, and surgery. In this case, the varix is located posterior to the trochlea, as
shown in Figures 76.1A and 76.1B.

Figure 76.2 Eyelid crease incision

A medial upper eyelid crease approach is utilized for this case: 4-0 silk
sutures are placed through the gray line for traction (Figure 76.2).

A B

Figures 76.3A and 76.3B Dissection in anterior orbit

After the orbital septum is opened, blunt dissection is performed in the anterior orbit. Here, the forceps are retracting the levator aponeurosis while the
preaponeurotic fat and Whitnall’s ligament is identified (Figures 76.3A and 76.3B). Blunt dissection is performed using specially designed orbital
instrumentation.

547
 A B

Figures 76.4A and 76.4B Identification of orbital varix

After meticulous dissection, the anterior aspect of the orbital varix can be seen slightly below Whitnall’s ligament (Figures 76.4A and 76.4B).

A B

Figures 76.5A and 76.5B Cannulation of orbital varix

A 20-gauge catheter is placed directly into the varix and then secured to the overlying skin with adhesive skin tape (Figures 76.5A and 76.5B).

A B

Figures 76.6A and 76.6B Mapping of lesion

Intraoperative fluoroscopy is then used to map the outflow of the lesion (Figure 76.6A). In this case, a single outflow vessel, the superior ophthalmic vein,
is visualized (Figure 76.6B).

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Chapter 76 Multidisciplinary management of orbital varix
548
 A B

Figures 76.7A and 76.7B Preparation of cyanoacrylate

With assistance from the interventional radiologist, cyanoacrylate and Lipiodol are mixed to delay the onset of hardening of the glue (Figure 76.7A). The
mixture is then placed into the IV port for injection (Figure 76.7B).

A B

Figures 76.8A and 76.8B Injection of cyanoacrylate

Fluoroscopy is started again and the glue is slowly injected under direct visualization (Figure 76.8A). Once the varix has filled, injection of the glue is
stopped, preventing flow into the superior ophthalmic vein (SOV, Figure 76.8B). Alternatively, if posterior dissection is undertaken, direct compression of
the SOV can be performed while the glue is injected to minimize undesired glue migration.

549
 A B

Figures 76.9A–C Removal of glued varix

The catheter is severed and the hardened varix is then removed. The superior oblique tendon is isolated with a 4-0 silk suture (Figure 76.9A). Blunt
dissection is then performed around the varix and the complex is removed en-bloc (Figure 76.9B). The base of the varix can be cauterized or a vascular
clip can be placed. Figure 76.9C shows the varix after removal.

Table 76.3 Complications

Complications Suggestions to reduce risk
Penetration through the posterior wall of the varix Retract the needle carefully; map and proceed with gluing
Glue spreading into adjacent tissues Identify and remove after varix has been removed

Table 76.4 Consumables used during surgery

N-butyl cyanoacrylate Trufill, Cordis, Inc.
Lipiodol Guerbet, USA

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