7 Oculofacial Plastic and

Orbital Surgery

2022–2023
BCSC
Basic and Clinical
®

Science Course™

Editorial Committee
Bobby S. Korn, MD, PhD, Chair
Cat N. Burkat, MD
Keith D. Carter, MD
Julian D. Perry, MD
Pete Setabutr, MD
Eric A. Steele, MD
M. Reza Vagefi, MD
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156 ● Oculofacial Plastic and Orbital Surgery

Superficial
temporal
artery

Facial
nerve
trunk

Parotid

Figure 9-5 Facial nerve branching within the parotid gland. (Courtesy of Cat N. Burkat, MD.)

Temporal branch CN VII

Parotid gland Zygomatic branch

CN VII

Posterior auricular nerve Buccal branch

CN VII

Great auricular nerve

Marginal mandibular
External jugular vein
branch CN VII
Cervical branch
CN VII

Figure 9-6 The 5 major branches of the facial nerve, cranial nerve (CN) VII. Note that the
branches progress from deep beneath the parotid gland to more superficial layers as they
cross the zygomatic arch or reach the anterior edge of the SMAS. (Illustration by Christine Gralapp.)
 CHAPTER 9: Facial and Eyelid Anatomy ● 159

Supraorbital a.

Ophthalmic a.
Supratrochlear a.

Internal
carotid a.
Angular a.

Infraorbital a.

Facial a.

Figure 9-9 Arterial danger zones of the face. Shading denotes areas to inject with caution. (Illustra-
tion courtesy of Mark Miller, based on a sketch by Cat N. Burkat, MD.)

Eyelids
The eyelids can be divided into the following 7 structural layers:
• skin and subcutaneous connective tissue
• muscles of protraction
• orbital septum
• orbital fat
• muscles of retraction
• tarsus
• conjunctiva
Figure 9-10 details the anatomy of the eyelids; Activity 9-2 is an online interactive tool
for self-testing knowledge of eyelid anatomy. See also BCSC Section 2, Fundamentals and
Principles of Ophthalmology, for additional discussion and numerous illustrations.
ACTIVITY 9-2 Upper and lower eyelid anatomy.
Illustration modified from Stewart WB. Surgery of the Eyelid, Orbit,
and Lacrimal System. Ophthalmology Monograph 8, vol 2. San Francisco: American
Academy of Ophthalmology; 1994:23, 85. Illustration by Cyndie C. H. Wooley.

Skin and Subcutaneous Connective Tissue

Eyelid skin is the thinnest skin of the body and is unique in having no subcutaneous fat layer.
Because the thin skin of the eyelids is subjected to constant movement with each blink, the
160 ● Oculofacial Plastic and Orbital Surgery

Subcutaneous fat
Orbital fat

Skin Superior transverse ligament

(Whitnall ligament)
Frontalis muscle
Krause glands
Subbrow fat pad
Conjunctival Levator palpebrae
Preorbital orbicularis fornix superioris muscle
muscle

Orbital septum
Superior rectus
Preseptal orbicularis muscle
muscle Superior oblique
Superior tarsal muscle muscle
(Müller muscle) Palpebral
Levator aponeurosis and bulbar
conjunctivae
Peripheral arterial arcade
Wolfring glands
Eyelid crease
Tarsus
Pretarsal orbicularis
muscle
Marginal arcade vessel Palpebral
and bulbar
conjunctivae
Meibomian gland orifices

Conjunctival
Orbicularis oculi muscle fornix

Lower eyelid retractors Inferior rectus

muscle
Orbital septum

Orbital fat
Capsulopalpebral
head
Suborbicularis oculi fat
Inferior oblique muscle

Figure 9-10 Upper and lower eyelid anatomy. (Modified from Stewart WB. Surgery of the Eyelid, Orbit, and
Lacrimal System. Ophthalmology Monograph 8, vol 2. San Francisco: American Academy of Ophthalmology; 1994:23, 85.
Illustration by Cyndie C. H. Wooley.)

laxity that often occurs with age is not surprising. In both the upper and the lower eyelids,
the pretarsal tissues are normally firmly attached to the underlying tissues, whereas the pre-
septal tissues are more loosely attached, creating potential spaces for fluid accumulation.
The contours of the eyelid skin are defined by the eyelid crease and the eyelid fold:
• The upper eyelid crease represents the attachments of the levator aponeurosis to the
pretarsal orbicularis muscle and skin. In the non-Asian eyelid, this site is near or at
the level of the superior tarsal border.
254 ● Oculofacial plastic and Orbital Surgery

A B
Figure 12-22 Bilateral upper eyelid retraction in thyroid eye disease. A, Preoperative appear-
ance. B, Same patient after upper eyelid retractor recession. (Courtesy of Bobby S. Korn, MD, PhD.)

from lower blepharoplasty or TED may resolve spontaneously over time. A variety of
surgical techniques have been developed to correct eyelid retraction that persists or that
poses an immediate threat to the eye. Except in cases of severe exposure keratopathy, sur­
gical intervention is undertaken only after serial measurements have established stability
of the eyelid position. Upper eyelid retraction can be corrected by excision or recession of
the Müller muscle (anterior or posterior approach), recession of the levator aponeurosis
with or without hang­back sutures or other spacer (Fig 12­22), measured myotomy of the
levator muscle, or full­thickness transverse blepharotomy.
If the patient has lateral flare, a small eyelid­splitting lateral tarsorrhaphy combined
with recession of the upper and lower eyelid retractors can improve the upper eyelid con­
tour; however, this technique may limit the patient’s lateral visual field.
As with correction of the upper eyelids, treatment of lower eyelid retraction is directed
by the underlying etiologic factors. Anterior lamellar deficiency (eg, excess skin resection
from blepharoplasty) requires recruitment of vertical skin by means of a midface­lift or ad­
dition of skin with a full­thickness skin graft. Middle lamellar deficiency (eg, posttraumatic
septal scarring) requires scar release and possible placement of a spacer graft. Posterior la-
mellar deficiency from congenital scarring or conjunctival shortage (eg, mucous membrane
pemphigoid) may require a full­thickness mucous membrane graft.
Severe retraction of the lower eyelids, common in patients with TED, may require a
spacer graft between the lower eyelid retractors and the inferior tarsal border. Autogenous
auricular cartilage, hard­palate mucosa, free tarsal grafts, acellular dermal matrix, and der­
mis fat are common spacer materials. It is often necessary to perform some type of hori­
zontal eyelid or lateral canthal tightening or elevation as well. However, because horizontal
tightening of the lower eyelid in a patient with proptosis may exacerbate the eyelid retrac­
tion, use of this technique requires caution.

Facial Paralysis

Paralytic Ectropion
Paralytic ectropion usually follows CN VII paralysis or palsy. Typically, concomitant upper
eyelid lagophthalmos is present secondary to paralytic upper eyelid orbicularis dysfunc­
tion. Poor blinking and eyelid closure lead to chronic ocular surface irritation from cor­
neal exposure, as well as inadequate tear film replenishment and distribution. Chronically
 Chapter 12: periocular Malpositions and Involutional Changes ● 255

Jaeger eyelid
protector

A B C
Figure 12-23 Tarsorrhaphy. A, The eyelid is split 2–3 mm deep. B, Epithelium is carefully re-
moved along the upper and lower eyelid margins; the lash follicles are avoided. C, The raw
surfaces are then joined with absorbable sutures. (Illustration by Mark Miller.)

stimulated reflex tear secretion, atonic eyelids, and lacrimal pump failure account for the
frequent reports of tearing in these patients.
Neurologic evaluation may be needed to determine the cause of the CN VII paralysis.
In cases resulting from stroke or intracranial surgery, clinical evaluation of corneal sensa­
tion is indicated because neurotrophic keratopathy combined with paralytic lagophthalmos
increases the risk of corneal decompensation.
Lubricating drops, viscous tear supplementation, ointments, taping of the temporal half
of the lower eyelid, or moisture chambers can be used. Such measures may be the only treat­
ment necessary, especially for temporary paralysis. In select patients with long­term or
permanent paralysis, tarsorrhaphy, medial or lateral canthoplasty, suspension procedures,
and horizontal tightening procedures are useful.
Tarsorrhaphy can be performed either medially or laterally. An adequate temporary tar­
sorrhaphy (1–3 weeks) can be achieved with placement of nonabsorbable sutures between
the upper and lower eyelid margins. A “temporary tarsorrhaphy” can also be created by
injection of botulinum toxin into the levator muscle. Permanent tarsorrhaphy involves de­
epithelialization of the upper and lower eyelid margins, avoiding the lash follicles. Absorb­
able or nonabsorbable sutures are then placed to unite the raw surfaces of the upper and
lower eyelids (Fig 12­23).
Occasionally, a fascia lata or silicone suspension sling of the lower eyelid may be indi­
cated. Vertical elevation of the lower eyelid is useful in reducing exposure of the inferior
cornea. This elevation may be accomplished through recession of the lower eyelid retrac­
tors, combined with use of a spacer graft. Surgical midface elevation can also play an
important role in lower eyelid support.

Upper Eyelid Paralysis

Upper eyelid loading remains the most commonly performed procedure for the treatment
of paralytic lagophthalmos. The appropriate weight can be selected through a process of
preoperatively taping eyelid weights of different sizes to the upper eyelid skin to determine