Oculoplastic Surgery

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Oculoplastic Surgery
The Essentials
William P. Chen, M.D., F.A.C.S.

Associate Clinical Professor
Department of Ophthalmology
UCLA School of Medicine
Los Angeles, CA;
Senior Attending Surgeon

Ophthalmic Plastic Surgery Service
Harbor-UCLA Medical Center
Torrance, CA;
Associate Clinical Professor

University of California
Irvine College of Medicine
Irvine, CA
2001
Thieme
New York • Stuttgart
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Thieme New York

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Library of Congress Cataloging-in-Publication Data
Chen, William Pai-Dei

Oculoplastic surgery : the essentials / William P. Chen.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-58890-027-4 (hardcover : alk. paper)
1. Ophthalmic plastic surgery. I. Title.
[DNLM: 1. Ophthalmologic Surgical Procedures. 2. Eyelids--surgery. 3. Surgery,
Plastic. WW 168 C518o 2001]
RE87 .C466 2001
617.7'1--dc21
2001027297
Copyright © 2001 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protected
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Printed in the United States of America
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TNY ISBN 1-58890-027-4
GTV ISBN 3-13-127451-4
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Contents
CONTRIBUTORS vii
PREFACE x
1. Ophthalmic Facial Anatomy, Don O. Kikkawa and Sunil N. Vasani ……………………………………… 1
2. Fundamentals of Oculoplastic Surgery, Dipak N. Parmar and Geoffrey E. Rose ………………………… 21
3. Entropion, Jan W. Kronish …………………………………………………………………………………… 41
4. Ectropion, David T. Tse and Ann G. Neff …………………………………………………………………… 55
5. Trichiasis, Jeffrey A. Nerad and Annie Chang ………………………………………………………………… 67
6. Ptosis Management: A Practical Approach, Steven Dresner ……………………………………………… 75
7. Ptosis: Levator Muscle Surgery and Frontalis Suspension, Philip L. Custer …………………………… 89
8. Facial Nerve Paralysis, Steven Dresner ……………………………………………………………………… 101
9. Essential Blepharospasm, John McCann, Stanley Saulny, Robert A. Goldberg, and Richard L. Anderson 111
10. Upper Blepharoplasty and Eyebrow Surgery, Clinton D. McCord ……………………………………… 125
11. Lower Blepharoplasty and Midface Descent, Norman Shorr and Julian D. Perry ……………………… 147
12. Laser Blepharoplasty, Jemshed A. Khan……………………………………………………………………… 165
13. Laser Skin Resurfacing, Jemshed A. Khan …………………………………………………………………… 179
14. Laser Facial Resurfacing: Dual Mode, Cary E. Feibleman ………………………………………………… 195
15. Asian Blepharoplasty, William Chen ………………………………………………………………………… 211
16. Periocular Skin Lesions and Common Eyelid Tumors, Gloria M. Bertucci ……………………………… 225
17. Full-Thickness Eyelid Reconstruction, Ralph E. Wesley, Kimberly A. Klippenstein, Samuel A. Gallo, and
Brian S. Biesman …………………………………………………………………………………………… 243
18. Lacrimal System, Marc J. Hirschbein and George O. Stasior………………………………………………… 263
19. Thyroid Ophthalmopathy: Eyelid Retraction, J. Justin Older …………………………………………… 289
20. Thyroid Opthalmopathy: Restrictive Myopathy, Sherwin J. Isenberg …………………………………… 297
21. Thyroid Ophthalmopathy: Compressive Optic Neuropathy, Clinton D. McCord ……………………… 305
v
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vi • CONTENTS
22. Thyroid Ophthalmopathy: Orbital Decompression for Aesthetic Indications, Mark A. Codner ……… 315
23. Enucleation, William Chen …………………………………………………………………………………… 327
24. Evisceration, William Chen …………………………………………………………………………………… 347
25. Exenteration, William Chen…………………………………………………………………………………… 355
26. Anophthalmic Socket, Richard A. Burgett and William R. Nunery ………………………………………… 369
27. Orbital Diseases, Joseph A. Mauriello Jr. …………………………………………………………………… 387
28. Orbital Surgery, John Shore…………………………………………………………………………………… 419
29. Craniofacial and Neurosurgical Approaches to the Orbit, M. Douglas Gossman, Dale M. Roberts,
and George Raque …………………………………………………………………………………………… 451
30. Management of Orbital Injuries, Stuart R. Seiff …………………………………………………………… 475
Index ………………………………………………………………………………………………………………… 490

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Contributors
Richard L. Anderson M.D. Samuel A. Gallo, M.D.

Salt Lake City, UT Department of Ophthalmology
University of Tennessee Health Sciences Center
Gloria M. Bertucci, M.D.
Memphis, TN
Associate Pathologist
Department of Pathology Robert A. Goldberg, M.D.
Long Beach Memorial Medical Center Associate Professor of Ophthalmology
Long Beach, CA Department of Ophthalmology
Brian S. Biesman, M.D. Jules Stein Eye Institute
Director of Laser Research University of California
Center for Eyelid and Aesthetic Surgery Los Angeles, CA
Nashville, TN
M. Douglas Gossman, M.D.
Richard A. Burgett, M.D. Associate Professor
Assistant Professor Department of Ophthalmology and Visual Sciences
Department of Ophthalmology University of Louisville
Indiana University Louisville, KY
Indianapolis, IN
Marc J. Hirschbein, M.D.
Annie Chang, M.D. Clinical Instructor
Eye Surgery Center of Colorado Wilmer Eye Institute
North Denver, CO
Mark A. Codner, M.D. The John Hopkins University
Clinical Assistant Professor Sinai Hospital of Baltimore
Department of Plastic Surgery Baltimore, MD
Emory University
Atlanta, GA Sherwin J. Isenberg, M.D.
Professor of Ophthalmology and Pediatrics
Philip L. Custer, M.D. Vice Chairman
Professor Department of Ophthalmology
Department of Ophthalmology and Visual Sciences Jules Stein Eye Institute
Washington University School of Medicine University of California
St. Louis, MO Los Angeles, CA
Steven Dresner, M.D. Jemshed A. Khan, M.D.
Assistant Clinical Professor
Clinical Professor
Doheny Eye Institute
University of Southern California
Los Angeles, CA Kansas University School of Medicine
Kansas City, KS
Cary E. Feibleman, M.D.
Assistant Clinical Professor of Dermatology, Emeritus Don O. Kikkawa, M.D.
Department of Medicine Associate Professor
Division of Dermatology Department of Ophthalmology
University of California at Los Angeles Medical School UCSD School of Medicine
Long Beach, CA La Jolla, CA
vii
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viii • CONTRIBUTORS
Kimberly A. Klippenstein, M.D. Dipak N. Parmar, B.Sc(Hons.), M.B.B.S.,

Assistant Clinical Professor of Ophthalmology F.R.C.Ophth.
Vanderbilt Medical Center Specialist Registrar in Ophthalmology
Nashville, TN Adnexal Department
Moorfields Eye Hospital
Jan W. Kronish, M.D. London, UK
Clinical Associate Professor
Department of Ophthalmology Julian D. Perry, M.D.
Bascom Palmer Eye Institute Department of Ophthalmic Plastic and Orbital Surgery
University of Miami School of Medicine Cole Eye Institute
Delray Eye Associates Cleveland Clinic
Delray Beach, FL Cleveland, OH
Joseph A. Mauriello, Jr., M.D. George Raque, M.D.

Clinical Associate Professor Associate Professor and Vice Chair
Department of Ophthalmology Department of Neurosurgery
University of Medicine and Dentistry—New Jersey University of Louisville
Medical School Louisville, KY
Summit, NJ Dale M. Roberts, M.D.
John McCann, M.D., Ph.D. Clinical Associate Professor
Assistant Professor Department of Plastic Surgery
Department of Ophthalmology University of Louisville
Louisville, KY
Jules Stein Eye Institute
University of California Geoffrey E. Rose, M.D., M.R.C.P., F.R.C.Ophth.
Los Angeles, CA Consultant Ophthalmic Surgeon
Orbital and Adnexal Department
Clinton D. McCord, M.S., M.D.
Moorfields Eye Hospital
Paces Plastic Surgery
London, UK
Atlanta, GA
Stanley Saulny, M.D.
Ann G. Neff, M.D.
Resident Physician
Assistant Professor
Department of Ophthalmology Jules Stein Eye Institute
University of Miami University of California
Bascom Palmer Eye Institute Los Angeles, CA
Miami, FL
Stuart R. Seiff, M.D., F.A.C.S.
Jeffrey A. Nerad, M.D. Professor of Ophthalmology
Professor Director of Ophthalmic Plastic and Reconstructive
Department of Ophthalmology Surgery
University of Iowa University of California San Francisco, and
Iowa City, IA Chief, Department of Ophthalmology
San Francisco General Hospital
William R. Nunery, M.D.
San Francisco, CA
Clinical Associate Professor
Department of Ophthalmology John Shore, M.D.
Indiana University, Texas Oculoplastic Consultants
Midwest Eye Institute Austin, TX
Indianapolis, IN
Norman Shorr, M.D., F.A.C.S.
J. Justin Older, M.D. Clinical Professor of Ophthalmology,
Clinical Professor Director, Fellowship in Orbital Facial Plastic Surgery
Department of Ophthalmology Jules Stein Eye Institute
University of South Florida College of Medicine University of California at Los Angeles
Tampa, FL Los Angeles, CA
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CONTRIBUTORS • ix
George O. Stasior, M.D., F.A.C.S. Sunil N. Vasani, M.D.

Clinical Professor Clinical Instructor
Department of Ophthalmology Department of Ophthalmology
Albany Medical College UCSD School of Medicine
Albany, NY La Jolla, CA
David T. Tse, M.D. Ralph E. Wesley, M.D.

Professor Clinical Professor of Ophthalmology
Department of Ophthalmology Vanderbilt University Medical College
University of Miami Nashville, TN, and
Bascom Palmer Eye Institute Clinical Professor of Ophthalmology
Miami, FL University of Tennessee Health Sciences Center
Memphis, TN
FM. 3/22/01 2:47 PM Page x
Preface
When I was approached three years ago regarding the feasibility of a book project on the
essentials of oculoplastic surgery, my thoughts were that there should be a better way to
present the modern concepts of this field in a succinct fashion. There are a few excellent
oculoplastic surgery books on the market, but the majority of them still present the ideas
with a lengthy and often traditional approach. My aim for this book was to solicit the best
group of authors who are excellent clinicians as well as teachers in the academic field,
and ask them to write about a special topic in their field of expertise.
To achieve this ambitious goal, I planned to design and orchestrate the flow of the
content so that it would be highly readable and clinically practical, supplemented with
clear illustrations as well as line drawings. The illustrations would include color images,
black and white photos, digital images, line drawings, and algorithms. We would add
“Pearls”, “Pitfalls”, and “Recommendations” to the text, as well as summaries of clinical
thought processes in the form of decision trees, or “Clinical Pathways”. The bibliography
of each chapter would be relevant and not encyclopedic. All this would make each indi-
vidual chapter and its content informative and practical; the book would serve as an excel-
lent teaching textbook, as well as provide updates on the most recent concepts of
oculoplastic surgery.
The aim was for our target audience to include comprehensive ophthalmologists
and resident physicians-in-training, as well as subspecialty-trained practitioners inter-
ested in a succinct update on the field of oculoplastic surgery. This latter group would
include head-and-neck surgeons, plastic surgeons, neurosurgeons, dermatologists, and
eye-care professionals.
In terms of the breadth of topics covered, traditional texts tend to concentrate on
reconstructive aspects of oculoplastic surgery. Some specialized textbooks concentrate
separately, and perhaps predominantly, on aesthetic surgery, while others concentrate
on orbital diseases and surgery. I have elected to cover fundamental aspects of oculo-
plastic surgery in a thorough fashion in the first nine chapters of this book, (entropion,
ectropion, trichiasis, ptosis, facial nerve paralysis, and blepharospasm). With the increas-
ing popularity and interest in aesthetic surgery, I have allocated six chapters to upper
and lower blepharoplasty, surgery of the eyebrows, the field of laser eyelid surgery and
facial resurfacing, as well as blepharoplasty methods unique for Asian patients. There is
a rich source of information in these chapters unavailable anywhere in a single text source.
The second half of the book has three chapters that deal with common eyelid lesions,
the entire spectrum of full-thickness eyelid reconstruction, and the important topic of the
lacrimal system and disorders. There are four chapters that deal with the problems asso-
ciated with thyroid ophthalmopathy, including eyelid retraction, post-inflammatory
restrictive myopathy, and orbital decompression for sight-threatening as well as aesthetic
indications.
The last seven chapters discuss pathology and trauma of the orbit, as well as surgi-
cal approaches. They include treatment of the anophthalmic socket and a comprehensive
chapter on orbital diseases, orbital surgery, orbital injuries, and the combined disciplines
of craniofacial and neurosurgical approaches to the orbit. The three chapters on enucle-
ation, evisceration, and exenteration provide the most up-to-date information on recon-
structive techniques and presently available implant materials, as well as information on
comparative costs and motility results. In essence, the book provides a concentrated
x
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PREFACE • xi
collection of information available from the three major fields of general oculoplastic
surgery, aesthetic oculoplastic surgery, and orbital diseases and surgery.
I am very pleased to say that we have achieved our goals for this project, drawing on
the expertise of 38 distinguished colleagues in the fields of oculoplastic surgery, orbital
surgery, plastic surgery, and other disciplines including neurosurgery, dermatology, and
pathology. Many of the authors are members of the American Society of Ophthalmic
Plastic and Reconstructive Surgery, most of whom are actively engaged in university
teaching programs, with nine of the contributors serving as Fellowship Preceptors
(Mentors) for accredited fellowship programs of the American Society of Ophthalmic
Plastic and Reconstructive Surgery.
I thank all of the contributing authors for making this project possible. I would not
have been able to complete this project without the help of every one of them, and for this
I am most grateful. On the personal side, I thank my wife Lydia, my children Katherine
and Andrew, and my mother Katie for being supportive and tolerant of my efforts.
Equally important, I thank the highly professional staff at Thieme Medical Publish-
ers for making this project possible: Andrea Seils for kindling my interest in the project;
Brian Scanlan (President, New York) for supervising the project; Owen Zurhellen,
Michelle Carini, and Thomas Soper (Editorial Assistants) for their tireless efforts and help-
ful suggestions; Esther Gumpert (Consulting Medical Editor) for helping me stay cen-
tered; and Anne Vinnicombe (Director of Production and Manufacturing), Felicity Edge
(Development Editor), and Chris Gauss for their editorial skills, as well as keeping me
informed at all stages. I am grateful to Linda Warren, Director of Medical Illustrations
and Audiovisual Education at Baylor College of Medicine in Houston, Texas, for her artis-
tic talents and uncompromising punctuality in completing the often-arduous assignments
I gave her. Lastly, I thank the library staff, including Emi Wong, at the Long Beach Memo-
rial Medical Center of Long Beach, California, for their assistance in all my article
retrievals and research needs over the period I worked on this project.
William P. Chen, M.D., F.A.C.S.

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I wish to express my gratitude to Dr. Sonny McCord for teaching me oculoplastic surgery.
CHEN01-001-020.I 3/26/01 8:22 AM Page 1
Chapter 1
OPHTHALMIC FACIAL ANATOMY

Don O. Kikkawa and Sunil N. Vasani
The expanding realm of the plastic and reconstructive the vertical plane and in the lower eyebrow, they are
ophthalmic facial surgeon demands an intimate directed upward from the vertical plane.3 Medially,
understanding of eyelid, lacrimal, orbital, and facial all cilia are directed superiorly. Brow incisions should
anatomy. With improvements in technique and instru- be planned accordingly to preserve cilia. With aging,
mentation, traditional surgical boundaries are now repeated frontalis muscle contraction creates deep
being surpassed. Hence, as always, the surgeon of the horizontal furrows in the forehead. Vertical glabellar
21st century must have a strong foundation in clinical furrows, medial to the eyebrow, result from repeated
and surgical anatomy to perform successful surgery. corrugator muscle contraction, while horizontal
glabellar furrows result from the procerus.
The adult palpebral fissures measure 9 to 11 mm
OPHTHALMIC FACIAL SURFACE vertically and 28 to 30 mm horizontally. Ideally, the
ANATOMY two medial canthi are separated by one horizontal
palpebral width. The upper eyelid is positioned at the
Facial Dimensions upper limbus and may cover 1 to 2 mm of the cornea.
The face has ideal aesthetic proportions. Artists have The highest point of the upper lid margin is just nasal
long recognized the visually pleasing ratios of the spe- to the central pupillary axis (Fig. 1–1). The upper eye-
cific vertical and horizontal facial dimensions. The lid crease is formed by the terminal interdigitations of
ideal facial dimensions are five eye widths wide and the levator aponeurosis along the superior tarsal bor-
eight eye widths high.1 The ideal face also has a der.4 Typically, the eyelid crease measures 10 to 12 mm
slightly oval shape. in women and 7 to 8 mm in men. Asians have a low or
Overall facial dimensions and proportions are crit- ill-defined eyelid crease because of the low insertion
ical in aesthetic and reconstructive surgery. The eyes of the orbital septum on the levator aponeurosis.5
and corresponding areas of the upper and midface The lower eyelid normally rests at the inferior lim-
represent key aesthetic units that must be visualized bus and its lowest point is just lateral to the pupil. The
in the context of overall facial features. lower eyelid crease is formed from cutaneous inser-
tions of the lower eyelid retractors. The retractors con-
Topography and Cutaneous Landmarks sists of the capsulopalpebral fascia and the inferior
The eyebrows are a foundation for the eyelids. They tarsal muscle. It begins medially 4 to 5 mm below the
typically arch above the supraorbital rim and their eyelid margin and slopes inferiorly as it continues lat-
lower border should lie 1 cm above the lateral portion erally. The malar and nasojugal folds represent the
of the orbital rim, with its highest point directly above cutaneous insertion of the orbitomalar ligament.6 Hor-
the lateral limbus.2 Eyebrow cilia are directed at dif- izontal skin folds (laugh lines) that emanate from the
ferent angles in the upper and lower eyebrow. In the lateral canthal angle result from skin folding due to
upper eyebrow, the cilia are directed downward from orbicularis oculi. With aging as well as thinning of
1
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2 • OCULOPLASTIC SURGERY: THE ESSENTIALS
Supratarsal
sulcus Superior
lid crease
Punctum
Superior eyelid
skinfold
Medial Lateral
commissure commissure
Inferior
lid crease
Punctum
Malar fold
Nasojugal
fold
Nasolabial fold
FIGURE 1–1 Normal eyelid topography.
dermis, these laugh lines become static and rhytids fascia.8, 9 Eyebrow fat can be mistakenly identified as
develop (“crow’s feet”). The lateral canthal angle is orbital fat and can be debulked in certain patients with
normally 2 mm higher than the medial canthal angle, prominent eyebrow bulk. Submuscular fat in the eye-
giving the eyelids a slight upward flare. brow region (ROOF) is continuous with suborbicularis
Surface marking of the nasolacrimal duct is seen by a oculi fat (SOOF) of the lower lid.
line joining the medial canthal angle of the eye to the
canine tooth (eye tooth) on the same side. The upper and
...
lower puncta are located in each eyelid 5 to 7 mm lat-
eral to the medial canthal angle. The lower puncta is
usually located 1 to 2 mm lateral to the upper punctum.
P EARL The surgeon dissecting in
region of the eyebrow fat must pay careful
attention to the presence of the supraorbital
nerve and vessels.10
The Eyebrow
The eyebrows form a key landmark of the upper
facial continuum. The skin of the eyebrows represents The Eyelids
a transition zone between the thinner skin of the eye- Eyelid skin is among the thinnest of the body and is
lids and the thicker skin of the forehead and scalp. useful for hiding cutaneous incisions. Eyelid skin
Evaluation of eyebrow position is critical in the plan- is nearly devoid of subcutaneous fat. Eyelid develop-
ning of surgery of the eyelids. ment occurs through a complex inductive interaction
The position of the eyebrows represents a dynamic between mesoderm and ectoderm (Fig. 1–2). Eyelid
interplay between elevating and depressing forces. The anomalies occur secondary to arrests in various stages
two forces are the elevators (frontalis) and the depres- of this process.
sors (orbicularis oculi, corrugator, and procerus). A One of the key surgical landmarks of the eyelids is
submuscular fat pad exists under the interdigitation of the orbital septum. The orbital septum defines the
the frontalis and orbicularis muscles.7 Termed the eye- anterior extent of the orbit and the posterior extent of
brow fat pad or retroorbicularis oculi fat pad (ROOF), the eyelids. It arises from the arcus marginalis, a white
it continues into the eyelid as the posterior orbicularis fibrous line that arises circumferentially along the
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OPHTHALMIC FACIAL ANATOMY • 3
Complex Inductive Interaction

of Eyelid Development
Mesoderm Ectoderm
Frontonasal Maxillary
Skin Conjunctiva
process process
Non-fusion Fusion
Between
[medial and
Colobomas lateral processes]
Upper Lower
eyelids eyelids
Separation
at 5 months
Failure or Normal
incomplete separation eyelids
Ankyloblepharon
FIGURE 1–2 Eyelid development.
periosteum of the bony orbital margin. In the upper plates and reflects onto the bulbar surface of the globe.
lid, the orbital septum fuses with the levator aponeu- The medial and lateral canthal ligaments anchor
rosis11 at or up to 10 mm from the superior tarsal bor- the eyelids horizontally to the orbital rims. The medial
der, and in the lower eyelid it fuses with the lower canthal ligament inserts on both the anterior and pos-
eyelid retractors just inferior to the tarsus. The orbito- terior lacrimal crests.14 The medial canthal ligament is
malar ligament emanates from the arcus marginalis associated with Horner’s muscle (the deep head of the
of the inferior orbital rim, traversing through the pretarsal and preseptal orbicularis muscle) with both
orbicularis oculi to insert into the dermis of the lower of them inserting on the posterior lacrimal crest.
lid. 12 This cutaneous insertion corresponds to the Lacrimal excretory pump function is dependent on
malar and nasojugal skinfolds. With aging, the orbit- the contraction of Horner’s muscle, which draws the
omalar ligament elongates and the orbital septum eyelids medially and posteriorly. The lateral canthal
attenuates, allowing orbital fat to move anterior and ligament inserts on Whitnall’s tubercle.
sometimes herniate below the inferior orbital rim. The tarsoligamentous band normally provides the
horizontal tension to keep the eyelids opposed to the
globe. Horizontal laxity that occurs with aging leads
EARL... Surgically, the orbital sep-
P tum may be identified by a traction test
to feel its firm attachments to the orbital rim.
to eyelid malposition. With globe protrusion from
exophthalmos a compensatory lengthening may
occur, reducing eyelid retraction.15
The main eyelid protractor is the orbicularis oculi
muscle. It forms part of the superficial muscu-
The backbone of each eyelid, the tarsus, is composed loaponeurotic system (SMAS). The orbicularis oculi is
of dense fibrous tissue and houses the meibomian divided into three parts: pretarsal, preseptal, and
glands. The tarsus measures 10 to 12 mm vertically in orbital.16 The muscle of Riolan is a small portion of the
the upper lid and close to 4 mm in the lower eyelid.13 pretarsal orbicularis that corresponds anatomically to
Conjunctiva firmly lines the inner aspect of the tarsal the gray line.17
CHEN01-001-020.I 3/22/01 1:20 PM Page 4
Superficial galea
Deep galea
Anterior and posterior
deep galea
Sub-brow fat pad (ROOF)
Frontalis muscle
Preaponeurotic fat
Orbital septum
Preseptal fat (ROOF)
Orbicularis oculi muscle
Müller’s muscle
Levator aponeurosis
Superior tarsus
Conjunctiva
Inferior tarsus
Inferior tarsal muscle
Capsulopalpebral
fascia (CPF)
Orbital septum
Orbital fat
Inferior oblique Orbicularis muscle

muscle Malar fat pad
FIGURE 1–3 Eyebrow and eyelid Suborbicularis oculi
anatomy (cross section). fat (SOOF)
The levator palpebrae superioris (Fig. 1–3) is one Müller’s muscle arises from beneath the levator
of the retractors of the upper eyelid. It is tendinous in palpebrae superioris, 15 mm from the upper tarsal
its distal 14 to 20 mm and the transition from muscu- border. It consists of smooth muscle and is firmly
lar to aponeurotic portions occurs at Whitnall’s liga- adherent to the conjunctiva. Müller’s muscle is inner-
ment. The aponeurosis inserts onto the anterior tarsal vated by the sympathetic nervous system and inserts
surface via an elastic fiber attachment,18 and interdig- on the superior tarsal border. It provides the upper
itates into the orbicularis muscle fibers and dermis, lid an additional 2 mm of lift. Recent studies have
creating the upper eyelid crease. Medially and later- shown that Müller’s muscle extends laterally between
ally the horns of the levator anchor to periosteum the orbital and palpebral lobes of the lacrimal gland
with the lateral horn of the levator dividing the along with the lateral horn of the levator. Hence it
lacrimal gland into orbital and palpebral lobes. may accentuate the lateral flare of the palpebral fis-
With advancing age, the levator rarefies and may sure frequently seen in eyelid retraction associated
disinsert from the tarsal attachments leading to ptosis.19 with thyroid eye disease.21
The lower eyelid retractors depress the lower eye-
lid in downgaze. They consist of the capsulopalpebral
EARL ... Medial dehiscence of the
P levator can lead to horizontal instability
that may create difficulty in adequately elevat-
fascia and the inferior tarsal muscle.20 The capsu-
lopalpebral fascia arises from the inferior rectus and
inferior oblique muscles. The inferior tarsal muscle
consists of smooth muscle. The lower eyelid retrac-
ing the upper eyelid during ptosis surgery.
tors are commonly incised during the transconjunc-
Another manifestation is the lateral shifting of tival surgical approach, but this leads to a relatively
the tarsal plate. low incidence of postoperative eyelid malposition
(Fig. 1–4).
CHEN01-001-020.I 3/22/01 1:20 PM Page 5
The Midface
The midface extends from an imaginary line between
the medial and lateral canthi to the mouth. Medially,
the maxilla and laterally the zygoma form most of the
bony skeleton of the midface. Prominent bony land-
marks include the infraorbital foramen, which lies
several millimeters inferior to the inferior orbital rim,
and, laterally, the zygomaticofacial foramen.
The muscles of the face that contribute to facial
expressions are called the mimetic muscles (Fig. 1–5).
Most of these muscles originate from the midfacial
region. The levator labii superioris alacque nasi mus-
cle originates on the frontal part of the maxilla and
FIGURE 1–4 Clinical photo of transconjunctival dissection inserts on the alar cartilage and the upper lip. It
of lower eyelid. Note forceps pointing to lower lid retractors. dilates the nostril, raises the upper lip, and deepens
the nasolabial fold. The levator labii superioris muscle
arises just superior to the infraorbital foramen and
PITFALL overlies the infraorbital vessels and nerve to insert in
the upper lip. Its main action is to raise the upper lip.
Disinsertion of the lower lid retractors leads to The levator anguli oris muscle arises inferior to the
vertical lower lid instability and is part of the infraorbital foramen and inserts into the angle of
the mouth. It causes the expression of contempt and
pathophysiology of both involutional ectropion
deepens the nasolabial fold. The zygomaticus major
and entropion. Clinically, this may be seen by
and minor clinically appear as one complex. They
decreased excursion of the lower lid and a arise from the zygoma close to the zygomaticomaxil-
white horizontal line in the inferior fornix. lary suture and draw the mouth upward and out-
ward, for example in smiling.
Frontalis muscle
Supraorbital
artery and nerve
Supratrochlear
nerve
Temporal branch
of facial nerve
Zygomatic branches Infraorbital nerve
of facial nerve
Levator labii superioris
Zygomaticus minor muscle
Buccal branches
of facial nerve Zygomaticus major muscle
Mandibular branch
of facial nerve
Cervical branch
of facial nerve
FIGURE 1–5 Muscles of facial expression and branches of facial nerve.

CHEN01-001-020.I 3/22/01 1:21 PM Page 6
SMAS AND SOOF artery. The superficial temporal artery lies superficial
to the muscle plane of the temporalis muscle.
Mitz and Peyronie described the SMAS, a distinct fibro- The internal carotid artery contributes to the eyelid
muscular layer that spreads out in a fan-like fashion over blood supply by the terminal branches of the oph-
the face. The SMAS functions to transmit and distribute thalmic, lacrimal, frontal, supraorbital, and nasal
the facial muscle contractions to the skin. The orbicularis arteries. The marginal and peripheral arcades of the
oculi muscle is part of the SMAS and has a distinct bony upper eyelid are formed by anastomosis between
attachment, the orbitomalar ligament.6 With aging, the the lacrimal and nasal arteries. The marginal arcade
midfacial soft tissues become ptotic, resulting in the typ- is located 2 to 3 mm from the upper eyelid margin,
ical biconvex topographic appearance.23 and the peripheral arcade lies along the upper tarsal
Fat located deep to the orbicularis oculi and ante- border near its attachment to Müller’s muscle. Eyelid
rior to the periosteum in the midface has been termed reconstruction with tarsoconjunctival pedicles and
the SOOF.22 Its descent contributes to the formation of tarsal fracture techniques should avoid interruption
“malar bags.” The SOOF varies in thickness from of the arcades if possible. The dual arcade in the lower
medial to lateral, being most prominent in the central eyelid is much less developed.
and lateral positions. In the midface it engulfs the
mimetic muscles and lies superficial to the periosteum.
...
EARL... With proper dissection in
P EARL The location of the super-
ficial temporal artery in the subcutaneous
P the SOOF plane, either subperiosteal or

preperiosteal, the entire midface can be ele-
plane makes this a good landmark during tem-
poral artery biopsy.
vated and mobilized22, 24 (Fig. 1–6).

The orbital and facial veins also anastomose in the
eyelids and midface. The angular, superior oph-
thalmic and supraorbital veins all communicate
NERVES, LYMPHATICS, superomedially in the orbit and hence can propagate
AND VASCULATURE facial infection into the cavernous sinus.
Medially, lymphatic drainage from the eyelids and
Both internal and external carotid arteries supply the
conjunctiva drains into the submandibular nodes
eyelids and midface. The external carotid artery con-
and laterally into the preauricular nodes.
tributes the facial artery, the superficial temporal
The eyelids are innervated by the facial nerve (cra-
artery, and the infraorbital artery. The facial artery
nial nerve VII), the oculomotor nerve (cranial nerve
courses from below the mandible and runs superiorly
III), the trigeminal nerve (cranial nerve V), and sym-
and medially; it terminates as the angular artery in the
pathetic nerves from the superior cervical ganglion.
medial canthal region. The angular artery lies 6 to
Motor innervation of the levator palpebrae superioris
8 mm medial to the medial canthus and 5 mm anterior
and Müller’s muscle, as well as sensory innervation of
to the lacrimal sac. Lacrimal and anterior orbitotomy
the eyelids are discussed in the orbital section, below.
incisions should be planned accordingly to avoid this
After exiting the stylomastoid foramen, the facial
nerve passes through the parotid gland and divides
into the following divisions: temporal, zygomatic,
buccal, mandibular, and cervical. The frontal branch
arises from the temporal division and travels within
the temporoparietal fascia (superficial temporal fas-
cia) to innervate the frontalis muscle.
PITFALL
The frontal branch is one of the most com-

monly injured nerves in surgical dissections of
the temporal region, particularly during fore-
head lifting procedures. Any dissection should
be accomplished beneath the plane of the tem-
FIGURE 1–6 Clinical photo of suborbicularis oculi fat poroparietal fascia to avoid injury to the nerve.
(SOOF) in left lower lid. Suture being passed through SOOF
prior to advancement to orbital rim.
CHEN01-001-020.I 3/22/01 1:21 PM Page 7
The orbicularis oculi is innervated by temporal,

...
zygomatic, and buccal divisions with extensive over-
lap between them. The remainder of the facial
mimetic muscles are innervated by the zygomatic and
P EARL Safe subperiosteal dissec-
tion may be accomplished along the lat-
eral wall and orbital floor for 25 mm and along
buccal divisions.
the medial wall and orbital roof for 30 mm.26
ORBIT
Orbital Margins (Fig. 1–7)
Orbital Shape and Dimensions The orbital margin is an incomplete circle and forms a
The shape of the bony orbit approximates a four- quadrilateral spiral due to the presence of the lacrimal
sided pyramid, which becomes three sided more pos- sac fossa medially. The superior orbital rim is formed
teriorly, due to the absence of the orbital floor in its entirety by the frontal bone. At the junction of the
posteriorly.25 In the adult, the medial walls of the orbit medial one third with the lateral two thirds of the supe-
are 25 mm apart and are parallel until they converge rior rim is the supraorbital notch (in 75% of the popu-
near the orbital apex. The anterior end of the medial lation) or foramen (in 25% of the population). The
wall lies 20 mm in front of the lateral wall. The medial orbital margin is formed by three bones: the
entrance to the orbit is rectangular, measuring 40 mm frontal bone, the posterior lacrimal crest of the lacrimal
horizontally by 32 mm vertically. In adults, the depth bone, and the anterior lacrimal crest of the frontal
from orbital rim to apex varies from 40 to 45 mm. process of the maxillary bone. The inferior orbital rim is
Orbital volume is roughly 30 cc, but varies with race derived from the maxillary bone medially and zygo-
and sex. matic bone laterally. The zygomaticomaxillary suture
Orbit
Margins Walls
Superior Lateral Medial Inferior Superior Lateral Medial Inferior
Frontal Superior Frontal Maxilla Frontal bone Zygoma Anterior maxilla Anterior
bone 1/4th frontal bone medially anteriorly anterior and lacrimal maxilla
+ +
Supra-orbital Inferior 3/4th Lacrimal Zygomatic Lesser wing Greater wing Ethmoid Antero-lateral
notch zygomatic (posterior laterally of sphenoid of sphenoid lamina zygoma
lacrimal crest) posteriorly posterior papyracea
+
Union of Strongest Maxilla Infra-orbital Fronto- Fronto- Posterior Posterior
medial 1/3 and Facial buttress (ant. lacrimal foramen ethmoid zygomatic body of palatine
lateral 2/3 crest) 1 cm inferior suture suture sphenoid
to margin
Sutura notha Upper limit Mark for Posterior Inferior

(lateral aspect for bony superior and anterior orbital
of maxilla) medial wall incision in lateral ethmoid fissure
removal wall removal foramen
Branch of Anterior and

infra-orbital posterior Upper limit Limit for
artery ethmoidal medial wall floor
arteries removal removal
May bleed
during
dacryocystorhinostomy
FIGURE 1–7 Orbital walls and margins.

CHEN01-001-020.I 3/22/01 1:21 PM Page 8
lies at the junction of the medial one third and lateral

...
two thirds of the inferior orbital rim. The infraorbital
foramen is closer to the orbital margin at birth and
grows further away, being 1 cm from the rim in the
P EARL Blunt trauma to the fore-
head can cause indirect traumatic optic
neuropathy due to the transmission of force
adult. The upper one fourth of the lateral orbital rim is
formed by the zygomatic process of the frontal bone along the orbital roof to the optic canal.
and the lower three fourths is formed by the frontal
process of the zygomatic bone. Articulation occurs at
the zygomaticofrontal suture, a site where a palpable Medial Orbital Wall
step is found in cases of fracture. The medial orbital wall is formed by the maxillary,
lacrimal, ethmoid, and sphenoid bones. The main
landmarks of the medial wall are the anterior and
posterior ethmoidal foramina located in a plane just
...
P EARL Along the lateral aspect of
the frontal process of the maxilla, a fine
groove, the sutura notha, can be found.27 This
superior to the medial canthal ligament; they are
20 mm and 35 mm posterior to the anterior lacrimal
crest, respectively. 27 The frontoethmoidal suture
marks the boundary between the roof and the medial
groove lodges a branch of the infraorbital artery,
wall and the upper limit for bone removal during
and is important when performing external orbital decompression. The optic foramen is located
dacryocystorhinostomy in that bleeding may be approximately 50 mm posterior from the anterior
encountered from this site. lacrimal crest.
Orbital Walls PITFALL

Seven bones take part in the formation of the orbit:
the frontal, sphenoid, lacrimal, ethmoid, maxilla, Cerebrospinal fluid (CSF) leaks can occur
zygomatic, and palatine (Fig. 1–8). Of these the sphe- with dissection along the medial wall. The
noid bone is present in three of the orbital walls and anterior cranial fossa is located at an average
contributes some of the most important structures.
of 8.3 mm superior to a point 10 mm poste-
Roof rior to the medial canthal tendon.28
The orbital roof is formed by the orbital plate of the
frontal bone and the lesser wing of the sphenoid
bone posteriorly. The anterior part of the roof is Orbital Floor
3 mm thick anteriorly near the frontal sinus, but it The orbital floor is formed primarily from the maxilla,
thins posteriorly. with contributions from the palatine bone posteriorly
Lesser
sphenoid
Greater sphenoid wing Frontal bone
wing
Palatine bone
Ethmoid
bone
Zygomatic
bone
Lacrimal
bone
Inferior orbital
fissure Nasolacrimal
canal
Infraorbital Orbital
groove plate of
FIGURE 1–8 Right adult human maxillary Maxilla
orbit (anterior lateral view). bone
CHEN01-001-020.I 3/22/01 1:21 PM Page 9
and the zygoma anterolaterally. Along the course of

the orbital floor from posterior to anterior, the
infraorbital nerve becomes intraosseous within
the infraorbital canal and is lined by periorbita.
The thinnest area of the orbital floor occurs pos-
teromedially to the infraorbital nerve. Most blowout
fractures occur here. Dissection along the medial
aspect of the floor can disrupt the origin of the inferior
oblique, located just lateral to the nasolacrimal canal.
PITFALL
The internal maxillary artery lies immediately FIGURE 1–9 Clinical photo showing marrow space of
behind the posterior wall of the maxillary greater wing of sphenoid during orbital decompression.
sinus. Orbital floor dissection posterior to the Lateral orbital rim and wall have been removed.
inferior orbital fissure could damage this
major vessel. Orbital Apex (Fig. 1–10)
Three key orbital apex landmarks—the optic foramen,
the superior orbital fissure, and the inferior orbital fis-
Lateral Wall sure—communicate with the intracranial cavity,
The lateral orbital wall divides the orbit from the tem- pterygopalatine fossa, and paranasal sinuses.
poralis muscle anteriorly and the middle cranial fossa The superior orbital fissure lies between the greater
posteriorly. It is composed of the zygoma and the and lesser wings of the sphenoid. The annulus of Zinn
greater wing of the sphenoid. Landmarks of the lat- divides the fissure into three parts. The trochlear,
eral orbital wall include Whitnall’s lateral orbital frontal, and lacrimal nerves, the superior ophthalmic
tubercle, and the zygomaticotemporal and zygomati- veins, and the recurrent lacrimal artery pass through
cofacial foramina. The posterior boundary of the lat- the upper part. The superior division of the third
eral orbital wall is the superior and inferior orbital nerve, the nasociliary nerve, the sympathetic root of
fissures. Whitnall’s tubercle is located approximately the ciliary ganglion, the inferior division of third
3 to 4 mm behind the orbital rim and 11 mm inferior nerve, and the abducens nerve are in the middle sec-
to the frontozygomatic suture.29 It is an insertion site tion. The inferior part has the ophthalmic veins.
for the lateral canthal ligament, the deep pretarsal The inferior orbital fissure is bounded laterally by
orbicularis insertion, the lateral horn of the levator the greater wing of the sphenoid and medially by the
aponeurosis, the check ligament of the lateral rectus palatine and maxillary bones. The inferior orbital fis-
muscle, the superior (Whitnall’s) and inferior (Lock- sure communicates with both the pterygopalatine and
wood’s) transverse ligaments, and an expansion of infratemporal fossae. Blood from the temporalis fossa
the superior rectus muscle sheath.30 can reach the orbit through this communication. The
During lateral orbitotomy, the zygomaticosphe- maxillary division of the trigeminal nerve, the infra-
noid suture is a natural breaking point for removal of orbital artery, the inferior orbital vein, and autonomic
the lateral rim. If further removal of bone is desired, branches from the pterygopalatine ganglion pass
deeper dissection within the greater wing of sphenoid through the inferior orbital fissure.
will reveal a marrow space and brisk hemorrhage.
The middle cranial fossa has been found to be 12 to
...
13 mm posterior from the superior osteotomy made in
a lateral orbitotomy.31 P EARL The infraorbital artery
gives blood supply to the inferior rectus
and inferior oblique muscles. The surgeon
...
P EARL Deep lateral wall removal
can be safely done during orbital decom-
pression. Dural exposure can occur if the inner
should be aware of these branches during infe-
rior orbitotomy.32
aspect of the greater sphenoidal wing is The optic foramen, located in the lesser wing of the
removed (Fig. 1–9). sphenoid, houses the optic nerve and ophthalmic
artery. The canal reaches adult size by 3 years of age.
CHEN01-001-020.I 3/22/01 1:21 PM Page 10
Orbital Apex
Superior orbital Inferior orbital Optic

fissure fissure foramen
22 mm length 20 mm length 8–10 mm
Between greater and lesser Laterally greater Medially Palatine Housed in lesser
wings of sphenoid bone wing of sphenoid bone of maxilla wing of sphenoid
Annulus of Zinn Zygomatic–N Optic nerve (IInd N)
(Divides fissure) Infraorbital–N Meninges
Branches of Ophthalmic
Upper Middle Inferior
pterygopalatine artery
ganglion
Frontal Superior Ophthalmic
nerve Vth div–IIIrd N veins Sympathetic
Infraorbital nerves
Trochlear Nasociliary N artery
nerve IVth Vth N
Lacrimal Sympathetic Inferior

nerve Vth nerves orbital vein
Recurrent Inferior
lacrimal artery div–IIIrd N
Superior VIth
ophthalmic vein Abducens N
FIGURE 1–10 Orbital apex.
The diameter of the canal is approximately 6.5 mm inferior orbital fissure, and optic canal, and is contin-
but can enlarge with pathologic processes. The optic uous with dura.
strut separates the optic foramen from the superior The periorbita provides a protective boundary for the
orbital fissure. 33 The optic nerve is vulnerable to intraorbital contents from adjacent disease processes,
injury within the canal.34, 35 limiting spread of infections and tumors. The subperi-
Although the medial aspect of the optic canal is pri- orbital space is an excellent surgical plane because of
marily formed by the sphenoid, in approximately 50% the ease with which the periorbita can be dissected from
of cases posterior ethmoid air cells are present.25, 36 the bone with minimal resulting hemorrhage.
This variability should be considered when perform-
ing extracranial optic canal decompression and pos- Orbital Fascia
terior ethmoidectomy during orbital decompression. Studies by Koornneef38, 39 have shown that the globe
The posterior ethmoidal foramen is an important and orbital soft tissues are suspended in a complex,
landmark in the orbital apex. The medial optic canal organized connective tissue matrix (Fig. 1–11A). This
ring, the opening of the optic canal, is located 6 mm network is divided into three parts: Tenon’s capsule
posterior to the posterior ethmoidal artery.37 (fascia bulbi), the extraocular muscles fascial sheaths
(Fig. 1–11A, 2), and the extensions and check liga-
Periorbita ments that attach the muscle sheaths to the periorbita
The periorbita is a thick fibrous layer that internally and eyelids (Fig. 1–11A, 3).
lines the bony orbit. Anteriorly, it is continuous with
the periosteum, and forms the arcus marginalis, the Fascia Bulbi
origin of the orbital septum. In the orbital apex, Tenon’s capsule fuses with the bulbar conjunctiva
the periorbita lines the superior orbital fissure, the anteriorly, and is composed of fibroelastic tissue. It
CHEN01-001-020.I 3/22/01 1:21 PM Page 11
A B
FIGURE 1–11 (A) Schematic arrangement of orbital fibrous septa. (Reprinted with permission from Koornneef 38.)
(B) Clinical photo of Whitnall’s ligament , right upper eyelid. This is a fibrous band found approximately 15 mm above the
superior tarsal border.
extends to the optic nerve posteriorly and is loosely the levator, just at the transition from the aponeu-
attached to the globe. Externally it attaches to the rotic to the muscular portions of the levator 42
fibrous septa of the orbital fat. (Fig. 1–11B).
Lockwood’s ligament arises from the fused fascia
of the inferior rectus and inferior oblique muscles.43 It
...
P EARL Anterior Tenon’s capsule,
when closed properly, provides the strong-
est barrier to extrusion of an orbital implant
is a hammock-like suspensory ligament that is
strongest anterior to the inferior oblique muscle, and
will support the globe after floor removal and maxil-
lectomy, provided that its medial and lateral attach-
following enucleation. ments are intact. Orbital fat, however, is essential for
its function in globe support.44
Fascial Sheaths (Fibroconnective Tissue Septa)

EARL... The periorbita and medial
Throughout their entire length, the extraocular mus-
cles are encompassed by a fascial sheath. The sheath
P orbital strut, a ledge of bone between the
maxillary and ethmoidal sinuses, play a large
attaches to the orbital walls via check ligaments and to
the intraconal fat septa.19 Anteriorly, the muscles are role in vertical globe support.45, 46
connected to the fascia, particularly at their insertion
onto the globe.
ORBITAL SOFT TISSUES
EARL ... This attachment can aid
P surgeons in finding a muscle if it is lost
during strabismus surgery.
Orbital Fat
Fat fills the space of the orbit not occupied by fascia,
the globe, muscles, nerves, vessels, and glands.
Orbital fat is more fibrous anteriorly, due to the
increased density of the fibrous framework, and more
Fine radial septa also connect the optic nerve to lobular posteriorly.
the medial, lateral, and inferior rectus muscles.40 The
intermuscular septum is formed by the muscle
sheaths prior to their insertion on the globe. Poste- PITFALL
rior to this, no common muscle sheath can be identi-
fied.38 Although it is an excellent surgical landmark,
The superior rectus and the levator palpebrae
orbital fat can be obstructive in deeper surgi-
superioris share an intermuscular fascia.41 The supe-
rior ophthalmic vein is also located in this complex.
cal dissection.
Whitnall’s ligament arises from the fascial sheath of
CHEN01-001-020.I 3/22/01 1:21 PM Page 12
medial and central fat pads are continuous, with the

valley of the inferior oblique dividing the two. The
central fat is separated from lateral fat pad by the
arcuate expansion of the inferior oblique muscle,
which courses inferotemporally.
...
P EARL The inferior orbital fat is an
excellent surgical landmark during tran-
sconjunctival inferior orbitotomy (Fig. 1–13).
The dissection plane can occur either preseptally,

remaining anterior to the orbital fat, or postseptally
FIGURE 1–12 Clinical photo showing preaponeurotic to approach the inferior orbital rim.
fat pad, right upper eyelid.
Vasculature
Superior orbital fat is divided into two distinct The ophthalmic artery, the first branch of the internal
compartments, the preaponeurotic and the medial fat carotid artery, provides the major blood supply to the
pads (Fig. 1–12). They are separated by the trochlea. orbit. The external carotid artery also contributes via
The preaponeurotic fat pad, which is more yellow in the middle meningeal and maxillary arteries.
color, extends laterally over the lacrimal gland to the The main venous drainage system of the orbit
superior edge of the lateral rectus muscle. 47 The occurs via the superior and inferior ophthalmic veins,
medial fat pad, being firmer and pale white in color, is which lie within the connective tissue septa. The larger
associated with the medial palpebral artery and the superior ophthalmic vein (SOV) arises superomedially
infratrochlear nerve. Deeper anesthetic placement is near the superior oblique tendon with contributions
usually required for removal of this fat pad during from the angular, supraorbital, and supratrochlear
blepharoplasty. Because of their close relationship to veins. It travels near the medial aspect of the superior
the trochlea, superior oblique palsy and Brown’s syn- rectus muscle, then enters the muscle cone and
drome have been reported from injury during upper receives branches from ciliary and superior vortex
eyelid blepharoplasty.48 veins. The SOV then travels beneath the superior rec-
The inferior orbital fat can be divided into three tus muscle along the lateral border of the muscle to
compartments.49 The medial fat pad is separated from enter the superior orbital fissure and subsequently the
the central fat by the inferior oblique muscle. The cavernous sinus. The SOV hammock is a connective
Preaponeurotic fat
Trochlea
Lacrimal
gland
Nasal fat pad
Lacrimal sac
Temporal
fat pad
Nasal fat pad
Arcuate Inferior oblique

expansion muscle
of inferior Central
oblique fat pad
muscle
FIGURE 1–13 Clinical compartments of anterior orbital fat.

CHEN01-001-020.I 3/22/01 1:21 PM Page 13
tissue structure seen on magnetic resonance imaging The oculomotor nerve (CN III) divides into supe-
(MRI), which supports the SOV in its course. The ham- rior and inferior divisions within the cavernous sinus
mock courses from the lateral rectus toward the super- prior to entering the orbit. The two divisions enter
omedial orbital wall.50 The smaller, more variable, the orbit through the superior orbital fissure, sepa-
inferior ophthalmic vein (IOV) forms along the orbital rated by the nasociliary nerve. The superior division
floor from a plexus with contributions from the infe- supplies the superior rectus and the levator. The infe-
rior extraocular muscles and inferior vortex veins. The rior division enters the intraconal space beneath the
IOV then courses posteriorly along the inferior rectus optic nerve and supplies the medial rectus, inferior
muscle and then empties into either the SOV or inde- rectus, and inferior oblique. The branch to the infe-
pendently into the cavernous sinus. rior oblique carries pupillomotor fibers to the ciliary
Although the orbit has been traditionally thought ganglion.
to be devoid of lymphatics, recent studies in the mon-
key orbit have identified the presence of lymphatics in
the dura of the optic nerve and the lacrimal gland.51 PITFALL
Orbital Nerves Injury to the nerve has been described in
Five of the twelve cranial nerves (CNs) supply the patients undergoing repair of orbital floor
orbit. Along with sympathetic and parasympathetic fractures, causing pupillary dilation.54
contributions, these nerves enter the orbit through the
orbital apex.
The optic nerve (CN II) is essentially a neural tract
extending from the brain, being covered by meninges, The trochlear nerve (CN IV) enters the orbit out-
surrounded by circulating CSF, and containing neu- side the annulus of Zinn through the superior orbital
roglial cells. The nerve has intraocular, intraorbital, fissure. It is unique in four aspects: it is the only motor
intracanalicular, and intracranial segments. The optic nerve to the extraocular muscles that remains outside
nerve is formed by retinal ganglion cells axons and exits the muscle cone, it has the longest intracranial course,
the globe at the lamina cribrosa. This intraocular seg- it arises from the brainstem dorsum, and it completely
ment is 1 mm long and 3 mm in diameter.52 The intra- decussates.
orbital segment measures 24 mm, 6 mm longer than the The abducens nerve (cranial nerve VI) enters the
direct length between the sclera and the opening of the orbit through the superior orbital fissure within
optic foramen. This slack allows unrestricted globe the annulus. It travels between the optic nerve and the
movement and some slack if proptosis should occur. lateral rectus muscle to innervate the muscles through
its inner surface.
The ophthalmic AV1 B and maxillary AV2 B divisions
...
P EARL Globe tenting, a radiologic
sign, is seen with severe proptosis, caus-
ing optic nerve tethering on the back of the
of the trigeminal nerve supply cutaneous sensory
innervation to the upper two thirds of the face and
the orbit. The ophthalmic division enters the orbit
globe.53 If the posterior scleral angle is less than through the superior orbital fissure and divides into
90 degrees, severe tension is present (Fig. 1–14). the lacrimal, frontal, and nasociliary nerves. The
lacrimal nerve courses superotemporally along the
upper border of the lateral rectus to supply the
lacrimal gland, lateral conjunctiva, and lateral upper
eyelid. The frontal nerve travels between the perior-
bita and the levator and branches into supraorbital
and supratrochlear nerves. The supratrochlear nerve
innervates the medial upper eyelid and glabellar
region. The supraorbital nerve exits the orbit through
the supraorbital notch or foramen and supplies the
forehead. The nasociliary nerve is the only branch to
enter the orbit above the optic nerve through the
annulus, and travels between the superior oblique
and medial rectus muscles. Branches of the nasocil-
iary nerve include the posterior and anterior eth-
FIGURE 1–14 Computed tomography (CT) scan of moidal nerves, several long ciliary nerves, a sensory
patient with left orbital abscess. Note stretching of left optic root to the ciliary ganglion, and the infratrochlear
nerve with globe tenting. nerve.
CHEN01-001-020.I 3/22/01 1:21 PM Page 14
The maxillary division AV2 B enters the ptery- terior to the globe. Parasympathetic fibers synapse in
gopalatine fossa through the foramen rotundum. the ganglion, while sympathetic and sensory axons
After branching as the zygomatic, sphenopalatine, pass through. Several short ciliary nerves exit the cil-
and posterosuperior alveolar nerves, the majority of iary ganglion, the majority of which supply the globe
the nerve enters the orbit via the infraorbital fissure lateral to the optic nerve.
as the infraorbital nerve. The zygomatic nerve
becomes the zygomaticofacial and zygomaticotempo- NOSE AND PARANASAL SINUSES
ral nerves. The zygomaticofacial nerve exits through
its named foramina to supply the cheek, while the Because of the proximity to the orbit, paranasal sinus
zygomaticotemporal nerve passes through its named diseases often present with orbital signs. Thus, it
foramen into the temporalis fossa to innervate the lat- behooves the orbital surgeon to be familiar with nasal
eral forehead. The infraorbital nerve exits the infraor- and sinus anatomy. The nasal cavity is divided into
bital foramen to supply the lower eyelid, the lateral two parts by the nasal cartilaginous septum and the
aspect of the nose, and the upper lip. vomer of the ethmoid bone. The turbinates (inferior,
Sympathetic nerve supply to the orbit causes pupil- middle, superior, and sometime supreme) are located
lary dilation, Müller’s and inferior tarsal muscle con- on the lateral nasal wall, and the space below each
traction, vasodilation, and hidrosis. Sympathetic turbinate is named respectively. The inferior turbinate
nerve fibers begin in the superior cervical ganglion is the largest, whereas the smaller middle and supe-
and enter the cavernous sinus surrounding the inter- rior turbinates arise from the ethmoid bone. The mid-
nal carotid artery. dle turbinate is easily seen on external examination.
Parasympathetic nerves supply the ciliary muscle,
...
P
pupilloconstictor fibers, lacrimal gland innervation, EARL The turbinates function to
and vasodilatory fibers. Preganglionic fibers from the
moisturize the inhaled air, filter particu-
Edinger-Westphal nucleus destined for the orbit
travel with the inferior division of the oculomotor late matter, and provide resistance during
nerve and, as mentioned previously, course with inhalation. Due to their importance, attempts
the nerve to the inferior oblique. They then synapse should be made to preserve them during naso-
in the ciliary ganglion before postganglionic fibers lacrimal procedures.
enter the globe as short posterior ciliary nerves. Most
of these fibers (90%) supply the ciliary body and the
remainder innervate the iris sphincter. Traditional The maxillary sinus is the largest of the sinuses.
thought is that lacrimal gland innervation is supplied Due to its predominantly inferior growth, the maxil-
by the nervus intermedius portion of the facial nerve. lary sinus drains superiorly into the hiatus semilu-
The ciliary ganglion is located between the lateral naris just posterior to the uncinate process of
rectus and the optic nerve approximately 15 mm pos- the middle meatus (Fig. 1–15). Relationships of the
Frontonasal
Sphenoid sinus Ethmoidal
ostium
ostium ostia
Frontonasal
duct
Ethmoidal bulla
Uncinate process
Semilunar hiatus
Middle
turbinate Maxillary sinus
ostium
Inferior Nasolacrimal
turbinate duct ostium
FIGURE 1–15 Lateral wall of the nose.

CHEN01-001-020.I 3/22/01 1:21 PM Page 15
FIGURE 1–16 CT scan (axial view) of ethmoid and sphe- FIGURE 1–17 CT scan (coronal view) of ethmoidal and
noid sinuses. Note opacification of right anterior ethmoidal maxillary sinuses. Note orbital strut found at the junction
air cells. of ethmoid and maxillary sinuses.
maxillary sinus include the nasolacrimal duct medi- with the internal carotid artery, the optic nerve, and
ally, and the pterygopalatine fossa and maxillary the cavernous sinus.
artery posteriorly. Creation of nasal antral window
can injure the nasolacrimal duct. GLOBE AND EXTRAOCULAR MUSCLES
The ethmoid sinuses arise during the fifth month The globe is located slightly superior and lateral to the
of gestation and continue to expand until puberty. center of the anterior orbit. The front surface of the
The ethmoid sinus is the most exhuberant sinus and globe is in the same plane as the superior, medial, and
it may pneumatize the frontal, sphenoid, palatine, inferior orbital rims but is anterior to the lateral rim by
and lacrimal bones. The ethmoids are best visual- 12 to 18 mm. Changes in eye position occur with
ized as a box that is slightly wider posteriorly aging when measured by exophthalmometry, orbital
(Figs. 1–16 and 1–17). Anterior and middle air cells width, and interpupillary distance.58 Exophthalmom-
drain into the middle meatus, whereas posterior air etry readings generally increase until age 20. In the
cells open into the superior meatus. Anterior eth- elderly, interpupillary distance increases, most likely
moidal air cells can extend anteriorly past the pos- due to atrophic changes.
terior lacrimal crest,25, 55 and may be encountered All extraocular muscles arise from the orbital apex
during dacryocystorhinostomy. except the inferior oblique. The four recti muscles
arise from the annulus of Zinn; the levator muscle and
superior oblique originate superomedially from the
PITFALL lesser wing of the sphenoid; and the inferior oblique
arises from the orbital floor anteriorly, just lateral to
the lacrimal sac.
Ethmoidectomy performed endoscopically or
externally can breach the lamina papyracea of
the medial orbital wall, placing the medial LACRIMAL SYSTEM (FIG. 1–18)
rectus and optic nerve at potential surgical Secretory System
risk.56 The lacrimal secretory system consists of the lacrimal
gland and the accessory lacrimal glands. They pro-
duce the aqueous component of the tear film. The
The frontal sinus expansion begins at about 6 years lacrimal gland is divided into a larger orbital lobe and
of age and continues until adulthood. The frontal a smaller palpebral lobe by the lateral horn of the lev-
sinus is divided by a midline septum and is a com- ator (Fig. 1–19).
mon site for mucocele development. It drains via the The orbital lobe molds within the space between
nasofrontal duct.57 the globe and the lateral orbital wall. The palpebral
The sphenoid sinus is pneumatized to a variable lobe resides beneath the levator aponeurosis and is
degree. Ethmoidal air cells may pneumatize the sphe- separated from the conjunctiva by Müller’s muscle.
noid sinus. It typically has a midline septum and Lacrimal gland prolapse can occur with laxity of the
drains into the sphenoethmoidal recess. The lateral attachments, causing a noticeable bulge in the lateral
wall of the sphenoid sinus has a close relationship portion of the upper eyelid.
CHEN01-001-020.I 3/22/01 1:21 PM Page 16
Lacrimal System
Secretory Excretory
Main lacrimal Accessory Lacrimal Upper and lower puncta

gland glands pump 1.0–1.5 mm diameter
Divided by Krause Wolfring Vertical (2 mm)

Pretarsal Horner's Canaliculi Horizontal (8 mm)
lateral horn
of levator orbicularis muscle
Open superior Open upper +

fornix 40–42 border of superior
Lacrimal
Orbital Palpebral glands tarsus 2–5 glands Compress Preseptal 4–5 mm extension
sac
lobe lobe ampullae orbicularis above M.C.T. *
(15 mm (fundus) of sac
x 5 mm)
Inferior Lower
10–12 fornix 6–8 border of inferior
secretory glands tarsus 2 glands Shortens Compress Interosseous
canaliculi and expand Nasolacrimal groove between
lobes duct (15 mm
lacrimal sac maxilla and
x 3 mm) lacrimal bones
Basic tear
Open at secretors
superolateral Valve of
conjuctival fornix Hasner
in inferior
No meatus
parasympathetic
Reflex supply
tear
secretion
Both parasympthetic
and sympathetic
innervations
*M.C.T., Medial Canthal Tendon
FIGURE 1–18 The lacrimal system.
Secretory ducts (10 to 12) from the orbital lobe pass glands are thought to be basic secretors, with the main
through the palpebral lobe or stay very close to it, to lacrimal gland responsible for reflex tearing.60
open into the superotemporal conjunctival fornix.
Both sympathetic and parasympathetic fibers Excretory System
innervate the lacrimal gland. The lacrimal gland is Tear flow and excretion is a dynamic process depen-
supplied by the lacrimal artery and from a branch of dent on eyelid blinking. Tear excretion begins in the
the infraorbital artery. Recent studies show that the puncta, which measure 0.3 mm in diameter and are
lacrimal artery also supplies the lateral aspect of normally in firm opposition to the globe.
Müller’s muscle.59
EARL... Usually not visible on ex-
P
The accessory lacrimal glands of Krause and Wol-
fring lack parasympathetic innervation. Approxi-
ternal examination, if the puncta can be
mately 20 accessory lacrimal glands are present in the
superior conjunctival fornix, and about half that num- seen without eyelid eversion, punctal ectropion
ber are present in the lower eyelid. Because they do is present.
not have parasympathetic innervation, the accessory
CHEN01-001-020.I 3/22/01 1:21 PM Page 17
Levator Superior canalicus

aponeurosis
Common canalicus
Orbital lobe
of lacrimal Valve of Rosenmüller
gland
Lacrimal sac
Valve of Krause
Spiral valve of Hyrtl
Inferior canalicus
Valve of Taillefer
Nasolacrimal duct Inferior turbinate
Valve of Hasner
Ductules
FIGURE 1–20 Nasolacrimal excretory system.
Palpebral
lobe of The nasolacrimal duct opens beneath the inferior
lacrimal gland
turbinate, but can extend to the nasal floor.62 The
FIGURE 1–19 Orbital and palpebral lobes of lacrimal gland. valve of Hasner is typically present at the opening
and may be imperforate at birth, causing epiphora in
The upper and lower canaliculi measure 2 mm ver- neonates. The nasolacrimal duct lies lateral to the
tically and 8 mm horizontally. Most of the time, the middle meatus and medial to the maxillary antrum.
canaliculi join to form a common canaliculus, located Because of this relationship, maxillary sinus masses
within the central portion of the medial canthal liga- can cause epiphora.
ment (Fig. 1–20). The valve of Rosenmüller is a func-
tional valve present at the opening of the common
EARL... Lacrimal sac swelling sec-
canaliculus into the lacrimal sac. Its function is to pre-
vent reflux, and in the presence of a coexistent naso-
lacrimal duct obstruction it may precipitate the
P ondary to infection typically occurs infe-
rior to the medial canthal ligament. Swelling
development of dacryocystitis. Recent studies have
superior to the medial canthal ligament is a
found that the canaliculi bend posteriorly behind the
medial canthal ligament, then anteriorly to enter warning sign of a lacrimal sac malignancy.
the sac at an angle of 58 degrees to the lateral wall
of the sac. This anatomic configuration may also
contribute to the one-way valve.61 SUMMARY
The lacrimal sac is located within the bony lacrimal
fossa and is covered by periorbita and surrounding Integrated knowledge of the superficial and deep lay-
fascia, making it technically external to the orbit. The ers of the face, eyelids, orbit, and lacrimal system is
sac measures 12 mm vertically, with 4 mm of it being essential for the clinical practitioner who deals with
superior to the medial canthal ligament. The aesthetic and reconstructive surgery of the eyelids,
intraosseus nasolacrimal duct measures 12 mm and it orbit, and surrounding adnexa. This chapter provides
extends an additional several millimeters into the a basic foundation of core knowledge in anatomy
inferior meatus. needed for oculoplastic surgery.
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51. Gausas RE, Gonnering RS Lemke BN, Dortzbach RK: lacrimal gland. Ophthalmic Plast Reconstr Surg
Identification of human orbital lymphatics. Ophthalmic 1998;14(4):235–238.
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CHEN02-021-040.I 3/26/01 8:23 AM Page 21
Chapter 2
FUNDAMENTALS OF
OCULOPLASTIC SURGERY
Dipak N. Parmar and Geoffrey E. Rose
Oculoplastic surgery draws upon a wide variety of minimum acceptable level by an internist. Alterna-
techniques and disciplines, but has emerged in recent tively, a rapidly reversible agent, such as intravenous
years as a distinct subspecialty. Although general and heparin, may be used to maintain anticoagulation
periocular plastic procedures have been described as during the perioperative period, before full oral anti-
early as the 6th or 7th century B.C., contributions from coagulation is resumed. Conditions that may cause
other disciplines have led to a plethora of oculoplastic immune suppression and predispose to postoperative
techniques; such specialties including general plastic infection should be sought, including diabetes melli-
and reconstructive surgery, otorhinolaryngology, tus, human immunodeficiency virus infection,
neurosurgery, neuroradiology, dermatology, and chemotherapy, or transplant-related immunosup-
radiation oncology.1, 2 Many oculoplastic procedures pression. Specific inquiry for previous periocular
are now available to treat any distinct surgical entity, surgery, trauma, or radiation should be made, the lat-
but adherence to the basic principles outlined below ter alerting the physician to the possibility of induced
will generally provide a good result with minimal malignancy. A family medical history is important to
scarring and excellent aesthetics. exclude hereditary disorders, such as malignant
hyperthermia and congenital ptosis.
A problem-oriented general, ophthalmic, and
EVALUATION oculoplastic examination should be performed and
Oculoplastic surgery is largely performed for func- this also provides a time to gain rapport with the
tional reasons, but aesthetic factors are invariably patient, a rapport vital to determining the patient’s
involved. It is therefore important to evaluate the expectations for surgery and whether these can be
patient from a medical, functional, aesthetic, and psy- realistically achieved. Functional and aesthetic con-
chological perspective. siderations are closely linked in oculoplastic surgery
An appropriate history and physical examination and so it is important to identify the patient who is
is mandatory in all patients, with particular attention psychologically unstable.3, 4 Such cases are unsuitable
directed toward factors that may cause problems dur- for aesthetic surgery and require a prompt reevalua-
ing or after surgery. Risk factors for intraoperative tion of the indications for functional surgery.
hemorrhage should be sought, including hyperten- Most nonorbital oculoplastic surgery is performed
sion, liver disease, anticoagulation therapy, and treat- under local anesthesia, with the option of monitored
ment with vitamin E, aspirin, or nonsteroidal intravenous sedation, and hence little preoperative
antiinflammatory agents. Such medications should be workup is required from the anesthetic aspect. Optic
stopped at least 14 days prior to surgery, although nerve function may be assessed in orbital disease by
anticoagulants cannot always be discontinued—as, color vision testing, visual field analysis, and possi-
for example, in patients with mechanical heart valves; bly visual-evoked potentials, whereas lacrimal prob-
in these cases anticoagulation should be reduced to a lems may entail dacryocystography. Computed
21
CHEN02-021-040.I 3/22/01 1:25 PM Page 22
tomography is invaluable in defining orbital and

adnexal disease, particularly when the expertise of
an orbital radiologist is available, although magnetic
resonance imaging occasionally provides further
information when there is associated optic nerve
pathology.
Photography
Photography is essential in the evaluation of any ocu-
loplastic patient, and ideally should be performed at
the first preoperative visit, in the operating theater,
and postoperatively.5 Although the medicolegal ben-
efits are obvious, photographs also provide a record
of both functional and aesthetic changes following
treatment, which is particularly useful in patients who FIGURE 2–1 Photograph demonstrating the use of over-
are excessively anxious. head lighting to show image depth by shadowing.
It is important to photograph the patient in the pri-
mary position of gaze, but further positions may also
occurs in an open, untreated wound. The sequence of
be useful—looking up or down, looking left or right,
physiologic events is similar in both categories,
and lateral views can be taken if required.6 The photo-
although wound contraction plays a predominant
graphic system used should provide consistent and
role in secondary wound healing.
correctly exposed images. The 35 mm single-lens reflex
Although wound healing has traditionally been
camera is ideal for oculoplastic use, particularly in con-
classified into four phases, it is important to realize
junction with a macrolens, to take well-magnified,
that this is actually a dynamic process with remodel-
undistorted images. The 50 mm macrolens is practi-
ing continuing often for years after the initial injury.9
cally the lightest with which to work, but requires close
proximity to the subject. A better option for the oper- Inflammatory Phase (4 to 7 Days After Injury)
ating theatre is the 90 mm macrolens, which allows a
Immediately following injury, the acute inflammatory
greater distance between the photographer and the
response is orchestrated to allow epithelialization of
operating field. Polaroid photography is a useful alter-
the wound. Inflammatory mediators and cytokines are
native, allowing instant images for discussion with the
released, which cause localized vasodilatation and
patient, but with a compromise in quality.
increased capillary permeability, recruiting acute
Digital photography is increasingly popular in
inflammatory cells such as granulocytes, macrophages,
today’s environment, with an image resolution that is
and lymphocytes to the wound.
continually improving and now comparable to tradi-
A fibrin-platelet clot initially bridges a well-
tional methods. Although this provides an efficient
sutured wound. Epithelial cells migrate and prolifer-
method of image capture and storage, it also allows
ate from the wound edges downward to the base
the likely postoperative appearance to be demon-
within hours, completely covering the wound within
strated to the patient using image manipulation.
12 to 24 hours. Capillary budding provides a frame-
work for proliferation of epithelium, which is reorga-
EARL... Oculoplastic photographs
P are best taken with eccentric illumination
from above, to show image relief (Fig. 2–1).
nized and aligned during days 10 to 15.
Fibroblastic Phase (Week 1 to 4)

Fibroblasts migrate into the wound during the inflam-
matory phase and produce increasing amounts of col-
lagen, followed by collagen lysis after day 17, so that
WOUND HEALING by 4 weeks an equilibrium is reached. An acellular
“ground substance” produced during this phase is
An understanding of cutaneous wound healing is essential for fibroblast proliferation and collagen syn-
important for the oculoplastic surgeon and has been thesis, being rich in chondroitin sulfate, hyaluronic
traditionally divided into two categories.7, 8 Primary acid, and other mucopolysaccharides.
wound healing, or healing by primary intention,
occurs when wound edges are apposed as they are in Maturation Phase (Week 4 to Several Years)
a sutured surgical wound. Conversely, secondary Fibroblasts leave the wound during this phase fol-
wound healing, or healing by secondary intention, lowed by alignment and restructuring of collagen
CHEN02-021-040.I 3/22/01 1:25 PM Page 23
FUNDAMENTALS OF OCULOPLASTIC SURGERY • 23
fibers, thus leading to near maximum wound strength of MMP. Inhibition of MMP activity has been shown
at 3 months. Although this process may continue for a to enhance wound strength in rats, suggesting that
year or more, overall wound strength never quite in due course MMP modulation may provide a
reaches that of uninjured skin. potential means of influencing wound healing and
maturation.13
Wound Contraction
Wound contraction plays a prominent role in sec-
ondary wound healing and is often extensive in open
wounds. Epithelial migration and proliferation TECHNIQUES
advances centrally with the release of proteolytic Anesthesia
enzymes along the advancing edge, using the fibrin
The anesthetic options for oculoplastic surgery range
clot as a scaffold. Myofibroblasts contain contractile
from local infiltration to general anesthesia, depend-
elements and drive the centripetal movement of the
ing on the patient’s age, level of anxiety, degree of
wound edges. The rate of wound contraction is high-
cooperation, and systemic status.14, 15 Most oculoplas-
est for 2 weeks after injury (resulting in an initial rate
tic procedures can be carried out under infiltrative
of closure of 0.6 to 0.75 mmday), continuing there-
local anesthesia, but the surgeon must be aware of
after for several months at a slower rate. Closure of a
rare cardiovascular reactions that may necessitate
contracting wound does not always proceed at the
resuscitation.
same rate in all directions and depends on several fac-
Adjunctive sedation with a benzodiazepine is often
tors, including attachments to surrounding tissues
useful in anxious patients or those undergoing pro-
and the shape of the defect.
longed procedures. Intravenous sedation, titrated by
Secondary wound healing is of limited use in ocu-
an anesthetist, is also useful in supplementing the
loplastic surgery, confined to selected cases of infec-
local block, particularly when a deeper level of seda-
tion and burns. Its use in periocular reconstruction is
tion is required or systemic problems preclude the use
controversial, although successful results have been
of a general anesthetic. The level of sedation can eas-
reported after resection of medial canthal, glabellar,
ily be lightened to increase the level of patient coop-
and eyelid margin cutaneous tumors (Fig. 2–2).10, 11
eration, as may be required during levator muscle
Matrix Metalloproteinases surgery. A general anesthetic is used in children and
for more extensive procedures such as major recon-
Matrix metalloproteinases (MMPs) are a family of
structions or orbital surgery.
zinc-dependent endopeptidases capable of degrad-
ing almost all extracellular matrix components,
including collagen.12 They are central to a wide range EARL... Levator muscle surgery is
of physiologic and pathologic processes and are
intricately involved in the fine balance between col-
lagen synthesis and degradation during wound heal-
P best accomplished using minimal local
anesthetic placed in the pretarsal orbicularis
ing. MMPs are an important determinant of final oculi muscle.
wound strength, being regulated by tissue inhibitors
A B
FIGURE 2–2 Secondary wound healing of a left lower eyelid medial defect following excision of a basal cell carci-
noma. (A) Day 1. (B) Month 5 postoperatively.
CHEN02-021-040.I 3/22/01 1:25 PM Page 24
Commonly used local anesthetic agents include

lidocaine (Xylocaine) 2% and the longer-acting bupi-
vacaine (Marcaine) 0.5%. As a vasoconstrictor, epi-
nephrine 1 : 100,000 or 1 : 200,000 is useful in reducing
operative hemorrhage and slows the systemic absorp-
1
tion of local anesthetic, thereby prolonging the dura-
tion of anesthesia. Hyaluronidase is only rarely
required but, if used, may facilitate the spread of the
anesthetic through tissue planes.
Discomfort associated with the local injection is
generally due to acidity of premixed solutions of lido-
caine containing epinephrine. This may be avoided by 2
a two-stage injection technique using a 28-gauge nee-
dle to initially inject a mixture of dilute local anes- 3
thetic before infiltrating with the complete mixture.
FIGURE 2–3 Oculoplastic incisions showing (1) upper lid
The first-stage injection consists of lidocaine 0.1% in
skin crease approaches, (2) lateral canthal, and (3) transcon-
injectable saline solution, warmed to body tempera-
junctival.
ture if possible, and is followed by the full-strength
second-stage injection a few minutes later.
Incisions
The ideal incision allows maximal access to the sur-
Asepsis geon while minimizing visible scarring. A preopera-
Oculoplastic surgery is performed in a modern oper- tive discussion with the patient regarding the skin
ating theater environment exercising standard meth- incision is mandatory and the site marked before infil-
ods of infection control. Aqueous povidone-iodine tration with local anesthetic.
solution is used to clean and prepare the skin, A cutaneous scar can be avoided altogether by
although chlorhexidine may be substituted if the using transconjunctival approaches for eyelid or
patient is allergic to iodine. Because these substances orbital surgery (Figs. 2–3 and 2–4).18 Alternatively, the
are irritating to the conjunctiva, it is important to irri- scar may be hidden by the hairline as is the case with
gate the eye immediately if there is inadvertent a coronal incision for endoscopic brow lifting. The
exposure. incision should be placed in preexisting skin creases
Due to the extensive palpebral vascular supply, the where possible, utilizing, for example, the upper lid
eyelids are remarkably resistant to infection. The role skin crease for surgery in the upper part of the orbit.19
of prophylactic antibiotics before and during surgery Otherwise incisions should be aligned parallel to the
is controversial, but may be of value in cases involv- relaxed skin tension lines of the face (Fig. 2–5).20
ing the sinuses, trauma, preoperative infection, or The skin is held taut, to avoid beveling or irregular
orbital or lacrimal reconstruction.16, 17 wound edges, and the incision made perpendicular
A B
FIGURE 2–4 (A) A 25-mm-diameter dermoid cyst being removed through a medial left transconjunctival approach
(globe indicated by arrow). (B) Everted upper eyelid (white arrow) showing large conjunctival cyst exposed through
an upper fornix incision (black arrows).
CHEN02-021-040.I 3/22/01 1:25 PM Page 25
(Fig. 2–6).21 The normal lymphatics of the eyelid

extend posteroinferiorly from the lateral eyelids to the
preauricular and submandibular lymph nodes. Verti-
cal incisions in the lateral canthus are thus highly dis-
ruptive to lymphatic outflow, while medial canthal
vertical incisions are less problematic.
PITFALL
Chronic severe eyelid lymphedema may

result from simultaneous vertical incisions of
medial and lateral canthi on the same eyelid.
Instruments and Tissue Handling

Instruments for oculoplastic surgery are larger than
those used for intraocular surgery, but generally
smaller and more delicate than those used in general
plastic surgery. It is important to use the appropriate
instrument for a given procedure, to minimize tissue
trauma that would impede wound healing. To allow
gripping of tissues without crushing, forceps should
be toothed rather than smooth, and scissors must
FIGURE 2–5 Relaxed skin tension lines of the face, always be sharp. The size of instrument chosen should
including periocular skin. also be of appropriate strength, such that the rugged
Adson forceps is used for scalp flaps requiring trac-
to the surface to reduce scarring. An exception is in tional manipulation, whereas the smaller, toothed
hair-bearing areas, such as the brow or scalp, where Jayle’s forceps are more suitable for eyelid work with
the incision is angled parallel to the hair shafts to relatively stationary tissue handling. Similarly West-
avoid damage to the follicles. The incision is com- cott spring-action scissors are extremely useful for fine
pleted in a single steady motion, starting from the work, whereas the sharp straight scissors are better
lowest point of the operating field and working suited for cutting tougher tissues, such as skin flaps or
upward, so as to avoid blood obscuring the view. large skin-muscle flaps. Fine skin hooks are of particu-
Consideration of the lymphatic drainage is impor- lar use in retracting tissue flaps with minimal trauma.
tant before any lid surgery, since a poor lymphatic Orbital and lacrimal surgery demand sturdier
outflow can adversely affect wound healing instruments, which include rongeurs, bone saws,
A B
FIGURE 2–6 Persistent edema of right lower eyelid following injury running across lines of lymphatic drainage.
(A) Four weeks after injury with marked edema. (B) Six months later with resolution.
CHEN02-021-040.I 3/22/01 1:25 PM Page 26
drills, and plating sets. Endoscopic surgical instru- Cautery allows immediate intraoperative hemo-
mentation now permits a further means of accessing stasis with minimal tissue destruction and is achieved
lacrimal and orbital structures, allowing transnasal using thermal, electrocautery, or laser modalities. Bat-
lacrimal surgery and posterior orbital work such as tery-powered high-temperature thermal cautery
orbital or optic canal decompression.22 (2200°C) is useful for oculoplastic surgery, unlike the
A scalpel with a disposable supersharp blade, such low temperature (1000°C) instrument, which is only
as the Bard-Parker 15, is excellent for most skin inci- suitable for conjunctiva or fine ocular tissues.
sions. Alternatively, the carbon dioxide laser or high- High-frequency electrocautery (diathermy) can be
frequency unipolar cutting electrocautery enable used for dissecting as well as cauterizing tissue,
virtually bloodless dissection and are appropriate in depending on the electromagnetic waveform emanat-
revision surgery with markedly vascular scar tissue. ing from the tip. In monopolar mode an indifferent
electrode is attached to the patient’s thigh or buttock,
allowing the instrument to be used for either cutting
EARL ... or coagulation.24 Since current passes through the
P Use toothed forceps of
appropriate size to avoid crushing tissue
during manipulation.
patient, monopolar electrocautery is contraindicated
in the presence of a cardiac pacemaker, and care
should be exercised to keep the indifferent electrode
dry during surgery—otherwise skin burns may result.
Bipolar electrocautery does not require an extra elec-
Hemostasis trode and allows direct coagulation of vessels that can
The rich vascular supply of the eyelids and ocular be held between the diathermy forceps. It is also use-
adnexa promotes healing and reduces the risk of ful for shrinking prolapsed orbital fat during surgery,
infection, but also makes hemostasis a challenge. which obviates the risk of bleeding associated with
Excessive hemorrhage prolongs operating time and excising fat. Bipolar electrocautery provides highly
may lead to a postoperative orbital hematoma, which localized coagulation and, therefore, is ideal when
may impede wound healing or lead to visual loss. working in the posterior part of the orbit where the
A history of abnormal bleeding should be specifi- optic nerve would otherwise be at significant risk of
cally sought and the patient’s medication list scruti- injury.25 The carbon dioxide laser can also be used for
nized. Aspirin and nonsteroidal antiinflammatory cutting or coagulation, depending on the intensity
drugs should be stopped at least 14 days before and duration of the beam, and is particularly useful in
surgery, although it may not be possible to discon- the presence of vascular scar tissue.26
tinue anticoagulants in certain patients. If surgery is Topical thrombogenic agents are useful when hem-
essential in these cases, admission to hospital and con- orrhage is so diffuse that cautery is impractical, as
version to intravenous heparin may be required, this seen with the mucosal surface bleeding during an
being stopped just prior to surgery and recommenced external dacryocystorhinostomy. Examples include
postoperatively. absorbable gelatin foam (Gelfoam), charged collagen
Perioperative blood pressure control should be products (Collistat, Helistat), oxidized cellulose (Sur-
optimal, ensuring that patients continue to take their gicel, Oxycel) and microfibrillar collagen (Avitene).
medications if hypertensive, and hypotensive anes- All may be left in the eyelids or orbit, apart from the
thesia may be required for complex orbital surgery. oxidized cellulose products, which cause unaccept-
Addition of vasoconstricting drugs, such as 1 : 100,000 able degrees of inflammation. Bone wax is extremely
epinephrine, to infiltration local anesthesia signifi- useful to control bleeding from the bone and can be
cantly reduces intraoperative hemorrhage. Similarly, applied directly to sites of hemorrhage, especially
topical intranasal cocaine 4%, intranasal oxymetazo- during orbital surgery.
line 0.05%, or conjunctival phenylephrine 2.5% or 10%
may be used during nasolacrimal or transconjuncti- Suture Materials
val surgery to markedly reduce hemorrhage at these A wide variety of sutures are available to the oculo-
sites. plastic surgeon and these can be broadly classified
Intraoperative hemostasis is achieved using pres- into absorbable or nonabsorbable types. They may be
sure tamponade, cautery, and topical thrombogenic braided or monofilament, and constructed from nat-
drugs.23 Pressure tamponade represents the simplest ural or synthetic material (Tables 2–1 and 2–2). Con-
method, but has the disadvantage of taking a rela- siderations influencing choice of suture include tissue
tively long time (up to 10 minutes) to achieve control type, wound tension, potential for tissue reaction and
and often produces a rather fragile clot, which can be infection, handling characteristics, patient tolerance,
easily dislodged. and pigmentation.
CHEN02-021-040.I 3/22/01 1:25 PM Page 27
TABLE 2–1 ABSORBABLE SUTURES TABLE 2–2 NONABSORBABLE SUTURES

Time to Monofi- Suture Synthetic (S) Monofilament (M)
lose 50% Synthetic lament material or natural (N) or braided (B)
tensile (S) or (M) or
Suture (days) natural braided Silk N B
material strength (N) (B) Nylon S M
Polypropylene
Plain catgut 7–10 N M (Prolene) S M
Chromic catgut 10–14 N M Polyester
Polyglactin 910 (Ticron) S B
(Vicryl) 14 S B Supramid S M
Polyglycolic acid Stainless steel S Wire
(Dexon) 14 S B
Polydioxanone
(PDS) 28–35 S M
excellent for confined spaces such as the medial and
lateral canthi and for lacrimal surgery. Longer com-
pound-curved needles are very useful for suturing
Nonabsorbable sutures should be removed within
deeply during socket reconstruction, whereas slightly
10 days and are often used for skin closure, since they
curved needles are more helpful for suturing eyelid
induce much less tissue reaction than absorbable
and tarsus.
sutures. Synthetic sutures, such as polyglactin
(Vicryl), are broken down by hydrolysis and are
Wound Closure
absorbed more slowly than natural material, such as
catgut, which is degraded enzymatically. Compared The goal of optimal wound closure is to achieve an
to monofilament, braided sutures are easier to handle aesthetically acceptable result with minimal scarring.
but are thought to be associated with a higher rate of The wound should be prepared so that necrotic tissue
infection. It should be noted that silk causes signifi- is removed and the margins straight with no ragged
cantly more inflammation, suture tracks, and ab- tissue. Any foreign bodies or clots should be removed
scesses than other nonabsorbable synthetic materials, and the wound thoroughly debrided in cases of
and, therefore, should probably not be a suture of first trauma or infection. Care is taken to prevent tissue
choice. Stainless steel wire is occasionally used for from drying out, as this distorts tissue planes and
canthal reconstruction, causing little reaction if well retards healing.
buried, but with minimal advantage over larger All wounds should be closed in appropriate layers
gauge nonabsorbable artificial sutures, such as so as to eliminate any dead space and relieve tension
polypropylene. on the wound. Deeper tissues are closed using
Patient tolerance and pigmentation further influ- absorbable sutures with the knot buried downward
ence choice of suture. Polypropylene or nylon is less carrying most of the tension, whereas skin is closed
painful to remove than silk when the suture has been
left in place for a while, as with, for example, a bol-
stered intermarginal eyelid suture. In children, an A B
absorbable suture is preferred for skin closure, to
avoid removal at a later stage.
Needles
Four main needle configurations are available to the
oculoplastic surgeon (Fig. 2–7): The cutting needle is
triangular in cross section with a sharp cutting edge
along the inner diameter of a 38 circle. The reverse cut-
ting needle is similar, but with a cutting edge along the C D
outer diameter. The spatula needle is flatter with sharp
sides and is useful for partial-thickness tarsal or scle-
ral sutures. Round needles are for loose connective tis-
sue, but are generally not used in oculoplastic surgery
since they are difficult to pass through the relatively FIGURE 2–7 Needle configurations. (A) Conventional
tough structures of the eyelid. Half-circle needles are cutting. (B) Reverse cutting. (C) Spatula. (D) Round.
CHEN02-021-040.I 3/22/01 1:25 PM Page 28
A B
C D
FIGURE 2–8 Principles of wound closure. (A) Large defect following excision of recurrent basal cell carcinoma.
(B) Deep closure complete, showing all tension taken by deep sutures. (C) Superficial running nylon placed to appose
wound edges. (D) Aperture opened at 8 weeks after primary reconstruction.
with nonabsorbable sutures that can later be removed there is little tension on the wound, and may be mod-
(Figs. 2–8 and 2–9B).) ified with a running technique for longer incisions.
Wound edges should be approximated with slight Although the placement of these may be technically
eversion, as they tend to invert during healing, and challenging, a figure-of-eight suture may be used and
this is particularly important with lid margin closure has the advantage of a lack of tissue reaction to the
where even slight inversion leads to an obvious notch. buried component, which is removed at the same
When viewed in cross section an everting suture time as the superficial portion (Fig. 2–9C).
should be of trapezoidal configuration, whereby more The end-on vertical mattress suture and the near-far,
deep tissue is included than skin (Fig. 2–9A). far-near sutures also provide excellent ways of elimi-
Many techniques can be applied for effective clo- nating dead space and relieving tension (Fig. 2–9D,
sure, but it is important to adhere to the principles E). These sutures tend to suppress local circulation
outlined above: Interrupted sutures are effective when and should be alternated with simple interrupted
CHEN02-021-040.I 3/22/01 1:25 PM Page 29
A A'
C D E
F N N F
FIGURE 2–9 Suturing techniques.

(A) Superficial closure with well-
apposed slightly everted wound edges.
(B) Deep wound closed in two layers
with deep buried suture and superficial
interrupted suture. (C) Figure-of-eight
F
suture used to close deep wound. Elim-
ination of dead space and relief of deep
tension can also be achieved by
(D) end-on vertical mattress and
(E) near-far, far-near sutures. (F) A hor-
izontal mattress suture provides a
broad area of tissue support.
sutures if possible. The horizontal mattress suture is edges, while minimizing the effect of suture materi-
useful in providing broad areas of support and is als on the epidermis; they do, however, first require
quickly placed as, for example, at the retroauricular tension-free subcutaneous closure (Fig. 2–10A). The
donor site for skin grafting (Fig. 2–9F). suture ends may be anchored, or left free for ease of
Subcuticular running sutures offer an aesthetically removal. Half-buried horizontal mattress sutures offer
desirable skin closure and serve to finely appose skin an excellent way to close skin at a tripartite junction,
A
B
FIGURE 2–10 Superficial skin closure using (A) subcuticular running suture or (B) half-buried horizontal mattress
suture at a tripartite junction.
CHEN02-021-040.I 3/22/01 1:25 PM Page 30
serving to bring the tips together without actually 2-octyl cyanoacrylate (Dermabond) have been used
involving them in the suture bite (Fig. 2–10B). for closure of eyelid skin grafts and facial lacerations
with impressive results.
EARL... Minimize scarring during

P wound closure by eradicating dead space
and relieving wound tension with deep sutures.
WOUND CARE AND DRESSINGS
Appropriate wound management is essential for opti-
Evert wound edges slightly with the skin sutures. mal wound healing. An antibiotic ointment, such as
topical fusidic acid, both minimizes infection and
keeps the wound moist and well lubricated. Ice com-
presses are valuable in reducing postoperative edema
A “dog-ear” is a relatively common problem due to and ecchymosis, as well as inducing relative analgesia
redundant tissue with unequal incisions and with cir- through local hypothermia.
cular or short elliptical incisions. The dog-ear may be In most cases a firm, but not heavily pressured, pad
excised as a second ellipse, to elongate the wound, and provides a compressive dressing that absorbs tissue
closed directly (preferably along the lines of relaxed fluid or hemorrhage and protects the incision. It must
skin tension) (Fig. 2–11A, B). Another approach is to be readily removable should inspection of the eye be
use an “M-Y plasty,” to remove two small triangles needed, if severe and increasing pain suggests a sight-
either side of the ellipse, with the tip at the end of the threatening postoperative orbital hemorrhage. The
linear incision (Fig. 2–11C). patient and staff should be advised to warn the sur-
geon of increasing postoperative pain, as evacuation
Tissue Glue of the hematoma might be required to prevent com-
Tissue glues, such as fibrin and cyanoacrylate-based pressive optic neuropathy.
adhesives, represent an alternative to sutures for In contrast, orbital surgery in the anophthalmic
wound closure.27, 28 The speed of application and the socket necessitates very firm dressings to discourage
lack of suture removal make this method ideal for edema or ecchymosis, which can be extensive in
children. Glues can generally be used for superficial major socket reconstruction. A thick eye dressing or
lacerations, but may be combined with subcutaneous double eye pad is secured with a very firm elastic
sutures for deeper wounds; they cannot, however, be adhesive strapping, using tincture of benzoin to
used for eyelid margin wounds, because the wounds improve adherence if so wished. A head bandage
are highly mobile and under considerable tension, may be used to increase pressure on the operative site.
and they require precise alignment. Lower lid ble-
pharoplasty incisions have been successfully closed Scar Management
with fibrin glue (Tissucol). Isobutyl cyanoacrylate Adherence to the principles of wound closure out-
(Histoacryl) and the stronger, longer carbon-chained lined above is likely to minimize scar formation.
FIGURE 2–11 Management of “dog-

ear” during wound closure. (A) Exci-
sion of ellipse with direct linear closure.
(B) Closure directed laterally toward
C
relaxed skin tension line. (C) M-Y plasty
directing closure along arms of Y.
CHEN02-021-040.I 3/22/01 1:25 PM Page 31
Occasionally, however, a hypertrophic scar develops closure. In patients prone to scar formation, a dermal
and this may be managed conservatively in the first platform technique can be used to minimize stimulation
instance, using massage with topical lubricant or of dermal fibroblast activity; only superficial scar tis-
steroid (such as triamcinolone) cream. A steroid sue is removed and underlying subcutaneous traction
may also be injected intradermally, although this may bands are left undisturbed with this procedure.
cause dermal atrophy and loss of pigmentation, a par-
ticular problem in heavily pigmented skins. Keloid Z-Plasty
represents an exuberant healing response extending This is a key technique for scar revision in both gen-
into tissue surrounding the scar, and may be man- eral and ophthalmic plastic surgery and is essentially
aged in a similar fashion to hypertrophic scars. For- a transposition flap (Fig. 2–12). The principle of the Z-
tunately, keloid is almost never seen in eyelid skin, plasty is to increase the length of the skin and tissue
the mechanism of this unique attribute not yet being along the line of the original scar while shortening the
understood.29 skin that lies at right angles to it. The tension lines are
thus redirected perpendicular to the original scar, ide-
Scar Revision ally toward the normal relaxed skin tension lines of
Scar revision should not be attempted until at least 6 the face.
months of wound healing have elapsed and the active The central limb of the Z is placed along the scar
contraction phase has passed. A realistic outcome is and parallel to the line of maximal tension. The
an improvement in the appearance of the scar, rather upper and lower arms of the Z are then placed at 60
than its complete removal. The methods available degrees to the central limb, such that all limbs of the
include dermabrasion, excision with dermabrasion, Z are of equal length. Two equilateral triangular flaps
excision with platform techniques, and redistribution of equal size are thus created and then extensively
of scar tension (Z-plasty or W-plasty).29 undermined to allow mutual transposition of the
Dermabrasion is an excellent technique for smooth- apices. Subcutaneous traction bands are dissected
ing the rough edges of a skin graft using a power- away and the flaps anchored with equal tension
driven drill with a rounded burr to abrade the distribution.
epidermal layer and “sculpt” the scar. This may be A conventional Z-plasty is often used to relieve
combined with simple excision of the whole scar and vertical contracture in injured eyelids, but may also
advancement of surrounding tissue with direct be modified to allow rotation of the eyelid and brow
y
a
x y
60° b
x
c
y
x
A B C
D E
FIGURE 2–12 Z-plasty. (A) Central limb of Z placed through line of scar, with limbs of equal length set at 60
degrees. (B) Flaps undermined and elevated. (C) Scar tissue excised. (D) Transposition of flaps. (E) Flaps sutured into
position, showing elongation of tissue along line of excised scar.
CHEN02-021-040.I 3/22/01 1:25 PM Page 32
For scars in thicker skin, such as the cheek, fore-

head or brow, the W-plasty is a useful alternative
(Fig. 2–15).30 Unlike the Z-plasty, it is essentially an
advancement flap in which W-shaped incisions are
made to run obliquely across the scar along relaxed
skin tension lines or wrinkle lines and scar tissue is
excised; the skin is then undermined and advanced to
closure without rotation of flaps. The W-plasty is
FIGURE 2–13 Modified Z-plasty technique to lower an
elevated brow, with limb lengths and angles set according to invariably accompanied by loss of tissue and is there-
the anatomically desired result. The end of the inferior limb fore not ideal when surplus skin is unavailable.
of the Z determines the future position of the brow and the
central limb is placed parallel to and under the arch of
the elevated brow. The superior arm of the Z is placed RECONSTRUCTIVE SURGERY
along the curve of the supraorbital rim and the flaps trans-
The oculoplastic surgeon often faces the challenge of
posed as shown, with care taken to avoid damage to lash
eyelid reconstruction, typically following tumor exci-
follicles.
sion. Primary closure is preferable if there is adequate
margin (Fig. 2–13).21 In this way it offers an alterna- tissue available to maintain normal function and
tive to skin grafting and is particularly useful in appearance, although occasionally healing by sec-
patients with extensive burns, in whom donor tissue ondary intent is utilized (see Wound Healing above).
may be severely limited. A larger defect will generally require closure using a
Multiple Z-plasties are useful when scars are too tissue flap or free graft; the donor blood supply
long for a single Z-plasty to allow adequate tissue rota- remains intact in a flap, whereas in a graft it is sev-
tion (Fig. 2–14). The initial incision is made along the ered and the tissue depends on vasculature from the
center of the scar with the upper and lower arms of the host site.
Z at 60 degrees to it. Additional arms are created par-
allel to these and extended along the length of the scar. Skin Flaps
Tissue flaps allow more rapid restoration of eyelid
function than free grafts, because their donor site vas-
EARL ...
P The limbs of a conven-
tional Z-plasty should be of equal length
and at 60 degrees to each other, the central limb
culature remains partially intact.21, 30 They are gener-
ally thicker than grafts and so may serve to fill a deep
defect, which might not otherwise be adequately cov-
lying along the scar line. ered with a free graft. Infection and pigment changes
are also less likely with a flap than with a graft.
A B, C
FIGURE 2–14 (A) Cicatricial ectropion due to facial and lower lid laceration. (B) Multiple Z-plasty (with notch
excision). (C) Dispersal of scar and correction of lower eyelid margin malposition.
CHEN02-021-040.I 3/22/01 1:25 PM Page 33
A sliding flap allows tension-free primary closure of

the defect after undermining of adjacent tissue
(Fig. 2–16A). This should be avoided when the defect
is adjacent to the eyelid margin since cicatricial ectro-
pion may result.
An advancement flap involves placing additional
relaxing skin incisions to allow advancement of the
undermined tissue for closure and is particularly use-
ful for square or rectangular defects (Figs. 2–16B and
2–17). The Cutler-Beard bridge flap, one example of an
advancement flap, uses a skin-muscle flap, advanced
from the lower lid, to replace a full-thickness upper
eyelid defect.31 The incision in the lower lid should be
made at least 5 mm below the eyelid margin, so that
the vascular supply to the lid margin is preserved. An
autologous cartilage graft may also be inserted
between the muscle and conjunctiva of the flap to sim-
ulate the upper lid tarsus.
The V-Y plasty and Y-V plasty represent special
FIGURE 2–15 W-plasty for repair of a straight scar. Tri- forms of advancement flap. The V-Y plasty can lengthen
angles become smaller at the end of the scar with tapering skin along lines of tension by effectively adding tissue
of limb length to avoid puckering. to the long limb of the Y and is occasionally used to
FIGURE 2–16 Skin flaps. (A) Sliding

flap with simple closure after under-
of mining of adjacent tissue. (B) Advance-
n
C Line tensio ment flap with relaxing incisions to
a l
maxim mobilize undermined tissue and lateral
extension of incisions at base to remove
Pivot
point dog-ears. (C) Rotation flap with relax-
ing backcut at pivot point. The circular
edge of the flap is four to five times the
length of the base of the defect.
(D). Classic bilobar flap, with the first
lobe rotated into a round defect and the
second smaller lobe filling the space
D vacated by the first; the defect left by
the second lobe is closed linearly. Tis-
sue is thus advanced from an area with
relatively lax skin to close a defect in an
area with less mobile skin.
CHEN02-021-040.I 3/22/01 1:25 PM Page 34
The O-Z plasty and rhomboid flaps represent spe-

cialized transposition flaps. The O-Z plasty converts a
round defect into a Z-shaped linear one and may be
used to close the abdominal site after donation of a
dermis-fat graft (Fig. 2–20A). A rhomboid flap is useful
for repairing rhomboid defects over the temporal
region, but requires wide tissue undermining to
ensure mobility for tissue transposition. It is most
important to place the incisional angles at 120 and 60
degrees (Fig. 2–20B).
...
FIGURE 2–17 Advancement flap for repair of round
P EARL The length of a skin flap
should be no greater than three to four
times the width of its base; a skin-muscle flap may
defect medially on lower eyelid.
be seven to eight times the width of its pedicle.
correct minor cicatricial ectropion or in medial canthal
reconstruction (Fig. 2–18A).32 The Y-V plasty effectively
relieves tension and adds tissue perpendicular to the Grafts
long limb of the Y, shortening the tissue that is parallel The eyelid is fortunate in possessing an extensive blood
to it, thus being particularly useful for correcting epi- supply that is highly supportive to grafted tissue and is
canthal folds (Fig. 2–18B). thus amenable to a wide range of grafting techniques.
A rotation flap is placed in the host site by rotating Grafts may be autologous (from the same person),
the flap at its base and the remaining defect at the homologous (from the same species, but different per-
donor site is closed directly (Fig. 2–16C). The semicir- son), or heterologous (from a different species).
cular myocutaneous Tenzel rotation flap rotates tis- Autologous grafts include skin, mucosa, tarsus,
sue from the lateral end of the upper eyelid to dermis, fat, fascia lata, cartilage, and bone. Occasion-
reconstruct the lower eyelid.33 ally homologous grafts of banked tissue are used, for
A transposition flap is similar to a rotational one, example, preserved fascia, irradiated sclera, cartilage,
except the flap is advanced into a nonadjacent defect.21 or bone. However, the trend is increasingly to use
Examples are the bilobar flap (Fig. 2–16D), the Z-plasty, autologous material where possible, because this
the temporal flap, and the glabellar flap (Fig. 2–19). avoids the risk of infectious disease transmission.
A V-Y Plasty
Length added
Direction of horizontally to
tissue shortage limb of “Y”
B Y-V Plasty
FIGURE 2–18 (A) V-Y plasty. Tissue

is added and tension relieved along the
limb of the Y. (B) Y-V plasty. Tissue is
removed along the limb of the Y and, Direction of Length added
perpendicular to it, length is added tissue shortage vertically subtracts
with relief of tension. from limb of “Y”
CHEN02-021-040.I 3/22/01 1:25 PM Page 35
A B
FIGURE 2–19 Glabellar transposition flap. (A) Flaps

marked out to cover large medial canthal defect. (B) Clo-
sure of defect with tension carried by deep sutures.
C (C) Result 9 months postoperatively.
B B
120°
B D'
A C A E'
60°
F
D D' D
FIGURE 2–20 (A) O-Z plasty. (B)
Loose skin Rhomboid flap, showing mandatory
F
angles of 120 and 60 degrees in the
E' defect. The short diagonal BD equals
the length of all sides of the flap and
E E CD¿ is parallel to E¿F.
CHEN02-021-040.I 3/22/01 1:25 PM Page 36
Skin Grafts
EARL ...
Full-thickness skin grafts are generally used for eyelid
reconstruction and may be taken from various donor
sites that, to prevent trichiasis, should be free of vis-
P A grafted socket should
never be left without a conformer during
the postoperative period, or severe contracture
ible hair. Retroauricular skin provides an excellent
match for lower lid skin, whereas contralateral may result.
upper eyelid skin is ideal for upper lid defects. Alter-
natives include the supraclavicular area or skin from
the inner aspect of the upper arm, although the color Mucous Membrane Grafts
and texture match of tissue from these sites is not as Mucosal grafts are often required in patients with
good. contraction of the conjunctival fornices secondary to
The donor site of a full-thickness skin graft should cicatricial disease.29–31 Simple mucosal grafts without
be planned, marked, outlined by incision with a knife, tarsal support can be taken from the healthy bulbar
and dissected thinly with scissors. Any subcutaneous or forniceal conjunctiva of the fellow eye, or, alterna-
fat is trimmed from the graft while stretched over the tively, oral mucosa from the lower lip, upper lip, or
surgeon’s finger. The size of the graft should be buccal surfaces can be used. Buccal mucosa is some-
slightly larger than the recipient template to allow for what thicker and more difficult to harvest, and care
shrinkage. Anchoring sutures are used to hold the must be taken to avoid the parotid duct opening,
graft in place and should be left long if a pressure which lies opposite the upper second molar tooth. If
stent is to be tied on top of the graft to apply it to the full-thickness oral mucosa is used, it may be har-
host bed. Alternatively a removable dressing may be vested freehand, but a Castroviejo mucotome may be
used, so that any blood collecting under the graft can used if a split-thickness graft is needed. In general, to
be easily detected and removed. replace bulbar conjunctiva the graft should be no
thicker than 0.4 mm, whereas that for relining sock-
ets may be about 0.6 mm thick.
A composite mucosal graft utilizes underlying tis-
EARL ...
P The graft should be se-
curely immobilized until sutures are
removed.
sue for additional mechanical support and is useful
when there is tarsoconjunctival contraction, as in cica-
tricial entropion, or where there is a loss of tarsal
structure after tumor resection. For example, an autol-
ogous tarsoconjunctival graft from the fellow upper
eyelid can be used for reconstruction of the posterior
Skin graft survival depends on precision in surgical lamella of a lower eyelid (Fig. 2–21). Hard palate
technique and meticulous preparation of the recipi- mucosa has a rigidity similar to tarsus and is an effec-
ent site. Scrupulous asepsis is vital and may warrant tive alternative for correction of upper or lower lid
the use of parenteral antibiotics during and after
surgery. The graft should be immobilized when in
place to allow adequate nutrient exchange and time
for capillary ingrowth, and the blood supply of the
recipient site should be adequate for the graft. If there
is any doubt, a pedicle flap graft should be consid-
ered. Sufficient hemostasis must be achieved, without
excessive cauterization, and some surgeons puncture
a large graft to allow for the egress of any pooled
fluid.
Split-thickness skin grafts are limited by their
marked tendency to contract and this may limit
their suitability for eyelid reconstruction. They
may, however, be used in exenterated sockets or for
facial burns, when the area needing grafting can be
quite extensive. Although a Watson’s knife may FIGURE 2–21 Harvesting tarsoconjunctival graft from
be used to harvest a partial-thickness skin graft, it everted right upper eyelid. Black arrow shows margin of
may be slightly easier to achieve a uniform thick- 4 mm remaining upper tarsus with donor tarsus (white
ness graft with a drum, an electric, or an air-driven arrows) still attached to Müller’s muscle and conjunctiva of
dermatome. upper fornix.
CHEN02-021-040.I 3/22/01 1:25 PM Page 37
A B
FIGURE 2–22 (A) Hard palate mucosa graft. (B) Donor site at 1 week after surgery.
retraction; it is also a valuable material for relining Cartilage Grafts

markedly contracted sockets, undergoing minimal Cartilage can be harvested from the posterior surface
postoperative shrinkage (Fig. 2–22). Nasochondral of the ear, in addition to the nasal septum as
mucosa from the nasal septum may also be used, but described above. It is particularly useful in posterior
is much thicker and somewhat too rigid for conform- lamellar reconstruction and as a spacer in cases of
ing to the globe; a further disadvantage can be long-standing lid retraction. Auricular cartilage is
marked mucus production due to the presence of obtained from the flattest portion between the helix
numerous goblet cells in the graft. laterally and antihelix medially, an area known as the
scaphoid fossa (Fig. 2–23). Larger grafts tend to curl
and this may be avoided by scoring one surface of
PITFALL the graft to relax and flatten it.
Where replacement of both tarsal and mucosal ele-
Buccal or mucosal grafts undergo significant ments is required, a chondromucosal graft, such as
hard palate or nasochondral mucosa, may be used.
contracture, whereas hard palate mucosal
Alternatively, auricular cartilage can be incorporated
grafts are much less susceptible to this. into a chondromucosal graft by a two-stage technique,
in which auricular cartilage is harvested and inserted
FIGURE 2–23 Auricular carti-

lage graft. (A) Donor site behind ear
A B lobe. (B) Harvested graft.
CHEN02-021-040.I 3/22/01 1:25 PM Page 38
into a buccal submucosal pocket.29 The graft is major craniofacial reconstructions and minimal
allowed to vascularize for 3 to 4 weeks, and the com- donor-site morbidity, although it might be advisable
pound graft of auricular cartilage and buccal mucosa to perform this procedure with a neurosurgeon, in
can then be harvested. view of possible intracranial complications.
Donor Sclera Biomaterials

Banked homologous donor sclera may be used in pos- A wide range of alloplastic biomaterials are used in
terior lamellar reconstruction, but is used infrequently oculoplastic surgery, all of which are designed to
due to risk of transmission of infectious diseases from cause minimal tissue reaction while attempting to
the donor. In practice, alternative materials are avail- restore function.29, 35 Silastic sheeting is extensively
able for almost all oculoplastic procedures in which used to repair uncomplicated orbital floor fractures,
donor sclera was previously indicated. Donor sclera is with Supramid sheeting and Teflon plates as alterna-
prepared according to standard protocol and, before tives. Titanium miniplates are used for more complex
use, is rehydrated with an antibiotic solution. As orbital fractures and allow rigid fixation to the orbital
sclera lacks a mucosa, opinion is divided as to the rim and skeleton.
need for conjunctival cover following placement and, Many biomaterials are used in eyelid procedures,
as sclera is more flexible than tarsus, there may be including silicone rod for frontalis suspension and
some instability of the reconstructed lid after its Mersilene mesh frontalis sling in certain types of pto-
usage. sis. Gold weights sutured to the tarsal plate are used
for lid retraction and lagophthalmos in facial nerve
palsies, whereas polytetrafluoroethylene (Gore-tex)
Dermis-Fat Grafts
may be used as a spacer in eyelid reconstruction.
Autologous dermis-fat grafts can be readily harvested Volume augmentation in the orbit can be achieved
from the patient’s lower lateral abdominal quadrant using many materials, including bone cement and
or lateral thigh and provide a satisfactory means of room-temperature-vulcanized (RTV) silicone. Soft tis-
volume expansion in the mildly contracted anoph- sue expanders are temporary implants that allow
thalmic socket. The attached dermis is thought to stretching of the overlying tissue following injection
facilitate vascularization and reduces the atrophy and expansion with saline. They distribute surround-
associated with free-fat grafts. It also serves as a use- ing tissue over a greater surface area and are removed
ful graft for filling facial soft tissue defects around the after adequate expansion is obtained.
orbit.34 A large variety of alloplastic materials have been
used as orbital implants for the enucleated or eviscer-
Autologous Fascia ated socket, including polymethylmethacrylate, sili-
Autologous fascia is typically used in ptosis surgery cone, titanium, tantalum mesh, and glass (Fig. 2–24).
and is generally harvested from tensor fascia lata on In recent years much interest has surrounded the use
the lateral aspect of thigh. It is relatively easy to obtain of hydroxyapatite implants, which are made from
in the adult, but may be difficult in a child with a hydrothermally converted marine coral or by a syn-
short thigh. Temporalis fascia is also occasionally thetic process, this material being porous and allow-
used in eyelid reconstruction to create a lateral can- ing permeation by host fibrovascular tissue. An
thal ligament. integrated peg system allows subsequent linkage of
the ball movement to the overlying artificial eye. Early
results have been encouraging with regard to motil-
Bone Grafts
ity, although the rate of implant exposure, infection,
Autologous bone grafts are used for orbital wall and peg-related complications is quite high. Porous
reconstructions and are typically harvested from the polyethylene implants are also available, become sim-
iliac crest or cranium. When compared to alloplastic ilarly integrated in the socket, and allow placement of
materials, such as bone cement, bone grafts offer a a titanium motility peg.
low rate of extrusion or infection, but have the disad-
vantage of graft reabsorption. Iliac crest bone is rela-
EARL ... Intraoperative antibiotic
tively straightforward to obtain and is useful for
correcting orbital floor and roof defects.
Cranial bone is membranous, embryologically sim-
P prophylaxis is advisable for all cases where
biomaterials are being implanted, as postopera-
ilar to the orbit, and may therefore offer a greater sur-
vival of graft volume than iliac crest bone. Further tive infection can be difficult to treat.
advantages are ease of access to the donor site during
CHEN02-021-040.I 3/22/01 1:25 PM Page 39
A B
FIGURE 2–24 Orbital implants made from (A) hydroxyapatite and (B) glass.
SUMMARY surgeons’ preferences will dictate which combina-

tion of techniques will achieve the best results for
This chapter reviewed the fundamental concepts of restoration of functional as well as aesthetic
oculoplastic techniques. Clinical circumstances and integrity.
REFERENCES
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(1896–1996). Ophthalmology 1996;103(8 suppl): s74–95. thesia. Oxford: Blackwell, 1983.
2. Bosniak SL, Smith BC: Advances in Ophthalmic Plastic 15. Epstein GA: Anesthesia in ophthalmic plastic surgery.
and Reconstructive Surgery: History and Tradition. New In: Hornblass A, ed. Oculoplastic, Orbital, and Recon-
York: Pergamon, 1986. structive Surgery, vol 1: Eyelids. Baltimore: William &
3. Hawes MJ, Bible HH Jr: The paranoid patient: surgeon Wilkins, 1988:42–51.
beware! Ophthalmic Plast Reconstr Surg 1990;6:225–227. 16. Hurley LD, Westfall CT, Shore JW: Prophylactic use of
4. Goin JM, Goin MK: Changing the Body: Psychological antibiotics in oculoplastic surgery. Int Ophthalmol Clin
Effects of Plastic Surgery. Baltimore: Williams & Wilkins, 1992;32:165–178.
1981. 17. Walland MJ, Rose GE: Factors affecting the success rate of
5. Tardy ME, Brown R: Principles of Photography in Facial open lacrimal surgery. Br J Ophthalmol 1994;78:888–891.
Plastic Surgery. New York: Thieme, 1992. 18. Lorenz HP, Longaker MT, Kawamoto HK Jr: Primary
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7. Koopman CF Jr: Cutaneous wound healing. An orbitotomy. Ophthalmic Plast Reconstr Surg 1999;
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11. Mehta HK: Spontaneous reformation of upper eyelid. 22. Hartikainen J, Antila J, Varpula M, Puukka P, Seppa H,
Br J Ophthalmol 1988;72:856–862. Grenman R: Prospective randomized comparison of
12. Kahari VM, Saarialho-Kere U: Matrix metallopro- endonasal endoscopic dacryocystorhinostomy and
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teinase inhibitors and wound healing: a novel enhancer 23. Christie DB, Woog JJ: Basic surgical techniques, technol-
of wound strength. Surgery 1998;124:464–470. ogy, and wound repair. In: Bosniak S, ed. Principles and
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Practice of Ophthalmic Plastic and Reconstructive Surgery, 30. Hyde KJ, Jormozi D: Basic principles of eyelid and
vol 1. Philadelphia: WB Saunders, 1996:281–293. adnexal surgery. In: Stephenson CM, ed. Ophthalmic
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Plast Reconstr Surg 1993;9:143–147. 31. Cutler N, Beard C: A method for partial and total upper
25. Schietroma JJ, Tenzel RR: The effects of cautery on the lid reconstruction. Am J Ophthalmol 1955;39:1–7.
optic nerve. Ophthalmic Plast Reconstr Surg 1990;6:102–107. 32. Reich R: General principles and considerations. In:
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27. Mommaerts MY, Beirne JC, Jacobs WI, Abeloos JS, De 1988:23–41.
Clercq CA, Neyt LF: Use of fibrin glue in lower ble- 33. Tenzel RR, Stewart WB: Eyelid reconstruction by semi-
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Surgery. New York: Raven Press, 1995:1–49.
CHEN03-041-054.I 3/26/01 8:24 AM Page 41
Chapter 3
ENTROPION
Jan W. Kronish
The physiologic integrity and clarity of the ocular ANATOMY

surface is dependent on properly apposed eyelids
and smooth eyelid margins. Due to infection, An understanding of eyelid anatomy and function is
inflammation, trauma, and involutional processes, paramount for the evaluation and surgical repair of
the stability and position of the eyelid can become entropion. From a surgical perspective, the eyelids are
disrupted. In entropion, the eyelid is rotated inward composed of two layers. The anterior lamella consists
in such a way that the eyelid margin, eyelashes, and of the skin, eyelashes, glandular structures, and the
skin of the eyelids rub against the globe resulting in orbicularis oculi muscle. The posterior lamella
irritative symptoms and possibly abrasion and includes the tarsus, conjunctiva, and retractors. The
scarring of the cornea. In most cases, surgical inter- tarsal plate is approximately 1 mm thick, and has a
vention is imperative to relieve the associated dis- vertical height of 9 to 10 mm in the upper lid (7 to
comfort and to prevent potentially vision-threatening 8 mm in Asians) and 3.9 to 4 mm in the lower lid. The
sequelae. medial and lateral canthal tendons anchor the eyelids
Numerous other conditions can mimic entropion; to the orbital bone periosteum.
however, they coexist with eyelid margins that are The lower eyelid retractors provide stability and
anatomically oriented. Trichiasis is an acquired dis- dynamic movement analogous to the levator aponeu-
order of misdirected eyelashes that originate from rosis and Müller’s muscle of the upper lid. They orig-
normally positioned eyelash follicles. Distichiasis inate from fibrous extensions of the inferior oblique
refers to aberrant eyelashes that arise from meta- muscle and form the capsulopalpebral head
plastic meibomian gland ducts and are in the prox- (Fig. 3–1A). The fascia splits anteriorly to surround
imity of, or directly contact, the ocular surface. the inferior oblique muscle and then fuses together to
Normal eyelashes can be mechanically pushed form Lockwood’s ligament. The posterior portion
toward the eye by redundant folds of skin such as includes adrenergic smooth muscle fibers, referred to
epiblepharon, typically seen in young children; epi- as the inferior tarsal muscle, whereas the anterior
canthal folds, preferentially found in children and extension consists of fibrous connective tissue. It con-
Asians; and dermatochalasis, a common condition tinues forward and superiorly as the capsulopalpe-
associated with advanced age. Eyelid margin destruc- bral fascia and ultimately inserts onto the inferior
tion may also be associated with abnormal eyelashes tarsal border, the orbital septum, the preseptal orbic-
or hair, scar tissue, and/or an epidermalized surface, ularis oculi muscle, and the inferior conjunctival
which can also simulate the presentation and effects fornix. Developmental and acquired disorders of the
of entropion. It is important to differentiate entro- tarsal plate, supporting tendons, and retractors of
pion from these other conditions, as the treatment the eyelids contribute to the development of eyelid
will vary. malpositions including entropion.
41
CHEN03-041-054.I 3/22/01 1:28 PM Page 42
Eye Dehiscence of
Inferior Inferior lower lid retractors
Tarsus tarsal muscle rectus muscle
Orbicularis oculi
muscle
Orbital septum
Inferior
Capsulopalpebral oblique muscle
fascia
Lockwood’s Orbital fat
A ligament B
FIGURE 3–1 (A) Sagittal diagram of the eyelid and inferior orbit showing the anatomic relationship of the retrac-
tors and protractors of the lower lid. (B) Schematic representation of lower eyelid with involutional entropion. Patho-
physiologic features include a dehiscence of the lower lid retractors, outward buckling of the inferior tarsus, and
overriding of the preseptal orbicular muscle.
CLASSIFICATION AND time or develop ocular surface complications, surgical

PATHOPHYSIOLOGY repair is directed to attaching the lower lid retractors
to the anterior lamella and possibly removing excess
Congenital Entropion and Epiblepharon skin and orbicularis muscle.
Congenital entropion is an extremely rare disorder
Involutional Entropion
that tends to be familial and can involve both the
upper and lower eyelids. Different pathophysiologic Involutional entropion is the most common type of
mechanisms have been proposed including hypertro- entropion and most often affects the lower eyelids of
phy of the pretarsal orbicularis muscle fibers and defi- the elderly. Five pathophysiologic mechanisms have
ciency of the tarsus. The improper development or been proposed that may contribute to the internal
incomplete attachment of the retractor aponeurosis rotation of the eyelid margin (Table 3–1). In almost all
insertion may be a contributing factor in some cases, stretching or loosening of the medial and lat-
cases.1–3 Another developmental form of entropion is eral canthal tendons leads to horizontal laxity of the
the horizontal tarsal kink syndrome, which usually eyelids. A similar mechanism may also lead to ectro-
involves the upper eyelids and frequently leads to pion; however, other pathologic changes as described
corneal ulceration. This unusual disorder may be below will influence the direction of lid margin rota-
associated with other systemic anomalies, and treat- tion.7 Jones8 demonstrated with anatomic studies that
ment should be performed with urgency.4 the lower lid retractors normally insert on the inferior
A much more common congenital eyelid disorder border of the tarsus and produce a stabilizing down-
is epiblepharon, seen most often in Asian children ward vector. He theorized that disinsertion or loosen-
and involving only the lower eyelids. A superiorly ing of this attachment leads to loss of this stabilizing
displaced fold of pretarsal skin and orbicularis muscle
greatest in the medial portion of the eyelids causes an
inward rotation of the eyelid margin and lashes. The TABLE 3–1 PATHOPHYSIOLOGIC
pathophysiologic mechanism is reportedly a defective MECHANISMS OF INVOLUTIONAL ENTROPION
lower lid retractor layer attachment to the anterior
Horizontal eyelid laxity (medial and lateral canthal
lamellar soft tissues in the region of the eyelid crease.
tendon stretching or attenuation)
Other associated anomalies, such as inferior oblique Dehiscence or weakening of the lower eyelid retrac-
insufficiency5 and antimongoloid eyelid slant, should tors
be suspected in non-Asian children.6 Most cases of Overriding or superior shift of the preseptal orbicu-
epiblepharon do not require surgical intervention laris muscle over the pretarsal space
because the majority of patients are asymptomatic Involutional changes of the tarsus
and the condition tends to improve with facial devel- Enophthalmos
opment. For those cases that do not improve with
CHEN03-041-054.I 3/22/01 1:28 PM Page 43
ENTROPION • 43
Trachoma is the leading cause of cicatricial entropion

and a major cause of blindness in many countries.
Other important conjunctival diseases that lead to
shrinkage of the posterior lamella of the eyelids
include chemical burns, trauma, ocular cicatricial
pemphigoid, Stevens-Johnson syndrome, erythema
multiforme, chronic blepharoconjunctivitis, herpes
zoster, chronic allergies, atopic keratoconjunctivitis,
membranous conjunctivitis, and pseudopemphigoid
secondary to long-term use of topical medications
such as miotics and idoxuridine. Determination of the
etiology of the cicatricial conjunctival process is criti-
cal from both a standpoint of medical control of the
disease as well as surgical intervention.
FIGURE 3–2 Clinical photograph of an elderly patient
with entropion of the lower eyelid. Dehiscence of the lower
lid retractors contributes to the entropic lid position, and is
analogous to dehiscence of the levator aponeurosis con- CLINICAL FEATURES AND PATIENT
tributing to upper lid ptosis also seen in this patient. EVALUATION
force and can progress to the rotation of the tarsal The majority of patients with entropion present with
plate along its horizontal axis, resulting in entropion the acute onset or recurrent symptoms of foreign
(Figs. 3–1B and 3–2). The third most significant alter- body sensation, burning, tearing, and photophobia.
ation is migration of the preseptal orbicularis muscle A thin mucoid or mucopurulent discharge may
fibers over the lower border of the tarsal plate due to accompany an inflamed eye and contribute to blurred
weakened attachments between the skin, preseptal vision. The lid malposition is often apparent when
orbicularis muscle, and septum.9 With eyelid closure, the eyelid margin is chronically turned inward. In
the contractile forces of the displaced orbicularis mus- cases of intermittent entropion, the eyelid may
cle promote the inward rotation of the eyelid margin. appear to be in normal position, and certain maneu-
Most modern surgical approaches for entropion vers may be necessary to yield a proper diagnosis.
repair incorporate corrective measures for all three of Having patients squeeze their eyelids closed force-
these pathologic changes. fully or look downward will usually elicit internal
Other features identified as contributing to the rotation of the lid margin in eyelids prone to entro-
development of entropion include enophthalmos and pion. Placing patients in a supine position maximizes
degeneration of the tarsal plate. Enophthalmos of any this effect. In patients with unilateral symptoms,
cause, including trauma, microphthalmos, anophthal- these techniques may unveil an impending entropion
mos, phthisis bulbi, and age related, reduces the pos- in the contralateral eyelid.
terior support of the lower eyelid and may destabilize A complete and thorough eye examination should
the tarsus.10 Also, thinning and reduction in the verti- be performed in all patients to assess the status of the
cal dimensions of the tarsus demonstrated on histo- ocular surface and potential etiologies of the lid mal-
logic studies7 may further exacerbate eyelid instability. position. Slit-lamp evaluation of the conjunctiva and
Of all of the various causes of involutional entropion, cornea typically reveals punctate or linear staining of
Benger and Musch11 concluded that laxity of the the epithelial surface due to the abrasive effects of the
retractors was probably the most important factor. eyelashes and keratinized skin. Biomicroscopy is
The acute onset of entropion may be caused by especially useful to detect subtle signs of scarring of
spasms or overactivity of the orbicularis oculi mus- the conjunctiva (Fig. 3–3), symblepharon, as well as
cles in cases of essential blepharospasm or induced by evidence of inflammatory processes, such as blephar-
ocular irritation from dry eyes or recent eye surgery. itis, that can lead to cicatricial entropion. The digital
In older patients, this form of spastic entropion results eversion test is also helpful in differentiating involu-
from involutional pathologic changes in the eyelid tional and cicatricial entropion. With the patient sit-
and should be classified as involutional entropion. ting upright and inhibiting blinking, the eyelid is
gently pulled downward and if it remains in its
Cicatricial Entropion proper vertical orientation, the etiology is involu-
The contractile forces of cicatrizing diseases of the tional. Alternatively, if the eyelid margin resumes an
conjunctiva and tarsus may lead to entropion in the inward rotation, then there is a shrinkage or retrac-
absence of eyelid laxity or dehiscence of the retractors. tion of the posterior lamella.
CHEN03-041-054.I 3/22/01 1:28 PM Page 44
EARL... Features of a dehiscence or

P disinsertion of the lower lid retractors
include an absent eyelid crease, a shallow infe-
rior fornix, and a rolled appearance to the eyelid
due to overriding of the preseptal orbicularis
muscle over the pretarsal orbicularis.
MEDICAL MANAGEMENT
When symptoms are mild from intermittent entro-
pion or while the patient is awaiting surgical repair,
FIGURE 3–3 Tarsal conjunctival scarring is identified in temporizing measures may be offered. Topical lubri-
this everted upper eyelid leading to cicatricial entropion. cating ointments and bandage contact lenses help to
provide a barrier between the ocular surface and
entropic lid margin. Pulling the eyelid down or later-
EARL... The digital eversion test is
P useful in differentiating involutional and
cicatricial entropion. With the patient sitting
ally with tape may alleviate the irritative symptoms.
This is best achieved by applying Mastisol or benzoin
to the pretarsal and preseptal eyelid skin to provide
better adherence of the tape to the eyelid. Botulinum
upright and inhibiting blinking, the eyelid is gen- A toxin (Botox) injections may also provide tempo-
tly pulled downward and if it remains in its rary relief by weakening the protractors of the eyelid,
proper vertical orientation, the etiology is invo- particularly in cases of associated essential ble-
lutional. Alternatively, if the eyelid margin pharospasm or hemifacial spasm. Underlying inflam-
resumes an inward rotation, then there is a matory disorders, such as blepharitis, should be
treated with appropriate topical and systemic med-
shrinkage or retraction of the posterior lamella.
ications. Autoimmune disorders contributing to con-
junctival cicatricial diseases should be managed in
conjunction with a rheumatologist or internist.
The eyelid should also be evaluated for horizontal
laxity. The snap back test is performed by exerting
downward traction on the eyelid margin and moni-
toring the position of the eyelid upon its release. Nor-
SURGICAL MANAGEMENT
mally, the eyelid will return promptly to its anatomic Involutional Entropion
position. In the setting of pathologic laxity, the eyelid
will remain below its proper position without globe Suture Repair
apposition. The distraction test helps to demonstrate A popular bedside or office technique that provides
the severity of eyelid laxity quantitatively. Normally, immediate symptomatic relief involves the placement
the eyelid can be manually withdrawn only 2 to 3 mm of full-thickness eyelid sutures for involutional as well
from the globe; however, in cases of poor tendon as spastic entropion of the lower lid. The use of
strength, the gap between the eyelid and globe may sutures for management of entropion dates back to
extend up to 20 mm. ancient Greek times; however, the first published
Clinical features of a dehiscence or disinsertion of reports of full-thickness sutures were by Snellen12 and
the lower lid retractors include an absent eyelid Hotz13 in the 19th century. The method popularized
crease, a shallow inferior fornix, and a rolled appear- more recently by Quickert and Rathbun14 provides an
ance to the eyelid due to overriding of the preseptal indirect tightening of the lower lid retractors and
orbicularis muscle over the pretarsal orbicularis. A transfers the eversion force to the anterior lamella.
gray coloration due to the underlying orbicularis This is achieved by eliciting an inflammatory cicatrix
muscle may be visible in the conjunctival fornix with an absorbable suture passed between the retrac-
between the inferior tarsal border and superior edge tors and orbicularis muscle and providing a barrier
of the dehisced retractors. In addition, when the eye- that prevents overriding of the preseptal orbicularis
lid retractors are disinserted, there will be loss of the muscle. This quick and easy treatment is considered a
normal 4 to 5 mm of lower lid excursion in downgaze temporary method of entropion repair with a rela-
(ptosis of the lower lid). tively high recurrence rate. Definitive long-term
CHEN03-041-054.I 3/22/01 1:28 PM Page 45
ENTROPION • 45
FIGURE 3–5 Mild overcorrection of spastic entropion

with slight eversion of the lid margin is desirable following
FIGURE 3–4 Full-thickness suture repair of lower lid a Quickert-Rathbun suture repair.
entropion. The horizontal mattress sutures are passed from
the inferior conjunctival fornix below the inferior tarsal bor- tional entropion, but many fail the test of time because
der, through the pretarsal orbicularis fibers and skin, and they do not address the underlying pathologic mech-
tied to create outward rotation. anisms. The goals of modern techniques are to correct
correction should be directed toward correcting the each anatomic defect either separately or in a com-
anatomic defects underlying the entropion. bined approach. The majority of cases of involutional
Local anesthesia is utilized when performing entropion respond well to the combination of re-
suture repair of entropion. Topical tetracaine is attaching the lower lid retractors to the inferior tarsus
applied to the eye and 2% lidocaine with 1 : 100,000 and horizontally tightening the eyelid with a lateral
epinephrine is injected subcutaneously and subcon- tarsal strip procedure. The retractor repair may be
junctivally in the inferior fornix across the length of approached anteriorly through a cutaneous incision15
the lower eyelid. The eyelid is pulled away from the or posteriorly via the conjunctiva.16
globe with a toothed forceps. One needle of a double-
armed 4-0 or 5-0 chromic gut suture is passed through
...
the conjunctiva and retractor layer in the depth of the
inferior fornix in a perpendicular fashion. It is
advanced anteriorly and superiorly through orbicu-
P EARL The anterior technique
offers better visualization of the dis-
placed lower lid retractors, whereas the post-
laris and skin to emerge 2 to 3 mm below the lash line erior method involves less dissection and avoids
(Fig. 3–4). The needle exit point can be placed higher a visible scar.
or lower, depending on how much everting effect is
desired. The second arm of the suture is passed
through the same pathway 3 mm from and parallel to Studies have shown that the efficacy of treatment is
the first arm. The arms of the suture are tied tightly greatest when eyelid tightening is performed in addi-
together without a bolster to evert the eyelid margin tion to reinsertion of the lower lid retractors17, 18; there-
slightly away from the globe. Two or three additional fore, these combination techniques are outlined below.
sutures are placed in a similar manner adjacent to
each other and divided evenly across the eyelid Anterior Approach to Lower Eyelid Retractor Repair
(Fig. 3–5). The most nasally placed suture should be Local anesthesia is preferable for almost all surgical
lateral to the punctum to avoid the induction of punc- methods for entropion repair with the exception of
tal eversion. Antibiotic ointment is applied twice daily children and uncooperative adult patients. It allows
until the sutures dissolve or fall out. If the eyelid the surgeon to judge the effectiveness of the technique
remains in an overcorrected position for more than 3 intraoperatively, to avoid lid retraction and overcor-
to 4 days or a significant ectropion develops, the rection, and reduce bleeding from the adrenergic-
offending sutures should be removed. induced vasoconstriction. Approximately 2 to 3 mL
of 2% lidocaine with 1 : 100,000 epinephrine is injected
Combined Retractor and Eyelid Laxity Repair subcutaneously across the whole lower lid and in the
Hundreds of surgical approaches and variations have lateral canthus and an additional 1 to 2 mL introduced
been described in the past century to repair involu- subconjunctivally in the inferior fornix.
CHEN03-041-054.I 3/22/01 1:28 PM Page 46
FIGURE 3–6 The left lower lid is being drawn laterally FIGURE 3–7 With the skin-muscle flap retracted inferi-
with forceps and the pointer demarcating the junction of the orly, the inferiorly dehisced edge of the left lower eyelid
lateral commissure and the proposed lateral tarsal strip. The retractor is identified (lower pointer) as well as the inferior
previously dissected skin-muscle flap is retracted inferiorly. edge of the tarsal plate (upper pointer).
A marking pen is used to demarcate an infraciliary pads and distention of the septum. With the fat and
incision from just below the lacrimal punctum to the septum retracted inferiorly, the detached or attenu-
lateral canthus. A 4-0 silk traction suture is placed ated lower lid retractors are visualized as a white fas-
through the gray line of the lid margin and retracted cial band (Fig. 3–7). To confirm the identification of
superiorly to put the posterior lamella on tension. A the retractors, the patient can be asked to gaze down-
blepharoplasty incision is made through the skin ward and a corresponding inferior movement should
with a size 15 Bard-Parker blade. The skin is under- be encountered as the retractors are grasped with a
mined for 5 to 7 mm below the lid margin at which forceps. The disinserted edge of the retractors is reat-
point the dissection is directed through the orbicu- tached to the inferior tarsal border with three or four
laris muscle at the inferior tarsal border. Dissection 6-0 polyglactin or polypropylene sutures with the
is continued inferiorly with a Wescott scissors or a knots placed away from the globe (Fig. 3–8). The
high-temperature disposable cautery between the retractors should not be secured to the anterior sur-
preseptal orbicularis muscle and the orbital septum face of the tarsal plate, as it may cause an ectropion.20
halfway to the inferior orbital rim. With the traction sutures removed, downward excur-
Horizontal lid tightening is usually necessary and sion of the eyelid can now be assessed with patient
can be addressed at this stage with a lateral tarsal strip cooperation. Excess orbital fat can be excised or
procedure19 to help stabilize the eyelid. The traction sculpted posteriorly with cautery if indicated.
sutures are released, and a lateral canthotomy 6 to
8 mm in length is carried out. The inferior crus of the
lateral canthal tendon and the lateral fascial attach-
ments of the lower lid retractors are divided so that
the lower lid rotates outward. The eyelid is pulled
temporally over the lateral orbital rim with an appro-
priate amount of tension to demarcate the amount of
tissue to trim (Fig. 3–6). A tarsal strip is created by
removing the excess skin and pretarsal orbicularis
muscle anteriorly, mucocutaneous margin superiorly,
and conjunctiva posteriorly and inferiorly. The lower
lid is once again placed on superior traction with the
previously placed marginal suture.
Attention is redirected to repair the dehisced lower
lid retractors by opening the orbital septum with a
scissors or hot cautery tip below the fusion of the sep-
tum and eyelid retractors. Identification of the septum
is facilitated by gentle pressure applied to the globe, FIGURE 3–8 The dehisced edge of the lower lid retrac-
which causes forward herniation of the orbital fat tors is sutured to the inferior edge of the tarsus.
CHEN03-041-054.I 3/22/01 1:28 PM Page 47
ENTROPION • 47
fast-absorbing plain gut. An ice pack is recommended

EARL ... Identification of the sep-
P tum is facilitated by gentle pressure
applied to the globe, which causes forward her-
for the first 2 days and antibiotic ointment is applied
to the incision twice daily for 1 to 2 weeks.
Posterior Approach to Lower Eyelid Retractor Repair

niation of the orbital fat pads and distention of In a similar manner as described above, the lower
the septum. eyelid and lateral canthus are anesthetized with 2%
lidocaine with 1 : 100,000 epinephrine. A lateral can-
thotomy and cantholysis of the inferior crus of the lat-
The lid tightening procedure can be completed by eral canthal tendon is performed with scissors. A 4-0
securing the lateral tarsal strip to the lateral orbital silk traction suture is placed through the gray line of
rim periosteum with two interrupted or a single ver- the lid margin. With the lateral attachments released,
tical mattress suture of 5-0 polypropylene (Fig. 3–9). the eyelid is everted over a lid plate, providing excel-
Dissolvable suture material, such as polyglactin, may lent exposure of the conjunctival surface of the eyelid
also be chosen, but carries a greater risk of prolonged and inferior fornix. The monopolar cutting cautery or
postoperative inflammation and suture granuloma high-temperature disposable cautery is used to incise
formation. The engagement of the suture to the the conjunctiva and attenuated lower lid retractors
periosteum should be at the level of Whitnall’s tuber- just below the inferior tarsal border from the lateral
cle inside of the lateral orbital rim and can be facili- canthus to the level of the punctum (Fig. 3–10). The
tated with the use of a short semicircular cutting inferior edge of the conjunctival incision is grasped
needle. If it is not feasible to attach the tarsal strip with forceps and elevated to guide the dissection
to the bony rim, it can be secured to the superior limb toward the inferior orbital rim in the relatively avas-
of the lateral canthal tendon. The ideal position of the cular plane between the retractors and anterior
lateral canthus is 1 to 2 mm above the level of lamella of the eyelid. The orbital fat is carefully sepa-
the medial canthus, and a slight overcorrection is rated from the lower lid retractors, and the fat pads
often desirable in anticipation of a small degree of a can then be excised if desired with the cutting cautery.
postoperative drop. The acute angle of the lateral In cases of unilateral entropion repair, fat removal, if
commissure is restored by passing a 6-0 or 7-0 performed, should be conservative to avoid signifi-
polyglactin suture through the gray line 1 mm from the cant asymmetry with the contralateral eyelid.
edge of both the upper and lower lids and burying A strip of orbicularis muscle, approximately 2 mm
the knot in the soft tissues. in width, is excised just below the inferior border of
A small amount of skin and preseptal orbicularis the tarsus across the entire length of the incision
muscle can be trimmed from the inferior edge of the (Fig. 3–11). This maneuver helps to create a cicatricial
incision. The orbicularis muscle layer is closed sepa- barrier to prevent overriding of the preseptal and pre-
rately with 6-0 or 7-0 polyglactin suture in the lateral tarsal orbicularis muscle fibers. The traction sutures
canthus overlying the tarsal strip. The skin incision is are released and the lower lid retractors are dissected
closed with a dissolvable running suture, such as 6-0 from the conjunctiva to create a free edge. This edge
FIGURE 3–9 Suture fixation of the lateral edge of the left FIGURE 3–10 A disposable cautery provides hemostasis
lower lid tarsal strip to the lateral orbital rim periosteum is while incising the inferior forniceal conjunctiva to expose
performed to correct underlying horizontal lid laxity. the lower lid retractors through a posterior approach.
CHEN03-041-054.I 3/22/01 1:28 PM Page 48
Cicatricial Entropion
Before surgery is considered in cases of cicatricial
entropion, the patient must undergo proper diag-
nostic and medical therapies. For example, ocular
cicatricial pemphigoid is a systemic autoimmune
disease that is typically progressive and requires
multidisciplinary management between ophthal-
mologist and chemotherapist. Surgical therapy
should be avoided because the cicatrizing process
may be exacerbated. Cryotherapy treatment of trichi-
asis as well as entropion repair should only be
undertaken when adequate immunosuppression has
been achieved in ocular pemphigoid. In other disor-
ders that are end-stage or nonprogressive, such as
FIGURE 3–11 A strip of preseptal orbicularis muscle is inactive trachoma or Stevens-Johnson syndrome,
excised inferior to the inferior tarsal border with a dispos- surgical intervention can be undertaken without
able cautery.
delay.
of retractors is reattached to the anterior aspect of the

inferior border of the tarsal plate with two or three
EARL... Cryotherapy treatment of
6-0 polyglactin buried sutures placed horizontally
across the lid (Fig. 3–12). If sutured to the posterior
aspect of the tarsus, the retractors will exert a con-
P trichiasis as well as entropion repair
should only be undertaken when adequate
tractile force that inverts the lid margin and could immunosuppression has been achieved in ocular
lead to cicatricial entropion. Conjunctival closure is pemphigoid.
unnecessary because the cut edge of the conjunctiva is
mobilized to the inferior tarsal border in conjunction
with the advanced retractors.
A lateral tarsal strip is fashioned and the lower lid Surgical procedures for cicatricial entropion
is tightened and secured to the lateral orbital rim involve either rotation of the eyelid margin or length-
periosteum. The canthotomy incision is closed in the ening of the posterior lamella relative to the anterior
same way as described for the anterior approach. In lamella. Preoperative assessment must include a
addition to ice packs and topical ointment, combina- determination of the adequacy of the tarsal plate.
tion antibiotic-steroid eye drops are prescribed post- Rotational procedures are technically simpler and,
operatively. therefore, preferable when sufficient tarsus is present.
When the tarsal plate is deficient or unstable, a graft
is usually necessary with potential sources that
include hard-palate mucoperichondrium, nasal chon-
dromucosa, ear cartilage, and full-thickness buccal
mucous membrane.
Wies Procedure and Marginal

Rotation Techniques
The Wies procedure was originally described for
treatment of involutional entropion,21 but is an effec-
tive marginal rotation technique for the management
of mild cases of cicatricial entropion. The technique
involves a full-thickness blepharotomy incision with
transection of the inferior tarsus and sutures that redi-
rect the vector forces from the lower lid retractors to
FIGURE 3–12 The lower lid is everted and retracted the anterior lamella to evert the eyelid margin.
inferiorly while a suture is passed to secure the dehisced After local anesthesia is obtained with subcuta-
edge of the lower lid retractors to the inferior edge of tarsus neous and subconjunctival infiltration of anesthetic, a
from a transconjunctival approach. horizontal line is outlined 3 mm below and horizontal
CHEN03-041-054.I 3/22/01 1:28 PM Page 49
ENTROPION • 49
FIGURE 3–13 A full-thickness blepharotomy incision is FIGURE 3–14 Three mattress sutures are passed
made parallel and 3 mm from the lower lid margin while a through the inferior cut edge of the tarsus and the orbicu-
chalazion clamp is used to protect the globe and minimize laris muscle of the superior edge, spacing them evenly
bleeding. across the eyelid incision.
to the lower eyelid lash line with a marking pen.* The rior segment. Three or four of these mattress sutures
line extends from 1 to 2 mm lateral to the punctum to are placed evenly divided across the length of the
the lateral canthal angle. incision (Fig. 3–14). Before each pair is tied, the skin
incision is closed with a 6-0 nylon or fast-absorbing
plain gut suture in a running fashion. The double-
...
P EARL When performing a mar-
ginal rotation procedure, a large chalazion
clamp can be used to stabilize the eyelid and
armed sutures are each tied over a small, moistened
cotton bolster (Fig. 3–15). As these knots are tight-
ened, mild to moderate eversion of the lid margin is
protect the globe. evident and desirable. Antibiotic-steroid ointment
is placed in the eye and over the bolsters, and a light
dressing is applied for 2 days. The ointment is contin-
Alternatively, two 4-0 silk traction sutures are ued three times a day until bolster and suture removal
passed through the lower lid margin and retracted is performed 7 to 10 days later.
superiorly while a lid plate is positioned in the infe-
rior fornix between the eyelid and globe. With a no. 15
blade, a full-thickness eyelid incision is made through
the central portion of the lid, being certain that the
conjunctival incision is made equidistant from the lid
margin as the skin incision. The incision is extended
medially and laterally to the end of the demarcation
with straight scissors or a blade (Fig. 3–13). If the
entropion is localized to the lateral portion of the eye-
lid, the incision may be limited to the lateral two
thirds of the eyelid.
One arm of a double-armed 4-0 silk suture is
passed through the inferior portion of the transected
tarsus in a lamellar fashion such that the suture does
not penetrate the conjunctiva. Both arms are then
passed parallel and 3 mm apart from each other FIGURE 3–15 The mattress sutures are tied over cotton
through the orbicularis muscle and skin of the supe- bolsters.
* The literature often quotes 4 mm from the lower lid margin as the preferred tarsotomy site. This is based on prior presumption that the
inferior tarsus may be up to 6 to 7 mm in vertical height. The average inferior tarsal height has since been found to be between 3.9 and
4.0 mm. Therefore, if one were to stay with 4 mm, one will more often than not end up right below the lower edge of the tarsus, and quite
likely injure the inferior tarsal arcade. A preferable distance from the lower lid margin is therefore 3 mm to get a true tarsotomy via a ble-
pharotomy, even though the eyelid tissue may be swollen and distended to a certain degree from local anesthetic infiltration (4 mm as mea-
sured on infiltrated skin; muscle may straddle only 3 mm of the underlying rigid tarsal plate).
CHEN03-041-054.I 3/22/01 1:28 PM Page 50
The same full-thickness procedure can also be

utilized to repair mild to moderate degrees of cica-
tricial entropion of the upper eyelid. Variations on
upper lid marginal rotation techniques have also
been described including the Hotz procedure22 and
Ballen procedure. 23 The Hotz procedure involves
vertical shortening of the anterior lamella across the
length of the eyelid and superior advancement of
the skin and orbicularis muscle layers to achieve an
Orbital
outward rotation of the eyelid margin. Ballen septum
described a technique analogous to the Wies proce-
dure without a skin incision. Marginal rotation is Müller’s
muscle
achieved following a transverse tarsotomy and the
placement of mattress sutures between the upper Levator
tarsal incision and anterior lamella at the base of the aponeurosis
Conjunctival
eyelashes. incision (optional)
Upper Eyelid Tarsal Advancement Flap

In more severe forms of cicatricial upper eyelid
entropion, techniques that lengthen the posterior
lamella in relation to the anterior lamella must be uti-
lized. One such method that avoids a free tissue graft Tarsus
uses the contracted upper lid tarsus as a direct
advancement flap.24, 25 The entire length of the eyelid
is infiltrated with 2% lidocaine with 1 : 100,000 epi-
nephrine both subcutaneously and subconjunctivally
in the superior fornix. A 4-0 silk traction suture is
placed through the upper lid margin at the gray line FIGURE 3–16 The posterior lamella is advanced 2 to
to facilitate eversion over a lid plate. A horizontal 3 mm inferiorly relative to the anterior lamella, and mat-
incision is made through the conjunctiva and tarsal tress sutures are placed to secure the midportion of the
plate across the length of the tarsus approximately tarsal advancement flap to the anterior lamella just above
the lash line.
2 mm from the lid margin. Blunt dissection is per-
formed superiorly along the anterior tarsal surface,
and the levator aponeurosis and Müller’s muscle are
EARL... If tension exists, a conjunc-
recessed.
The tarsoconjunctival flap is advanced below the
existent lid margin and should remain several
P tival incision at the superior tarsal border
may be performed and creates a more mobile
millimeters below the uneverted lid margin without bipedicled flap. The superior conjunctival defect
tension. If tension exists, a conjunctival incision at re-epithelializes primarily without closure and
the superior tarsal border may be performed and effectively lengthens the posterior lamella.
creates a more mobile bipedicled flap. The superior
conjunctival defect that is created by this technique
re-epithelializes primarily without closure and effec- A modification of the tarsal advancement proce-
tively lengthens the posterior lamella. Three double- dure was recently described by Seiff et al26 in which
armed 6-0 polyglactin sutures are placed in a the tarsal margin is rotated over the flap. By rotat-
lamellar fashion through the tarsal portion of the tar- ing the inferior portion of the tarsus 180 degrees,
soconjunctival flap and passed through the recessed additional eversion of the lid margin is achieved,
anterior lamella superior to the lash line (Fig. 3–16). thereby reducing the risk of recurrent entropion.
With these sutures tied, the upper lid margin and Complications of any of these tarsoconjunctival
eyelashes are rotated anteriorly and the advance- advancement techniques include lid retraction,
ment flap extends 1 to 2 mm below the lid margin. A ptosis, and buckling of the tarsus.
corticosteroid-antibiotic ointment is applied and the
eye is patched for 1 or 2 days. Topical eye drops or Lower Eyelid Posterior Lamella Graft
ointment are continued for 2 weeks postoperatively When a marginal rotation procedure is insufficient to
upon removal of the patch. correct a cicatricial entropion of the lower eyelid,
CHEN03-041-054.I 3/22/01 1:28 PM Page 51
ENTROPION • 51
mucous membrane grafts can be used to lengthen the

posterior lamella. There are many different sources
from which autogenous mucosal grafts can be har-
vested, including the buccal mucous membrane graft
of the lower lip, hard palate mucoperiosteum, nasal Buccal mucosa
septum or turbinate, and upper eyelid tarsus. Hard membrane graft
palate grafts should be avoided in the upper eyelids
because the keratinized surface can irritate the ocular
surface. Non–mucosal-lined grafts from autogenous
ear cartilage and donor sclera will epithelialize from
adjacent mucosa.
The technique to employ such grafts for lower lid
cicatricial entropion is described for lower lip buccal
mucosal grafts: Local anesthesia is achieved by inject-
ing 2% lidocaine with 1 : 100,000 epinephrine subcu-
taneously and subconjunctivally in the inferior fornix
across the length of the lower eyelid. A 4-0 silk trac-
tion suture is placed through the lid margin at the FIGURE 3–17 The spacer graft is sutured in place to
gray line and the lid is everted over a Desmarres lengthen the posterior lamellae and evert the lid margin in
retractor or lid plate. A horizontal incision is made cicatricial entropion.
through the full thickness of the tarsal plate across the
length of the eyelid in the midportion of the tarsal or the suture ends are externalized and tied over the
plate. The lower segment of the tarsus and adjoining skin to minimize irritation of the ocular surface.
lower lid retractors are dissected from the overlying Antibiotic ointment is applied to the inferior fornix.
orbicularis muscle and recessed inferiorly. Cautery Modified Frost sutures are taped to the forehead to
should be used sparingly to avoid compromising the elevate the eyelid, and a pressure bandage is applied
vascular supply of the bed of the proposed graft. The over the eye to keep the graft on stretch. The patch
length and width of the defect are measured to deter- and Frost sutures are removed 5 to 7 days later. The
mine the size of the graft to be harvested. donor site requires no specific treatment and will re-
Full-thickness buccal mucous membrane of the epithelialize in 7 to 10 days. A soft diet and viscous
lower lip are readily accessible, relatively easy to har- lidocaine may be used to reduce discomfort.
vest, and will contract less than thinner graft materi-
als. Harvesting begins with local anesthesia injected COMPLICATIONS
in the lower lip to provide hemostasis and distend the Recurrence of entropion is the most common compli-
mucosal surface for ease of dissection. Towel clips are cation of surgical repair and may develop following
applied to outer borders of the lower lip to provide practically any technique.27 Recognition and treatment
exposure. A marking pen is used to outline the of the causative factors contributing to the lid malpo-
dimensions of the graft and a no. 15 blade is used to sition help to avoid a recurrent lid malposition. For
incise the mucosa along this demarcation. Westcott example, the long-term success of involutional entro-
scissors are used to dissect in the submucosal plane pion repair is achieved when the three main etiologic
and excise the graft while countertraction is applied factors are addressed: eyelid laxity, disinsertion of the
with forceps. Because local anesthetic infiltration will lower lid retractors, and overriding of the preseptal
tend to distend the donor site and the mucous mem- orbicularis muscle. Danks and Rose18 demonstrated
brane invariably contracts upon harvesting, one can the importance of horizontal shortening in cases of
expect a 3 : 1 ratio of graft shrinkage upon harvesting involutional entropion, even when milder degrees of
when determining the proper size of graft needed. A lid laxity exist, in the prevention of recurrence.
thin strip of Gelfoam may be placed against the open
defect to control bleeding, whereas cauterization
should be avoided to limit contracture and postoper- PITFALL
ative pain.
The graft is draped over the finger to trim adherent Entropion is more likely to recur if eyelid
submucosal tissue and placed over the defect created
laxity is not addressed with a horizontal
in the lower eyelid. The graft is sutured in position
with a 6-0 plain or 7-0 chromic suture in a running
tightening procedure.
fashion (Fig. 3–17). The knots must either be buried
CHEN03-041-054.I 3/22/01 1:28 PM Page 52
or more of the offending sutures can be removed

within the first week followed by massage to reverse
the malposition. Ectropion or lid retraction may also
result if the lower lid retractors are overadvanced on
the anterior surface of the tarsal plate or too much
skin is removed (Fig. 3–18).
Eyelid margin necrosis and loss of eyelashes are
known complications when the vascular integrity is
violated with transverse blepharotomy and marginal
rotation procedures. Wound infection and hemor-
rhage can be avoided with standard surgical care.
Fistula formation, wound dehiscence, pyogenic gran-
uloma formation, symblepharon, graft necrosis, and
corneal injury are less common complications associ-
FIGURE 3–18 Ectropion in patient who underwent ated with entropion repair.
entropion repair with overadvancement of the lower lid
retractors and insufficient correction of horizontal lid laxity.
SUMMARY
A slight overcorrection at the time of repair is The clinical pathway (Fig. 3–19) illustrates the surgical
desired following full-thickness sutures or marginal solutions to management of entropion. Diagnosis
rotation procedures. However, ectropion may depends on accurate identification of the parameters
develop if the sutures exit through the anterior for spastic, involutional, and cicatricial factors fol-
lamella too close to the lid margin. In such cases, one lowed by corrective measures.
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2. Quickert MH, Wilkes DI, Dryden RM: Nonincisional 12. Snellen H: Suture for entropion. Congres Periodique
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9. Dalgleish R, Smith JL: Mechanics and histology of 21. Wies FA: Surgical treatment of entropion. J Int Coll Surg
senile entropion. Br J Ophthalmol 1966;50:79. 1954;21:758–760.
10. Bick MW: Surgical management of orbital tarsal dis- 22. Dortzbach RK, Callahan A: Repair of cicatricial entro-
parity. Arch Ophthalmol 1966;75:386–389. pion of upper eyelids. Arch Ophthalmol 1971;85:82–89.
CHEN03-041-054.I
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1:28 PM
Entropion
Page 53
Lower lid Upper lid
Spastic
Tarsal conjunctival scarring and/or Mild Moderate cicatricial Severe cicatricial
foreshortened inferior fornix entropion entropion entropion
Involutional
Cicatricial
Tarsal scarring Mild tarsal conjunctival Severe tarsal scarring
absent scarring with buckling
Fornix Suture MILD
Repair
Poor snap back and Shallow inferior fornix and Adequate forniceal Severe conjunctival cicatrization
positive distraction test loss of lower lid excursion conjunctiva +/– symblepharon Hotz Ballen Tarsal
procedure procedure advancement flap
Lower lid laxity/ Lateral Lower lid retractor Marginal rotation/ Posterior Lamellar
canthal dehiscence dehiscence Weis procedure grafting
Lower lid Retractor dehiscence

tightening repair
FIGURE 3–19 Clinical pathway showing surgical management of entropion.

53
CHEN03-041-054.I 3/22/01 1:28 PM Page 54
23. Nasr AM: Eyelid complications in trachoma, I: cicatri- 26. Seiff SR, Carter SR, Tovilla y Canales JS, Choo PH:
cial entropion. Ophthalmic Surg 1989;20:800–807. Tarsal margin rotation with posterior lamella superad-
24. Baylis HI, Silkiss TZ: A structurally oriented approach vancement for the management of cicatricial entropion
to the repair of cicatricial entropion. Ophthalmic Plast of the upper eyelid. Am J Ophthalmol 1999;127:67–71.
Reconstr Surg 1987;3:17–20. 27. Lyon DB, Dortzbach RK: Entropion, trichiasis, and dis-
25. Shorr N, Christenbury JD, Goldberg RA: Tarsocon- tichiasis. In: Dortzbach RK, ed. Ophthalmic Plastic
junctival grafts for upper eyelid cicatricial entropion. Surgery: Prevention and Management of Complications.
Ophthalmic Surg 1988;19:316–320. New York: Raven, 1994:31–48.
CHEN04-055-066.I 3/26/01 8:31 AM Page 55
Chapter 4
ECTROPION
David T. Tse and Ann G. Neff
Ectropion is a commonly encountered eyelid malpo-

sition, characterized by eversion of the eyelid margin
away from the globe. Though the upper or lower eye-
lid may be affected, this eyelid malposition more
commonly involves the lower eyelid. Chronic expo-
sure of the globe and palpebral conjunctiva results in
dry eye symptoms with reflex tearing. The exposed
palpebral conjunctiva becomes chronically inflamed
and may develop metaplastic changes of epidermal-
ization. An exposed punctum can become stenotic,
contributing to symptoms of epiphora. Additionally,
corneal exposure contributes to epithelial breakdown,
with increased risk of infectious keratitis.
A variety of factors, either singly or in combination,
may contribute to the development of ectropion. In FIGURE 4–1 Involutional ectropion of the lower eyelid.
the lower eyelid, six causative elements have been
identified: horizontal eyelid laxity, medial canthal ten-
don laxity, punctal eversion, lower eyelid retractors
disinsertion, vertical skin tightness, and orbicularis being the primary etiologic factor (Fig. 4–1). Lower
paresis.1 Identification of the underlying anatomic eyelid tension can be assessed by pulling the central
defect is essential in selecting the appropriate surgical portion of the eyelid away from the globe. If the
correction. lower eyelid can be distracted more than 1 cm from
Upper eyelid ectropion may result from cicatricial the globe, horizontal laxity is present (Fig. 4–2). Ten-
changes of the anterior lamella related to previous sion can also be assessed by pulling the lower eyelid
injury, such as laceration or burn. Iatrogenic upper away from the globe, and then releasing it. Upon
eyelid ectropion may occasionally occur following release, a normal eyelid should snap back against the
ptosis repair or blepharoplasty. globe immediately. A lax eyelid may require one or
more blinks to return to the normal position, or in
the case of ectropion, never return to the normal
HORIZONTAL EYELID LAXITY position.
Horizontal laxity is primarily caused by dehiscence
Evaluation or stretching of the lateral canthal tendon.2 Lateral
Involutional, or senile, ectropion is the most com- canthal tendon laxity usually results in rounding of
mon type of ectropion, with horizontal eyelid laxity the lateral canthal angle, or a medially displaced
55
CHEN04-055-066.I 3/22/01 1:30 PM Page 56
from the lacrimal recess, rendering the punctum inef-

fective for tear drainage.
Surgical Technique: Lateral Tarsal Strip

Infiltration
The lateral canthal region is infiltrated with lidocaine
2% with 1 : 100,000 epinephrine using a 30-gauge nee-
dle. The temporal portion of the inferior fornix and
the periosteum overlying the lateral orbital rim are
also infiltrated. When injecting the inferior fornix,
stand on the patient’s opposite side, and aim the nee-
dle toward the ear to prevent inadvertent globe dam-
age if the patient moves. Inject slowly to avoid
FIGURE 4–2 Distraction test demonstrating marked sudden, reflexive head movement in response to pain.
lower eyelid laxity. Allow the anesthetic to hydraulically dissect ahead of
the needle tip.
lateral canthal angle. Medial canthal tendon laxity,
considered in the next section, is also a commonly
EARL... Place a small cotton pled-
associated finding in horizontal eyelid laxity. Stretch-
ing of the tarsal plate has also been described as a con-
tributory factor in horizontal eyelid laxity.3
P get moistened with 4% lidocaine in the lat-
eral inferior fornix 5 minutes before injection to
Management minimize the pain of the needle prick.
If the canthal tendons appear stable, but laxity of the
eyelid is present, full-thickness wedge resection may
be performed at the lateral canthal angle. However, Skin Incision
full-thickness resection may cause rounding of the lat- A lateral canthotomy is performed using Stevens scis-
eral canthal angle, lateral displacement of the punc- sors, incising the lateral canthal tissues to the level of
tum, phimosis of the fissure, and recurrence of the periosteum overlying the lateral orbital rim
ectropion due to tension exerted against the canthal (Fig. 4–3). Avoid incising the periosteum, as this will
tendons. Additionally, there is risk of eyelid margin be the anchoring point for the tarsal strip. As with all
notching and trichiasis. surgical procedures, hemostasis is imperative for
Surgical correction of ectropion due to lateral visualization of anatomic landmarks and for reduc-
canthal tendon laxity should address the underlying tion of ecchymosis at the surgical site.
defect. The lateral tarsal strip procedure, which is
the most common procedure performed to tighten the
lower eyelid, is preferred as it shortens the eyelid at
the lateral canthus and corrects the primary anatomic
defect.4 This procedure also has the benefit of pre-
serving the normal almond-shaped canthal angle, and
avoiding phimosis of the fissure.
The lateral tarsal strip procedure is also effective in
correcting lower eyelid laxity and supporting an ocu-
lar prosthesis for patients with an anophthalmic
socket. Additionally, immediate support to the lower
eyelid is effected with the lateral tarsal strip proce-
dure for patients with ectropion secondary to orbicu-
laris paresis.
It is imperative to recognize and treat concomitant
medial canthal tendon laxity. The lateral tarsal strip FIGURE 4–3 Upright view of left lateral canthus. The
procedure may be combined with medial canthal ten- canthotomy incision is made to the level of the periosteum
don plication in this setting. Tightening the eyelid lat- overlying the lateral orbital rim. The tip of the Freer
erally in the presence of unrecognized medial canthal periosteal elevator is inside the lateral orbital rim, against
tendon laxity will displace the inferior punctum away the periosteum.
CHEN04-055-066.I 3/22/01 1:30 PM Page 57
ECTROPION • 57
Inferior Cantholysis about 4 to 4.5 mm, inadvertent excision of tarsal sub-

The inferior crus of the lateral canthal tendon is incised stance will narrow the strip, rendering it less effective
at the attachment to the lateral orbital rim, allowing as a fixation structure. The palpebral conjunctiva is
mobilization of the lower eyelid. The temporal orbital scraped off the tarsus using a no. 15 Bard-Parker blade
fat pocket may prolapse through the incision, and can while the tarsal strip is stabilized over a metal plate.
be cauterized and shrunk with bipolar cautery. Removal of the epithelial lining prevents epithelial
inclusion cyst formation within the surgical wound.
Splitting the Eyelid
Sharp Westcott scissors are used to split the eyelid at Determining the Strip Length
the gray line, taking care to avoid cutting into the The terminal edge of the tarsal strip is grasped and
tarsal plate. This maneuver separates the anterior pulled laterally with sufficient tension to place the
lamella from the epitarsal surface (Fig. 4–4). The inci- inferior punctum slightly lateral to the superior punc-
sion length depends on the amount of eyelid shorten- tum. The edge of the strip is draped over the lateral
ing required. orbital rim to determine the amount of redundant tis-
sue. Usually the redundant inferior crus of the lateral
canthal tendon is excised. Rarely, the tarsal substance
EARL ... In a chronically inflamed
P eyelid, the gray line may not be apparent.
The gray line is situated immediately anterior to
is excised.
Suturing the Strip

the meibomian gland orifices, which can be iden- The tarsal strip is secured to the periosteum on the
tified by gently squeezing the tarsal plate with a inner aspect of the lateral orbital rim with a 4-0
polyglactin 910 suture on a half-circle needle. Alter-
nontoothed forceps, causing expression of oily
natively, a 5-0 permanent suture, such as mersilene,
secretions from the glands. may be used. The needle is brought through the supe-
rior portion of the tarsal strip, 1.5 to 2 mm from the
lateral edge to prevent “cheese-wiring” through
Creating the Tarsal Strip the tarsus. The needle then engages the periosteum on
The tarsal strip is created by making a horizontal inci- the inner aspect of the orbital rim, and is brought
sion along the inferior border of the tarsal plate, sev- through anteriorly (Fig. 4–5). Placement on the inner
ering the attachment of conjunctiva and lower eyelid aspect of the rim is important to prevent anterior dis-
retractors. The length of horizontal incision should traction of the canthus. An additional suture is placed
equal the amount of lid splitting. The mucosa along through the inferior portion of the strip and the perios-
the superior border of the strip is excised, taking care teum in a similar manner. A slight overcorrection in
to avoid excising any part of the tarsal plate. As the tautness and height is desired to allow for mild relax-
vertical height of the lower eyelid tarsal plate is only ation of the tissue in the early postoperative period.
FIGURE 4–4 Upright view of left lower eyelid. The eye- FIGURE 4–5 Upright view of left lateral orbital rim. The
lid is split at the gray line, separating the anterior lamella needle engages the periosteum on the inner aspect of the
from the epitarsal surface. lateral orbital rim and exits anteriorly.
CHEN04-055-066.I 3/22/01 1:30 PM Page 58
allows for protection of the inferior canaliculus and

EARL ... Gently engage the tarsal
P
provides restoration of the normal anatomic position
of the medial lower eyelid.
strip to avoid crushing the tissue, which
can predispose to “cheese-wiring” of the suture
through the tarsus. Surgical Technique: Medial Canthal Tendon
Plication
Anesthesia
The medial canthus and medial lower eyelid are infil-
PITFALL
trated with lidocaine 2% with 1 : 100,000 epinephrine.
Appropriate support for the tarsal strip will
Incision
not be provided if the tension-bearing perios-
An incision is made over the medial canthal tendon,
teum is not engaged with the suture. To ver-
beginning in a vertical direction, then curving infero-
ify proper placement of the suture, gently laterally along the medial lower eyelid margin. The
pull the suture anteriorly. If the periosteum is incision should extend to approximately 3 mm below
properly engaged, there should be no move- the punctum. A Bowman probe is placed in the infe-
ment of the tissue overlying the suture. rior canaliculus for identification and protection of the
structure. A Freer periosteal elevator is used to bluntly
dissect the orbicularis fibers, exposing the medial can-
Closing the Incision thal tendon and the medial edge of the tarsal plate
The lash-bearing portion of the anterior lamella over- (Fig. 4–6).
lying the tarsal strip is then excised. The skin edges
are reapproximated with 6-0 or 7-0 nylon sutures Suture Placement
placed in an interrupted fashion. Antibiotic ointment A double-armed 4-0 Polydek suture is passed through
is applied three times daily. The sutures are removed the medial end of the tarsal plate. One end is tunneled
in 7 days. beneath the orbicularis muscle, and brought through
the superior margin of the medial canthal tendon
insertion. During suture placement, it is important to
MEDIAL CANTHAL TENDON LAXITY keep the needle anterior to the Bowman probe to pre-
Evaluation vent laceration or incarceration of the inferior
Laxity of the medial canthal tendon is a common fea- canaliculus. The other arm of the suture is passed par-
ture of involutional ectropion, frequently associated allel to the first (Fig. 4–7). The ends of the suture are
with lateral canthal tendon laxity. Medial canthal ten- tied with enough tension to place the inferior punc-
don laxity can be identified by pulling the lower eye- tum in vertical alignment with the superior punctum.
lid laterally, and observing for lateral displacement of
the inferior punctum. If the punctum can be displaced
beyond the medial limbus or to the central cornea on
primary gaze, then tendon laxity is present.
Management
If medial and lateral canthal tendon laxity is present,
the medial canthal tendon should be repaired before
proceeding with lateral eyelid tightening. Without
addressing the medial canthal tendon pathology first,
the inferior punctum would be displaced further tem-
porally after lateral eyelid shortening.
Various surgical procedures have been described
for correction of medial canthal tendon laxity. The
medial tarsal strip may be used in the setting of a non-
functioning inferior canaliculus, or when loss of func-
tion of the inferior canaliculus would be desirable.5 FIGURE 4–6 Upright view of medial canthal tendon. The
Otherwise, it is preferable to preserve the function of overlying orbicularis fibers have been dissected to expose
the canaliculus. Medial canthal tendon plication the medial canthal tendon.
CHEN04-055-066.I 3/22/01 1:30 PM Page 59
ECTROPION • 59
FIGURE 4–7 Schematic drawing demonstrating suture FIGURE 4–8 The everted punctum, no longer in apposi-
placement through the medial end of the tarsal plate of left tion with the globe.
lower eyelid, and through the insertion of the medial can-
thal tendon.
The skin is closed with 7-0 nylon suture in an inter- Management

rupted fashion. Surgical correction is indicated for symptomatic patients
and those with severe punctal eversion. Procedures
described for the correction of punctal eversion include
EARL... The Polydek suture should
P be tied with enough tension to place the
superior and inferior puncta in alignment. Avoid
the “lazy-T” technique,6 consisting of horizontal and ver-
tical shortening of the medial eyelid, and transverse ble-
pharotomy with rotational sutures.7 The medial spindle
is another technique, which has the benefit of correcting
overtightening, as this produces an accordion the underlying anatomic defect.8, 9 This technique
effect on the inferior canaliculus emphasizes uniting the lower eyelid retractors with the
tarsal plate to return the punctum to a normal position.
It may be performed alone or in conjunction with a hor-
izontal-shortening procedure if there is a component of
PUNCTAL EVERSION horizontal eyelid laxity. If the punctum is stenotic sec-
ondary to chronic exposure, a three-snip punctoplasty
Evaluation may also be done simultaneously.
The inferior punctum is normally oriented posteri-
orly, in apposition with the globe, and in vertical Surgical Technique: Medial Spindle
alignment or just slightly lateral to the superior punc-
tum. Punctal eversion may be seen in conjunction Anesthesia
with generalized lower eyelid ectropion or may occur Lidocaine 2% with 1 : 100,000 epinephrine is injected
alone, without evidence of canthal tendon laxity or under the skin of the lower eyelid, 1 cm below the
anterior lamella cicatrix. Isolated punctal eversion is punctum. The medial inferior forniceal conjunctiva is
likely due to segmental dehiscence or disinsertion of also infiltrated. Infiltrating the conjunctiva first can
the lower eyelid retractors along the medial eyelid minimize discomfort during skin infiltration.
(Fig. 4–8).
Punctal eversion can produce symptoms of expo-
...
sure keratopathy due to disturbance of the tear
meniscus and corneal wetting. Epiphora is another
common symptom, secondary to abnormal tear
P EARL Place a cotton pledget
moistened with 4% lidocaine in the medial
inferior fornix 5 minutes prior to injection to
drainage. The exposed medial palpebral conjunctiva minimize discomfort from the needle prick.
is at risk for development of epidermalization, and
stenosis of the punctum may result. Punctal ever-
sion as a consequence of retractor disinsertion must Excision of Conjunctiva
be differentiated from anterior lamella cicatrix. The A Bowman probe is inserted into the inferior canalicu-
skin is usually pliable in the former, but taut in the lus, and the lower eyelid is everted (Fig. 4–9A). The
latter. conjunctiva just below the inferior border of the tarsal
CHEN04-055-066.I 3/22/01 1:30 PM Page 60
Lid margin
Punctum
Inferior margin
of tarsal plate
Retractors
Conjunctiva
Fornix
A B
C D
FIGURE 4–9 Medial spindle procedure. (A) Surgeon’s view, with right lower eyelid everted and Bowman probe
inserted in the inferior canaliculus. (B) Retractors visible anterior to conjunctiva. Passage of suture through retractors
at the lower edge of incision, and through tarsal plate and conjunctiva at the upper edge of incision. (C) Suture pass-
ing full-thickness through the eyelid, inferior to the lower edge of incision. (D) Medial spindle procedure on a lower
eyelid—the suture is tied on the anterior eyelid surface, producing an inverting effect.
plate is grasped, and a diamond-shaped piece of con- Full-Thickness Lid Suture

junctiva excised (Fig. 4–9B). The diamond, with a ver- The inferior conjunctival edge is grasped and pulled
tical height of 4 to 6 mm and a width of 6 to 8 mm is superiorly, and the needle is passed in a backhand
centered beneath the inferior punctum. If a greater fashion, from the inferior fornix, full-thickness through
amount of inversion is desired, a larger excision in the the eyelid (Fig. 4–9C, D). Both arms are passed in a
vertical dimension is designed. similar manner, exiting the skin surface 12 to 15 mm
inferior to the lid margin. The sutures are tied on the
Suturing the Incision skin surface, with appropriate tension to invert, but
not overcorrect, the medial eyelid margin. The suture
A double-armed 5-0 chromic suture is passed in a
is allowed to absorb in place.
backhand fashion through the retractors, identified
anterior to the conjunctiva at the lower edge of the inci-
sion. Both needles are then passed through the upper LOWER EYELID RETRACTORS
edge of the incision, and the suture is pulled superi- DISINSERTION
orly (Fig. 4–9B). This unites the medial portion of the
retractors with the conjunctival edge superiorly. The Evaluation
lateral portion of the retractors is united with the infe- The retractors of the lower eyelid are analogous to the
rior border of the tarsal plate. levator aponeurosis of the upper eyelid. The lower
CHEN04-055-066.I 3/22/01 1:30 PM Page 61
ECTROPION • 61
eyelid retractors originate as the capsulopalpebral

head from the fascia surrounding the inferior rectus
muscle. The capsulopalpebral head splits into two
sections, which envelop the inferior oblique muscle.
Distal to the inferior oblique, the two layers reunite to
form Lockwood’s ligament. Anterior to Lockwood’s
ligament, the fascial tissue is termed the capsu-
lopalpebral fascia. Most of the fascia continues anteri-
orly to insert on the inferior border of the tarsal plate.
Some fibers of the capsulopalpebral fascia insert into
the inferior fornix, and fibers also extend anteriorly as
septa through the orbital fat. Unlike the levator mus-
cle, fibers do not insert on the anterior tarsal border or
extend through the orbicularis to insert into the sub-
cutaneous tissue. FIGURE 4–10 Tarsal ectropion due to lower eyelid
Dehiscence or disinsertion of the lower eyelid retractors disinsertion.
retractors may result in either ectropion or entro-
pion, depending on the differential forces imparted the eyelid. After reinserting the retractors, concomi-
by the anterior and posterior lamellae, and the tant horizontal eyelid laxity may be repaired with the
medial and lateral canthal tendons. Retractors disin- lateral tarsal strip procedure.
sertion can be a difficult element to recognize, and
several clinical clues may be sought to help identify Surgical Technique: Retractors Reinsertion
this element of pathology. The inferior fornix may
become deeper due to loss of the attachments from Anesthesia
the capsulopalpebral fascia. The lower eyelid may The lower eyelid is infiltrated across its entire length
also display a higher resting position due to loss of with lidocaine 2% with 1 : 100,000 epinephrine. The
the attachment of the retractors to the inferior tarsal conjunctiva inferior to the tarsal plate is also
plate. The higher resting position may be demon- infiltrated.
strated by manually returning the eyelid from the
ectropic position. Lack of fascial attachment to Conjunctival Incision
the inferior tarsal border frequently results in An incision is made through the conjunctiva, parallel
decreased lower eyelid excursion from upgaze to and inferior to the tarsal border, to the level of the
downgaze. The distal end of the disinserted retrac- postorbicular fascial plane. This incision is enlarged
tors may occasionally be visualized through the con- medially and laterally, along the length of the eyelid.
junctiva inferior to the tarsal plate. This can be Dissection is carried inferiorly in the postorbicular
difficult to identify, however, due to conjunctival fascial plane until the orbital fat pads are identified.
injection from exposure. The orbital fat is retracted anteriorly with a Desmarres
If horizontal laxity is present in addition to retrac- retractor. The inferior edge of the conjunctival inci-
tors disinsertion, both elements need to be identified sion is grasped, and the disinserted retractors can be
and addressed. Repair of horizontal laxity alone, in visualized immediately anterior to the conjunctiva,
the presence of retractors disinsertion, may precipi- several millimeters inferior to the conjunctival edge.
tate tarsal ectropion.10 Tarsal ectropion is an extreme Upon grasping the edge of the disinserted retractors,
form of ectropion in which the inferior tarsal plate is a pull should be felt as the patient looks downward,
completely everted (Fig. 4–10). confirming the identification of the retractors.
Management
...
Repair of the disinserted retractors is best approached
by a transconjunctival incision, through which the
retractors are identified and reattached to the inferior
P EARL Look for the key land-
mark—the orbital fat pads. The capsu-
lopalpebral fascia is situated immediately
border of the tarsal plate.11 Full-thickness eyelid posterior to the fat pads.
sutures are then placed to produce an inverting effect
on the eyelid margin. The concept of this procedure is
identical to the medial spindle procedure. Instead of Suture Placement
using one double-armed suture beneath the punctum, The disinserted retractors are then reattached to the
three double-armed sutures are evenly spaced along inferior tarsal border using three double-armed 5-0
CHEN04-055-066.I 3/22/01 1:30 PM Page 62
FIGURE 4–11 Suture passing through the anterior edge FIGURE 4–12 Cicatricial ectropion of the lower eyelids
of the retractors of a right lower eyelid. The retractors are following laser resurfacing.
located immediately anterior to the conjunctiva, and imme-
diately posterior to the orbital fat pads.
chromic sutures spaced evenly across the eyelid. One the skin. Long-standing ectropion from other causes
arm of the suture is placed horizontally through the may predispose to secondary contracture of the ante-
anterior edge of the retractors (Fig. 4–11). The lower rior lamella, resulting in a complex ectropion.
eyelid margin is everted, and the needle is passed
through the inferior tarsal border in a backhand fash- Management
ion. The other end is brought through the tarsal bor- Treatment of cicatricial ectropion must first be
der in a similar manner, 5 mm from the first arm. The directed at releasing the scar bands to allow vertical
other two double-armed sutures are placed the same lengthening of the anterior lamella. If a linear verti-
way. When pulled superiorly, the sutures serve to join cal scar is present (Fig. 4–13), a Z-plasty may be per-
the edge of the retractors to the inferior tarsal border. formed. If more diffuse contracture is present, a
full-thickness skin graft must be used to replace the
Inverting Suture Placement deficit after releasing the scar bands.
The inferior conjunctival edge is grasped and pulled Horizontal eyelid tightening is often employed to
superiorly, and the suture is then passed into the infe- augment a skin grafting procedure. Occasionally, the
rior fornix, and brought full-thickness through the tarsal strip is not long enough to reach the periosteum
eyelid, exiting 12 to 15 mm inferior to the eyelid mar- of the lateral orbital rim, or even if the strip reaches,
gin. The other arm is passed in the same manner. This there may be marked tension on the strip. An effec-
is repeated with the other two double-armed sutures. tive method to augment the fixation is to reflect a
The three sets of sutures are then tied on the skin sur- piece of periosteum onto the anterior surface of the
face, with appropriate tension to invert, but not over-
correct, the eyelid margin position. The sutures are
left to absorb.
CICATRICIAL ECTROPION
Evaluation
Cicatricial ectropion is caused by vertical tightness of
the eyelid skin, which pulls the eyelid margin away
from the globe. Actinic damage is a commonly
encountered source of anterior lamella contracture
with resultant lower eyelid ectropion. Other causes
include thermal burn, chemical burn, trauma, laser
resurfacing, chemical peel, or surgery (Fig. 4–12).
Inflammation due to dermatitis and infections such FIGURE 4–13 Cicatricial ectropion of the lower eyelid
as herpes zoster may induce cicatricial alterations of secondary to vertical scar band from previous trauma.
CHEN04-055-066.I 3/22/01 1:30 PM Page 63
ECTROPION • 63
tarsal plate. A 5*7 mm periosteal flap, with the base Placement of the Graft
at the anterior tip of the lateral orbital rim, is elevated The graft is placed in the recipient bed, and trimmed
off the temporal surface of the rim with a Freer as necessary. The donor graft is sutured into position
periosteal elevator. The periosteal flap is reflected using interrupted 7-0 Vicryl sutures. Additionally,
onto the tarsal plate and secured with two 5-0 Vicryl interrupted 6-0 silk sutures are placed and left long. A
sutures. Telfa sheet and sponge bolster are placed over the
graft site, and tied in place using the preplaced long
Surgical Technique: Repair of Cicatricial 6-0 silk sutures. The eyelid margin traction suture is
Ectropion with Skin Graft affixed to the forehead to maintain the recipient bed
on stretch. A light pressure dressing is placed to max-
Anesthesia imize graft contact with the recipient bed. The bolster,
The lower eyelid is infiltrated subcutaneously with Telfa, and silk sutures are removed in 7 days.
2% lidocaine with 1 : 100,000 epinephrine. A 4-0 silk
suture is then placed through the gray line for trac-
tion and affixed to the drape superiorly. POSTBLEPHAROPLASTY ECTROPION AND
LOWER EYELID RETRACTION
Incision
A no. 15 Bard-Parker blade is used to make an inci- Evaluation
sion approximately 2 mm inferior and parallel to the Lower eyelid malposition, such as retraction with
lower eyelid margin. All vertical scar bands are inferior scleral show or ectropion, is a common com-
released, and the dissection is continued to the depth plication following lower eyelid blepharoplasty
required to allow the eyelid margin to return to its (Fig. 4–14). This results in a cosmetically unacceptable
original position. Meticulous hemostasis is essential outcome, frequently associated with symptoms of
before graft placement, as hematoma formation exposure keratopathy. Factors contributing to lower
underneath the graft may compromise its survival. A eyelid malposition include laxity of the canthal ten-
template of the anterior lamella defect is made from a dons, decreased orbicularis tone, skin shortage, and
piece of Telfa. cicatricial forces within the middle lamella. Concomi-
tant lower eyelid laxity should be treated at the time
Harvesting the Graft of blepharoplasty to aid in maintaining proper eyelid
The template is placed over the skin graft donor site and lateral canthal position.
and is outlined with a marking pen. The graft should
be slightly larger than the defect to allow for contour Management
of the recipient bed and for shrinkage. The graft may Various procedures have been described that may be
be harvested from the upper eyelid if dermatochalasis performed during or following blepharoplasty to treat
is present. Non–hair-bearing skin from the preauricu- lateral canthal tendon laxity. The inferior retinacular
lar, retroauricular, or supraclavicular regions may be lateral canthoplasty, which may also be performed as
used. After the donor site is anesthetized, the skin is a canthopexy, utilizes existing surgical incisions to
incised along the preplaced marking. The edge of the tighten the lateral canthal tendon.12 The tarsal tuck
graft is elevated with a forceps, and the full-thickness and the lateral retinacular suspension have also been
skin graft is dissected from the subcutaneous tissue.
The edges of the donor site are undermined, and the
defect is closed with subcutaneous tension-bearing
5-0 Vicryl interrupted sutures. The skin is closed with
interrupted 6-0 nylon sutures, which are removed at
7 days.
Preparing the Graft

The donor skin graft is placed skin-side down on the
index finger of the surgeon. Stevens scissors are used
to excise the subcutaneous tissue from the graft until
the dermal papillae are visible. Full-thickness slits
may be placed in the center of the graft, to permit FIGURE 4–14 Cicatricial ectropion and retraction of the
egress of fluid from beneath the graft after placement lower eyelids with scleral show following transcutaneous
in the recipient bed. lower eyelid blepharoplasty.
CHEN04-055-066.I 3/22/01 1:30 PM Page 64
described as adjunctive procedures to tighten and sta- secondary contracture of the anterior lamella has
bilize the lower eyelid as a preventive measure.13, 14 occurred, skin grafting may be required. Other pro-
Lower eyelid retraction or ectropion in the imme- cedures performed to promote eyelid closure include
diate postoperative period should be treated with tarsorrhaphy, and placement of a gold weight or
upward massage. Steroid injection may be cautiously palpebral spring in the upper eyelid.
employed, keeping in mind that subcutaneous atro-
phy can occur.
Persistent eyelid retraction or ectropion despite PITFALL
conservative therapy generally requires surgical inter-
vention. The vertical traction test identifies the pres- Temporary paralytic ectropion may develop
ence of middle lamella scarring, which aids in following botulinum toxin injection for treat-
determining the procedure for repair. Using the index ment of essential blepharospasm.
finger to apply vertical traction to the lower eyelid,
resistance and limited upward movement occur in the
presence of middle lamella scarring. If residual lower
Because the effect of the toxin will subside within a
eyelid laxity is present, without severe anterior
few months, corneal protection can often be provided
lamella deficiency or middle lamella scarring, a lat-
by lubrication while awaiting recovery of orbicularis
eral canthal tightening procedure, such as the lateral
tone. Occasionally, botulinum toxin injection will
tarsal strip, can be utilized.
unveil a subclinical case of involutional eyelid laxity,
For moderate retraction and lagophthalmos, the
manifesting as profound ectropion. In this scenario,
“Madame Butterfly” procedure may be used, which
surgical intervention with either a lateral tarsal strip
employs lysis of the middle lamella cicatrix, lateral
or lateral tarsorrhaphy may become necessary.
canthal reconstruction, and cheek elevation to provide
anterior lamella.15 Severe eyelid retraction often
requires the use of spacer material, such as a hard CONGENITAL ECTROPION
palate graft, to provide vertical height and stiffness
following release of the cicatrix.16 The use of full- The congenital form of ectropion usually involves the
thickness skin grafting should be avoided if possible, lower eyelids, and is caused by a vertical deficiency
because this requires additional incisions and is often of anterior lamella. Exposure keratopathy and
aesthetically unacceptable. However, for severe skin epiphora are common sequelae. Congenital ectropion
shortage, full-thickness skin grafting may be required. rarely occurs as an isolated anomaly, more commonly
occurring within the setting of other abnormalities,
such as blepharophimosis syndrome or Down syn-
PARALYTIC ECTROPION drome. Conservative management with lubrication is
recommended initially. More severe forms require
Evaluation surgery, which may include tarsorrhaphy, horizontal
Permanent or temporary seventh nerve palsy com- eyelid tightening, or skin grafting.
monly results in brow ptosis, lower eyelid ectropion, Congenital upper eyelid eversion is an extreme
and reduced blink frequency. Exposure due to ectro- and unusual form of ectropion, characterized by com-
pion and the associated decreased blink and lagoph- plete eversion of the upper eyelids (Fig. 4–15). This is
thalmos from loss of orbicularis tone produce reflex
tearing. Decreased tear pump function secondary to
decreased orbicularis tone also contributes to tear-
ing. Treatment is directed at minimizing exposure
keratopathy and epiphora, and preventing corneal
ulceration.
Management
For temporary loss of seventh nerve function, patients
may only require frequent lubrication, taping of the
lower eyelid, and/or use of a nocturnal moisture
chamber.17 Patients with permanent seventh nerve
palsy frequently require surgical intervention for
treatment of exposure keratopathy. Horizontal eyelid
tightening, such as the lateral tarsal strip procedure,
provides immediate support to the lower eyelid. If FIGURE 4–15 Congenital upper eyelid eversion.
CHEN04-055-066.I 3/22/01 1:30 PM Page 65
ECTROPION • 65
usually bilateral, and is more common in black remains refractory to conservative therapy, surgical
infants, Down syndrome, and infants of multiparous intervention such as tarsorrhaphy, skin grafting, hor-
mothers (where the mother has had two or more izontal eyelid resection, or full-thickness inverting
pregnancies). Proposed pathophysiologic mecha- sutures may be required.
nisms include failure of orbital septum attachment to
the levator, vertical deficiency of anterior lamella, and CONCLUSION
orbicularis hypotonia.18 Birth trauma is thought to ini-
tiate eversion, with subsequent venous engorgement The treatment of ectropion of the lower and upper
and chemosis sustaining the malposition. The condi- eyelids requires careful assessment of pathologic fac-
tion is generally self-limited; however, conservative tors (Figs. 4–16 and 4–17), differentiating between
management with lubrication and moisture chambers anterior lamella shortage, posterior lamella weakness
usually requires weeks to achieve resolution. Reduc- or dehiscence, tendinous disinsertion, or paralytic
tion of the everted lids with immediate placement of component relating to aging or neurologic causes. A
pressure patches for 48 to 72 hours is an effective ini- step-by-step approach and correction of these various
tial nonsurgical treatment.19 If the malposition factors will ensure optimum treatment outcome.
Lower Eyelid Ectropion
Horizontal eyelid Medial canthal Punctal Lower eyelid Vertical skin Orbicularis
laxity tendon laxity malposition retractors disinsertion tightness paresis
Excess laxity on Lateral Eversion of the Tarsal ectropion; deep Anterior lamella Decreased blink;
snapback test or displacement of the punctum away from inferior fornix; cicatrix; inability lagophthalmos;
distraction of lower inferior punctum with the globe; rule out decreased lower eyelid to return eyelid seventh nerve palsy;
eyelid lateral traction on associated canthal excursion; visible band margin to normal history of botulinum
the lower eyelid tendon laxity and of disinserted retractors position toxin injection
anterior lamella inferior to tarsal border
contracture
Lower eyelid Medial canthal Medial spindle if Reattach Z-plasty for linear Lubrication, moisture
tightening with tendon plication isolated punctal retractors scar band; full- chamber; for severe
lateral tarsal strip eversion thickness skin graft exposure, lateral tarsal
strip or tarsorrhaphy
FIGURE 4–16 Management of lower eyelid ectropion.
Upper Eyelid Ectropion
Congenital upper Cicatricial skin shortage

eyelid eversion Posttraumatic following surgery
Complete eversion Skin contracture; internal Tight anterior lamella;

of the upper eyelids contracture secondary lagophthalmos; eversion
following birth to adhesions with of the upper eyelid margin
orbital septum
Reduction of eyelid and Release of scar bands and Full-thickness skin graft
placement of pressure patch placement of full-thickness
skin graft; exploration and FIGURE 4–17 Management of upper
lysis of internal scar bands eyelid ectropion.
CHEN04-055-066.I 3/22/01 1:30 PM Page 66
REFERENCES
1. Frueh BR, Schoengarth LD: Evaluation and treatment 12. Jelks GW, Glat PM, Jelks EB, et al: The inferior retinac-
of the patient with ectropion. Ophthalmology 1982;89: ular lateral canthoplasty: a new technique. Plast Recon-
1049–1054. str Surg 1997;100:1262–1270.
2. Neuhaus RW: Anatomical basis of “senile” ectropion. 13. Fagien S: Algorithm for canthoplasty: the lateral reti-
Ophthalmic Plast Reconstr Surg 1985;1:87–89. nacular suspension: a simplified suture canthopexy.
3. Stefanyszyn MA, Hidayat AA, Flanagan JC: The Plast Reconstr Surg 1999;103:2042–2053.
histopathology of involutional ectropion. Ophthalmol- 14. Jordan DR, Anderson RL: The tarsal tuck procedure:
ogy 1985;92:120–127. avoiding eyelid retraction after lower blepharoplasty.
4. Anderson RL, Gordy DD: The tarsal strip procedure. Plast Reconstr Surg 1990;85:22–28.
Arch Ophthalmol 1979;97:2192–2196.
15. Shorr N, Fallor MK: “Madame Butterfly” procedure:
5. Jordan DR, Anderson RL, Thiese SM. The medial tarsal
combined cheek and lateral canthal suspension proce-
strip. Arch Ophthalmol 1990;108:120–124.
dure for post-blepharoplasty, “round eye,” and lower
6. Smith B: The “lazy-T” correction of ectropion of the eyelid retraction. Ophthalmic Plast Reconstr Surg 1985;
lower punctum. Arch Ophthalmol 1976;94:1149–1150. 1:229–235.
7. Kristan RW, Stasior OG: Infracanalicular full-thickness
16. Patel BCK, Patipa M, Anderson RL, et al: Management
transverse blepharotomy for medial ectropion. Oph-
of postblepharoplasty lower eyelid retraction with hard
thalmic Plast Reconstr Surg 1987;3:127–129.
palate grafts and lateral tarsal strip. Plast Reconstr Surg
8. Nowinski TS, Anderson RL: The medial spindle proce-
1997;99:1251–1260.
dure for involutional medial ectropion. Arch Ophthal-
mol 1985;103:1750–1753. 17. Seiff SR, Chang JS: The staged management of oph-
thalmic complications of facial nerve palsy. Ophthalmic
9. Tse DT: Surgical correction of punctal malposition. Am
Plast Reconstr Surg 1993;9:241–249.
J Ophthalmol 1985;100:339–341.
10. Putterman AM: Ectropion of the lower eyelid sec- 18. Blechman B, Isenberg S: An anatomical etiology of con-
ondary to Müller’s muscle-capsulopalpebral fascia genital eyelid eversion. Ophthalmic Surg 1984;15:
detachment. Am J Ophthalmol 1978;85:814–817. 111–113.
11. Tse DT, Kronish JW, Buus D: Surgical correction of 19. Kronish JW, Lingua R: Pressure patch treatment for
lower-eyelid tarsal ectropion by reinsertion of the congenital upper eyelid eversion. Arch Ophthalmol 1991;
retractors. Arch Ophthalmol 1991;109:427–431. 109:767–768.
CHEN05-067-074.I 3/26/01 8:30 AM Page 67
Chapter 5
TRICHIASIS
Jeffrey A. Nerad and Annie Chang
Trichiasis is the condition in which eyelashes are in defined anterior and posterior edge, which is nearly
contact with the eye. These lashes are misdirected square when viewed in cross section. From anterior
toward the globe while the eyelid itself is in a rela- to posterior, the visible structures include the skin
tively normal position. In contrast, entropion is the edge, the lashes, gray line (pretarsal orbicularis mus-
condition where the eyelids are inverted, causing cle), meibomian gland orifices, and the mucocuta-
the lashes to rub against the eye. Entropion is not neous junction. The mucocutaneous junction is where
traditionally categorized as a cause of trichiasis, the nonkeratinized palpebral conjunctiva meets the
although cicatricial and involutional entropion can keratinized skin of the eyelid margin.
also cause the lashes to rub against the eye. Trichiasis Normally there are approximately 100 eyelashes
can be divided into congenital causes such as epible- in the upper lid and 50 in the lower lid. They are
pharon and distichiasis, and acquired causes such as arranged in three or four irregular rows in the upper
marginal entropion, trauma, and metaplasia. eyelid and two or three irregular rows in the lower
The most common complaint associated with eyelid. They originate from the anterior lamella, arise
trichiasis is persistent foreign body sensation. Reflex anterior to the gray line, and are directed away from
tearing also occurs secondary to corneal and conjunc- the globe. The conditions that cause trichiasis can all
tival irritation. As a result, patients are sometimes be explained by anatomic abnormalities of the eye-
photophobic as well. The severity of disease can vary lid margin.
between patients. Some patients are relatively asymp-
tomatic, whereas others may be severely debilitated
and complain of pain, depending on the number of
CLASSIFICATION
lashes rubbing against the eye. Epiblepharon
There are many treatment options for this condi- This condition is most commonly seen in Asian chil-
tion. The offending lashes can be destroyed by vari- dren and commonly involves only the lower lids. In
ous modalities such as mechanical or laser epilation, epiblepharon, the pretarsal skin and muscle rides
cryotherapy, or electrolysis. If larger segments of above the lid margin and pushes the lashes against
lashes are involved, procedures such as wedge resec- the globe (Fig. 5–2). The eyelid and margin itself is in
tion, lid margin eversion, and lid splitting can be per- normal position. Often more than half of the eyelid is
formed. involved. In some cases the lashes do not contact the
globe except in downgaze. Symptoms are usually
minimal, with photophobia being the most common.
ANATOMY Patients usually present by age 4 or 5. If photophobia
It is important to understand the anatomy of the eye- or moderate corneal staining is present, treatment is
lid margin to better evaluate and treat trichiasis. The recommended. Some children may outgrow the con-
normal lid margin (Fig. 5–1) should have a well- dition as the facial features mature.
67
CHEN05-067-074.I 3/22/01 1:33 PM Page 68
Meibomian
glands
Mucocutaneous
junction Gray line
FIGURE 5–1 Normal lid margin.
A B
FIGURE 5–2 (A) Epiblepharon (front view). (B) Epiblepharon (lateral view).
Distichiasis
This is a relatively rare congenital condition where an
additional row of lashes arises from the meibomian
gland orifices. It is an autosomal-dominant disorder
with variable expressivity. It has been associated with
strabismus, ptosis, cleft palate, congenital ear defects,
trisomy 18, and mandibulofacial dystosis. This is a
developmental abnormality in which pilosebaceous
units are present in the posterior lamella rather than
just the normal sebaceous secreting meibomian
glands (Fig. 5–3). Often this extra row of lashes is
incomplete (Fig. 5–4). These lashes can be fully
formed or appear smaller and less pigmented.
Marginal Entropion
Distichiasis
This term refers to the subtle and often overlooked
inturning of the eyelid margin only (Fig. 5–5). The lid FIGURE 5–3 Distichiasis—note lashes emerging from
itself is grossly in normal position except for the meibomian gland orifices.
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TRICHIASIS • 69
FIGURE 5–4 Distichiasis—note incomplete row of lashes FIGURE 5–5 Marginal entropion—note rounded lid
arising from meibomian gland orifices (arrows). margin.
lid margin. Although marginal entropion is, strictly normal to abnormal part of the eyelid will make it
speaking, a type of cicatricial entropion, the degree easier to appreciate this anterior migration of the muco-
of inversion is less pronounced than in most cases of cutaneous junction. The anteriorization of the mucocu-
cicatricial entropion. taneous junction and rounding of the lid margin are
In cases of marginal entropion the posterior lid the hallmarks of marginal entropion (Fig. 5–7).
margin loses its defined and square edge. Instead, it
becomes more rounded as the posterior margin is
EARL... Marginal entropion is the
pulled posteriorly (Fig. 5–6). In most cases there may
be no obvious abnormality to cause the shortening of
the posterior lamella. Occasionally some scar tissue
P most common cause of trichiasis in adults.
may be present. More commonly, signs of blepharitis

and mild inflammation are present along the lid mar- Trauma
gin. Marginal entropion may involve just a segment of Misdirected lashes can occur as sequelae to previous
the lid or the entire lid itself. The involved area will injury or surgery. Usually only a segment of the lid is
show anterior migration of the mucocutaneous junction. involved. These lashes tend to point in random direc-
As the normally keratinized portion of the lid mar- tions and no longer retain their previous parallel ori-
gin is pulled posteriorly, it rests in the tear lake, which entation to each other. The spacing between lashes is
allows the conjunctival mucosa to migrate forward often irregular, often with areas of missing lashes.
onto the lid margin. Frequently this junction can be This is in contrast to marginal entropion where the
seen at or anterior to the meibomian gland orifices. If parallel orientation and regular spacing between
only a segment of the lid is involved, comparison of the lashes are preserved.
Mucocutaneous
junction
Meibomian
glands orifice
Marginal Entropion
FIGURE 5–6 Marginal entropion—note rounding of lid FIGURE 5–7 Marginal entropion—note anterior migra-
margin and anterior migration of mucocutaneous junction. tion of mucocutaneous junction (arrows).
CHEN05-067-074.I 3/22/01 1:33 PM Page 70
Metaplasia the hair shaft by manually everting the lid margin. It

Chronic irritation and inflammation can result in meta- has been recommended to start the settings at 300 mil-
plasia of the meibomian glands to produce hair folli- liwatts for 0.5 seconds with a 50-m spot size. A burn
cles. Conditions such as ocular cicatricial pemphigoid, that is 1 to 2 mm deep is necessary to destroy the fol-
Stevens-Johnson syndrome, rosacea, trachoma, chronic licle without damage to the surrounding tissue. Gen-
pilocarpine use, and chemical injury have been associ- tian violet can be used to color nonpigmented lashes
ated with metaplastic changes within the meibomian for more efficient laser uptake. The success rate
glands, resulting in aberrant hair growth. These lashes ranges from 45 to 80%.
are often shorter and less pigmented.
Cryotherapy
TREATMENT This is a relatively effective treatment for treating
areas of misdirected lashes that may be too broad for
There are many options for treating trichiasis. If the electrolysis or the various modes of epilation. A liquid
patient is asymptomatic and without sign of corneal nitrogen probe is used to permanently destroy the
irritation, then no treatment is indicated. If the patient lash follicles. The follicles die at –20°C,whereas the
is symptomatic and the corneal surface is disturbed, surrounding eyelid tissue can withstand temperatures
then treatment is recommended. Strategies for treat- of –40°C. A double freeze thaw technique is used to
ment are based on the etiology of trichiasis and the maximize the success rate of about 75%.
number of lashes involved. The lid is first anesthetized with local anesthetic
containing epinephrine. The vasoconstriction pro-
vided by the epinephrine allows a rapid freeze fol-
Trichiasis Limited to a Small lowed by a slow thaw. The cryoprobe is placed on the
Segment of the Eyelid lid skin adjacent to the misdirected lashes. The probe
The procedures described below are most commonly is placed for 30 seconds along the upper lid and for
performed when only a small segment of the lid is 25 seconds along the lower lid. An ice ball should
affected, such as in mild cases of distichiasis, meta- form to about 2 or 3 mm beyond the edge of the
plastic lashes, or areas of previous trauma or surgery. probe. Each area is treated twice allowing the tissues
to thaw slowly in between. The lashes are then
Mechanical Epilation mechanically epilated and should easily slide out
This procedure is simple and fast, but provides only without much resistance.
temporary relief. Most lashes will regrow in 4 to 6 Occasionally the lashes will recur and may need
weeks. It is not unusual for the irritation to be more repeat treatment. Although effective, complications
severe when the lashes recur, as the new lashes are have been noted with this procedure. Depigmentation
often shorter and stiffer. Epilation is easily performed can occur, especially in darker-skinned individuals
at the slit lamp, but in most cases it should be used as because dermal melanocytes do not survive beyond
a temporizing measure performed prior to a more –10°C. Lid notching can occur from overaggressive
definitive procedure. freezing, which can damage the surrounding soft tis-
sue. There is debate whether exacerbation of symble-
Electrolysis or Hyfercation pharon formation occurs in patients with ocular
This procedure can be used to destroy a limited num- cicatricial pemphigoid, so pre- and posttreatment
ber of lashes. The lid is anesthetized with a local with oral steroids is advised. Significant swelling,
anesthetic. An electrolysis wire or a wire tip con- burning, and pain occur postoperatively. Narcotics
nected to the hyfercater is introduced down into the may be prescribed.
hair follicle and a low current is then applied. The
power is increased slowly until the tissue around the
follicle coagulates. This is intended to be a perma-
Trichiasis Involving a Localized
nent cure; however, the failure rate is high—50 to
Segment of the Eyelid
70% of the lashes recur and multiple treatments may Pentagonal Wedge Resection
be necessary. Pentagonal wedge resection of the lid margin can be
used to remove a localized segment of lashes. Trichi-
Laser Epilation asis secondary to trauma is commonly treated this
This is another option when only a few lashes are way. One fourth to one third of the eyelid can be
involved. The argon green laser is aimed parallel to removed depending on the degree of laxity.
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TRICHIASIS • 71
Trichiasis Involving
the Majority of the Eyelid
Tarsal Fracture Operation
Most cases of trichiasis that involve the majority of the
lid margin are due to marginal entropion. The tarsal
fracture operation is used to correct marginal entro-
pion, rotating the lid back to its anatomic position. To
do this, a full-thickness horizontal incision is made
through the posterior surface of the tarsus (Fig. 5–9).
A no. 15 blade or Colorado needle is used to make this
incision, which should extend 2 to 3 mm laterally
beyond the area of the entropion. The marginal artery
can be avoided by cutting midway down the tarsal
plate. (In a normal inferior tarsus with a height of
4 mm, the incision should be at least 2 mm down from
the lid margin.)
Sutures are then placed to hold the lid in an
everted position. Double-armed 6-0 Vicryl sutures are
Deep tarsal passed full thickness through the lid from the most
suture distal portion of the wound and exiting just under the
lashes. Three pairs of suture are needed to evert
Skin suture the involved length of lid. The sutures are then tied.
Slight overcorrection should be achieved so that there
FIGURE 5–8 Lid margin repair. The lid margin is is a subtle eversion of the lid margin at the end of the
repaired using lamellar sutures in the tarsus and vertical procedure. The posterior lamellae will granulate in
mattress sutures in the lid margin. place.The tarsal fracture operation is most commonly
used for the lower eyelid. The tarsal fracture opera-
The lid is repaired using the same principles for tion can be used for upper lid marginal entropion
eyelid margin reconstruction (Fig. 5–8). A pentagon repair, but the sutures must be buried in the wound to
is first marked, which should extend 2 to 3 mm prevent corneal irritation.
beyond the abnormal lashes. A no. 15 blade should
be used to incise the lid margin, and straight scis- Terminal Tarsal Rotation Operation
sors used to excise the pentagon. This will allow the This procedure can be used to provide a more pro-
edges to be cut cleanly for accurate reapproxima- nounced eversion of the upper lid when cicatricial
tion. After the involved segment of lashes is entropion without lid retraction is present. The entire
removed, the lid margins are then aligned with a 7-0 margin is dissected and rotated away from the eye. It
Vicryl suture passed through the base of the lash fol- is similar to the above procedure. This procedure,
licles. The tarsal plate is then sutured with 5-0 Vicryl reserved for severe degrees of entropion, is more dif-
sutures placed in lamellar fashion through the tarsal ficult to perform and results in slower healing. The
plate. This will serve to relieve any tension at the lid “terminal” portion of the tarsus or the lid margin is
margin. The lid margin closure is then completed rotated 180 to 270 degrees outward and sutured into
with one or two 7-0 Vicryl sutures in vertical mat- position. The raw surfaces eventually heal with a rea-
tress fashion. The first suture is placed through the sonably stable lid margin. For even more severe cases
meibomian gland orifices. A second suture can be of cicatricial entropion, especially if there is lid retrac-
placed to align the eyelashes. The incision on the lid tion, the posterior lamella should be incised horizon-
margin should be everted afterward to prevent any tally and a mucous membrane graft interposed into
future lid notching. The overlying skin is then position to prevent postoperative contraction.
closed without much tension on the wound. If nec-
essary, 5-0 Vicryl sutures can be placed in a separate
layer through the orbicularis muscle to relieve any Treatment of Epiblepharon and Distichiasis
tension. When performed carefully, a continuous Epiblepharon repair involves excising the extra and
row of normally oriented lashes should be the end redundant skin and muscle (Fig. 5–10). Usually the
result. lower lids are involved. Simple lubrication may be
CHEN05-067-074.I 3/22/01 1:33 PM Page 72
A B
C D
FIGURE 5–9 (A) The tarsal fracture operation for correction of marginal entropion. The lower lid margin is secured
with a traction suture. A tarsotomy is made horizontally halfway down the posterior surface of the inferior tarsus.
(B) Placement of everting sutures. Double-armed sutures are applied from the conjunctival side below the inferior
tarsal border, exiting partial thickness, then in an epitarsal fashion to the skin close to the ciliary border. (C) Appear-
ance of the repair after the 3 double-armed sutures are tied and trimmed. (D) Cross-sectional view of the repair of mar-
ginal entropion.
enough if the symptoms are mild. Surgical excision In children, general anesthesia is required. The
of the redundant skin and muscle is recommended redundant skinfold is outlined with a marker.
if there is significant photophobia and corneal Care should be taken to include the full width of
staining. the fold, especially medially. The amount to be
excised should be carefully assessed, as recurrence of
the problem can occur if too little tissue is excised or
ectropion can ensue if too much is removed.
After local anesthetic with epinephrine is injected,
a no. 15 blade or Colorado needle is used to excise
the skin and muscle. Usually a narrow elliptical por-
tion of tissue is removed. If any fat is present near
the lid margin, it should be excised also. The skin
edges can then be closed with 7-0 Vicryl or 5-0 fast-
absorbing gut.
This procedure is somewhat more complicated in
the upper lid, as treatment commonly results in upper
lid crease formation, which may not be desired.
In treating distichiasis, many procedures can be
performed. Treatment of a few lashes can be success-
ful with hyfercation or laser epilation. However, if
FIGURE 5–10 Epiblepharon repair. A narrow ellipse of most of the eyelid is involved, a lid-splitting procedure
skin and muscle is marked and excised. combined with cryotherapy is useful. This is done by
CHEN05-067-074.I 3/22/01 1:33 PM Page 73
TRICHIASIS • 73
splitting the lid into the anterior and posterior lamella

along the gray line. Cryotherapy is then applied to the
posterior lamella where the aberrant lashes originate
(Fig. 5–11). The anterior lamella is then recessed dur-
ing reconstruction.
SUMMARY
The clinical pathway in Fig. 5–12 summarizes the
evaluation and treatment options for trichiasis.
FIGURE 5–11 Distichiasis repair. The lid has been split

into anterior and posterior lamellae. The cryoprobe is
applied to the posterior lamella.
Trichiasis
Congenital Acquired
Distichiasis Epiblepharon Marginal entropion Trauma Metaplesia of meibomian glands
Aberrant lashes from Extra fold of skin/ Inturned lid margin with Randomly Aberrant lashes
meibomian orifices pretarsal orbicularis anterior migration of directed lashes
mucocutaneous junction
Lid-splitting Excision
and cryotherapy
of posterior lamella Mechanical Electrolysis Laser Cryotherapy Surgery
epilation (hyfercation) epilation
*
Pentagonal Tarsal Terminal Tarsal-splitting with

wedge resection fracture tarsal rotation mucous-membrane graft
*Shading indicates increasing complexity of procedure
FIGURE 5–12 Clinical pathway illustrating the evaluation and treatment modalities for trichiasis.
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CHEN06-075-088.I 3/26/01 8:32 AM Page 75
Chapter 6
PTOSIS MANAGEMENT:
A PRACTICAL APPROACH
Steven Dresner
Ptosis of the upper eyelid is a condition in which the tem for repair. On a practical basis, ptosis can be
upper eyelid margin is in an abnormal inferiorly dis- viewed as either minimal, moderate, or severe. A log-
placed position. It may cover a significant portion of ical system with appropriate choices can then be
the cornea and pupillary aperture so as to cause visual applied to each of these three categories.
impairment. The treatment of ptosis requires accurate
and consistent evaluation and measurement as well Ocular Exam
as skillful use of surgical techniques to implement a In addition to the documenting the visual acuity, the
functional and aesthetic correction. patient’s ocular motility and pupillary function
This first of two chapters on ptosis describes eval- should be evaluated. Any anisocoria suspicious for
uation and measurement of ptosis, the corrections Horner’s syndrome should be fully worked up. The
for minimal ptosis (Müllerectomy, Fasanella-Servat presence or absence of Bell’s phenomenon should be
procedure), and levator aponeurotic repair for documented as well as the tear film and breakup,
patients with involutional changes. Frontalis sus- cornea, and quantitative tear functions. Children with
pension and Whitnall’s sling are presented. External ptosis should have full-dilated exams, retinoscopy,
tarsoaponeurectomy is described by the editor. and assessment of amblyopia.
Chapter 7 completes the description on levator
resection and aponeurotic surgery, frontalis suspen- Ptosis Assessment and Documentation
sion, and management of blepharophimosis syn- The amount of ptosis is important to document to the
drome. A summary clinical pathway for management nearest 0.5 mm if possible. This is better documented
of ptosis is included. by the margin-to-reflex distance 1 (MRD1),2 which is
the distance from the central pupillary light reflex to
EVALUATION OF A PTOSIS PATIENT the upper eyelid margin. The margin-to-reflex dis-
tance 2 (MRD2) is the distance from the central pupil-
The history is important in evaluating the ptosis lary light reflex to the lower eyelid margin. The MRD1
patient. If the ptosis is congenital, one should ques- plus the MRD2 should equal the palpebral fissure
tion the patient or family as to the absence or pres- measurement.
ence of jaw winking. With acquired ptosis, a history of The levator excursion is the best clinical test of lev-
fatigability would warrant a workup for myasthenia ator function. The levator excursion is documented
gravis. Any history of trauma, previous ocular his- in millimeters, measuring the distance from extreme
tory, or contact lens wear may also be germane. upgaze to downgaze with the brow immobilized by
There are numerous classifications for ptosis, such the examiner’s thumb to eliminate any contribution
as congenital versus acquired, neurogenic, myogenic, of the brow to lid elevation. A millimeter ruler is
traumatic, and mechanical.1 None of these classifica- used vertically in the pupillary axis to assess the full
tions, however, provides a practical approach or sys- excursion. Levator excursion of 10 mm or greater is
75
CHEN06-075-088.I 3/22/01 1:35 PM Page 76
considered good function, 5 to 9 mm of excursion is phrine test precludes the use of the Müller’s muscle
fair function, and 4 mm or less is poor function. conjunctival procedure because of the unpredictabil-
Patients with minimal ptosis (2 mm or less) should ity of the procedure in this setting.2
have a phenylephrine test performed in the involved Callahan and Beard1 have stated that minimal or
eye or eyes after appropriate ptosis measurements mild ptosis is 2 mm or less, moderate ptosis is 3 to
have been evaluated and documented. Either 2.5 or 4 mm, and severe ptosis is 4 mm or greater. Usually
10% phenylephrine is instilled in the affected eye or patients with minimal ptosis will have good levator
eyes. Usually two drops are placed and the patient is excursions. The moderate-ptosis patients usually have
reexamined 5 minutes later. The MRD1 is rechecked good to fair excursion, and typically patients with
in the affected and unaffected eyes (Fig. 6–1). A rise in severe ptosis have poor levator excursions.
the MRD1 of 1.5 mm or greater is considered a posi-
tive test. This indicates that Müller’s muscle is viable, Surgical Options Based on Levator Function
and the Müller’s muscle conjunctival resection proce- For patients with minimal ptosis (2 mm or less) there
dure can be performed. It may also give the patient a are three viable options: (1) Müller’s muscle conjunc-
reasonable prediction of the desired result. tival resection, (2) Fasanella-Servat, or (3) levator
The contralateral eye must also be rechecked in aponeurotic surgery. If the phenylephrine test is pos-
patients with unilateral ptosis. With the ptotic eye itive in the affected eyelid or eyelids, the Müller’s
occluded, if the MRD1 decreases appreciably in the muscle conjunctival resection procedure is the most
opposite eye, this usually indicates that bilateral pto- precise and predictable surgical option.2 For many
sis is present, consistent with Herring’s law.3 This ptosis surgeons, this is the preferred approach for
may necessitate bilateral surgery. A negative phenyle- minimal ptosis because of its ease, predictability, and
FIGURE 6–1 (A) The margin-to-reflex distance 1 (MRD1) is measured on both upper lids and repeated 5 minutes
after instillation of 2.5 to 10% phenylephrine eye drops in the ptotic side of the eye. (B) The right upper eyelid responds
to the stimulating effects of the phenylephrine and shows a reduction of the ptosis (an increase of the MRD1). Note the
contralateral ptosis, consistent with Herring’s law.
CHEN06-075-088.I 3/22/01 1:35 PM Page 77
PTOSIS MANAGEMENT: A PRACTICAL APPROACH • 77
the ability to grade the correction. If, however, the SURGICAL MANAGEMENT
phenylephrine test is negative, one must consider
other procedures due to the unpredictability of Müller’s Muscle Conjunctival Resection
Müller’s muscle conjunctival resection in this setting. Müller’s muscle conjunctival resection is reserved for
The Fasanella-Servat procedure is the next option that patients with minimal ptosis (2 mm or less) with nor-
should be considered with minimal ptosis and a neg- mal levator excursion and a positive phenylephrine
ative phenylephrine test. The Fasanella-Servat proce- test. This technique was originally described by Put-
dure, although not quite as predictable as Müller’s terman and Urist10 in 1975. Various modifications
muscle conjunctival resection, is nearly as predictable have been described to modify this technique.2, 11
and equally easy to perform.4 Because it is in a sense a Müller’s muscle is a smooth muscle that originates
tarsectomy with little Müller’s muscle resected, it is from the undersurface of the levator and inserts with
viable in the absence of a positive phenylephrine test. a 0.5- to 1-mm tendon into the superior tarsal plate.12
Levator aponeurotic repair is the third option for When denervated in Horner’s syndrome, this muscle
minimal ptosis. Many surgeons prefer this technique relaxes, causing 2 to 3 mm of clinical blepharoptosis.
because of the ability to set the eyelid height on the The levator aponeurosis has been shown to insert on
operating table. It is quite useful for patients who the anterior 7 to 8 mm of the upper tarsus, with addi-
have contour abnormalities and who have ptosis tional interdigitations to the orbicularis oculi’s inter-
requiring concomitant blepharoplasty.5 There are, muscular septum, forming the eyelid crease. 13
however, many variables that may affect the results, Whitnall, however, recognized Müller’s muscle as
including the need for patient cooperation, the effects another important primary attachment or insertion of
of sedation or local anesthetic infiltration, and the the levator. When Müller’s muscle is advanced, it
need to overcorrect the affected side or sides on strengthens the posterior lamella and appears to pli-
the operating room table. It is also difficult to grade cate the levator aponeurosis with healing and subse-
under general anesthesia. Indeed, many reports have quent scarring in the posterior lamella. This plication
suggested that predictability and success with this is successful in maintaining a permanent elevated
procedure may vary up to within 2 mm of the other position of the upper eyelid.2
affected eyelid.6, 7 However, in the setting of minimal
ptosis, success ought to be judged to within 0.5 mm. Surgical Technique
Nonetheless, levator aponeurotic repair is useful for A frontal nerve block is unnecessary for this proce-
many minimal ptosis patients. dure; 1 or 2% Xylocaine is used as a regional block for
Levator aponeurotic repair is the treatment of the upper eyelid. Epinephrine is omitted to avoid
choice for nearly all patients with moderate ptosis. stimulation of Müller’s muscle; 2 to 3 cc of the solu-
These patients usually have good to fair levator excur- tion mixed with hyaluronidase (10 cc anesthetic
sions, and usually have negative phenylephrine tests. mixed with 150 units hyaluronidase Wydase) is
Patients with severe ptosis typically have poor lev- injected just below the superior orbital rim. Tetracaine
ator excursions and require some type of frontalis sus- topical anesthetic eye drops are then placed on the
pension. Patients with unilateral congenital ptosis and conjunctival surface. A 4-0 silk suture is placed
levator excursions of only 4 to 5 mm are often helped through the tarsus at the eyelid margin in the pupil-
with Whitnall slings or maximal levator aponeurotic lary axis. The eyelid is reflected over a Desmarres
advancement. This can be augmented by simultane- retractor. Marks are made at one-half the distance of
ous tarsectomy as well. the total resection amount medially, centrally, and lat-
Bilateral severe ptosis patients, or patients with erally, measured with a caliper and beginning 0.5 mm
very poor levator excursion, need some type of above the tarsal plate. Another mark is made centrally
frontalis suspension. Congenital severe ptosis with to measure the total extent of resection desired4
little levator excursion is best served with autoge- (Fig. 6–2).
nous fascia lata grafts. Nonautogenous materials are Three 4-0 silk traction sutures are placed through
available and can be used if necessary; however, the the conjunctiva and Müller’s muscle centrally, medi-
long-term results are poorer than with autogenous ally, and laterally at the halfway marks. Each bite is
materials.8 Acquired severe ptosis, such as seen with approximately 3 mm long and deep to the underly-
third nerve palsy, progressive external ophthalmo- ing Müller’s muscle, but should not penetrate the lev-
plegia, or oculopharyngeal dystrophy, is best ator aponeurosis or orbicularis muscle. The sutures
treated by frontalis suspension using a silicone are separated into two bundles and tied on them-
(Silastic) rod because of its adjustability and the pos- selves, to be used as traction sutures to elevate the
sibility for subsequent removal if the cornea required amount of conjunctiva and Müller’s muscle
becomes compromised.9 to be resected (Fig. 6–3).5
CHEN06-075-088.I 3/22/01 1:35 PM Page 78
FIGURE 6–2 A 4-0 silk traction suture is placed through FIGURE 6–3 Three 4-0 silk traction sutures are placed
the tarsus and the eyelid is reflected over a Desmarres eye- through Müller’s muscle and conjunctiva.
lid retractor. Marks are made medially, centrally, and later-
ally at one-half the distance of the total vertical amount of
resection desired. A separate mark is made centrally to indi- is removed. Antibiotic ointment is placed in the eye.
cate the height of total resection desired. No patch is necessary.
Excellent results can be seen with minimal ptosis
The Desmarres retractor is removed and the lid ranging between 1 and 2 mm (Fig. 6–7). The advan-
marginal suture is clamped superiorly to the head tages of this technique are that it is quick, predictable,
drape. The bundles of sutures are elevated. One bun- and quantifiable. Late failures are quite rare.
dle is held by the surgeon and the other by an assis- Complications include a rare superior corneal abra-
tant. The Müller’s muscle conjunctival resection sion, undercorrection, or overcorrection. Usually an
clamp (Karl Ilg Instruments, Villa Park, IL) is placed abrasion heals spontaneously if it is small. A bandage
over the elevated tissues. The clamp is placed so that contact lens can also be placed if desired. Overcorrec-
the most superior central mark is adjacent to the tion is rare with this technique. If it occurs, the plain
resection clamp. suture can be cut under topical anesthetic in the office,
A 6-0 plain suture is placed under the clamp with a and the wound can be separated gently with a cotton
horizontal mattress technique approximately 0.5 to swab. Undercorrection requires another procedure at
1 mm below the clamp (Fig. 6–4). The clamp tissues a later date.
are excised with a no. 15 blade, metal on metal
(Fig. 6–5). The conjunctiva is closed with a running Fasanella-Servat Procedure
baseball stitch in the reverse direction of the original In 1961 Fasanella and Servat13 described their tarsec-
pass. The suture is tied on itself (Fig. 6–6). Exterioriz- tomy operation for correcting small amounts of ptosis
ing the suture is not required. The eyelid is returned in patients with normal levator function. In 1972
to its anatomic position and the eyelid margin suture Putterman14 developed a clamp to supplant the use of
FIGURE 6–4 The sutures are elevated in two bundles

and the clamp is placed over the tissues. A 6-0 plain catgut FIGURE 6–5 The clamped tissues are incised with a no.
suture is placed underneath the clamp. 15 Bard-Parker blade, along the lower edge of the clamp.
CHEN06-075-088.I 3/22/01 1:35 PM Page 79
FIGURE 6–6 The conjunctiva is closed with the 6-0 plain B

catgut suture.
FIGURE 6–7 Pre- (A) and postoperative (B) photographs
curved hemostats for the Fasanella-Servat procedure. of a man with 2 mm of ptosis, left upper lid, and after
This clamp is best known today for its use in the Müllerectomy.
Müller’s muscle conjunctival resection procedure. The
Fasanella-Servat procedure is well suited for minimal limeter of tarsus should be resected for each millimeter
ptosis. Because patients with a positive phenylephrine of ptosis. The tissues are elevated via the two traction
test are treated with a Müller’s muscle conjunctival sutures and the clamp is placed over the tarsus and
resection procedure, the Fasanella is reserved for conjunctiva (Fig. 6–10). The screw device is turned
patients with minimal ptosis and a negative phenyle- until the tissues are firmly secured. A 6-0 polypropy-
phrine test who do not require blepharoplasty. lene (Prolene) suture is placed through the anterior
lamella under the clamp, then passed back and forth in
Surgical Technique a horizontal mattress fashion and exteriorized out the
Fasanella and Servat described performing their pro- anterior skin lamella at the other end of the clamp.14
cedure with two curved hemostats. Placing these The clamped tissues are excised with a no. 15 blade
hemostats can be cumbersome, and malplacement can (Fig. 6–11). The eyelid is reflected back in its anatomic
lead to postoperative contour abnormalities or central position and the suture is tied over itself along the pre-
peaking. A modified Putterman clamp (Karl Ilg) can tarsal area. The suture is removed in 5 to 7 days.
be used in place of the two hemostats (Fig. 6–8). This Although this procedure is not as predictable as the
clamp is modified with a screw closure, which assists Müller’s muscle conjunctival resection procedure, it
in crushing the tarsus. is nearly so, and can yield excellent results in patients
Anesthesia is obtained by injecting 1% Xylocaine who have 1 to 2 mm of ptosis (Fig. 6–12). Correction
with 1:100,000 dilution epinephrine and hyaluronidase of 3 mm of ptosis is not recommended with this
through the superior cul-de-sac. The eyelid is everted
and two 4-0 silk sutures are placed through the con-
junctival tarsal border medially and laterally (Fig. 6–9).
The tarsus is marked centrally along the pupillary axis,
measuring the proposed resection amount. One mil-
FIGURE 6–8 The modified Putterman clamp can be used FIGURE 6–9 Two 4-0 silk traction sutures are placed
in place of two hemostats in performing the Fasanella- through the conjunctiva toward a subcutaneous plane along
Servat procedure. the superior tarsal border medially and laterally.
CHEN06-075-088.I 3/22/01 1:35 PM Page 80
FIGURE 6–10 The tarsal resection is marked and the FIGURE 6–11 The clamped tarsus, levator aponeurosis,
clamp is placed over the tissues. A 6-0 Prolene suture is Müller’s muscle, and conjunctiva are excised with a no. 15
placed under the clamped tissues, originating externally in Bard-Parker blade, cutting along the lower border of the
the pretarsal skin area and terminating externally as well. clamp. The two ends of the externalized suture are then tied
to itself in the pretarsal area.
procedure because of the need to excise large amounts 4 mm), it is the procedure of choice. A maximal leva-
of tarsus. tor aponeurotic advancement or Whitnall sling can be
Complications include undercorrection, overcor- employed for patients with severe unilateral ptosis.
rection, and the rare corneal epithelial defect. Over- This can be further augmented by excising additional
corrections can usually be treated by early removal of amounts of tarsus to elevate the eyelid margin.
the suture and by digital massage. Undercorrections The levator palpebral superioris extends from the
will need either a full-thickness eyelid resection or a annulus of Zinn posteriorly through the superior orbit
levator aponeurotic repair. to Whitnall’s ligament, which serves as a suspensory
This procedure can be performed on patients with ligament for the upper eyelid (Fig. 6–13). At this point
or without positive phenylephrine tests; however, the muscle becomes aponeurotic and whitish in
patients with a positive phenylephrine test are usu- appearance. The aponeurosis courses downward to
ally better served with Müller’s muscle conjunctival insert on the inferior two thirds of the anterior surface
resection. The advantages of this modified Fasanella- of the tarsal plate, the fibrous septi of the orbicularis
Servat technique include avoiding the need for two and the subcutaneous tissues.15 Further anterior to
hemostats, the absence of contour abnormalities, and the aponeurosis is the pre-aponeurotic fat pad and the
the ability to quantitate the procedure well. orbital septum.
Levator Aponeurotic Repair Surgical Technique

Levator aponeurotic repair is useful for minimal to The procedure is best performed under local anes-
moderate ptosis and can be employed if Müller’s thetic with minimal intravenous sedation. Small
muscle conjunctival resection or Fasanella-Servat are amounts of local anesthetic are used to avoid paralyz-
not indicated, such as in patients with a large con- ing the levator muscle. Epinephrine is recommended
junctival filtering bleb or when concomitant ble- for adequate hemostasis. Approximately 1 to 2 cc of
pharoplasty is desired. For moderate ptosis (3 to 1% Xylocaine with epinephrine is usually sufficient.
A B
FIGURE 6–12 Pre- (A) and postoperative (B) photographs of a woman with 1.5-mm ptosis, right upper lid, and
after a Fasanella-Servat procedure.
CHEN06-075-088.I 3/22/01 1:35 PM Page 81
Superficial galea
Deep galea
Anterior and posterior
deep galea
Sub-brow fat pad (ROOF)
Frontalis muscle
Preaponeurotic fat
Orbital septum
Preseptal fat (ROOF)
Müller’s muscle
Levator aponeurosis
Superior tarsus
Conjunctiva
Inferior tarsus
Inferior tarsal muscle
Capsulopalpebral
fascia (CPF)
Orbital septum FIGURE 6–13 Schematic line draw-
Orbital fat ing of upper lid. The levator muscle
extends from the annulus of Zinn ante-
Orbicularis muscle
Inferior oblique riorly to Whitnall’s ligament, where it
muscle Malar fat pad transitions into the levator aponeurosis.
Suborbicularis oculi It courses downward to insert onto the
fat (SOOF) anterior two thirds of the tarsal plate.
The eyelid crease is marked prior to local infiltra- underlying Müller’s muscle (Fig. 6–15). Dissection is
tion. If unilateral ptosis is to be performed, the inci- carried upward, as high as Whitnall’s ligament if
sion is marked approximately 1 mm below the crease necessary. A double-arm 6-0 Vicryl suture is placed
on the opposite eyelid, because postoperatively the partial thickness through the central portion of the
crease will rise slightly. If bilateral surgery is planned, upper tarsus in two 3-mm bites. This suture is then
the incision can be symmetrically placed at the taken up through the aponeurosis at the desired
desired location, but placing the incision too high height (Fig. 6–16). This is temporarily tied and the
beyond the superior tarsal border of the upper tarsus level is examined. Usually sitting the patient up on
should be avoided. the table gives a more accurate assessment. A 1- to
After the local anesthetic is injected on the lid, 1.5-mm overcorrection is desirable, because the pro-
topical tetracaine eye drops are placed on the con- tractors (orbicularis) are paralyzed by local anes-
junctival surface. The patient is prepped, and pro- thetic and there can be some stimulation of Müller’s
tective corneal shields can be placed over the globes. muscle by the epinephrine. Additional sutures can
The incision can be made with a no. 15 Bard-Parker be placed medially and laterally for contour adjust-
blade or a CO2 laser set to incisional mode. A skin- ment; however, often they are unnecessary. The
muscle flap is developed to expose the orbital sep- excess levator aponeurosis is trimmed. A strip of
tum. The septum is incised over the upper one third skin–orbicularis flap superiorly can be excised if nec-
to avoid incising or damaging the underlying levator essary, or bilateral blepharoplasties can be per-
(Fig. 6–14).21 The preaponeurotic fat pad is reflected formed with this surgical technique. The wound is
upward and the whitish aponeurosis is seen under- then closed with a 6-0 suture of choice with
neath. A high-temperature hand-held cautery is supratarsal fixation on every other bite of the suture.
used to disinsert the aponeurosis from the tarsal Excellent results can be obtained with this approach
plate, which separates the aponeurosis from the (Fig. 6–17).
CHEN06-075-088.I 3/22/01 1:35 PM Page 82
FIGURE 6–14 The orbital septum is transected in the FIGURE 6–15 The levator is dissected off of the tarsus
upper one third. with a hand-held cautery.
Whitnall Sling the affected eyelid from the normal side of excursion.
The Whitnall sling procedure is a maximal levator This number is then multiplied by 1.2 to identify the
aponeurotic advancement. In actuality, the levator mus- amount of levator aponeurotic advancement. For
cle’s Whitnall’s ligament is sewn to the superior tarsal example, if one side has an excursion of 6 mm and the
plate without cutting the medial and lateral horns of other side is 14 mm, then the levator is advanced
the levator and aponeurosis. This is usually utilized 9.6 mm.
in unilateral congenital ptosis with levator function in If additional elevation is required, a tarsectomy can
the 5 mm range. be performed at the time of Whitnall’s sling. Two to
4 mm of tarsus can be excised at the time of surgery.
Surgical Technique With this method, each millimeter of tarsus is equiv-
Because this technique is often performed under gen- alent to 2 mm of aponeurotic advancement.
eral anesthesia, an empirical formula needs to be used Complications with aponeurotic surgery include
to set the height of the lid margin. The gaping tech- contour abnormalities, overcorrection, and undercor-
nique described by McCord16 suggests that in con- rection. Conjunctival prolapse is rare. These complica-
genital ptosis, one adds 3 mm to the amount of ptosis tions are usually best addressed 1 week postsurgery.7
present and that this amount of gaping or lagoph- With overcorrections, the wound can be opened and
thalmos is established on the operating table. For the aponeurotic sutures cut. The aponeurosis is
instance, if there is 3 mm of ptosis present, the eyes
should be left open 6 mm on the operating table.
Another formula is to subtract the levator excursion in
FIGURE 6–16 Double-armed 6-0 Vicryl sutures are FIGURE 6–17 Pre- (A) and postoperative (B) pho-
placed through the central superior tarsus in two broad tographs of a man with bilateral ptosis, after levator
bites and then up through the aponeurosis and tied. aponeurotic resection.
CHEN06-075-088.I 3/22/01 1:35 PM Page 83
recessed slightly with cotton swabs and the eyelid Metzenbaum scissors, the fascial strips are incised
level is reassessed. Undercorrections are opened and lengthwise. The strip is transected on both ends with
the aponeurosis advanced appropriately. Contour curved scissors or Jorgenson’s scissors, and pulled
abnormalities are handled in a similar fashion. (For out of the wound. The fascia lata is not repaired. The
levator resection, see Chapter 7.) subcutaneous tissues are closed with 4-0 or 5-0 Vicryl
sutures, and the skin can be closed with a 5-0 plain
Frontalis Suspension Using Fascia Lata suture.
Patients with severe ptosis and poor levator function
are candidates for frontalis suspension with autogenous
Surgical Technique
fascia lata. Patients with synkinetic ptosis (Marcus-
Gunn jaw-winking ptosis) may also be candidates for A number of patterns for frontalis suspensions have
this procedure with or without levator extirpation. been described. A simple pentangular pattern is use-
Generally, autogenous fascia lata gives more pre- ful for both fascia lata and silicone rod and requires a
dictable and long-lasting results.8 Eye-bank– limited length of material.
preserved tissues can be utilized when the patient is Local anesthetic with epinephrine is injected pre-
younger than 3 years of age or at the family’s request. tarsally and to the suprabrow region. Two incisions
Autogenous fascia lata is easy to harvest freehand, are marked adjacent to the medial and lateral corneal
obviating the need for fascial strippers. A 3- to 4-cm limbus over the midtarsus. Three-millimeter incisions
incision is marked in the midthigh longitudinally, are made down to the tarsal plate. A 2- to 3-mm width
halfway between the head of the fibula and the fascial strip is then pulled through the incisions with
anterior superior iliac spine (Fig. 6–18). Although a Wright fascia lata needle. The fascial strips can be
this procedure is usually performed under general pulled upward to the medial and lateral eyebrow to
anesthesia, 0.5% Marcaine with 1:100,000 dilution mark the two brow incisions, ensuring a proper vec-
epinephrine is injected subcutaneously for hemosta- tor and eyelid contour. The medial and lateral
sis and postoperatively analgesia. The foot is suprabrow incisions are incised down to the perios-
pronated slightly by a nonscrubbed assistant or can teum with a no. 15 Bard-Parker blade. While the globe
be taped to immobilize the leg and place the fascia is protected by a lid plate, a Wright needle is passed
lata on stretch. The incision is begun with a no. 15 downward from the medial and lateral brow incisions
Bard-Parker blade, and dissection is carried down through the preaponeurotic fat pads to the lid inci-
through the subcutaneous fat to the fascia. For bilat- sions. The fascia strip is then pulled through the
eral surgery, a harvested strip of fascia needs to be at medial and lateral brow incisions. It is then crossed
least 6 mm in width and 8 to 10 cm in length. Two centrally over the pupil to mark the central incision, at
incisions are made 8 to 10 cm apart into the fascia a point 4 to 5 mm above the two incisions. The central
with a no. 15 Bard-Parker blade. The fascia is exposed incision is made down to the periosteum and the two
superiorly and inferiorly by dissecting bluntly with ends of the fascial strip are tunneled into the central
small “peanuts” (small wrapped cotton balls). A sur- incision with the Wright needle. This approach helps
gical assistant moves along the incisions with army- to ensure the proper vectors of pull and a normal eye-
navy retractors to expose the field. Using long lid contour. The fascia is pulled up until the lid mar-
gin approximates the upper limbus and is then tied
with one half of a surgeon’s knot. A 6-0 Prolene suture
or braided nylon suture is sewn through the knotted
strips and tied, securing the knot. It is then sewn into
the frontalis muscles superiorly. Excess fascia is
trimmed, and 4 to 5 mm of remnant fascia is tucked
into the central incision. The lid and brow incisions
are then closed with 6-0 plain suture.
Variations
A variation of this technique can be performed by
making a lid crease incision and sewing the fascia
directly to the tarsal plate. This is helpful in some
instances when one wants to excise excess skin or to
provide a more defined lid crease. The pretarsal inci-
FIGURE 6–18 A 3- to 4-cm incision is made at the lat- sion technique described previously, however, is
eral surface of the midthigh to obtain autogenous fascia lata. faster and creates an appropriate upper eyelid crease.
CHEN06-075-088.I 3/22/01 1:35 PM Page 84
Frontalis Suspension Using a Silicone (Silastic) and just above the eyebrow centrally, medially, and
Rod laterally. The lid crease incision is made and the tarsal
Silicone (Silastic) rod suspension is useful in myo- plate is exposed by dissection through the orbicularis.
genic ptosis conditions such as progressive external The silicone rod is sewn onto the tarsal plate with
ophthalmoplegia, oculopharyngeal dystrophy, and three to five interrupted 6-0 braided nylon or
myasthenia gravis, or in third nerve palsy patients. polypropylene (Fig. 6–20). The rod is then pulled up
Rarely, an adult with severe bilateral congenital ptosis to the eyebrow to mark the medial and lateral brow
with no previous surgical correction or with under- incisions. This will help to optimize the contour of the
correction from previous surgeries may present with upper eyelid margin. Incisions are made down to
absent or poor Bell’s protective eye phenomenon. the periosteum. With the globe protected, the rods are
These patients are usually better served with silicone passed through the preaponeurotic space to the
rod frontalis suspension. medial and lateral brow incisions with the passing
Silicone rod frontalis suspension is recommended needles (Fig. 6–21). The medial and lateral ends of the
in patients with progressive neuromuscular disorders Silastic rod are then pulled up and crossed centrally to
and third nerve palsy because of the possibility of mark the central incision. This is usually above the
recovery of illness, possible favorable response to ther- pupil or just medial to the pupil. The two ends of
apeutics, and allowance for postoperative adjustment. the rod are passed through a small Silastic sleeve to
The 1-mm solid silicone (Silastic) rods are available secure them at an optimum length and tension. The
commercially (Fig. 6–19). The Silastic rod package lid level is set between 1 and 3 mm above the pupil,
comes with passing needles and Silastic sleeve, which depending on the condition being treated. (One
eliminate the need for the Wright fascia lata needle. should not elevate these lids to the limbus, as one
does with congenital ptosis.) The rods are trimmed
and left with 5 to 8 mm of length on either end for
Surgical Technique
possible future adjustment. The ends of these rods are
The surgery can be done under general anesthesia or then tucked into the wound. A 6-0 braided nylon or
local anesthesia; however local anesthesia is preferred polypropylene suture is sewn around the sleeve,
to fine-tune the eyelid level and contour intraopera- which is then sewn superiorly to the deeper frontalis
tively. A simple pentangular design similar to what muscle (Fig. 6–22). The brow incisions are closed and
is used for the fascial frontalis suspension works well the lid crease incision is closed, usually with
for this procedure. A lid crease incision, however, is supratarsal fixation every other bite to create a
more appropriate in this case to attach the silicone rod defined lid crease. One can adjust the lid level and
directly to the tarsal plate. contour postoperatively in the office by exposing the
One percent Xylocaine with epinephrine and Silastic sleeve under the central suprabrow incision.
hyaluronidase is injected under the lid crease incision This is best done within the first few weeks after
surgery because once a pseudocapsule forms
around the rods, adjustment may be more difficult.
If indicated, the rod can be entirely removed at any
time postoperatively. The Silastic rod offers the
extra advantage and flexibility of adjustability, and
FIGURE 6–19 Commercially available Silastic rod set

from Visitec (no. 5192, available from 7575 Commerce
Court, Sarasota, Florida 34243-3212). The set comes with 0.9-
mm stainless steel threading needles, a 40-cm length of
Silastic rod with diameter of 0.8 mm, and a 10-mm segment
of Silastic sleeve that has an external diameter of 2 mm and
an internal diameter of 1 mm. FIGURE 6–20 The Silastic rod is sewn to the tarsal plate.
CHEN06-075-088.I 3/22/01 1:35 PM Page 85
FIGURE 6–21 The rods are passed through the pre- FIGURE 6–22 The medial and lateral ends are crossed
aponeurotic space to the medial and lateral suprabrow centrally to mark the exact central incision. The ends are
incisions. passed through the central brow incision and then through
the Silastic sleeve. The appropriate tension and adjustment
is made so that the lid is at the desired level and the con-
comparable results to fascia lata techniques can be tour is judged optimal. A 6-0 permanent suture is sewn
obtained (Fig. 6–23). around the sleeve and then stitched into the frontalis mus-
cle under the superior edge of the incision.
EDITOR’S SUPPLEMENT
are to be excised). The skin is incised with a no. 15
External Tarso-Aponeurectomy of McCord
blade. The orbicularis along the superior tarsal border is
For the majority of acquired ptosis seen in a clinical oph- traversed horizontally to expose the anterior tarsal sur-
thalmologist’s practice, with levator function=10 mm face as well as the insertion of the levator aponeurosis.
or greater, the external tarso-aponeurectomy of McCord17 The amount of resection is determined by adding 3 mm
is a very useful technique. The upper lid is anesthetized to the amount of ptosis to be corrected. For example, if
from the conjunctival side superior to the tarsus as well one needs to lift the lid 3.5 mm, the amount to be
as from the skin side. The tarsus is everted and the resected will be 3.5+3.0=6.5 mm. It is then marked
height of the tarsus measured; this helps in placement out over the plane of the tarsus and aponeurosis, such
of the lid crease incision (this will be the lower line of that half of the 6.5 mm is on the aponeurosis side and
incision if some redundant skin and orbicularis muscle the rest over the tarsal plate (Fig. 6–24). After making
sure that corneal protective shield is in place, resection
is carried out by first incising through the tarsal plate
with a no. 15 blade and then cutting out the spindle-
shaped segment of tarsus and aponeurosis with a sharp
spring scissors (Fig. 6–25). Bleeding will be at both cor-
ners of the wound from the superior tarsal arterioles
and may be easily controlled with bipolar wetfield
cautery. A double-armed 7-0 silk suture is used to take
A
an anterior tarsal bite along the central portion of the
superior cut edge of the tarsus (aligned at or just nasal
to the pupillary center); then each of the suture ends are
passed through the superior cut edge of the levator
aponeurosis. Two additional double-armed sutures are
similarly placed, one medially and one laterally along
the superior tarsal border (Fig. 6–26). The three sutures
are temporarily tied and the contour adjusted to create
B
an ideal lid shape. The sutures are then permanently
FIGURE 6–23 Pre- (A) and postoperative (B) pho- tied (Fig. 6–27). The lid crease wound may be closed
tographs of a woman with chronic progressive external with a 7-0 silk suture, or enhanced by concurrent place-
ophthalmoplegia after frontalis suspension using Silastic ment of five to six 6-0 silk in a skin-aponeurosis-skin
rods. fashion.
CHEN06-075-088.I 3/22/01 1:35 PM Page 86
FIGURE 6–24 Amount of resection of tarsus as well as FIGURE 6–25 After verifying that the protective eye
levator aponeurosis is marked over the tarso-aponeurotic shield is in place and properly seated, tarsal incision is ini-
junction. tiated with a no. 15 Bard-Parker blade, and then excision is
completed with a pair of sharp Westcott scissors.
Advantages Recommendation
The technique allows for accurate placement and The “add-on” factor of 3 mm to be added to the
design of the lid crease, removal of skin-muscle amount of desired lift was originally designed to lift
redundancy in an elderly patient, an open view, the upper lid margin to a point 1 mm below the supe-
assessment of the integrity of the levator muscle, more rior corneal limbus. I have been setting the ideal level
accurate contouring of the palpebral fissure in case of now in elderly patients to 2 mm below the limbus,
dehiscence of the medial horn of the levator that is, 1 mm lower than I used to, and therefore I use
(Fig. 6–28), avoidance of lateral peaking as well as 2 mm as the add-on factor now in determining the
medial undercorrection of the ptosis quite often seen amount of tarso-aponeurectomy.
with Fasanella-Servat correction, and a precise degree I have not had to straddle the superior tarsal bor-
of resection. These are advantages over the Fasanella- der (i.e., equal division of the resection between the
Servat procedure, which is an internal approach tarso- tarsus and aponeurosis) or take more than 2 mm of
Müller-aponeurectomy. the tarsus plus levator aponeurosis because most
patients exhibit ptosis no worse than around mid-
pupil (5 mm of the cornea is covered by the upper
lid). In this situation, to lift the eyelid to a point 2 mm
below the superior limbus, the amount for resection is
3 mm of lift plus the add-on factor of 2 mm, resulting
in 5 mm of resection. I would then choose to straddle
FIGURE 6–26 The cut edge of the aponeurosis is reanas-

tomosed to the superior edge of the tarsus using three
double-armed 7-0 black silk sutures. (A piece of white Telfa
dressing is placed between the eye shield and the eyelid to FIGURE 6–27 Reattachment of the levator aponeurosis
enhance the contrast of this illustration.) to the tarsus has been completed.
CHEN06-075-088.I 3/22/01 1:35 PM Page 87
than half of the cornea, resection using the above for-

mula while resecting no greater than 2 mm of the tar-
sus seems to yield equally satisfactory correction. It is
quite possible that with a greater amount of tarso-
aponeurectomy, one is further from the superior
tarsal border and is resecting levator aponeurosis that
is not as thinned out or degenerated. The effective lift
from resection of these tissue is just as effective
millimeter-for-millimeter as when the actual tarsal
plate is being resected. To preserve as much of the
upper tarsus as feasible, resecting no more than 2 mm
of tarsus seems to yield as good a result as equal
straddling of the superior tarsal border for as long as
the appropriate amount of aponeurosis is resected.
Individual ocular and orbital factors as well as the
FIGURE 6–28 Involutional dehiscence of the medial
horn of levator muscle in an elderly patient’s left upper lid relative position of the opposite eyelid of the patient
(surgeon’s view). One can see through the translucent con- will necessarily determine the adjustments that work
junctiva to the underlying black protective eye shield. well with one’s surgical technique.
2 mm of tarsus and 3 mm of the distal levator aponeu- SUMMARY

rosis for resection. The resected specimen includes
Müller’s muscle underneath aponeurosis as well as The clinical pathway in Fig. 6–29 summarizes the
conjunctiva. In patients whose ptosis covers more surgical management of ptosis.
Minimal ptosis Moderate ptosis

1–2 mm 3–4 mm
Good levator excursion Fair levator excursion
Levator aponeurotic repair
Positive Negative
phenylephrine test phenylephrine test
Müller’s muscle Fasanella–Servat or levator

conjunctival resection aponeurotic repair
Severe ptosis
4–7 mm
Fair to poor levator excursion
Unilateral Bilateral
Whitnall’s sling Frontalis suspension

and tarsectomy fascia lata
OR OR
Unilateral frontalis Silicone rod
suspension
FIGURE 6–29 Management of ptosis.

CHEN06-075-088.I 3/22/01 1:35 PM Page 88
REFERENCES
1. Callahan M, Beard C: Ptosis, 4th ed. Birmingham: Aes- 10. Putterman AM, Urist MJ: Müller muscle-conjunctival
culapius, 1990. resection. Arch Ophthalmol 1975;93:619–623.
2. Dresner SC: Further modifications of the Müller’s mus- 11. Weinstein GW, Buerger GF: Modifications of the
cle conjunctival resection procedure. Ophthalmic Plast Müller’s muscle-conjunctival resection operation for
Reconstr Surg 1991;7:114–122. blepharoptosis. Am J Ophthalmol 1982;93:647.
3. Meyer DR, Wobig JL: Detection of contralateral eyelid 12. Beard C: Müller’s superior tarsal muscle: anatomy,
retraction associated with blepharoptosis. Ophthalmol- physiology and clinical significance. Ann Plast Surg
ogy 1992;99:366–369. 1985;14:324–333.
4. Dresner SC: Minimal ptosis management. In: Kikkawa 13. Fasanella RM, Servat J: Levator resection for minimal
DO, ed. Aesthetic Ophthalmic Plastic Surgery. Philadel- ptosis:another simplified operation. Arch Ophthalmol
phia: Lippincott-Raven, 1997:151–162. 1961;65:493–496.
5. Older JJ: Ptosis repair and blepharoplasty in the adult. 14. Putterman AM: A clamp for strengthening Müller’s
Ophthalmic Surg 1995;4:304–308. muscle and the treatment of ptosis: modification, the-
6. Shore JW, Bergin DJ, Garrett SN: Results of blepharop- ory and a clamp for Fasanella-Servat operation. Arch
tosis surgery with early postoperative adjustment. Oph- Ophthalmol 1972;87:665–667.
thalmology 1990;97:1502. 15. Collin JRO, Beard C, Wood I: Experimental and clinical
7. Berlin AJ, Vestal KP: Levator aponeurosis surgery. data on the insertion of the levator palpebral superioris
Ophthalmology 1989;96:1033–1037. muscle. Am J Ophthalmol 1978;85:792–801.
8. Crawford JS: Repair of ptosis using frontalis muscle 16. McCord CD,Tannenbaum M: Oculoplastic Surgery. New
and fascia lata: a 20 year review. Ophthalmic Surg 1977; York: Raven Press; 1987.
8:31–40. 17. McCord CD: An external tarso-aponeurectomy. Trans
9. Older JJ, Dunne PB: Silicone slings for the correction of Am Acad Ophthalmol Otol 1975;79:683.
ptosis associated with progressive external ophthal-
moplegia. Ophthalmic Surg 1984;15:379–381.
CHEN07-089-102.I 3/26/01 8:33 AM Page 89
Chapter 7
PTOSIS: LEVATOR MUSCLE SURGERY

AND FRONTALIS SUSPENSION
Philip L. Custer
This is the second of two chapters on ptosis. It pro-

vides further discussion of levator aponeurotic and
...
levator muscle resection and frontalis suspension uti-
lizing fascia lata and a Silastic rod, and management
of blepharophimosis syndrome.
P EARL Surgery may not be indi-
cated in patients with minimal disease or
coexisting conditions that increase the risk of
Ancient surgeons treated ptosis by excising upper postoperative complications.
eyelid skin, a technique that remained popular in the
early 1800s, as evidenced by the reports of Scarpa1 and
Hunt.2 This “blepharoplasty” approach to ptosis Ptosis repair should be limited or avoided in
repair was essentially a suspensory procedure, allow- patients with poor tear production, reduced motility,
ing more effective elevation of the lid with frontalis absent Bell’s phenomenon, an enlarged pupil, or
muscle function. Surgeons subsequently created a marked retraction of the lower eyelid (Table 7–1).
more reliable connection between the ptotic eyelid and A variety of procedures may be used to elevate a
forehead through the use of skin flaps or the subcuta- ptotic eyelid.
neous implantation of various materials. Bowman
reported the first Müller’s muscle-levator procedure
EARL... The degree of levator func-
in 1857, when he described a technique of ptosis repair
involving resection of the posterior eyelid lamella.3
The skin approach to levator muscle–aponeurotic
P tion is the primary determinate as to
which technique is ideal for an individual patient.
shortening was initially described in 1883, in separate
reports by Eversbusch4 and Snellen.5 The modern-day
ptosis procedures of frontalis suspension and levator Levator or Müller’s muscle surgery is generally
aponeurotic resection have evolved from these early performed when there is moderate to good levator
surgical techniques. function. A suspensory procedure is often needed
TABLE 7–1 PTOSIS SURGERY: RED FLAGS

EVALUATION AND TIMING FOR Preexisting keratitis or ocular irritation
SURGICAL CORRECTION Decreased basic secretory rate of tears
Limited ocular motility or absent Bell’s phenomenon
Patients request ptosis surgery to improve visual func- Preexisting photophobia, large pupil, or sector
tion and enhance cosmetic appearance. A comprehen- iridectomy
sive preoperative evaluation will assist in determining Lower eyelid retraction with inferior scleral show
which individuals will benefit from treatment.
89
CHEN07-089-102.I 3/22/01 1:36 PM Page 90
Levator Function (mm)

15 10 5 0
Good Fair Poor
Müller’s Muscle Levator Suspensory Procedure

Resection Aponeurotic/Muscle
Resection Compensatory brow elevation?
Yes No
Active Brow Internal Eyelid Static Brow

Suspension (Whitnall’s) Suspension
Suspension
Conditions requiring undercorrection of eyelid position:

• Decreased basic secretory rate • Poor Bell’s phenomenon
• Limited ocular motility • Lower eyelid retraction
• Enlarged pupil • Orbicularis weakness
FIGURE 7–1 The degree of levator function is the primary determinate as to which procedure will be ideal for an
individual patient.
when muscle function is poor (Fig. 7–1). Surgery bilateral ptosis. The management of patients with
should be delayed until the etiology of the ptosis has severe unilateral congenital ptosis is particularly chal-
been determined. Levator aponeurotic dehiscence is lenging. Unilateral frontalis suspension is effective
the most common cause of acquired ptosis, usually when patients exhibit preoperative compensatory ele-
appearing later in life from involutional changes. vation of the ipsilateral eyebrow. Unfortunately, chil-
Aponeurotic dehiscence may also develop from dren without this finding may not effectively utilize a
chronic contact lens wear or conditions that result in brow suspension. These individuals may be con-
eyelid edema, such as trauma, ocular surgery, or ble- verted to bilateral cases by ablating the normal,
pharochalasis. Fortunately, ptosis caused by levator contralateral levator at the time of bilateral frontalis
aponeurotic dehiscence is easily repaired, yielding a suspension. A similar approach may be used to treat
stable eyelid position with a low rate of recurrence. severe synkinetic (“jaw-winking”) ptosis.6 Bilateral
The repair of congenital ptosis is usually delayed levator muscle ablation is performed to reduce the
until the preschool years, when the child can cooper- wink and also force the activity of both frontalis mus-
ate with preoperative measurements and postopera- cles. Although this technique usually provides an
tive care. Earlier surgery should be performed in the excellent cosmetic and functional result, many parents
rare child who develops occlusion amblyopia from a are hesitant to approve surgery on the normal eyelid.
severely ptotic eyelid. Mild to moderate congenital A severely ptotic eyelid may also be suspended inter-
ptosis is effectively corrected with external levator nally by maximally shortening the levator aponeuro-
aponeurotic/muscle resection. Frontalis suspension sis and muscle. Unfortunately, this procedure results
usually provides a superior result in cases of severe in marked postoperative lagophthalmos.
CHEN07-089-102.I 3/22/01 1:37 PM Page 91
PTOSIS: LEVATOR MUSCLE SURGERY AND FRONTALIS SUSPENSION • 91
A B
FIGURE 7–2 (A) A child with neurofibromatosis resulting

in right upper eyelid ptosis. (B) The neurofibroma is diffusely
infiltrating the region of Müller’s muscle. (C) Postoperative
appearance after debulking the neurofibroma and reattach-
C ing the levator aponeurosis.
Ptosis is a common presenting finding in patients A variety of ancillary procedures are occasionally
with either infiltrative or encapsulated orbital mass needed in the management of ptosis patients. Upper
processes. Ptosis surgery should generally be deferred eyelid blepharoplasty is readily combined with leva-
until the underlying orbital pathology has been tor surgery in adults suffering from both bilateral pto-
treated because eyelid position usually spontaneously sis and dermatochalasis.
improves when the mass is no longer present. An
exception to this rule is the ptosis found in patients
EARL ...
with neurofibromatosis. This lesion often causes a
segmental ptosis of the lateral eyelid secondary to
infiltration of Müller’s muscle and dehiscence of the
P Skin resection is usually
not indicated in children or cases of uni-
lateral ptosis.
levator aponeurosis. These eyelids are often horizon-
tally lax, with excessive tissue in the lateral canthal
region. An extensive procedure is usually needed, Patients with blepharophimosis often require a
involving horizontal tightening of the eyelid, debulk- staged approach to reconstruction. Initial medial can-
ing of the neurofibroma, and reattachment of the lev- thoplasty improves the telecanthus and epicanthal
ator aponeurosis (Fig. 7–2). folds, often facilitating later frontalis suspension.
Anophthalmic patients develop ptosis from a vari- Lower eyelid ectropion repair is occasionally needed
ety of etiologies. A volume deficit is often present in these children.
within the socket following enucleation, causing pto- Patients with acquired myopathies, such as myas-
sis secondary to poor inferior support of the eyelid thenia gravis or chronic progressive external ophthal-
structures. Augmentation of the prosthesis or surgi- moplegia, are often poor candidates for ptosis
cal volume augmentation of the orbit will often surgery. Even minimal postoperative lagophthalmos
restore a more normal upper eyelid position. Any in these patients may result in severe exposure ker-
residual ptosis is usually related to levator aponeu- atopathy due to the limited ocular motility and absent
rotic dehiscence, resulting from either chronic pros- Bell’s phenomenon often present in these conditions.
thetic wear or the postoperative swelling associated External levator aponeurotic resection may be per-
with enucleation. formed in mild cases. However, the improvement is
CHEN07-089-102.I 3/22/01 1:37 PM Page 92
usually transient because the ptosis typically returns adjustments. Pediatric surgery is performed under
as these conditions worsen. Subsequent surgery is general anesthesia, necessitating empirical adjustment
usually deferred until the ptosis becomes disabling. of lid position. Patients with significant medical con-
Initial medial canthoplasty, lateral tarsorrhaphy, or ditions should be evaluated for surgery by their fam-
elevation of the lower eyelid may be needed to nar- ily physician. Preoperative anesthesia consultation
row the palpebral fissure, reducing the risk of later may be indicated in certain cases.
ptosis repair.7 Limited frontalis suspension may then Cataract or general surgical instruments are not
be performed, attempting to position the eyelid just appropriate for eyelid surgery. The surgeon must
above the pupil. ensure that the desired instrumentation is available,
particularly when operating at multiple or unfamiliar
facilities. Surgeons differ in the type of cautery unit
PREOPERATIVE PREPARATION they prefer. Bipolar cauterization is effective in oculo-
AND INCISION PLANNING plastic surgery, resulting in minimal tissue destruc-
tion, particularly when used in conjunction with
The preoperative evaluation includes a complete dis-
saline irrigation (“wetfield”). Fine-tipped (Colorado
cussion of the surgical procedure, its risks (Table 7–2),
needle) monopolar cautery and radiosurgery (Ellman)
and postoperative management. The anticipated cos-
units may also be used for dissection and to obtain
metic and functional results are emphasized, such as
hemostasis. Some surgeons use an incisional CO2
the need to raise and lower the brow for eyelid open-
laser in eyelid surgery. This device should be
ing and closing in patients undergoing frontalis sus-
employed only by individuals experienced in its use.
pension. Levator resection for congenital ptosis
Although significant bleeding is uncommon during
usually results in nighttime lagophthalmos and eyelid
ptosis surgery, a suction unit should be available. A
retraction in downgaze, conditions that should be dis-
trained assistant is needed during several portions of
cussed with parents prior to treatment. Overcorrec-
the ptosis procedure. Most surgical technicians or
tion, undercorrection, and poor eyelid contour
nurses are capable of filling this role.
represent the most common complications of ptosis
repair. Patients should be informed that surgical revi-
sion is occasionally necessary. It is wise to obtain prior
EARL ... The patient is examined
determination of insurance coverage before proceed-
ing with surgery. Photographs showing the upper
eyelid position in primary gaze confirm the severity
P both sitting and supine prior to surgery,
determining positional effects upon the eyelids.
of ptosis, while visual fields document the degree of
visual obstruction. Peripheral isoptors are plotted
with and without manual elevation of the ptotic eye- Any change in lid margin position must be consid-
lid, demonstrating the amount of field loss that can ered during the procedure because ptosis repair is
be attributed to the eyelid malposition. performed with the patient supine. The patient is
Ptosis surgery in adults is generally performed placed on the operating table, ensuring that the head
using local infiltrative anesthesia, allowing intraoper- is flat, without significant neck flexion or extension.
ative adjustment of eyelid position. A short-acting This facilitates adjusting the lids with the patient look-
sedative reduces the discomfort of the injection. Some ing in primary gaze. The entire face is prepped and
patients require sedation throughout the procedure, draped, even when unilateral surgery is performed.
limiting their ability to cooperate with intraoperative The drapes must not place tension on the face so that
the soft tissue are not distorted. The incision is
marked across the eyelid in the location of the desired
eyelid crease (Fig. 7–3). The position of a normal con-
TABLE 7–2 PTOSIS SURGERY: tralateral crease may be matched in unilateral cases.
SURGICAL RISKS Several factors should be considered when determin-
ing crease position in adults with bilaterally absent or
Anesthesia
Incisional scarring or irregularity
poorly positioned creases. The crease is typically
Inadequate or asymmetrical creases higher in females and patients with large bony orbits
Infection or deep superior sulci. The average male crease is
Hemorrhage located 8 to 9 mm above the central lash line, whereas
Overcorrection, undercorrection, or inadequate the female crease is 9 to 10 mm above the lashes.
contour Although each individual’s anatomy should be con-
Exposure keratitis, loss of vision sidered in determining crease contour, the medial
crease is usually 2 mm lower and the lateral crease
CHEN07-089-102.I 3/22/01 1:37 PM Page 93
x
Females x=9-10 mm
x-1 x-2 Males x=8-9 mm
Pediatrics x=y*1/3
FIGURE 7–3 Upper eyelid crease incision planning.
1 mm lower than the central measurement. In pedi- thesia in adult cases. The use of epinephrine
atric cases, the central crease is approximately one (1 : 200,000) within the anesthetic prolongs anesthesia
third of the distance between the lash line and infe- time and facilitates hemostasis. A similar anesthetic
rior brow, measured with the eye in downgaze.8 The mixture may be injected after the induction of general
eyelid crease incision forms the lower boundary of anesthesia in pediatric cases, to both decrease bleed-
skin resection in patients undergoing combined ptosis ing and provide postoperative analgesia.
repair and blepharoplasty. This incision is extended
medially and laterally in a more horizontal orienta- EXTERNAL LEVATOR
tion to minimize web formation in the canthal regions. APONEUROTIC/MUSCLE RESECTION
Forceps are then used to determine how much skin
may be excised, while leaving sufficient redundancy A two-plane dissection is generally employed to
to allow full lid function and closure. Subcutaneous expose the levator muscle complex (Fig. 7–4). Skin
infiltration of a mixture of lidocaine 1% and Marcaine and orbicularis muscle are divided in a plane perpen-
0.375% (1 to 2 cc per eyelid) provides adequate anes- dicular to the skin surface. The skin incision may be
CHEN07-089-102.I 3/22/01 1:37 PM Page 94
anterior to the orbital septum. The septum may be

confused with the aponeurosis because both have
an avascular fibrous appearance. Identification of
Sub-brow
fat pad the levator is facilitated by observing the structure
as the patient looks in up- and downgaze. The leva-
tor should demonstrate significantly more move-
ment than the septum. Inferior traction on the
septum will also be restricted due to its attachment
Preaponeurotic to the arcus marginalis of the superior orbital rim,
fat whereas the levator may be grasped and freely
mobilized inferiorly.
After the levator is exposed, patients are asked to
open their eyes so that the surgeon may determine
the effects of the local anesthetic and surgical dissec-
Müller’s muscle tion upon the eyelid. Any elevation or depression of
with fatty the lid margin should be considered when later
infiltration
adjusting the lid position. The levator is separated
from the tarsus via a horizontal incision through the
aponeurosis over the superior third of the tarsus.
Blunt and sharp dissection are then used to separate
the aponeurosis from underlying Müller’s muscle.
Light cauterization of the fine vessels within
FIGURE 7–4 A two-plane dissection is performed to Müller’s is often needed, being careful not to inad-
expose the levator aponeurosis. The preaponeurotic fat vertently damage the underlying cornea. A com-
should not be confused with either fatty infiltration of
bined advancement-resection of aponeurosis and
Müller’s muscle or the fat pad of the brow.
Müller’s muscle may be performed in children
and adults in whom the aponeurosis is markedly
created with any fine, sharp blade. Traction along the attenuated. The two structures are elevated off of the
longitudinal axis of the crease facilitates the incision, conjunctiva as a combined unit in such cases.
particularly in patients with lax skin. Skin excision is The aponeurosis is advanced and reattached to the
then performed in blepharoplasty patients. The orbic- tarsus with three double-armed permanent sutures
ularis muscle is divided longitudinally, minimizing [6-0 braided polyester (Mersilene)]. These sutures are
bleeding by separating the muscle fascicles (Fig. 7–5). passed partial thickness through the anterior surface
Hemostasis is maintained throughout the procedure of the tarsus, 1 to 2 mm below its superior border. The
using cauterization. The dissection plane now three sutures are evenly spaced across the central two
changes, angling upward toward the superior orbit. thirds of the tarsus.
The orbital septum is divided, exposing the orbital
(preaponeurotic) fat. The levator muscle and aponeu-
rosis lie just deep to this fat.
...
EARL ...
P EARL The lid is everted and the
posterior tarsus is inspected to ensure
P The preaponeurotic fat

should not be confused with other adipose
tissue within the lid. Many patients have fatty
the sutures are not exposed on the conjunctiva.
infiltration of Müller’s muscle, which may The central suture is initially passed through the
aponeurosis in a mattress fashion and temporarily
become visible after opening the orbicularis,
tied. Eyelid position is now examined with the patient
particularly in cases of aponeurotic dehiscence. looking in primary gaze. Adjustment of the suture
may be needed to achieve the appropriate lid height,
compensating for any elevation or depression that
This fat is typically positioned more inferiorly developed from supine positioning, anesthetic injec-
within the eyelid and contains numerous fine ves- tion, or the surgical dissection. Marked eyelid edema
sels. The fat pad of the brow occasionally extends may interfere with lid adjustment. In such cases, it is
inferiorly into the eyelid, having a denser, more helpful to examine the lid in downgaze, where the
fibrous texture than orbital fat and being positioned effects of swelling on lid position are less marked.
CHEN07-089-102.I 3/22/01 1:37 PM Page 95
A B
C D
FIGURE 7–5 (A) Levator aponeurotic resection. The orbital septum has been divided, exposing the aponeurosis and
preaponeurotic fat. (B) The aponeurosis (forceps) has been separated from tarsus and Müller’s muscle. (C) A braided
6-0 polyester suture has been placed partial thickness through the tarsus. The lid should be everted and inspected to
ensure the suture is not exposed on the conjunctival surface. (D) The aponeurosis has been advanced and temporar-
ily reattached to the tarsus.
The amount of aponeurotic resection is empirically

determined in those patients under general anesthe-
EARL ...
P The height of both lids
should be adjusted simultaneously in bilat-
eral cases, minimizing the effects of Hering’s law
sia. Prior to surgery the surgeon determines how
much elevation is desired. Lid position is noted after
induction of anesthesia. Sufficient aponeurosis and
on lid position. muscle are resected to achieve the predetermined
amount of elevation. Undercorrection may be indi-
cated if marked lagophthalmos is present after the ini-
A variable amount of aponeurotic advancement- tial adjustment.
resection is necessary. Simple reattachment of the The medial and lateral tarsal sutures are used to
structure may be needed in patients with good levator adjust the contour of the lid margin after the central
function and aponeurotic dehiscence, whereas increas- suture is permanently tied. Excess levator tissue is
ing amounts of tissue resection must be performed in then excised. A stable and predictable eyelid crease
cases with poorer levator activity. In occasional may be formed by a variety of techniques. The edge
patients simple reattachment of a dehisced levator of the pretarsal orbicularis muscle may be sutured to
aponeurosis results in an overcorrected eyelid posi- the aponeurosis with either interrupted or running
tion. This finding is usually caused by a coexisting sutures. Alternatively, the wound edges may be
dehiscence of the medial levator horn, which normally approximated with interrupted sutures that incorpo-
functions as a check ligament, limiting posterior excur- rate the aponeurosis at the height of the desired crease.
sion of the muscle. Suture reattachment of the horn The skin incision is typically closed with a running 7-0
will usually improve the overcorrection (Fig. 7–6). polypropylene (Prolene) suture. Fast-absorbing gut
CHEN07-089-102.I 3/22/01 1:37 PM Page 96
A B
FIGURE 7–6 (A) An overcorrected eyelid may result

after simply reattaching the aponeurosis in patients with
medial horn dehiscence. (B) A suture has been placed in
preparation to reattach the medial levator horn to the
medial canthal tendon. (C) The overcorrection is reduced
C after medial horn plication.
(6-0) sutures may be used in young children, avoiding ficient length of tissue is available in younger chil-
the need for later suture removal (Fig. 7–7). dren. The use of donor fascia lata obviates the need
for a second surgical site. However, 28% of patients
develop recurrent ptosis, presumably due to failure
FRONTALIS SUSPENSION of the donor material.9 Alloplastic implants, such as
A variety of suspensory materials may be used to silicone rods or Mersilene mesh, are often used in
transfer frontalis function to the eyelid. Autogenous patients who prefer to avoid either general anesthe-
fascia lata is an ideal implant material, with little risk sia or the second surgical site needed to harvest fascia
of infection, extrusion, or breakage. Fascia lata may lata.10 Silicone rods are easily adjusted, and are suit-
be harvested in patients over 3 years of age. An insuf- able when later eyelid revision is needed, for example
A B
FIGURE 7–7 (A) Levator aponeurotic resection. Preoperative appearance of an adult patient with bilateral, asym-
metrical ptosis. (B) Postoperative appearance after bilateral levator aponeurotic resection.
CHEN07-089-102.I 3/22/01 1:37 PM Page 97
EARL... The preoperative eyebrow

P contour determines incision planning and
the “pattern” of implant placement.
A rectangular or pentagonal implant is used in

patients who diffusely elevate their brow. Some indi-
viduals have segmental elevation with a “peaked”
brow contour. A triangular implant will be most effec-
tive in these cases (Fig. 7–8). The implant may be
placed in the eyelid blindly through stab incisions or
under direct visualization via an open eyelid crease
approach. The latter technique allows fixation of the
implant to the tarsus and the formation of an eyelid
crease. The brow incisions are 5 to 8 mm in length and
are placed either at the superior border of the eye-
brow or in preexisting forehead creases. The eyelid
incision and dissection are performed as in an exter-
nal levator resection, exposing the anterior surface of
the tarsus (Fig. 7–9). Brow incisions are beveled in the
direction of the brow hair, minimizing trauma to the
FIGURE 7–8 Brow contour will determine incision place- nearby hair follicles. These incisions are placed
ment and the pattern of implant insertion. through the subcutaneous tissue, exposing the plane
of the frontalis muscle.
in patients with chronic progressive external ophthal- Fascia lata is harvested in cases using autogenous
moplegia. Alloplastic materials occasionally extrude, tissue. Sufficient fascia for bilateral cases may be
become infected or inflamed, and may break follow- obtained from a single leg, which is positioned in
ing trauma. slight knee and hip flexion. A longitudinal incision
FIGURE 7–9 (A) Frontalis suspen-

sion. The tarsus is exposed through an
upper eyelid crease incision. (B) A sili-
cone rod has been attached to the cen-
A, B tral portion of the tarsus and passed to
exit through the suprabrow incisions.
(C) The eyelid crease has been formed
and the eyelid incision closed. The sili-
cone rods have been passed a second
time to exit through the central above-
brow (forehead) incision. Variable ten-
sion will be placed on the two ends of
the rod to adjust the lid position and
contour. The ends will then be joined
and buried deep to the subcutaneous
tissue. (D) Appearance at completion
of procedure, after closing the brow
C, D incisions.
CHEN07-089-102.I 3/22/01 1:37 PM Page 98
(3 to 4 cm) is marked and created on the lateral aspect when pentagonal or rectangular implants are used,
of the leg, 4 to 6 cm above the lateral condyle of the bringing both ends of the implant together. It is easi-
femur. The fascia lata will be visible as a glistening est to form the eyelid crease and close the eyelid inci-
white layer deep to the fatty subcutaneous tissue. sion prior to adjusting the lid height or contour.
Blunt dissection with long Metzenbaum scissors is Variable traction on the ends of the implant is used to
used to separate the subcutaneous tissue from the fas- obtain the most ideal contour and height of the eyelid
cia lata. Two parallel incisions are made through the margin. The ends are then joined with permanent
fascia lata, approximately 6 mm apart. The Crawford sutures and buried in a “pocket” deep to the subcuta-
fascia lata stripper is inserted under the intervening neous tissue of the forehead. The forehead incisions
band of fascia lata. A 6-mm-wide strand of fascia is are closed in layers.
created by passing the dissector up the leg, aiming
toward the greater trochanter of the hip. The lower
end of the fascial strip is transected and threaded
BLEPHAROPHIMOSIS SYNDROME
through the Crawford fascial divider, which is then The treatment of children with blepharophimosis
passed up the leg to cut the fascia at the desired length requires a staged approach. A variety of techniques
(12 to 15 cm). Manual pressure is applied to the donor have been used to improve the telecanthus and epi-
site for several minutes and the wound is inspected canthal folds associated with this syndrome. The
for hemostasis. The leg incision is closed in layers. The epicanthal folds arise from a vertical shortage of skin
entire leg is wrapped for 24 hours with a light com- within the canthus and are treated by mobilizing skin.
pression dressing using elastic bandages, ensuring the Medial advancement of the canthal tendons is needed
distal foot pulses are intact and palpable. to improve the telecanthus. Mild deformities may be
The implant material is divided into 3-mm strips corrected with a simple Y-V plasty of the medial can-
and sutured to the anterior face of the tarsus with thi. The Mustarde11 technique of combined Y-V plasty
partial-thickness 6-0 braided polyester (Mersilene) and transposition flaps is effective in children with
sutures. The width of this attachment partially deter- more dramatic findings (Fig. 7–10). The skin flaps are
mines the postoperative eyelid contour. Narrow fixa- initially elevated. There is usually an abundance of
tion results in a peaked eyelid, whereas a wide subcutaneous tissue, which may be thinned to give a
attachment gives a flat, “square” appearance to the lid more hollow appearance to the canthus. The anterior
margin. An ideal contour is usually achieved by arm of the canthal tendon is then disinserted from the
suturing the implant horizontally to the central third medial periorbita and advanced medially to widen
of the tarsus. Each end of the implant is threaded the palpebral fissure. The tendon is reattached to the
through the Crawford fascial needle, which is used to periorbita with a 6-0 polyglycolate (Vicryl) suture.
pass the material deep to the orbital septum, above Transnasal wiring may also be employed to advance
the superior orbital rim, to exit through the brow inci- both medial canthal angles toward the midline. The
sions. A second pass through the forehead is needed wire is passed through small holes placed posterior
FIGURE 7–10 Epicanthal folds may

be reduced by either (A) Y-V plasty or
(B) the double transposition flap tech-
nique of Mustarde.
CHEN07-089-102.I 3/22/01 1:37 PM Page 99
to the anterior lacrimal crest. Both tendons are POSTOPERATIVE COMPLICATIONS

attached to the wire and drawn medially as it is tight-
ened. The popularity of this technique is limited by Recognition of risk factors, proper patient selection,
its potential disruption of the nasolacrimal systems and meticulous surgical technique will reduce the fre-
and risk of damaging nasal or intracranial structures. quency of postoperative complications. The surgeon
The skin flaps are mobilized and sutured (6-0 fast- must maintain rapport with patients who develop
absorbing gut) after the canthal tendons have been problems following surgery. Their concerns should be
advanced. Lateral canthotomy may also be used to acknowledged and problems thoroughly discussed.
horizontally widen the palpebral fissure. Suturing the Lagophthalmos and secondary exposure keratopathy
anterior and posterior eyelid lamella at the cantho- are among the most frequent and potentially serious
tomy will help prevent fusion of the new lid margins. complications of ptosis surgery. Transient orbicularis
Ptosis repair should be delayed until there has been muscle weakness often results in temporary lagoph-
complete healing and scar maturation of the canthal thalmos, which typically resolves several weeks after
incisions. Bilateral frontalis suspension is usually surgery. Variable lagophthalmos is usually present
needed to improve the severe ptosis associated with following repair of congenital ptosis, even when the
blepharophimosis (Fig. 7–11). lid is not overcorrected. Topical lubricants may be
needed to prevent ocular exposure immediately fol-
POSTOPERATIVE CARE lowing surgery. Fortunately, severe keratopathy
requiring eyelid revision is uncommon in children
Ptosis surgery is generally performed in an outpatient with normal lacrimal production and an intact Bell’s
setting. Patients are observed prior to discharge, phenomenon. An abnormally high eyelid margin in
ensuring there is no evidence of postoperative hem- primary gaze indicates that the ptosis was overcor-
orrhage or hematoma formation. Ice packs are used rected. Although digital massage or “squeezing” exer-
as tolerated while the patient is awake for the first 24 cises may minimally lower the eyelid, significant
to 48 hours. A topical antibiotic ointment may be spontaneous improvement should not be expected.
applied to the incisions several times a day until the Surgical revision of the eyelid is usually needed and
wounds have healed. Patients undergoing frontalis should be performed emergently in patients with sig-
suspension receive a 1-week course of prophylactic nificant exposure keratopathy. Otherwise, it is best to
oral antibiotics. Lagophthalmos is frequent in the delay treatment until postoperative edema has
early postoperative period, even in patients with good resolved. Revision performed within 1 week after the
levator function. Topical lubricating ointment or primary procedure requires minimal anesthetic or
drops will minimize the risk of exposure keratopathy. surgical dissection.12 The wound and tissue planes are
Sutures are usually removed 5 to 7 days after surgery. easily separated. The aponeurosis is recessed when
A B
FIGURE 7–11 (A) Preoperative appearance of a

child with blepharophimosis syndrome. (B) Initial
repair of the epicanthal folds with medial canthal
tendon advancement has been performed. (C) Final
postoperative appearance after bilateral frontalis
C suspension.
CHEN07-089-102.I 3/22/01 1:37 PM Page 100
overcorrection is present following levator resec- Severe corneal abrasion may develop if sutures are
tion/advancement surgery. The technique to repair exposed on the conjunctival surface. Bandage soft
overcorrections following frontalis suspension is contact lenses are often effective in protecting the
determined by the type of suspensory material placed cornea until the sutures are removed.
during the initial procedure. Overcorrection follow- Conjunctival prolapse occasionally develops follow-
ing insertion of silicone (Silastic) rods may be ing large levator aponeurotic resections. The risk of this
improved by opening the central brow incision and complication may be reduced by adequately separat-
loosening the Silastic sleeve placed over the ends of ing the levator from Müller’s muscle-conjunctiva at the
the rods. Other materials may develop adhesions to time of surgery, preventing the mobilization of these
the surrounding tissue and require open adjustment layers when the aponeurosis is advanced and short-
through the eyelid crease incision. The loop of mater- ened. If conjunctival prolapse is recognized in the early
ial is divided where it crosses the central tarsus, cre- postoperative period, the tissue may often be manually
ating two strands still attached to the brow. These two repositioned and held in place with full-thickness (dou-
ends are then recessed and reattached to the tarsus or ble-armed 5-0 chromic) eyelid sutures, which are tied
aponeurosis, decreasing the lid retraction. on the skin surface. Adhesions often prevent the repo-
Undercorrection or poor eyelid contour should be sitioning of chronically prolapsed conjunctiva. The
observed until all swelling has resolved. There is exposed tissue may simply be excised.
often spontaneous improvement in the eyelid posi-
tion as postoperative edema resolves. Persistent SUMMARY
undercorrection or contour abnormalities may be cor-
rected by surgically adjusting the levator or suspen- A thorough preoperative evaluation is essential to
sion material. determine which patients are acceptable candidates
Indistinct or asymmetrical creases may be present for ptosis surgery. The degree of levator function,
following ptosis repair. A new crease may be formed lacrimal production, motility status, and presence of a
by incising the lid at the position of the desired crease. Bell’s phenomenon should be considered when
The underlying orbicularis muscle is thinned and the choosing the type and amount of surgery to perform.
subcutaneous tissue at the wound edge is sutured to The physician should strive to minimize postopera-
the levator aponeurosis, reforming the crease. It may tive lagophthalmos, in an effort to prevent exposure
be difficult to lower an abnormally high crease keratopathy. Aggressive management and early sur-
because permanent adhesions usually develop gical revision of overcorrected cases will usually pre-
between the anterior and posterior eyelid lamellae in vent the development of severe visual complications,
that location. These layers must be divided. It is occa- while yielding an acceptable final cosmetic result. The
sionally possible to mobilize orbital fat between the clinical pathway in Fig. 7–12 summarizes the surgical
lamellae to prevent readhesion. management of ptosis.
REFERENCES
1. Scarpa A: Practical Observations on the Principal Diseases 7. Holck DE, Dutton JJ, DeBacker C: Lower eyelid reces-
of the Eyes. Briggs J, trans. London: T Cadell and sion combined with ptosis surgery in patients with
W Davies, 1806. poor ocular motility. Ophthalmology 1997;104:92–95.
2. Hunt RT: On the treatment of ptosis by operation. Lon- 8. Zamora RL, Becker WL, Custer PL: Normal eyelid crease
don Med Gazette. 1830;7:361. position in children. Ophthalmic Surg 1993;25:42–47.
3. Bader D: Report of the chief operations performed at 9. Esmaeli B, Chung H, Pashby RC: Long-term results of
the Royal London Ophthalmic Hospital, for the quarter frontalis suspension using irradiated, banked fascia
ending 25th September 1857. Royal London Ophthalmic lata. Ophthalmic Plast Reconstr Surg 1998;14:159–163.
Hospital Reports 1857;1:33–35. 10. Hintschich CR, Zurcher M, Collin JRO: Mersilene mesh
4. Eversbusch O: Zur Operation der congentialen Ble- brow suspension: efficiency and complications. Br J
pharoptosis. Klin Monatsbl Augenheilkd 1883;21:100–107. Ophthalmol 1995;79:358–361.
5. Beard CH: Ophthalmic Surgery, 2nd ed. Philadelphia: 11. Mustarde JC: The treatment of ptosis and epicanthal
Blakiston, 1914. folds. Br J Plast Surg 1959;12:252.
6. Khwarg SI, Tarbet KJ, Dortzbach RK, Lucarelli MJ: 12. Dortzbach RK, Kronish JW: Early revision in the office
Management of moderate-to-severe Marcus Gunn jaw- for adults after unsatisfactory blepharoptosis correc-
winking ptosis. Ophthalmology 1999;106:1191–1196. tion. Am J Ophthalmol 1993;115:68–75.
CHEN07-089-102.I 3/22/01 1:37 PM Page 101
Ptosis
Aponeurotic Myogenic Neurogenic Mechanical

(increase length, "Congenital": Horner's syndrome, involution:
separation, thinning mild to severe ptosis, IIIrd nerve palsy neurofibroma,
of aponeurosis) no crease, (diabetes, trauma, surgery, trauma,
*poor: LF = 0–5 mm, tumor, vascular and floppy eyelids
**fair: LF = 6–10 mm disease infection,
neuro-emergency)
"Acquired": Double elevator palsy Debulk mass or

Involutional (superior rectus weakness) remove scar
mild to moderate ***Marcus-Gunn ptosis, Management of IIIrd N. Palsy
ptosis, high crease, blepharophimosis, is best with frontalis
excellent LF ≥ 11 mm, myasthenia gravis, suspension (adjustable
lateral shift tarsal plate chronic progressive Silastic rod) Solution: based on
external ophthalmoplegia, levator function,
muscular dystrophy as appropriate
Solution: Solution:
External tarso- *Poor LF S Frontalis suspension
aponeurectomy (fascia lata or adjustable Silastic rod)
of McCord; aponeurotic **Fair LF S Levator resection
resection, repair, or ***Aberrant levator:
advancement; Marcus–Gunn ptosis S levator excision
Müllerectomy with adjustable frontalis suspension
Fasanella–Servat
FIGURE 7–12 Surgical management of ptosis—critical pathway. LF=levator function.

CHEN07-089-102.I 3/22/01 1:37 PM Page 102
CHEN08-103-112.I 3/26/01 8:34 AM Page 103
Chapter 8
FACIAL NERVE PARALYSIS

Steven Dresner
Patients with facial nerve paralysis may present to the pontine lesion. The facial nerve emerges from the
ophthalmologist primarily with symptoms of corneal brainstem with a vestibular acoustic nerve at the cere-
exposure related to poor eyelid closure, or may be bellopontine angle. The nervus intermedius (respon-
referred by a colleague for the management of these sible for tearing, salivation, and taste) is between these
symptoms. An understanding of the anatomy of the nerves and carries facial nerve sensory and parasym-
facial nerve and the etiology of the facial nerve paral- pathetic information. The anterior inferior cerebellar
ysis is essential in managing the patients’ symptoms artery courses between cranial nerves VII and VIII. A
with medical treatment or surgical rehabilitation. tortuous anterior inferior cerebellar artery or poste-
rior inferior cerebellar artery (PICA) or other vessels
ANATOMY in this area may compress the facial nerve to produce
hemifacial spasm.
The facial nerve, cranial nerve VII, is divided into four The facial nerve traverses the temporal bone
anatomic segments: supranuclear, nuclear, fascicular, through the internal auditory canal with the nervus
and peripheral. The supranuclear neurons that inner- intermedius and the acoustic nerve. Leaving the
vate the facial nerve nucleus lie in the precentral gyrus acoustic nerve, the facial enters the fallopian canal,
of the frontal lobe. Discharges from the motor or facial where it courses serendipitously for approximately
area are carried through fascicles of the cortical bulbar 30 mm through the labyrinthine tympanic and mas-
tract to the internal capsule, descending through the toid segments. The labyrinthine segment of the facial
upper midbrain to the lower brainstem where they nerve includes the geniculate ganglion, which yields
synapse, and the facial nerve nucleus is located in the the first branch of the facial nerve, the greater petrosal
pons. The cortical bulbar tracts for the upper face nerve. This branch carries sensory motor fibrils to the
cross and recross in reaching the facial nerve nucleus. lacrimal gland. The motor branches of the facial nerve
The tracts for the lower face are crossed only. These leave the fallopian canal at the base of the skull
anatomic differences account for the resultant lower through the stylomastoid foramen. The facial nerve
facial weakness seen in supranuclear lesions involv- immediately enters the parotid gland, which the main
ing the descending motor pathways. A cortical lesion trunk of the nerve usually divides into superior (tem-
that produces a lower facial weakness is usually asso- porofacial) and inferior (cervicofacial) divisions.
ciated with weakness of the arm, fingers, and hand on Branching patterns are quite variable from individual
the same side as the facial weakness. to individual in the temporal and zygomatic buccal,
The facial motor nucleus is in the lower third of mandibular, and cervical branches (Fig. 8–1). The
the pons, beneath the fourth ventricle. In this area, the numerous connections among these branches corre-
facial nerve is proximal with cranial nerves VI and late with the clinical picture seen with aberrant regen-
VIII. Peripheral facial nerve palsies associated with eration following facial nerve paralysis. Common
hearing loss and/or abducens palsy should suggest a manifestations of aberrant regeneration include ptosis
103
CHEN08-103-112.I 3/22/01 1:38 PM Page 104
Frontalis muscle
Supraorbital
artery and nerve
Supratrochlear
nerve
Temporal branch
of facial nerve
Zygomatic branches Infraorbital nerve
of facial nerve
Levator labii superioris
Zygomaticus minor muscle
Buccal branches
of facial nerve Zygomaticus major muscle
Mandibular branch
of facial nerve
Cervical branch
of facial nerve
FIGURE 8–1 Peripheral branches of the facial nerve.
upon chewing or smiling, and tearing with eating being to document the onset and duration of the
food, such tears being known as crocodile tears. The facial paralysis.
temporal branch of the facial nerve exits the parotid
gland and runs within the superficial muscular
...
aponeurotic system (SMAS) over the zygomatic arch
and temple to enter the frontalis muscle. P EARL Idiopathic paresis or paral-
ysis of the facial nerve or Bell’s palsy is the
most common cause of facial nerve weakness.
PITFALL Other specific causes should be considered. Con-

sultation with an otolaryngologist is advisable
The nerve is particularly vulnerable to dam- because early diagnosis and treatment can shorten the
age over the zygomatic arch and, to a lesser course of paralysis in some cases. The possible causes
extent, in the lateral brow, and may be injured for consideration are the following:
in facial rhytidectomy or with coronal or A history of diabetes is important because these
endoscopic brow lifting. patients may have a higher incidence of facial
nerve weakness.
Sarcoidosis can cause either unilateral or bilateral
ETIOLOGY facial nerve paralysis.
Immunization history should be obtained because
The etiology of facial nerve paralysis may help deter- immunizations for polio or influenza have been
mine whether the paralysis is permanent or whether associated with facial nerve weakness.
the causes are treatable. Therefore, it is important that A recent onset of a viral illness may also be related
the physician take a full medical history, the first step to a facial nerve palsy. Some physicians use
CHEN08-103-112.I 3/22/01 1:38 PM Page 105
FACIAL NERVE PARALYSIS • 105
acyclovir to treat Bell’s palsy, addressing the

EARL... If numbness in the face is
P
possibility that the paralysis may represent a
viral neuronitis.
present, a lesion within the temporal bone
Lyme disease may lead to facial paralysis. The rash of
Lyme disease known as erythema chronicum or a compressive disorder at the brainstem or
migrans consists of multiple expanding ring cerebellopontine angle should be suspected.
lesions with central clearing. A history of this rash
in a geographical area where tick bites are
endemic may also be helpful in the diagnosis. Dryness of the eye, a common symptom, may be
Herpes zoster ophthalmicus or the Ramsay Hunt syn- secondary to diminished tear production resulting
drome is a frequent cause of facial nerve paralysis. from a lesion at or proximal to the geniculate ganglion
The varicella-zoster virus is the usual cause. This affecting sympathetic innervation. More often, how-
syndrome consists of pain in the affected ear, facial ever, dryness is linked to ectropion, lid retraction, or a
nerve paralysis, and eruption of vesicles on the poor blink mechanism and lagophthalmos. The
oracle or external auditory canal, and may be asso- patient may also have conjunctival injection, corneal
ciated with hearing loss, tinnitus, and dizziness. drying changes, or frank corneal ulceration. Presen-
Acute otitis media with or without mastoiditis in chil- tations of eyelid and eyebrow malposition and facial
dren or adults can lead to facial nerve paralysis. nerve paralysis will differ according to the age of the
Acute or chronic osteitis in the fallopian canal is injury and the etiology.
also a possible cause.
A history of carcinoma in a patient with facial nerve
EARL ... Most commonly, the pa-
paralysis should be investigated to rule out
metastasis or local tumor involvement of the
facial nerve anywhere along its course. Appro-
P tient presenting with the combination of
eyebrow ptosis, lower eyelid retraction, and
priate radiologic imaging, such as computed
ectropion has acute facial nerve paralysis.
tomography or magnetic resonance imaging is
also indicated.
A schwannoma is the most common neoplasm of the
facial nerve. The slow progressive onset of facial This patient may also have a poor blink mechanism
nerve paralysis from this tumor contrasts the and lagophthalmos. Patients with an early paresis or
acute onset of paralysis in Bell’s palsy. a permanent paralysis may also have upper eyelid
Malignancies of the parotid gland may also affect retraction.
the facial nerve; a palpable and visible mass in the An upper eyelid mechanical ptosis is secondary to
vicinity of this gland is usually apparent on exam. eyebrow ptosis. In an old facial nerve paralysis with
Acoustic neuromas cause facial nerve paralysis by aberrant regeneration, the eyelid fissures may be nar-
compression of the cerebellopontine angle. The rowed. Facial movement such as smiling or chewing
patient may also present with hearing loss, tinni- may exacerbate the narrowing. Another common
tus, or other neurologic signs or symptoms. manifestation of aberrant regeneration is tearing with
Trauma to the facial nerve can occur with fractures to eating food, such tears being known as crocodile
the temporal bone or during mandibular surgery. tears.
The temporal branches of the facial nerve are par- As was stated in the anatomy section, lower facial
ticularly vulnerable to trauma over the zygomatic weakness can suggest supranuclear lesions involving
arch and over the temple superolateral to the brow. the descending motor pathways; lower facial weak-
ness associated with weakness in the arm, fingers, and
hand on the same side as the facial weakness usually
suggests a cortical lesion. Peripheral facial nerve palsy
EVALUATION is associated with hearing loss and/or abducens palsy
to suggest a pontine lesion.
Patients may present to the ophthalmologist with a
variety of symptoms associated with facial nerve
paralysis that may suggest an etiology. Pain behind
EARL... Hemifacial spasms suggest
the ear or in the mastoid region may accompany facial
nerve paralysis. Although this pain is usually associ-
ated with the Ramsay Hunt syndrome or herpes
P that a tortuous anteroinferior or pos-
teroinferior cerebellar artery or other vessels in
zoster, it also may be seen in approximately 50% of this area may be compressing the facial nerve.
patients with Bell’s palsy.
CHEN08-103-112.I 3/22/01 1:38 PM Page 106
Ocular Exam Taping of the eyelids at night can be helpful in

The ocular exam is the ophthalmologist’s assessment selected patients. If upper eyelid retraction is promi-
of the condition of the patient’s eyes and can help con- nent, the upper eyelid can be taped down to the cheek
firm the etiology. The ocular exam should include slit- after ointment is applied. Usually lower eyelid retrac-
lamp biomicroscopy and testing for acuity and for tion and ectropion are more prominent, requiring, in
corneal sensation. Extraocular motility should be eval- addition to ointment, that the cheek be taped up to
uated and documented. The tear films should be the brow. Patients who find this method uncomfort-
assessed and basic Schirmer testing performed. able may be better served with commercially avail-
The upper and lower eyelid positions should be able moist chambers or swimming goggles, in
examined. The margin-to-reflex distance 1 (MRD1) addition to ointment. Patching by the patient or fam-
and 2 (MRD2), and upper and lower eyelid to pupil- ily is often incomplete and can allow the cornea to be
lary light reflex distance should be documented. The exposed under the patch.
eyebrow position, blink mechanism, and amount of
lagophthalmos with gentle closure should be SURGICAL MANAGEMENT
assessed. The presence or absence of Bell’s phenome-
non can be assessed by having the patient close the When medical management by itself will not prevent
eyes while the examiner pulls the upper eyelids corneal complications or when recovery from the
upward with moderate force. facial paralysis is not expected, surgical rehabilitation
The facial musculature should be assessed to dif- should be considered. The specific presenting
ferentiate a partial paresis from complete facial nerve anatomic abnormalities and the patient’s symptoms
paralysis. Having the patient forcefully close the eyes should dictate the choice of surgical method for man-
against the examiner’s resistance approximates the aging problems caused by the facial nerve paralysis.
orbicularis force. Both sides of the face are examined A temporary lateral canthoplasty or tarsorrhaphy can
and compared. Aberrant regeneration is elicited by be performed in emergent situations to promote
having the patient open the mouth wide, or by smil- corneal healing.
ing or chewing. If aberrant regeneration is present, the
upper eyelid will often come down and the lower eye- ...
lid may ride up as well.
The head, neck, and hearing should also be exam-
ined. The auricle and pinna should be examined to
P EARL Permanent tarsorrhaphy
should be avoided if possible. Newer pro-
cedures, including gold weight implantation and
evaluate for vesicles of herpes zoster. Hearing can be elevation of the lower eyelid with perhaps better
roughly assessed by whispering in each ear or by rub- positions, are better options for less urgent
bing fingers and thumb together next to the ear, with cases because they preserve peripheral vision
the patient comparing the difference on each side. The and compromise cosmetic appearance less.
parotid gland should be palpated because infiltrative
tumors may produce the facial nerve paralysis. Head
and neck adenopathy should also be checked because A medial canthoplasty is a useful addition to
the presence of nodes may indicate an infectious or these procedures in patients who continue to have
neoplastic process. corneal exposure.
Lateral Canthoplasty
MEDICAL MANAGEMENT
The most common eyelid malposition seen with facial
If recovery from a paresis is expected, medical man- nerve paralysis is ectropion (Fig. 8–2). Lateral cantho-
agement alone should suffice for the duration. All plasty is the mainstay of surgical rehabilitation; it is
patients with facial nerve paralysis are at risk for the most efficient and anatomic approach to lower
punctate keratopathy, corneal ulceration, and/or per- eyelid shortening. Shortening the lower eyelid at the
foration. Artificial tears and lubricating ointments are lateral canthus avoids vertical blepharotomy or
the mainstays of medical management of facial nerve wedge resection. An incision is made at the lateral
paralysis. Artificial tears should be liberally applied canthus with a no. 15 blade. The canthoplasty is com-
every hour or every half hour if necessary. If lagoph- pleted with a Stevens scissors. The inferior crus at the
thalmos is evident or is suggested by the corneal lateral canthal tendon is cut with the needle tip of
exam, then lubricating ointment should be used at the monopolar cautery. The eyelid is pulled laterally
night. Patients with more severe symptoms may need and marked for shortening.
ointment during the day and/or more viscous artifi- With the facial nerve paralysis, it is prudent to
cial tear supplements. tighten the lower eyelid as much as possible because
CHEN08-103-112.I 3/22/01 1:38 PM Page 107
FIGURE 8–2 Left lower lid ectropion from facial nerve FIGURE 8–3 The patient following repair of ectropion
palsy. through lower lid tightening and lateral canthoplasty.
there is usually poor orbicularis tone and recurrences injury to the canaliculi. The anterior lamella is sewn
of ectropion are common. The tarsus is separated together with vertical mattress sutures of 6-0 plain.
from the orbicularis and skin and a new lateral can-
thal tendon is fashioned out of lateral tarsus (see Sur- Lower Eyelid Retraction
gical Technique: Lateral Tarsal Strip in Chapter 4). Many patients with facial nerve paralysis have some
The new cutaneous margin is trimmed. The lower degree of lower eyelid retraction and midfacial
eyelid retractors are detached from the lower margin descent that lateral and medial canthoplasty would
of the tarsal strip. The strip is shortened appropriately not completely address. These patients can be helped
and reinserted on the inner aspect of the lateral orbital with grafts of either hard palate or ear cartilage to the
rim through the periosteum with a 4-0 polypropylene posterior lamella with lateral canthoplasties. Hard
suture and tied temporarily. The patient can then be palate grafts are preferable in most cases because they
examined for tone and contour. An overcorrection is are stiff but pliable, and give the best cosmetic results.
desirable, with the lateral canthus residing at least Ear cartilage grafts, however, can be used when very
2 mm or more above the level of the medial canthus. large grafts are desirable and the patient refuses hard
A second 4-0 polypropylene suture is passed on the palate surgery.
lower portion of the tarsal strip, and both are tied. The hard palate is harvested from the lateral aspect
Remnants of the anterior lamella are laterally of the palate 3 to 4 mm from the adjacent molars and
trimmed and the wound is closed with 6-0 or 5-0 plain incisors. The submucosal tissues are infiltrated with
sutures. Figure 8–3 illustrates a patient following local anesthetic and epinephrine. The graft is har-
repair of ectropion through lower lid tightening and vested free hand with a no. 15 blade. Absorbent
lateral canthoplasty. gelatin sponge (Gelfoam) can be placed in the palatal
defect and a hard palate stent can be fabricated by a
Medial Canthoplasty dentist. If the patient wears dentures, these will serve
Medial canthoplasty is a useful adjunct to lateral can- as a stent.
thoplasty in patients with facial nerve paralysis. The The lateral canthoplasty begins with a canthal inci-
addition of a medial canthoplasty will improve clo- sion using a no. 15 blade. The canthoplasty is com-
sure and minimize lagophthalmos. Local anesthetic pleted with a Stevens scissors. A 4-0 silk traction
with epinephrine and hyaluronidase is injected into suture is placed through the lid margin. With the nee-
the upper and lower eyelids medially. The upper and dle point of the cautery, an incision is made through
lower puncta are dilated and a double Bowman probe the conjunctiva and the lower lid retractors along the
is passed into the upper and lower canaliculi. A lower tarsal border. A pocket is developed in which to
V-shaped incision is made medial to the punctum and place the graft, which recesses the lower eyelid retrac-
anteriorly in both upper and lower eyelid skin. The tors and helps support the lid at a higher position.
anterior and posterior lamellae are separated by mak- Usually a 2 : 1 graft to retraction ratio is desired; thus,
ing a small incision and a muscle flap. The posterior 2 mm of lower eyelid retraction requires a 4-mm graft.
lamella from the lower eyelid is sewn to the post- The graft is cut into a pendant shape and the upper
erior lamella of the upper eyelid with a series of 6-0 border sewn into the lower edge of the tarsal plate
polygalactin sutures. Care must be taken to avoid with 6-0 plain suture, and the lower portion of the
CHEN08-103-112.I 3/22/01 1:38 PM Page 108
FIGURE 8–5 Patient with left facial palsy following

FIGURE 8–4 Hard palate graft in place; it is interposed repair with medial canthoplasty.
between conjunctiva and lower lid retractor.
graft is sewn to the conjunctiva and lower lid retrac- in 0.2-g increments. These implants are placed in the
tors in a similar fashion (Fig. 8–4). The lateral canthus upper eyelids to correct retraction and to assist in clo-
is tightened with a tarsal strip as previously described. sure. The size of the weight is determined preopera-
Figure 8–5 shows a patient after medial canthoplasty tively in the office with the patient seated. Fitting
and Figure 8–6 shows the patient after both medial weights can be purchased or a few weights can be
and lateral canthoplasties with lower lid elevation. kept in stock and tried in the office. A trial weight is
Another useful adjunct in patients with signifi- applied to the upper pretarsal eyelid with double-
cant midfacial descent is to perform a subperiosteal stick tape or benzoin, and the patient is examined
cheek lift in conjunction with a posterior lamellar (Fig. 8–7). The goal is improved or complete closure
graft and canthoplasty. This procedure elevates the with 1 mm of induced ptosis or less. Usually 1.2 to
cheek and midface and may prevent recurrent lid 1.4 g is adequate for implantation.
retraction and/or ectropion. The gold weight can be autoclaved. It is surgically
implanted with a central 1- to 1.5-cm lid crease inci-
Upper Eyelid Retraction sion. Dissection is taken down through the orbicularis
Patients with lagophthalmos may benefit from gold to the tarsal plate. The weight is inserted and sewn
weight implantation. Patients with upper eyelid into the upper tarsus with three 6-0 braided nylon
retraction should be considered for levator aponeuro- sutures (Fig. 8–8). The orbicularis is closed with a
sis recession with or without a gold weight. Gold series of 6-0 polygalactin sutures and the wound
weights are available in sizes ranging from 0.6 to 1.6 g closed with running 6-0 polypropylene sutures.
FIGURE 8–7 A trial weight has been applied over the

FIGURE 8–6 The patient underwent hard palate graft right upper lid of a patient with facial palsy and lagoph-
and lateral canthoplasty. thalmos.
CHEN08-103-112.I 3/22/01 1:38 PM Page 109
FIGURE 8–8 Gold weight is sutured on the anterior FIGURE 8–9 Facial palsy patient with left brow ptosis.
tarsal surface of the palsied upper lid. The brow incision is just above the upper border of eyebrow
cilia.
The advantages of gold weight implantation The amount of brow ptosis is assessed preopera-
include the simplicity of insertion and a lower extru- tively with the patient seated. An elliptical incision is
sion rate; the disadvantages include its occasional marked over the brow. The subcutaneous tissues are
visibility through the dermis and the need for gravity infiltrated with local anesthetic with epinephrine. The
assistance in its effectiveness. The use of a stainless incision is begun with a no. 15 blade. The brow is
steel spring to help reanimate the upper eyelid pre- excised with the scissors or the cutting cautery. The
sents another alternative. The thinness of the spring incision is deeper laterally, but does not need to
wire makes it relatively invisible in the upper eyelid, extend down to the periosteum (Fig. 8–9). As the exci-
and it does not need gravity assistance. Its major dis- sion proceeds medially, a shallow dissection is made
advantages include the technical difficulty of the to avoid injury to the supraorbital neurovascular bun-
operation, the need for postoperative adjustment, dle. The subcutaneous tissues along the inferior inci-
and a fairly high extrusion rate anteriorly and poste- sion are fixed to the deep tissues and periosteum
riorly. However, it is useful in patients with pro- superiorly with a series of 4-0 polypropylene sutures
found facial nerve paralysis after tumor surgery tied firmly but not tight. The wound can be closed
when no return of function is expected. Successful with vertical mattress sutures of 4-0 polypropylene
implantation of springs require a surgeon experi- (Fig. 8–10). Usually a slight undercorrection is desir-
enced in this technique. able to avoid further lagophthalmos.
Patients who have recovered from a Bell’s palsy
Ptosis and Brow Ptosis Surgery may have varying amounts of aberrant regeneration.
Many patients with facial nerve paralysis will have This may be manifested as minimal ptosis in the upper
brow ptosis that can cause mechanical ptosis of the
upper eyelid. For patients with severe exposure and
lagophthalmos, it is better to rehabilitate the upper
and lower eyelids to improve closure and to attend to
the eyebrow position at a later date if necessary. How-
ever, for those who do not have severe exposure or
for those with partial recovery, eyebrow surgery can
be performed at the same time as eyelid surgery to
reposition the eyebrow in a more anatomic position.
To effectively raise and stabilize the eyebrow position
in the patient with facial nerve paralysis, eyebrow
surgery is best performed either directly over the
brow or in the midforehead. Endoscopic brow
surgery may be useful for unilateral brow ptosis, but
as yet has not been significantly studied in a series of
patients. Transeyelid brow–pexy is also not as effec- FIGURE 8–10 Wound closure completed with deep
tive as direct brow-plasty and may further weaken placement of 4-0 Prolene as well as superficial vertical mat-
the eyelid protractors or orbicularis force. tress sutures of 4-0 Prolene.
CHEN08-103-112.I 3/22/01 1:38 PM Page 110
eyelid. The ptosis is often exacerbated with eating,

chewing, or smiling. In symptomatic patients, Botox
can be used to lessen the affect of aberrant regenera-
tion, although care must be taken to avoid further
weakening of the facial and eyelid musculature.
EARL... The Müller’s muscle con-

P junctival resection procedure is an excel-
lent operation in the setting of post–Bell’s palsy
with aberrant regeneration to elevate the
ptotic eyelid and yet avoid lagophthalmos with
corneal exposure.
FIGURE 8–11 The temporalis muscle and fascia are har-
vested in a midface lift incision.
The Müller’s muscle conjunctival resection proce- Overcorrection at the time of surgery is necessary
dure can correct from 1 to 3 mm of ptosis in patients to better establish facial tone. The defect in the tem-
with a positive phenylephrine test. This technique pli- ple can be replaced by a temporalis fossa implant if
cates Müller’s muscle via an internal approach. desired. The postoperative patient can initiate smil-
Because no skin incision is required, the protractors ing or movement of the face by chewing or biting the
are not weakened further in a condition in which they teeth together. Mid- and lower facial reanimation in
are already compromised. The extent of increase in conjunction with lower eyelid resuspension with
ptosis induced from facial animation remains undi- either gold weight or eyelid spring can give very grat-
minished, but the procedure does allow the lid fis- ifying results (Figs. 8–12 and 8–13); patients’ general
sures to be better normalized and it lessens the appearance and psychological well-being are all
tendency for the lid to encompass the pupillary axis greatly improved, and their vision is preserved and
with facial movement. protected as well.
Facial Reanimation Surgery

The temporalis muscle can be used to reanimate the
face in long-standing facial paralysis where the fifth
cranial nerve is intact.
EARL... The temporalis muscle can

P function as a motor activator to the
cheeks, upper lip, and nasolabial fold.
Although strips from the temporalis muscle with

attached fascia can also be placed in the upper and
lower eyelid as slings, this method is much less satis-
factory than mid- and lower facial reanimation.
Through an extended facelift incision, the temporalis
muscle and deep temporalis fascia can be harvested
(Fig. 8–11). The central portion of the muscle is mobi-
lized from the bony temporalis fossa, reflected over FIGURE 8–12 Preoperative photograph of a patient with
the zygomatic arch, and then sewn to the nasolabial left facial palsy; note brow droop, lower eyelid ectropion,
folds and the corner of the mouth. Fascial extensions absence of nasolabial fold, and lack of animation of orbicu-
are used if necessary. laris oris muscles.
CHEN08-103-112.I 3/22/01 1:38 PM Page 111
CONCLUSION
The ocular signs and symptoms of facial nerve weak-
ness include ectropion, lid retraction, lagophthalmos,
brow ptosis, and impaired blinking, resulting in dry-
ness of the eye. The patient’s medical history and ocu-
lar exam determine whether medical treatment alone
will suffice and whether the condition requires surgi-
cal correction. If surgery is required, the patient’s spe-
cific anatomic abnormalities and symptoms dictate
the choice of surgical method (Fig. 8–14).Although the
patient’s comfort and cosmetic appearance are impor-
tant considerations, preserving and restoring corneal
health is the chief goal of surgery.
FIGURE 8–13 Same patient as in Fig. 8–12, following left

lateral canthoplasty, gold weight implantation to left upper
lid, left midface lift, and facial animation surgery.
Facial Palsy
Exposure Ectropion Lower eyelid Lagophthalmos Brow ptosis Selective cases

(medial bulbar retraction of facial atonicity
surface)
Medial Lower lid Posterior Gold weight Browplasty, Reanimation

canthoplasty tightening lamellar graft implantation repair of of facial
(Tarsal-strip (hard palate, acquired nerve
procedure, lateral ear cartilage) ptosis
canthoplasty)
FIGURE 8–14 Clinical pathway showing management of facial nerve palsy.

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CHEN09-113-124.I 3/26/01 8:35 AM Page 113
Chapter 9
ESSENTIAL BLEPHAROSPASM
John D. McCann, Stanley Saulny, Robert A. Goldberg, and Richard L. Anderson
Blepharospasm (literally, spasm of the eyelids) is an and movements, functional and cosmetic deformities
idiopathic disease distinguished by repetitive, spon- of ptosis, and eyelid malposition, were often as bad
taneous, and involuntary bilateral contractions of the as the disease.
entire orbicularis oculi. Spasm limited to the eyelids is
present in only a minority of blepharospasm patients;
the majority manifests other facial or regional body
spasms. Blepharospasm is a progressive disease, and
most patients present with, or later develop, squeez-
ing of the lower face and neck (Meige’s syndrome,
orofacial dystonia, or oromandibular dystonia) or
dystonias in regions outside the distribution of the
facial nerve (segmental cranial dystonia or craniocer-
vical dystonia).
HISTORY
The first record of blepharospasm and lower facial
spasm is found in the 16th century in a painting titled
“De Gaper” (Fig. 9–1). At that time, and for several
ensuing centuries, patients with such spasms were
regarded as being mentally unstable, and were often
institutionalized in insane asylums. Little progress
was made in the diagnosis or treatment of ble-
pharospasm until the early 20th century, when Henry
Meige (pronounced “mehzh”), a French neurologist,
described a patient with eyelid and midface spasms,
“spasm facial median,” a disorder now known as
Meige’s syndrome. About the same time the first FIGURE 9–1 “De Gaper” by Flemish artist Brueghel. The
medical treatments became available, including alco- painting depicts the grotesque distorted face, of a woman
hol injections into the facial nerve, facial nerve avul- suffering an acute episode of eyelid, lower face, and neck
sion, neurotomy, and neurectomy. The side effects of spasm, which subsequently has been referred to as
these treatments, including loss of facial expression Brueghel’s syndrome.
113
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Benign Essential Blepharospasm

EARL... At onset, there is increased
Benign essential blepharospasm (BEB), or simply,
essential blepharospasm, defines a disorder encom-
passing spasms of the muscles of the eyelids (pre-
P frequency of blinking, particularly in
response to a variety of common stimuli includ-
tarsal, preseptal, and periorbital orbicularis oculi),
and of the upper face (corrugator, procerus) in the ing wind, air pollution, sunlight, noise, and move-
absence of any other ocular or adnexal cause. ments of the head or eyes, and in response to
Patients with essential blepharospasm often suffer stress or the environment.
for prolonged periods before the proper diagnosis is
made and treatments begun. Misdiagnosis as a psy-
chiatric disorder frequently delays definitive treat- Patients may complain of photophobia and ocu-
ment. Diagnosis and treatment is further lar surface discomfort, and especially of dry eye
complicated by frequent fluctuation of symptoms, symptoms. These symptoms progress over a vari-
with transient remission and exacerbation. Jankovic able period to include involuntary unilateral
and Orman1 report that over 50% of patients have spasms, which later become bilateral. Patients may
symptoms for 4 to 10 years prior to diagnosis, and report that they are disabled to the point where
20% have symptoms for over 10 years. Although they have stopped watching television, reading,
there is no known cure for essential blepharospasm, driving, or walking. Patients may develop anxiety,
there are several effective modes of treatment cur- become depressed, avoid social contact, and
rently available. There is no known way to prevent become occupationally disabled. A family history
this disease. positive for dystonia or blepharospasm further aids
It is estimated that there are at least 50,000 cases of in the diagnosis. Blepharospasm is commonly asso-
benign essential blepharospasm in the United States, ciated with dystonic movements of other facial
with up to 2000 new cases diagnosed annually. The muscles.6 Anatomic changes associated with long-
prevalence of blepharospasm in the general popula- standing blepharospasm include eyelid and brow
tion is approximately 5 in 100,000 (Nutt, unpub- ptosis, dermatochalasis, entropion, and canthal
lished observations). In a review of 264 patients with tendon abnormalities.7
blepharospasm, Grandas et al.2 reported a female The early symptoms of blepharospasm include
preponderance of 1.8 to 1. The spasms are absent increased blink rate (77%), eyelid spasms (66%), eye
during sleep3 and are most often bilateral (88% of irritation (55%), midfacial or lower facial spasm (59%),
cases).4 The mean age of onset is 55.8 years2 and two brow spasm (24%), and eyelid tic (22%). Symptoms
thirds of patients are 60 years of age or older. Dysto- commonly preceding diagnosis include tearing, eye
nias are found elsewhere in the body in 78% of irritation, photophobia, and vague ocular pain.8
patients.2 About one third of patients have at least Although these complaints are common in the aver-
one first- or second-degree relative with a movement age ophthalmology practice, awareness of this disor-
disorder, such as blepharospasm, Meige’s syndrome, der and proper suspicion may aid in early diagnosis.
Parkinsonism, or essential tremor,4 suggesting that Conditions relieving blepharospasm included sleep
there is a genetic predisposition in a third of the (75%), relaxation (55%), inferior gaze (27%), artificial
patients. In its more severe form, blepharospasm tears (24%), traction on eyelids (22%), talking (22%),
results in depression and social isolation, and singing (20%), and humming (19%). Comorbid diag-
approximately 12% of pretreatment blepharospasm nosis include dry eyes (49%) and other neurologic
patients are considered totally incapacitated, or disease (8%).9
“blind” due to their affliction.5 Once a clinical history suspicious for blepharo-
spasm is obtained, efforts to eliminate other entities
within the differential diagnosis should be made.
EVALUATION Close examination of the patient with nonvolitional
contraction of the orbicularis oculi will aid in diagno-
At one end of the clinical spectrum, essential ble- sis. If muscular spasm is isolated to only one side of
pharospasm is manifested by simple increased blink the face, then the proper diagnosis is likely hemifacial
rate and intermittent eyelid spasms, and at the other spasm (be aware that during a transient initial period,
end of the spectrum, blepharospasm is a disabling BEB may present unilaterally). If only a single fiber
condition with ocular pain and functional blindness. within the orbicularis oculi is observed to spasm, then
It usually begins in late-middle or older age, and is the patient likely has ocular myokymia. If examina-
twice as frequent in women as in men in a ratio that tion at the slit lamp reveals acute corneal or conjuncti-
exceeds 2 : 1. val pathology, then the patient likely suffers from
CHEN09-113-124.I 3/22/01 1:39 PM Page 115
ESSENTIAL BLEPHAROSPASM • 115
reactive blepharospasm. On the other hand, chronic

external ocular disease coexists commonly with BEB. TABLE 9–1 BLEPHAROSPASM: DIFFERENTIAL
If bilateral eyelid spasms are associated with twitches DIAGNOSIS
or spasms of the midface, then the eponym Meige’s
syndrome or “idiopathic cranial-cervical dystonia” is Essential blepharospasm
most accurate. Use of dopamine-blocking drugs (neu- Parkinson’s disease, Huntington’s disease, Wilson’s
roleptics), dopamine-stimulating drugs (e.g., lev- disease, Creutzfeldt-Jakob disease, progressive
odopa), or nasal decongestants containing antihis- external ophthalmoplegia, postencephalitic
syndrome
tamines or sympathomimetics should be investigated
Reflex blepharospasm
as possible potentiators of blepharospasm.
Meige’s syndrome
Apraxia of eyelid opening
EARL... If the patient has difficulty
P
Hemifacial spasm
Gilles de la Tourette’s syndrome
opening the eyelids when the orbicularis
Habit spasms
oculi is not in forceful contracture, then the
Encephalitis
patient may suffer from apaxia of eyelid opening.6 Ocular myokymia
Tardive dyskinesia
Myotonic dystrophy, tetany, tetanus
Many patients with BEB have a component of
Facial nerve misdirection (synkinesis)
apraxia of eyelid opening, but pure apraxia of eyelid
opening is rare. Drugs (antipsychotic, antiemetics, anorectics, nasal
decongestants, levodopa)
Patients with blepharospasm visit, on average, five
Ocular disease (conjunctival and corneal irritation,
doctors with complaints of their illness before the cor-
iritis, uveitis)
rect diagnosis is made.8 In one series, 97% of patients
Functional (hysterical)
with essential blepharospasm consulted more than
Spurious
one physician prior to proper diagnosis.10 The cost of
Seizure (absence, complex, partial)
making the correct diagnosis was found to be greater
Posterior subcapsular cataract
than $1000 in 59% of patients eventually identified
with the condition, and it exceeded $50,000 in 1% of
patients.9 Most patients have symptoms for over
5 years before diagnosis is made.1 It is indeed a bilateral involuntary spasms of the muscles of the eye-
tragedy that the average patient with blepharospasm lids (pretarsal, preseptal, and periorbital orbicularis
suffers a prolonged period of pain and expense prior oculi), and of the upper face (corrugator, procerus) in
to the accurate diagnosis and initiation of treatment, the absence of other adenexal disease.
when the diagnosis does not require sophisticated or Parkinson’s Disease, Huntington’s Disease, Wil-
complicated testing. son’s Disease, Creutzfeldt-Jakob Disease, Progres-
sive External Ophthalmoplegia, Postencephalitic
Differential Diagnosis Syndrome Blepharospasm can occur in a variety of
Only a minority of patients who carry the diagnosis neurodegenerative disorders. Patient’s with these
of blepharospasm actually satisfy the criteria for cortical and subcortical diseases often demonstrate
BEB.5 The diagnosis of essential blepharospasm is not only spontaneous blepharospasm, but also
one of exclusion. Careful examination must be con- heightened reflex blepharospasm and apraxia of
ducted to rule out dystonic movement disorders, eyelid opening.
which simulate blepharospasm, and the numerous
causes of secondary blepharospasm. Once the diag- Reflex Blepharospasm Reflex blepharospasm occurs
nosis of essential blepharospasm becomes most in response to provocative, irritating, mechanical or
likely, it can be affirmed if necessary by negative neu- light stimuli, such as in ocular surface disease, light
rologic examination and neuroimaging to exclude scatter, or in the irritation of any branch of the trigem-
other disorders. Other entities that share many of the inal nerve.
same characteristics as BEB and that should be
included in the differential are listed in Table 9–1,
...
and are summarized below:
Essential Blepharospasm Essential blepharospasm

P EARL Common causes of reflex
blepharospasm include blepharitis, trichia-
sis, dry eye syndrome, corneal disease, and uveitis.
defines an idiopathic disorder encompassing episodic
CHEN09-113-124.I 3/22/01 1:39 PM Page 116
Reflex blepharospasm may be incorrectly labeled clearing, barking, and the utterance of obscenities
as essential blepharospasm, resulting in the lack of (coprolalia), or obscene gestures (copropraxia) and
recognition of a potentially treatable underlying dis- other behavioral abnormalities.
order. Certain toxins are also known to induce reflex
blepharospasm, these include the chemotherapeutic Habit Spasms Habit spasms, nervous twitches,
agent tegafur (fluranyl-5-fluorouracil) and several mannerisms, or facial tics are usually stereotyped and
dibenzoxazepines used in riot control.5 repetitive, with variable frequency. Onset frequently
occurs in childhood. They usually occur during situa-
Meige’s Syndrome (Blepharospasm–Oromandibular tions of emotional stress. Unlike essential ble-
Dystonia, Orofacial-Cervical Dystonia, Brueghel’s pharospasm, muscle contracture in habit spasms can
Syndrome) Meige’s syndrome consists of ble- be inhibited upon command.
pharospasm plus oromandibular dystonia, character-
ized by dystonic movements of the lower face, jaw Encephalitis Meningeal inflammation caused by
and neck. These movements may produce involun- meningitis, encephalitis, or subarachnoid hemorrhage
tary chewing, lip pursing, mouth opening, deviations may present with referred pain in the first trigeminal
of the jaw, protrusion or retraction of the tongue, division and reflex blepharospasm.
spasms of the vocal cords (spasmodic dysphonia),
swallowing or respiratory problems, torticollis, or Ocular Myokymia Ocular myokymia is a relatively
retrocollis. The most frequent presenting complaint is common condition occasionally confused with ble-
blepharospasm, although it is not always present. The pharospasm. It features benign episodes of continu-
full syndrome may take years to develop. ous fibrillary twitching or flickering of the eyelid,
Apraxia of Eyelid Opening In apraxia of eyelid usually involving a unilateral lower eyelid. Ocular
opening, the patient suffers from passive involuntary myokymia is a localized form of facial myokymia,
closure of the eyelids; that is, the eyelids fail to open which involves contraction of a larger portion of the
even in the absence of squeezing. The eyelids appear orbicularis oculi muscle or other facial muscles.
relaxed and the eyebrows are often raised in the
patient’s desperate attempt to elevate the upper eye-
...
lid. Apraxia of opening is occasionally seen coexist-
ing with blepharospasm, and is often seen in
extrapyramidal diseases such as Parkinson’s, Hunt-
P EARL Myokymia occurs in normal
individuals, and is usually caused by fatigue,
physical exertion, emotional strain, or excessive
ington’s, and Wilson’s diseases, and with supranu- caffeine ingestion, and is usually self-limiting.
clear palsy and Shy-Drager syndrome. The incidence
of apraxia of eyelid opening among patients with ble-
pharospasm is estimated to be 7%.11 Other causes are suspected to involve changes in
the microenvironment of the motor neuron or its axon,
such as those due to edema, ischemia, demyelination,
EARL ...
P Electromyogram (EMG)
testing will reveal inactivation of the orbic-
ularis oculi and inhibition of the levator muscle.
metabolic disturbance, or toxin. In contrast to benign
transient myokymia, persistent facial myokymia may
uncommonly be an initial sign of a peripheral neu-
ropathy, brainstem tumor, pontine tuberculoma, cere-
bellopontine angle tumor, carcinomatous meningitis,
Hemifacial Spasm Hemifacial spasm involves the
sarcoidosis, cysticercosis, hypoparathyroidism,
ipsilateral lower face. The chief difference is that
syringobulbia, subarachnoid hemorrhage, multiple
hemifacial spasm remains unilateral, whereas ble-
sclerosis, or Guillain-Barré syndrome.5
pharospasm features bilateral involvement. Hemifa-
cial spasms affect the muscles innervated by the facial
Tardive Dyskinesia Tardive dyskinesia consists of
nerve, such as the orbicularis oculi, the platysma, and
rapid, continuous, and stereotyped movements of the
midfacial muscles. Patients with hemifacial spasm do
orofacial region, and the history reveals an exposure
not have photo-oculodynia or ocular surface irritation
to antidopaminergic, antipsychotic, or antiemetic
as is common in blepharospasm.
drugs. The duration of exposure observed to incite
Gilles de la Tourette’s Syndrome Tourette’s syn- tardive dyskinesia spans from 3 days to 11 years, with
drome may mimic blepharospasm when it involves an average of about 3.7 years, and the onset of the
upper facial tics. This rare syndrome has its onset in dyskinesia may occur up to 1 year after cessation of
childhood, and is associated with other motor multi- the offending drug.5 Movements in tardive dyskinesia
focal tics, or vocalizations such as grunting, throat are more choreic, rather than sustained or dystonic.
CHEN09-113-124.I 3/22/01 1:39 PM Page 117
Some patients treated with antipsychotic agents Seizure (Absence, Complex, Partial) Rarely, epilep-
develop an iatrogenic disorder with more sustained tic activity arising in the motor cortex of the face can
facial movements, which may have other associated manifest as clonic facial movements. Patients with
dystonias, clinically similar to Meige’s syndrome, but absence or complex partial seizures may have contin-
appropriately identified as tardive dystonia.6 uous fluttering of the eyelids during the ictal phase.
When carefully observed, the involved distribution of
Myotonic Dystrophy, Tetany, Tetanus Several neu- muscles corresponds more closely to contiguous
romuscular disorders, particularly myotonic dystro- motor cortex than to the distribution of the facial
phy, tetany, and tetanus, are associated with nerve. A postictal paralytic period (Todd’s paralysis)
blepharospasm. is often witnessed. The electroencephalogram (EEG)
is useful in confirmation and localization of the
epileptic discharge.
Facial Nerve Misdirection (Synkinesis) If the facial
nerve is damaged, as in Bell’s palsy, it may regenerate
aberrantly, with misdirection to other facial muscles, Posterior Subcapsular Cataract Certain lenticular
or with cross-innervation from the contralateral side. opacities, particularly posterior subcapsular cataract,
As a result, a synkinetic group of facial muscles cause such significant light scattering as to induce
responds when only one muscle is intentionally con- reactive blinking. Treatments include use of sun
tracted. A history of facial paralysis or nerve injury, visors, sunglasses, and cataract extraction.
and electrophysiologic studies may be helpful in
revealing signs of synkinesis and denervation. ETIOLOGY
Drugs (Antipsychotic, Antiemetics, Anorectics, Nasal In normal blinking, eyelid closure is the result of activ-
Decongestants, Levodopa) Commonly used drugs ity and co-inhibition of two groups of muscles—the
implicated in blepharospasm include dopamine- protractors of the eyelids (the orbicularis oculi, corru-
blocking drugs (neuroleptics), dopamine-stimulating gator superciliaris, and procerus muscles), and the
drug (e.g., levodopa), nasal decongestants containing voluntary retractors of the eyelids (the levator palpe-
antihistamines, and sympathomimetics. bra superioris and the frontalis muscles). During the
normal blink, the protractors and retractors have co-
inhibition and function only at separate times.
Ocular Disease (Conjunctival and Corneal Irritation,
Iritis, Uveitis) Ocular diseases are a frequent cause
of irritation and photophobia and consequent sec-
EARL... In patients with blepharo-
ondary blepharospasm. A thorough ophthalmic
examination should identify any such potentially
treatable offending stimuli.
P spasm, this inhibition between the pro-
tractors and retractors is lost.9
Functional (Hysterical) Functional or hysterical

blepharospasm is quite rare. It usually occurs in chil- A specific etiology for blepharospasm has yet to be
dren and young adults, generally has sudden onset, identified. In the past, many physicians believed ble-
and is usually preceded by a traumatic emotional pharospasm to be essentially psychogenic in origin.13
event. Afflicted individuals usually have other seri- Psychologically oriented clinicians likened the spasms
ous psychological problems. There is limited evidence to “crying without tears” and have postulated that
to suggest that blepharospasm is very rarely a mani- patients closed eyes to avoid “seeing what they did
festation of a conversion reaction.12 not want to see.”13 Stress has long been observed to
trigger and worsen blepharospasm, causing the illness
Spurious Spurious blepharospasm or feigning of to appear psychogenic. As in any chronic, debilitating
eyelid spasm for secondary gain is distinctly less com- condition, blepharospasm can affect the psychology
mon than true blepharospasm. Coordinated move- of the patient, thus increasing comorbid anxiety and
ment of the eyebrow and eyelid during eyelid closure depression. Consequently, some patients occasionally
suggests the diagnosis. In essential blepharospasm, find relief in psychotherapy and behavioral therapy.
careful observation reveals that during the contractile The bizarre nature of the spasms, their fluctuating
phase of the orbicularis oculi, the brow remains sta- course, and the confounding associations between the
tionary, or more commonly moves upward, against patient’s emotional state and the spasms are often
the closing upper lid. In spurious blepharospasm, the misconstrued as evidence for a psychopathologic
brow tends to move downward with the upper lid. etiology for blepharospasm.
CHEN09-113-124.I 3/22/01 1:39 PM Page 118
Modern physicians realize that blepharospasm is a or various other trigeminal stimulants. These stimuli
neuropathologic, rather than psychopathologic, dis- are transmitted to the central control center, which
order. The cause of blepharospasm is multifactorial. may be genetically predisposed or weakened by
injury or age. This abnormal central control center
fails to regulate the positive feedback circuit. The
EARL ...
P It is likely that a central
control center for coordination and regu-
lation of blink activity exists, somewhere in the
motor pathway is composed of the facial nucleus,
facial nerve, and the orbicularis oculi, corrugator, and
procerus muscles.
If patients with isolated blepharospasm are fol-
basal ganglia, midbrain, or brainstem. lowed, 80% will progress to more extensive facial and
body dystonias.9 This finding suggest that ble-
pharospasm represents an isolated dystonia related
It is unlikely that a single defect in this elusive con- to more generalized dystonias.14 Although essential
trol center is the primary cause of this disease. Today, blepharospasm may begin simply with an increased
most view blepharospasm as a defect in circuit activ- frequency of blinking (not sustained “dystonic” con-
ity, rather than a defect at a specific locus. If the cen- tractions), as the disorder progresses, sustained clo-
tral control center fails to regulate blinking in sure of the eyelids occurs. A similar pattern of early
blepharospasm, it is thought to be only one compo- jerking and rapid contractions followed by the devel-
nent of an overloaded, defective circuit. This circuit opment of sustained muscular contraction is seen in
forms a blepharospasm vicious cycle, which has a dystonic disorders, such as in spasmodic torticollis
sensory limb, a central control center located in the (involuntary head turning).
midbrain, and a motor limb (Fig. 9–2). The sensory Some patients with blepharospasm report a famil-
limb responds to multifactorial stimuli, including ial occurrence of the affliction. In families with auto-
light, corneal or eyelid irritation, pain, emotion, stress, somal-dominant familial dystonia, affected members
Sensory Motor
Pain Dystonia
Photophobia
Foreign body sensation
Orbicularis
oculi
Initiating event:
External ocular
disease
Facial
Central nerve
control
center
Optic
Photoreceptors nerve
Trigeminal
Ocular nerve
nocioceptor
Cervical sympathetics
FIGURE 9–2 The blepharospasm vicious cycle.

CHEN09-113-124.I 3/22/01 1:39 PM Page 119
may have a generalized dystonia (involving at least

one leg and the trunk) or segmental dystonia (involv- TABLE 9–2 TREATMENT OPTIONS FOR
ing two contiguous muscle groups, such as arm and BLEPHAROSPASM
neck), whereas other members have various focal
dystonias (involving a single body part), such as iso- Conservative
lated blepharospasm. The familial relationship Information
between individuals with differing varieties of dys- Sunglasses
Dry-eye treatment
tonias and individuals with isolated blepharospasm
Blepharitis treatment
suggests a genetic component, and supports the view Interventional
that blepharospasm is a form of dystonia. Chemodenervation (Botox)
A common feature of dystonias is that various Oral medications
tricks can be used to suppress or break the dystonia. Sympatholysis
Torticollis patients can often break a head turn by Myectomy
placing a hand on the side of the face, or by resting Chemomyectomy
the back of the head against a chair. Correction of eyelid malposition
Aesthetic surgery
...
P EARL Patients with essential ble-
pharospasm can frequently break an
attack by talking, singing, yawning, whistling,
The first line of treatment for all patients addresses
the sensory limb of the blepharospasm “vicious” cycle
circuit (Fig. 9–3). Such measures include wearing
coughing, humming, or by placement of a finger tinted sunglasses with ultraviolet blocking, to decrease
on the lateral margin of the orbit. light sensitivity (photo-oculodynia). Lid hygiene to
decrease irritation and blepharitis should be encour-
aged. Frequent applications of artificial tears and
These various similarities and relationships punctal occlusion to alleviate dry eyes often improve
between dystonias and essential blepharospasm sug- symptoms.
gest the concept that blepharospasm itself is a form
of dystonia.
Medical Management
Pharmacotherapy
Benign Essential Blepharospasm Research
Because the central control center for blepharospasm
Foundation (BEBRF)
is unknown, drug therapy directed against this as-of-
Formed in 1981, the purpose of this foundation is to yet unidentified center tends to follow a “shotgun
undertake, promote, develop, and search for a cure approach.” Historically, an extensive list of drugs
for BEB, Meige’s syndrome, and related disorders. have been used to treat blepharospasm, in part
This organization also promotes awareness of these
conditions to both physicians and the general public,
organizes support groups throughout the world, and
obtains funding for research and education.15
TREATMENT
Blepharospasm is a chronic condition that too often
progressively worsens. Although no cure currently
exists, patients have excellent treatment options (Table
9–2). Because the disease frequently progresses,
patients may become frustrated. Desperate patients
have resorted to a variety of unconventional remedies,
and unfortunate patients sometimes become the vic-
tims of charlatans. The most effective of today’s con-
ventional treatments include education and support
provided by the BEBRF, pharmacotherapy, botulinum
toxin injections, and surgical intervention. Unconven-
tional treatments have included faith healing, herbal
remedies, hypnosis, and acupuncture. FIGURE 9–3 Conservative treatment options.
CHEN09-113-124.I 3/22/01 1:39 PM Page 120
the associated muscles. Botulinum-A toxin is the

TABLE 9–3 DRUG CLASSES USED IN THE product of the bacteria Clostridium botulinum. Of the
TREATMENT OF BLEPHAROSPASM eight immunologically distinguishable exotoxins pro-
duced by this bacteria, three (A, B, and E) cause paral-
Antipsychotics (phenothiazine, butyrophenone, ysis in humans. Type A was the first approved for use
reserpine) in humans. The type A toxin is a high molecular
Affective disorder agents (lithium carbonate, weight protein (about 900,000 daltons), which consists
tetrabenazine)
of two multiprotein subunits that dissociate in solu-
Antianxiety agents (meprobamate)
Stimulants (amphetamine)
tion.17 Once injected, the toxin rapidly and firmly
Sedatives (phenobarbital) binds at receptor sites on cholinergic nerve terminals
Parasympathomimetics (lecithin, choline, in a saturable fashion. The toxin is internalized
physostigmine) through the synaptic recycling process. Paralysis
Antimuscarinics (tincture of belladonna, scopolamine, of muscle is a result of the inhibition of the release of
catecholamine synthesis inhibitors) vesicular acetylcholine (ACh) from the nerve termi-
Antihistamines (diphenhydramine hydrochloride) nal. It is assumed that the toxin attaches to the ACh-
Anticonvulsants (clonazepam) containing vesicles in the nerve terminal and prevents
calcium-dependent exocytosis.17 Histopathologically,
the nerve terminals show a mild degree of demyeli-
because blepharospasm was initially considered a native changes, and subsequent regeneration (which
manifestation of psychiatric illness, and because no is seen as onion bulb formation and newly formed
one drug was demonstrably more efficacious than sproutings at the neuromuscular junctions). The den-
another. Recently, these psychoactive medicines have ervated muscle shows atrophy.17
been used not for their psychotropic action but for Botulinum-A toxin (Botox, distributed by Allergan
their motor system action. Pharmaceuticals, Irvine, CA) is available in a freeze-
Most patients respond incompletely or not at all to dried, frozen, lyophilized form, and if stored at or
pharmacotherapy. At best, pharmacotherapy pro- below –5°C, should remain stable for 4 years. Once
vides only partial, transient relief. Patients react dif- the toxin is hydrated, it is said to deteriorate within a
ferently to the various pharmacologic agents, and few hours. The toxin is said to be fragile, and its
there is no way to predict which patient may respond potency is easily diminished by mechanical forces
to any particular agent. Tricyclic antidepressants do such as from frothing during reconstitution or from
not directly help blepharospasm, but are is useful if rapid subcutaneous injection. It is also readily
there is depression exacerbating the symptoms. Drugs degraded by heat, incorrect concentration, improper
with the highest percentages of favorable patient pH, chemical contaminants,17 and some believe by
responses include lorazepam (67% of patients), clon- contact with the alcohol prep applied to the skin prior
azepam (42%), and Artane (41%).9 The relief provided to injection. The authors have not observed Botox to
by these agents is variable. be as unstable as reported.
Although drugs from a variety of different classes One vial of Botox contains 100 units, at approxi-
have demonstrated some effectiveness in blepharo- mately 0.25 ng per unit. A unit is defined as the
spasm (Table 9–3), drug therapy for blepharospasm amount that has 50% (LD50) chance of causing death in
and facial dystonias is usually based on three Swiss Webster mice.18 It is available at a cost of $330 to
unproven pharmacological hypothesis: (1) choliner- $360 per vial in 1999.18 The mean lethal dose (LD50) for
gic excess, (2) g-aminobutyric acid (GABA) hypo- humans is estimated at 39 units per kilogram.17 When
function, and (3) dopamine excess. Pharmacotherapy the toxin is injected locally into muscle, it binds the
is generally less effective than Botox injections and is tissues rapidly and firmly, with little possibility of sys-
thus reserved as second-line treatment for spasms temic effects caused by toxin passing into the circula-
that poorly respond to Botox, such as in midface and tory system.17 Rarely reported systemic effects include
lower-face spasm. generalized weakness and a flu-like syndrome.18 It is
believed that the very small doses usually used in the
Botulinum Toxin treatment of facial spasms do not produce generalized
Botulinum-A toxin (Botox, formerly called Oculinum) systemic effects.3 The paralytic effect is dose related,
is regarded as the most effective treatment of choice with a peak of effect at 5 to 7 days postinjection.
for the rapid, but temporary, treatment of orbicularis Patients typically note onset of relief 2 12 days postin-
spasm. More than 95% of blepharospasm patients jection,3 with a mean duration of relief from symp-
report significant improvement with use of the toms of 3 months.16 Over 5% of treated patients have
toxin.16 The toxin interferes with acetylcholine release sustained relief for over 6 months,16, 17 and some
from nerve terminals, causing temporary paralysis of patients require injections as often as monthly. It takes
CHEN09-113-124.I 3/22/01 1:39 PM Page 121
as long as 6 to 9 months for the injected muscles to

recover from the effects of the toxin, and occasionally
muscles do not fully return to their preinjection level
of function.3 Although various authors have noted
increased duration of effect with larger doses,
increased potency of treatment in patients with prior
surgery for blepharospasm, and the loss of potency of
treatments with repeated injections, these findings are
inconsistent and controversial.3, 16, 17, 19 Some have sug-
gested that the development of antitoxin antibodies or
the progressive atrophy of muscle may account for
variations in the dose-response curve, but no studies
have supported these findings.16
The therapeutic indications for botulinum toxin
FIGURE 9–4 Distribution of Botox injection sites.
injection includes strabismus, acquired nystagmus,
myokymia, spastic lower lid entropion, spastic dys-
phonia, aberrant regeneration of the seventh cranial Subsequent treatments should be adjusted depen-
nerve, spasmodic torticollis, corneal ulcer, corneal expo- dent on patient response to the initial doses. At each
sure, hemifacial spasm, and essential blepharospasm. site, inject 2.5 to 10 units of Botox. Use of higher con-
Food and Drug Administration (FDA) approval was centrations is suggested to avoid the risk of spread to
granted in 1990 for use in the treatment of strabismus adjacent areas.
and dystonias. When used to treat blepharospasm,
complications of botulinum toxin injections include pto-
...
sis (7–11%), corneal exposure/lagophthalmos (5–12%),
symptomatic dry eye (7.5%), entropion, ectropion,
epiphora, photophobia (2.5%), diplopia (6 1%), ecchy-
P EARL The solution should be
injected subcutaneously over the orbicu-
laris oculi and intramuscularly over the thicker
mosis, and lower facial weakness.16, 17 One of the more
common side effects, ptosis, is due to diffusion of toxin corrugator and procerus muscles.
from the upper eyelid injection sites to the exquisitely
sensitive levator muscle. The incidence of ptosis has
been reported as high as 50% of patients treated more The patient may return home without restrictions
than four times. The frequency of this complication is of activity. Physicians often schedule patients
decreased if less toxin is used (less than 25 units are requiring Botox injections on the same day for full
used per eye),16 and if the middle upper eyelid site is utilization of the reconstituted solution during its
avoided. Use of Botox is contraindicated in pregnant or peak of activity. Most patients require repeated
breast-feeding patients.18 treatment every 3 months but this ranges from 1 to 5
Meticulous technique in the administration of months.
Botox will help ensure reliable and consistent results.
Botox should be hydrated with 0.9% nonpreserved Surgical Management
saline, which should be introduced slowly into the Botox therapy has reduced the need for surgical ther-
vacuum-sealed vial to prevent frothing. Most physi- apy for benign essential blepharospasm. Some
cians reconstituted Botox in 2 cc of saline. Once recon- patients never achieve adequate control of symptoms
stituted, the solution should be used within a few with Botox, or with prolonged use the Botox becomes
hours, or refrigerated. The manufacturer recommends less effective. It is often unclear if the patient has
discarding after several hours of reconstitution, but developed resistance to Botox or if the blepharospasm
several studies have shown clinical activity for weeks has progressed to a severity that is no longer control-
after reconstitution. lable with Botox. The strength of the orbicularis oculi
muscle should be objectively tested 2 weeks after
Botox injections. In patients who have objective weak-
...
P EARL At the first treatment, use
of a total dose of no more than 25 units
per eye, divided among four to six periocular
ness, a limited surgical myectomy should be consid-
ered, and in patients who do not demonstrate
weakness, an extended myectomy is more likely to be
beneficial.
injection sites (Fig. 9–4), is recommended to It is also important to consider if spasm of the
avoid side effects. orbicularis oculi muscle is the patient’s primary prob-
lem. Patients may “fail” Botox therapy because they
CHEN09-113-124.I 3/22/01 1:39 PM Page 122
Blepharospasm
Botox injection
Repeat every 1–6 months
Botox “failure”
Botox doesn't Photo-oculodynia Botox causes Functional

Apraxia Aesthetic Spasm outside
cause objective objective weakness eyelid
eyelid opening concerns orbicularis oculi
weakness but spasms persist malposition
Extended Cervical Sympathetic Limited Reconstructive Limited myectomy Blepharoplasty Oral

myectomy Block myectomy surgery and frontalis sling upper face lift medication
midface lift
FIGURE 9–5 Interventional treatment options for blepharospasm.
have eyelid malposition, aesthetic concerns, apraxia band of pretarsal muscle is preserved at the eyelid
of eyelid opening, or photo-oculodynia. These condi- margin, and the rest of the pretarsal muscle is
tions require surgeries in addition to or in place of removed in block 1 (Fig. 9–7). If the patient has invo-
myectomy (Fig. 9–5). lutional ptosis an external levator advancement can
be performed without violation of the orbital septum.
Violation of the orbital septum is prevented by dis-
Myectomy secting the levator and septum off of the anterior sur-
The mainstay of surgical treatment of spasm of the face of the tarsus as a single unit. Dissection then
orbicularis oculi is myectomy.9, 20 Nearly all centers proceeds superior in a plane between skin and muscle
have abandoned neurectomy because of the higher to above the eyebrow. The orbital septum is left intact
complication rate than that of myectomy. Limited to prevent adhesion of the dermis to the levator.
myectomy involves surgical extirpation of protractors
of the eyelids including the pretarsal, preseptal, and
orbital portions of the upper and lower eyelid orbicu-
laris oculi muscle. Extended myectomy includes
removal of the procerus and corrugator muscles.
Myectomy is a staged procedure with upper eyelid
surgery typically performed first, followed by lower
eyelid surgery if symptoms persist. Simultaneous
upper and lower eyelid myectomy is avoided, as it
typically leads to chronic lymphedema.
Adequate access to the orbicularis oculi, corruga-
tor, and lateral procerus muscle can be gained
through an upper eyelid crease incision (Fig. 9–6). If
dermatochalasis is present a conservative amount of
skin should be removed. Muscle is removed in three
en-bloc sections. Dissection begins in a plane FIGURE 9–6 Myectomy surgery via an upper lid crease
between skin and pretarsal muscle. A 1- to 2-mm incision with en-bloc removal of muscle.
CHEN09-113-124.I 3/22/01 1:39 PM Page 123
observed in areas where the patch provided the least

compression. These areas should be molded flat on
the day the patches are removed.
Many patients with BEB have aesthetic concerns
about eyebrow ptosis or forehead rhytids that can be
E
safely addressed at the time of myectomy by sculpt-
2 ing or repositioning of the retro-orbicularis oculi fat
pad or by endoscopic forehead lift surgery.
1
Many patients with BEB have a component of
3 apraxia of eyelid opening. Apraxia of eyelid opening
responds less well to Botox and myectomy than does
blepharospasm, so the presence of apraxia becomes
L more evident after treatment. It is estimated that
almost 50% of patients who are considered “failures”
of Botox treatment suffer from apraxia of eyelid open-
ing.11 Frontalis suspension and limited myectomy
with complete removal of the pretarsal orbicularis
should be considered for patients who are visually
disabled by apraxia of eyelid opening.
FIGURE 9–7 Facial muscle diagram showing zones of Superior Cervical Ganglion Block
myectomy. Treatment of BEB focuses heavily on reducing the
A thin band of muscle is left beneath the eyebrow to motor component of the disease. It is important to
prevent alopecia with the rest of the preseptal and remember that there is also a sensory loop of the dis-
orbital orbicularis removed in block 2. In block 3 the ease that is harder to quantify because it involves the
orbicularis is removed over the lateral raphe and patient’s subjective complaints of ocular surface irrita-
extending into the lateral portion of the inferior tion and photosensitivity. In some patients that “fail”
orbicularis. The lateral dissection is aided by retroil- Botox treatment, a careful history and exam will reveal
luminating the skin muscle flap. that Botox does reduce spasm and weakens the orbic-
In patients who do not develop objective weakness ularis muscle but does not relieve the sensory symp-
of the orbicularis after Botox injection, an extended toms of the disease. For patients who complain of
myectomy is performed. An extended myectomy debilitating light sensitivity (photo-oculodynia), inter-
requires that dissection be continued superior so the vention by a pain clinic may benefit the patient. Two
corrugator and lateral procerus can be identified and reports have demonstrated reduction of photo-
extirpated. Visualization of these structures is oculodynia after superior cervical ganglion blocks to
enhanced if a suprabrow incision is made. However, chemodenervate the orbital sympathetics21, 22 (Fig. 9–8).
many patients want to avoid the potential scar left by These preliminary studies suggest that the sympathetic
a suprabrow incision. Fortunately, very good expo- nervous system may play a role in maintaining the
sure of these structures can be obtained through the afferent loop of the disease. Stressful situations and
eyelid crease incision. Care must be taken when fatigue have been demonstrated to increase the rate at
removing the lateral corrugator to avoid the supraor- which the orbital sympathetics nerves discharge. This
bital neurovascular bundle. The supratrochlear neu- may explain the connection between stress, fatigue,
rovascular bundle is often sacrificed. Dissection must and exacerbation of the disease.
proceed efficiently to minimize blood loss. Excessive
cauterization of the skin flap can be avoided by com- Investigational Treatment
plete removal of the underlying muscular layer. After
removal of the underlying muscle, the skin edges Chemomyectomy
have a tendency to curl under. Care must be taken Doxorubicin (Adriamycin), a cytotoxic anthracycline
when suturing to find the skin edges and fixate them used to treat disseminated neoplasms, is under inves-
deeply over the superior tarsal plate. When lower lid tigation for use in treating patients with essential
myectomy is required, adequate access can be blepharospasm. It damages muscle fibers relatively
obtained via a lower eyelid crease incision. selectively by altering intracellular calcium hemosta-
Patients often require drains and bilateral uni- sis. Doxorubicin opens calcium channels in internal
formly compressive patches for 24 to 72 hours. After cisternae and activates calcium release from the sar-
removal of the patches, localized hematomas are often coplasmic reticulum. In animal experiments, muscle
CHEN09-113-124.I 3/22/01 1:39 PM Page 124
mass is lost, with greatest effect near injection sites. It

produces fibrosis of muscles and permanent muscular
weakness.17 Skin ulceration at injection sites is a fre-
quent complication.23
SUMMARY
With greater understanding and research into the eti-
ology of blepharospasm, greater choices are now
available in the medical and surgical management of
this condition. This includes botulinum toxin injec-
tion, pharmacotherapy, myectomy, chemodenerva-
tion, and chemomyectomy. Combination of these
treatments provides a far more effective and gentler
FIGURE 9–8 Local anesthetic sympatholysis for a patient solution than modalities used until recently, such as
with photo-oculodynia associated with blepharospasm. surgical extirpation of facial nerve branches.
REFERENCES
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542–546. Pergamon Press, 1985:87–91.
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Optom Assoc 1987;58:646–651. foundation, purpose and implementation of goals. In:
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Surgery—Blepharospasm, vol 4. New York: Pergamon
93:1–3.
Press, 1985:93–95.
9. Anderson RL, Patel BC, Holds JB, Jordan DR: Bleph- 20. Gillum WN, Anderson RL: Blepharospasm surgery.
arospasm: past, present, and future. Ophthalmic Plast An anatomical approach. Arch Ophthalmol 1981;6:
Reconstr Surg 1998;14(5):305–317. 1056–1062.
10. Freu B, et al: A profile of patients with intractable 21. Fine PG, Digre KB: A controlled trial of regional sym-
blepharospasm. Trans Am Acad Ophthalmol Otolaryngol patholysis in the treatment of photo-oculodynia syn-
1976;81:591–594. drome. J Neuroophthalmol 1995;15:90–94.
11. Jordan DR, Anderson RL, Digre KB: Apraxia of lid 22. McCann JD, Gauthier M, Morschbacher R, et al: A
opening in blepharospasm. Ophthalmic Surg 1990;21: novel mechanism for benign essential blepharospasm.
331–334. Ophthalmic Plast Reconstr Surg 1999;15:384–389.
12. Volow MR, Cavenar JO, Grosch WN, et al: The diag- 23. Wirtschafter JD: Chemomyectomy of the orbicularis
nostic dilemma of blepharospasm. Am J Psychiatry oculi muscle for the treatment of localized hemifacial
1980;137:620–621. spasm. J Neuroophthalmol 1994;14(4):199–204.
CHEN10-125-146.I 3/26/01 8:35 AM Page 125
Chapter 10
UPPER BLEPHAROPLASTY
AND EYEBROW SURGERY
Clinton D. McCord
The upper lid and the eyebrow behave as a unit and dures, in most cases, must be performed before the
are interdependent. Commonly, eyebrow procedures blepharoplasty procedure.
are needed for stabilization before performing the The following eyebrow procedures are commonly
upper lid blepharoplasty. Because of this sequence, used by this author in conjunction with upper lid
the eyebrow procedures are discussed first in this blepharoplasty:
chapter. Eyebrows are normally positioned above the
Internal browpexy is performed through the upper
level of the superior orbital rim but, with age, may
blepharoplasty incision for correction of laxity in
migrate below the rim, causing redundancy and fold-
the lateral third of the brow. It is commonly used
ing of the upper eyelid skin. This process also pro-
by itself in conjunction with upper lid blepharo-
duces a narrowed spacing between the eyebrow hairs
plasty or used as a supplement to the endoscopic
and the lashes, which can cause a frowning appear-
eyebrow forehead lift or the direct eyebrow lift
ance in the patient. The mechanics of brow ptosis are
for elevation of the lateral third or tail of the brow.
similar to that of a curtain rod that has loosened and
Endoscopic assisted eyebrow forehead lift is used more
fallen, causing folding in the curtain.
commonly in females for the nasal two thirds of
It is important to recognize the problem of eye-
the brow and glabellar area (it is commonly sup-
brow laxity before performing upper lid blepharo-
plemented with the internal browpexy).
plasty because failure to correct brow laxity or
Direct eyebrow lift is used, generally, in males. It is also
displacement before the blepharoplasty will impair
commonly supplemented with the internal
the result. Upper lid blepharoplasty performed with-
browpexy.
out correction of a lax or ptotic eyebrow results in
Temporal forehead lift is used for the lateral third of
postoperative residual upper lid folds and a narrow-
the brow when there is severe skin laxity lateral
ing of the spacing between the eyebrow and eyelashes
to the brow, beyond the lateral orbital rim.
(brow–lash distance).
Performed through a subgaleal approach, it is
commonly used as a supplement to the cheek lift
EARL... The goal of upper lid ble-
P pharoplasty is to remove redundant skin-
folds and produce a clear strip of skin above the
procedure.
ANATOMY
eyelash line (the eye shadow space in females).
It is important to have firm knowledge of anatomy in
the eyebrow area to avoid complications and to pro-
Any preexisting laxity or ptosis of the eyebrows duce the best possible result with eyebrow surgery.
requires surgical correction for the surgeon to obtain Appreciation of the anatomic relationship of the
this goal of upper lid blepharoplasty. Eyebrow proce- frontal branch of the facial nerve to the fascial layers is
125
CHEN10-125-146.I 3/22/01 1:41 PM Page 126
important to define the safe level of dissection for Motor and Sensory Nerves
protecting the nerve when operating in the brow and The frontal branch of the facial nerve provides motor
temporal region. innervation to the frontalis and corrugator muscles.
The course and depth of the nerve has been well
Fascia and Attachments defined and extends along a line beginning 0.5 cm
There are three fascial layers in the temporal region below the tragus to 1.5 cm above the lateral aspect of
that are important landmarks for localization of the the brow.
frontal branch of the facial nerve. The superficial tem-
poral fascia is the most superficial layer. The deep
...
temporal fascia is made up of a superficial layer and a
deep layer1, 2 (Fig. 10–1).
The deep temporal fascia is a dense double-layered
P EARL The frontal branch lies
within the superficial temporal fascia as it
traverses the zygomatic arch and is at greatest
fascia covering the temporalis muscle. The temporal risk for injury at this level.
line of fusion is a transverse line at the level of the
superior orbital rim extending laterally over the fascia
and represents fusion of the two layers superior to Superior to the zygomatic arch, the nerve is super-
this line. The fascia is separated inferior to the line by ficial to the superficial layer of the deep temporal fas-
the superficial temporal fat pad, which is located cia within the superficial temporal fascia.1–3
between the superficial and deep layers of the deep The supratrochlear and supraorbital nerves provide
temporal fascia and extends to the level of the zygo- sensory innervation to the forehead scalp and eyelid
matic arch. The deep temporal fat pad lies beneath the region. The ophthalmic (V1) division of the trigeminal
deep temporal fascia 2 cm above the zygomatic arch nerve traverses the cavenous sinus and enters the
and overlies the temporalis muscle and tendon; it is orbit through the superior orbital fissure. The oph-
an extension of the buccal fat pad through the zygo- thalmic nerve has three divisions: frontal, nasociliary,
matic arch. lacrimal. The frontal nerve runs along the superior
The superficial temporal fascia is the layer that con- aspect of the orbit and divides into the supratrochlear
tains the frontal branch of the facial nerve on its deep and supraorbital nerves. The supratrochlear nerve
subaponeurotic surface. This layer represents an emerges from the medial aspect of the superior orbital
extension of the submuscular aponeurotic system rim and provides sensory innervation to the glabella,
(SMAS). The subaponeurotic plane consists of loose medial forehead, medial upper eyelid, and conjunc-
areolar tissue that separates the superficial temporal tiva. The supraorbital nerve exits the orbit in the cen-
fascia from the deep temporal fascia. The subaponeu- tral aspect of the superior orbital rim most commonly
rotic plane is avascular and extends inferiorly to the through a notch. A true supraorbital foramen exists
zygomatic arch. The temporal region of the sub- as an anatomic variant in 25% of orbits. The supraor-
aponeurotic space and the subperiosteal space are bital nerve provides sensory innervation to the scalp,
connected by division of the periosteal reflection lateral forehead, lateral upper eyelid, and conjunctiva.
along the superior temporal line that marks the ori-
gin of the deep temporal fascia. This transition zone Muscles of Animation
lies along the anterior crest of the temporal bone. The musculature in the forehead and brow that con-
The galea is contiguous with the superficial tempo- tributes to animation in the forehead and glabella
ral fascia, and the periosteum of the skull is continu- region includes the frontalis, procerus, and corrugator
ous with the deep temporal fascia. The confluence of supercilii muscles (Fig. 10–3).
these fascial planes to the skull and attachment to the The frontalis muscle travels above the galea and is
brow tissue have a characteristic configuration known the elevator of the eyebrow and glabella area. Its
as the fusion line and orbital ligament. This confluence insertion does not extend past the fusion line and has
produces a vertical band 5 to 6 mm wide just medial reduced effect in the lateral brow. It is a paired muscle
to the temporal fusion line of the skull, which has a that is an extension of the galea aponeurotica and
continuation as the superior temporal line. In this occipitalis muscle. The vertically oriented fibers insert
area, the deep layers of the superficial temporal fascia into the supraorbital dermis and elevate the eyebrow
and the galea are bonded to the periosteum and fixed during contraction. Increased frontalis activity, which
to the bone (Fig. 10–2). At the edge of the orbital rim in is needed to maintain an elevated brow position in
this fusion line is a fibrous band attached to the bone response to brow ptosis, can cause transverse lines
called the orbital ligament, which can limit superficial across the forehead. The frontalis muscle is a primary
temporal fascia movement and effectively tethers the brow elevator and should therefore not be weakened
lateral eyebrow to the orbital rim. during a procedure aimed at brow elevation.
CHEN10-125-146.I 3/22/01 1:41 PM Page 127
Temporal fusion line

Galea
Periosteum
Frontalis m.
Superficial
temporal Deep temporal
fascia fascia
Frontal branch
facial nerve Fusion point
A (orbital ligament)
Scalp
skin
Galea
aponeurosis
Sub-aponeurotic
plane (loose-areolar)
Temporal
fusion line (orbital ligament)
Superficial temporal fascia
(SMAS) => galea
Superficial layer DTF
Superficial
temporal Deep temporal fascia
Anterior branch superficial fat pad (DTF) => periosteum
temporal artery
Deep layer DTF
Temporal branch
facial nerve Temporalis muscle
Deep temporal fat pad

Zygoma arch
(Buccal fat pad)
Medial Pterygoid muscle
Parotid duct
Parotid gland
Mandible
Buccal branch Masseter muscle

facial nerve
Platysma muscle
B (continuous with SMAS)
FIGURE 10–1 (A) The fascial and muscular planes in the scalp and forehead area. The course of the frontal branch
of the facial nerve is shown traveling through the superficial temporal fascia. (B) On the temporal side of the face, the
galea aponeurosis covers the fascia of the temporalis muscle as the superficial temporal fascia (SMAS, superficial
musculoaponeurotic system). Just superior to the zygomatic arch, the temporal branch of the facial nerve and the
anterior branch of the superficial temporal artery lie within this plane of the SMAS. The galea splits into the superfi-
cial and deep temporal fasciae (DTF) at the superior origin of the temporalis muscle on the skull. Further inferiorly, at
the line of fusion, the deep temporal fascia splits into a superficial and a deep layer, with both attaching to the zygoma.
The superficial temporal fat pad lies deep to the superficial layer of the DTF, whereas the deep temporal fat pad
beneath the deep layer of the DTF is a superior extension for the buccal fat pad. Below the zygoma, the parotid gland
lies between the SMAS (superficial temporal fascia) and the masseter muscle. Further inferiorly the SMAS is contigu-
ous with the platysma muscle. The masticatory muscles of the temporalis and medial pterygoid insert onto the medial
side of the mandible, whereas the masseter inserts onto the lateral side.
127
CHEN10-125-146.I 3/22/01 1:41 PM Page 128
Superior
temporal line Temporal fusion
line (orbital
Inferior ligament)
temporal line
Parietal bone
Temporal bone
FIGURE 10–2 The insertion lines of Zygomatic

the fascia planes on the skull in the bone
placement of the temporal fusion line
and orbital ligament.
The procerus muscle is a midline muscle that cle. Contraction of the corrugator muscles causes
originates from the nasal bones and upper lateral inferior and medial displacement of the eyebrow
cartilages. The vertically oriented fibers insert into and the vertical oblique lines of the glabella. Weak-
the dermis of the glabella at the medial border of the ening the medial portion of the corrugator con-
frontalis. Contraction of the procerus causes inferior tributes to medial brow elevation and correction of
and medial displacement of the medial eyebrow and glabellar frown lines. The lateral portion of the cor-
a transverse line at the nasal radix. The procerus rugator is felt to produce slight lateral brow eleva-
muscle has innervation from the buccal branch of the tion and should be preserved. Motor innervation of
facial nerve. The procerus is a primary brow depres- the corrugator is from the frontal branch of the facial
sor and therefore should be weakened to achieve nerve.
medial brow elevation.
The corrugator supercilii muscle is a paired muscle
that originates from the periosteum of the superior CHANGES IN THE EYEBROW
medial orbital rim. The fibers are oriented in an WITH AGE
oblique direction inserting into the dermis of the
medial eyebrow skin with lateral interdigitations The development of eyebrow laxity and ptosis with
with the medial portion of the orbicularis oculi mus- aging is attributed to the progressive laxity of the
scalp and forehead soft tissues over time. This mech-
Procerus
anism, aided by gravity, can produce an overall sym-
Corrugator metrical downward displacement of the eyebrow
with narrowing of the spacing between the eye-
brows and eyelashes (decreased brow–lash dis-
tance). There are specific forces and tissue conditions
in the lateral and nasal eyebrow that may allow
selective depression of those areas. In the lateral por-
Orbicularis tion or tail of the eyebrow, the force of orbicularis
(orbital- contracture, and increased mobility, allowed by fatty
preseptal)
layers in the area, all are added to the forces of grav-
ity and laxity, causing more selective brow ptosis in
that area. In the nasal portion of the brow, the
depressor muscles, corrugator supraciliaris and pro-
cerus, together with contracture of some local orbic-
FIGURE 10–3 The protractor muscles of the brow and ularis fibers, serve to counteract the lifting effect of
eyelid area. The corrugator and procerus muscles together the frontalis muscle and bring the nasal brow down-
with a portion of orbicularis nasally are brow depressors. ward (Fig. 10–4). The shape of the eyebrow is usu-
Laterally, orbicularis fibers act as depressors of the tail of ally more arched in females and flatter in males and
the brow. may remain so with age.
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UPPER BLEPHAROPLASTY AND EYEBROW SURGERY • 129
Laxity and gravity
Orbicularis Corrugator
contracture contracture
Standard Brow-Lash Distance Narrow Brow-Lash Distance
FIGURE 10–4 The normal brow spacing and position (left) and the downward displacement of the brow from
forces counteracting the frontalis muscle elevation (right).
EYEBROW PROCEDURES Surgical Technique

This procedure is usually performed during the course
The Internal Browpexy of upper lid blepharoplasty, but if a full blepharoplasty
is not needed, then a limited lateral incision in the
This procedure is effective only for elevation and upper lid crease can be used. Vertical skin marking is
support of the lateral one third (the tail) of the brow. made above the lateral brow area by palpating the
It is used to enhance the lateral crease and is com- ridge that is the insertion of the deep temporal fascia.
monly performed as an adjunctive procedure to At the lateral portion of the upper lid crease inci-
upper blepharoplasty. It is also routinely used by this sion, an upper lid skin-muscle flap is retracted with
author in conjunction with the endoscopic eyebrow the rake retractors and dissection beneath the brow
forehead lift in females and the direct eyebrow lift in fat in the preperiosteal plane is carried out with the
males as a supplementary procedure for its effect in coagulating Bovie needle tip (Fig. 10–5). This can be
the lateral brow. If there is significant nasal brow lax- done extensively laterally but care must be taken
ity or ptosis then one should not use the internal nasally to avoid the supraorbital sensory nerve. The
browpexy by itself because it will accentuate any orbital ligament is detached with this dissection.
nasal laxity or ptosis.4 Once the edge of the deep temporal fascia is reached,
FIGURE 10–5 Operative views of

internal browpexy. (A) Area to be
undermined in lateral brow and tem-
poralis fossa area. (B) Dissection in
the planes superficial to the perios-
teum and deep temporal fascia,
exposing the juncture of the deep
temporal fascia to the skull, the
A B fusion point, and the orbital ligament.
CHEN10-125-146.I 3/22/01 1:41 PM Page 130
The suture is then tied with a double throw snugly

to observe the position of the brow. Figure 10–7
shows the effect of the internal browpexy in a patient.
Endoscopic Assisted Eyebrow Forehead Lift

In recent years it has been more common to perform
the eyebrow forehead lift with endoscopic assis-
tance through small incisions.5–8 This procedure is
used by this author primarily in females for correc-
tion of ptosis in the nasal two thirds of the brow and
the frowning contracture lines in the glabellar area.
This procedure is also used by this author usually
supplemented with an internal browpexy performed
through an upper blepharoplasty incision to correct
ptosis or laxity in the lateral third of the brow.
Surgical Technique
Instrumentation Instrumentation includes a camera
and video equipment, endoscope, light source, retrac-
tor, and endoscopic surgical instruments (graspers
FIGURE 10–6 A fixating 4-0 Prolene suture has been and periosteal elevators with varying curves). These
placed in the deep temporal fascia at its point of fusion to
instruments are used to create the subperiosteal opti-
the skull periosteum. The suture will subsequently be
cal space, in which the procedure is performed. The
inserted into the fat and orbicularis fibers under the flap at
the level of the inferior eyebrow hairs and then tied for development of this space is the primary requirement
brow support. in endoscopic surgery and visibility is maintained by
a retractor-mounted endoscopic system.
additional dissection is carried out with a rigid cotton Various camera systems include one-chip, three-
applicator. chip, and digital formats. The video cart setup gener-
A suture (4-0 Prolene with a half circle needle) is ally includes a high-resolution video monitor, VCR
then placed in the deep temporal fascia at its junction and printer, camera source, and a light source with
with the periosteum at the fusion line (Fig. 10–6). It is fiberoptic attachment to the endoscope.
then introduced into the skin flap at the level of the The currently available endoscopes are rigid, glass
inferior edge of eyebrow hairs through the retro- Hopkins rod-type endoscopes. Because the size of the
orbicularis fat and orbicularis muscle. The suture optical cavity that can be created during endoscopic
must not be placed too close to the skin because dim- brow lift is limited, the 5-mm external diameter endo-
pling will occur. Varying degrees of elevation in the scope size is recommended. Various angles of visual-
lateral brow can be obtained depending on the posi- ization with the endoscope are available, but the
tioning of the suture in the deep temporal fascia. 30-degree downward view is most commonly used to
A B
FIGURE 10–7 A patient undergoing internal browpexy. (A) Before surgery. (B) After upper lid blepharoplasty
combined with internal browpexy.
CHEN10-125-146.I 3/22/01 1:41 PM Page 131
Central
incision
A
A
B
B
FIGURE 10–8 Endoscopic sleeve with retracting spoon

extension.
view the anatomy in the supraorbital region. The opti-

cal cavity is maintained through tissue retraction
using the retractor-mounted endoscopic system or
with the use of a special sleeve or spoon that extends
beyond the end of the endoscope (Fig. 10–8).
The patient is placed on the operating table with
the head extended slightly beyond the head rest to
facilitate clearance for the use of the endoscope and
instruments. The procedure is usually performed FIGURE 10–9 Placement of three incisions for endo-
under general anesthesia. Generous infiltration with scopic assisted eyebrow forehead lift. The central incision
0.25% Xylocaine with epinephrine (1:400,000) is used serves as a port for the endoscope. The lateral incisions
in the scalp and forehead area for hemostasis. serve only as openings for placement of screw fixation. Posi-
tion A for the lateral incisions is used for patients who
Placement of Scalp Incisions Three scalp incisions require maximum nasal brow and glabellar lift. Position B is
are made—one midline and two lateral (Fig. 10–9). The for patients who need more general brow elevation.
location of the lateral incisions depends on the desired
vector of pull on the eyebrow. In patients who have scopic visualization. The dissection then proceeds
unusually severe nasal brow laxity and glabellar fold- down to the superior orbital rim with direct visual-
ing, the incisions are placed closer to the midline inci- ization. (Figs. 10–11 and 10–12). Several different sizes
sion to gain maximum traction and closer to the nasal and curves of periosteal elevators are available for use
brow and glabellar area. In patients with general brow depending on the contour of the frontal bone and the
laxity, the lateral incisions are placed in a wider pat- distance from the brow to the hairline.
tern and slanted to produce both nasal and some tem-
poral elevation. All incisions are placed behind the Periosteal Release Once adequate visualization of
hairline to minimize scar visibility. If possible, inci- the optical cavity to the orbital rim has been achieved,
sions should avoid sites of maximal hairline recession. the surgeon places a horizontal relaxing incision
through the periosteum. The periosteum is divided
Creation of an Optical Space The initial optical along the edge of the supraorbital rim transversely
space is created with a subperiosteal dissection using with a relaxing incision using a sharp periosteal ele-
a straight elevator through the three scalp incisions. vator (Fig. 10–13). A curved periosteal hook or curved
Undermining in the subperiosteal space extends ini- endoscopic scissors can be used to divide the perios-
tially to within 1 cm of the supraorbital rim and to the teum. Periosteal division continues laterally along the
superior temporal line laterally. Undermining behind orbital rim to the level of the lateral canthus using a
the scalp incisions is also performed to prevent redun- narrow, curved elevator. The procerus and corruga-
dancy and folding when the forehead and scalp are tor muscles can then be visualized centrally once the
advanced posteriorly (Fig. 10–10). The subperiosteal periosteum is divided.
plane has an advantage of firm postoperative reat-
tachment with healing following brow elevation. Ini- Resection of Corrugator and Procerus Muscles Once
tially, subperiosteal dissection is begun anteriorly the opening of the periosteum has been completed,
through the central incision without using the endo- biopsy forceps are introduced and used to resect por-
scope, stopping 1 to 2 cm above the superior orbital tions of the procerus and corrugator muscles that
rim. At this point the endoscope with a retraction cause the glabellar frown lines. Hypertrophy of the
sleeve and spoon is then inserted through the central procerus or corrugator muscles produced by repeated
incision into the optical cavity to continue subpe- frowning is improved by the myectomy, which weak-
riosteal dissection in the lower forehead under endo- ens these muscles. A variety of biopsy forceps are
CHEN10-125-146.I 3/22/01 1:41 PM Page 132
Superior temporal
line
FIGURE 10–10 Placement of the three standard scalp incisions the (left). The area of periosteal undermining per-
formed for visualization before the endoscope is inserted (right).
available; however, blunt-tipped Takahashi biopsy supratrochlear nerve crosses the corrugator and is
forceps allow precise muscle resection, which mini- deep to the orbicularis oculi fibers. A nerve hook can
mizes the potential overdissection of the underlying be used to retract the supratrochlear nerve. The supra-
subcutaneous tissue and dermis, which could result trochlear nerves can be seen with the underlying
in a visible deformity in the glabellar region. Removal oblique fibers of the corrugator muscle and the trans-
of the procerus is first performed in the midline at the verse supratrochlear vein. The supraorbital nerves are
level of the superior orbital rim. Dissection then pro- visualized laterally.
ceeds laterally with removal of the corrugator on both Following procerus and corrugator myectomy,
sides of the supratrochlear nerve (Fig. 10–14). The inspection for hemostasis is performed. Electro-
Periosteum Cutting periosteal

elevator
Endoscope
camera
Spoon
sleeve
FIGURE 10–11 Insertion of the endoscope with retracting spoon through the central incision and the insertion of
a periosteal elevator (or other endoscopic tool) through a lateral incision (left). The spoon extension on the endoscope
allows better retraction of the brow tissue for visualization (right).
CHEN10-125-146.I 3/22/01 1:41 PM Page 133
FIGURE 10–12 Operating room

view showing surgical position of endo-
scope and endoscopic instrument.
cautery using an insulated grasper controls any bleed- ation have been used.8–12 This author favors the screw
ing points. fixation methods. Screw fixation methods have
included the permanent placement of surgical screws
Brow and Forehead Elevation and Fixation The that anchor galeal support sutures or are temporary
forehead and scalp are then advanced upward and percutaneous screws that are removed 1 to 2 weeks
retracted to produce brow elevation so that fixation after surgery and rely on periosteal adhesions for per-
of the tissue can be performed. Several methods of fix- manency. Only the lateral incisions are used for fixation.
A B
FIGURE 10–13 Intraoperative endoscopic images

showing creation of relaxing incision through the
periosteum at the level of the superior orbital rim.
(A) Insertion of reversed sharp periosteal elevator to
the periosteum. Initial periosteal incision (B) and exten-
C sion laterally (C).
CHEN10-125-146.I 3/22/01 1:41 PM Page 134
Corrugator
Procerus
muscle
muscle
Supraorbital
nerve
Opening in
periosteum
Supratrochlear
nerve
A
B1 B2
B3 B4
FIGURE 10–14 (A) Insertion through the opening in the periosteum of a grasping device for partial resection of cor-
rugator and procerus muscles. Branches of the supratrochlear nerve are contained within the corrugator and should
be spared. The supraorbital nerve is usually visualized laterally in the notch but is away from the resection area.
(B) Endoscopic images showing excision of corrugator muscles. Top left and right: Stripping of the corrugator on the
right side utilizing a Takahashi biopsy forceps. Bottom left: Forceps pointing at left corrugator, with portion of supra-
trochlear nerve visible within the muscle. Bottom right: View of glabellar area after corrugators have been stripped
bilaterally.
134
CHEN10-125-146.I 3/22/01 1:41 PM Page 135
8 mm
4 mm
Calvarium
FIGURE 10–15 A drill bit with a 4-mm guard used to

create drill holes in the calvarium at the posterior edges of
the lateral scalp incisions.
B C
A guarded drill bit 4 mm in depth (Fig. 10–15) is used
to place a drill hole in the calvarium at the posterior
edge of the lateral incisions. There is some reposition-
ing of the lateral incisions posteriorly by traction
before the drill holes are made. A 2-mm diameter tita-
nium screw, 12 mm in length, is then placed in the
hole, thereby allowing an 8-mm length to traverse
the scalp so that the screw head remains external
to the scalp (Fig. 10–16). Once the screw is secured at
the posterior aspect of the lateral radial incisions
(Fig. 10–17), the scalp is advanced posteriorly along
the vector of the incision with a single-hook retractor FIGURE 10–16 Positioning of the 12-mm screw in the
(Fig. 10–18). After the scalp has been advanced to calvarium.
achieve proper brow elevation with some considera-
tion for overcorrection, surgical staples are placed Direct Brow Lift or Suprabrowpexy
posterior to the screw to close the incision and main- This procedure is used primarily in males to lift the
tain the scalp advancement (Fig. 10–19). All remaining nasal two thirds of the brow (the body of the brow)
scalp incisions are closed with staples. when the endoscopic assisted forehead lift cannot be
Staple and screw removal occurs 10 to 14 days after used or if the lateral internal browpexy alone is not
surgery. No drains are required. The postoperative adequate. Contraindications to the procedure include
edema is mild and the incidence of hematoma is low. patients who are hypertrophic scar formers.13 Also,
Views of a patient before and after endoscopic eye- fair-skinned and red-headed individuals who produce
brow forehead lift are seen in Fig. 10–20.
FIGURE 10–18 Retraction of scalp with large skin hook

to advance the forehead upward and scalp posteriorly to
FIGURE 10–17 Placement of screw in the calvarium at cause a lift in the brow. Upward counterforce on the fore-
the posterior edge of a lateral incision. head is also used.
CHEN10-125-146.I 3/22/01 1:41 PM Page 136
FIGURE 10–19 Placement of staples behind the screw

so that the advanced scalp and forehead position is main-
tained postoperatively.
B
more visible scars and individuals who are intolerant
FIGURE 10–20 Patient undergoing eyebrow forehead
of any visible scar should be approached with caution. lift. (A) Before surgery. (B) After surgery.
Surgical Technique
The goal of skin excision design is to reduce the visi- included in the excision, so that the final scar is posi-
bility of the scar occurring in a very conspicuous area. tioned as close as possible to the brow hairs. Combin-
ing the direct browpexy with the internal browpexy is
the author’s usual approach to correcting male eye-
EARL ...
P The incision lines of the
skin ellipse to be excised are confined to
the central two thirds of the brow and without
brow ptosis.
The width of the skin excision can be determined
preoperatively by facing the patient, elevating the
brow the desired amount, and measuring with a ruler
extending to the nasal or lateral part of the
the width of skin movement.
brow. This avoids scarring in these visible areas. After the ellipse of skin is marked, the brow is
stretched with two-finger traction. The skin is incised
The incision lines should be placed so that the final down to the level of the brow fat (Fig. 10–21). The inci-
stitches are at the edge of the eyebrow hairs. In some sion at the upper edge of the brow can be slanted in the
male patients with full eyebrows, a few hairs slightly direction of the hair follicles, so as to avoid loss of hair
within the superior edge of the brow can also be follicles, although this is not usually a consideration in
FIGURE 10–21 The direct eye-

brow lift. It is almost always per-
formed in males. (A) Position of A
excision is placed in the central two
thirds of the brow hugging the upper Frontalis
edge of the brow hairs. Incisions muscle
should be made down to the frontalis Sub-brow
fat
muscle through subcutaneous fat.
(B) Traction on the edge of the wound
allows dissection through the brow
fat evenly. B
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Sub-brow B
fat
Frontalis FIGURE 10–22 The direct eyebrow
muscle
lift. (A) Planes of ellipse excision above
the brow hairs. (B) A coagulating Bovie
needle is used to square off the deep
edges.
the male patient. After the initial skin incision has UPPER LID BLEPHAROPLASTY
been made, a skin hook is placed in the nasal end of
the wound for traction and with additional vertical It is important, when performing upper lid blepharo-
traction so that undermining through the sub-brow plasty, for the surgeon to produce an aesthetically
fat pad and the plane of the frontalis muscle can be pleasing upper eyelid in the patient, but also to use
performed. Commonly the corners of the brow fat are techniques that reduce lagophthalmos of the upper
not squared off so as to avoid interfering with even lid, which may cause exposure symptoms in the
skin closure. The uneven brow fat edges in the wound patient postoperatively. The perception that the goal
can be sculpted using the coagulating Bovie tip of blepharoplasty is only to remove a certain quantity
(Fig. 10–22). Any liquefied fat is irrigated away with of skin from the upper lid is perilous.
cold water. The goal of upper blepharoplasty in the large
Deep sutures are placed in the sub-brow fat pad. majority of patients is to restore visibility of a clear
Even depth placement on either side of the wound is strip of skin above the lashes and produce a well-
needed for even skin closure. This is done in two or defined eyelid crease. This visible strip of skin above
three places, in the desired area of lift. When the the lashes is referred to as the eye shadow space in
sutures are tightened, the skin edges should approxi- females, and the degree of desired visibility can be
mate well so that scar formation will be reduced in defined by the patient preoperatively (Figs. 10–24 and
this conspicuous area. Further everting of the wound 10–25).
edges is accomplished with mattress sutures of 4-0 Generally, females desire a higher lid crease and a
Prolene before final closure. Final closure is then more well-defined eye shadow space and crease than
accomplished with continuous vertical mattress do males (Fig. 10–26). As mentioned previously,
sutures of 6-0 nylon. The 6-0 nylon sutures are placed proper eyebrow position and stability and spacing of
to encompass the full-thickness wound edge. Views the eyebrow above the eyelids play a critical role in
of a patient before and following a direct brow lift is producing the desired effect, and brow integrity must
seen in Fig. 10–23. be considered in surgical planning.14, 15 Adjunctive
A B
FIGURE 10–23 Patient undergoing direct eyebrow lift and upper blepharoplasty. (A) Before surgery. (B) After
surgery.
CHEN10-125-146.I 3/22/01 1:41 PM Page 138
A B
FIGURE 10–24 Patient showing ideal formation of upper eyelid crease and restoration of eye shadow space.
(A) Before upper blepharoplasty. (B) After upper blepharoplasty.
FIGURE 10–25 Same patient as

in Fig. 10–24 showing side view.
(A) Before upper blepharoplasty.
(B) After upper blepharoplasty. A B
eyebrow procedures are commonly needed in distortion and an alkalinizing solution is used to
patients seeking upper lid blepharoplasty. It is possi- reduce the stinging of injection. A 10-minute wait
ble to produce the goal of crease formation and fold before surgery is customary to allow vasoconstriction
clearance with minimal skin excision when adequate in the tissue to occur. The patient should be prepped
brow stabilization and debulking of the upper lid is with soap (Betadine), which is blotted dry instead of
also performed. scrubbed with water so methylene blue will adhere to
the skin.
Surgical Technique
When upper blepharoplasty is performed with local Designing the Skin Excision
anesthesia, a supraorbital nerve block is performed The central position of the upper lid crease is marked
together with eyelid crease infiltration and injection at 9 to 10 mm above the lashes in females and 8 mm in
of the nasal fat pad. Wydase is used to reduce tissue males while stretching the tissue (Figs. 10–27 and
Crease
Postoperative crease
FEMALE MALE
FIGURE 10–26 Diagrammatic representation of the dif- FIGURE 10–27 Measuring and marking of the upper
ference to be desired in the exposed pretarsal skin area and blepharoplasty crease incision. The skin is placed on stretch
the position of the eyelid crease in female and male patients. and 10 mm is measured in the female.
CHEN10-125-146.I 3/22/01 1:41 PM Page 139
FIGURE 10–28 A mark for the height of the upper lid FIGURE 10–29 The upper lid crease is marked at least 5
crease with methylene blue is made at 10 mm. to 6 mm above the lateral and nasal canthus.
10–28). The rest of the lid crease marking is performed and thin skin of the upper lid (Fig. 10–31). Equal dis-
freehand and should be placed approximately 6 mm tances will give even creases postoperatively if the
above the lashes laterally at level of the lateral can- brows are spaced symmetrically.
thus. At the lateral end, the marking is angled upward Bunching to determine the amount of skin removal
pointing toward the end of the brow and should be should not be used in the central or nasal portion of
spaced so that the lowest point will be at least 5 mm the eyelid because the amount of skin excision in
above lateral canthus. Medially, the marking is angled these areas should be conservative and less than that
upward with 5-mm vertical spacing nasally just obtained with the bunching technique.
beyond the punctum. Symmetry of design should be
checked from side to side (Fig. 10–29).
EARL... In general terms, the sur-
For marking the superior edge of the skin excision
ellipse, the bunching technique is used only at the lat-
eral canthus (Fig. 10–30). The proper amount of
P geon should maximize the skin excision
laterally and minimize the skin excision centrally
bunching in this area should show some slight ever- and nasally.
sion of lashes. One way of ensuring symmetry in final
upper lid crease position is to measure the distance of
the superior edge of the marked ellipse from the brow Any lagophthalmos in the upper lid is poorly tol-
hairs above. The superior line of the ellipse should be erated if it occurs in the central or nasal portion of the
measured from the inferior edge of the brow hairs lid. It should be emphasized that the desired effect in
and generally is located at the juncture of the thick the upper lid—the creation of a crease and a smooth
A Junction of thick and 10 mm

thin skin
B
5 mm
FIGURE 10–31 The usual configuration of the ellipse

marked for excision in upper lid blepharoplasty. Equal
FIGURE 10–30 Diagnosis of redundant skin laterally measurements of the upper edge of the blepharoplasty
with bunching technique: the skin is gathered until lashes ellipse from the inferior brow hairs allow for more consis-
rotate slightly upward. tency between the two sides.
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FIGURE 10–33 Excision of the skin-muscle-septum flap

is made flush with the levator aponeurosis.
B
orbicularis muscle and orbital septum across its
FIGURE 10–32 (A) Initial incision through the skin
using a surgical blade (see inset). (B) The Bovie cutting nee- entire width of the upper lid. Preaponeurotic fat will
dle is then used to incise through the orbicularis muscle. be seen to balloon (Fig. 10–32).
Scissors are used to incise through the orbital septum, The skin-muscle septal flap is then elevated and
which is the third layer. excised through the lower incision of the marked
ellipse. The flap is elevated with gentle traction, sepa-
exposed pretarsal skin area—is not obtained primar- rating the edges of the skin incision while it is being
ily by skin excision but by rearrangement of tissue, excised (Fig. 10–33). Straight scissors are used slanting
adequate debulking of the eyelid above the crease, away from the insertions of the levator aponeurosis
and fixation of the pretarsal skin. so as not to disrupt the insertions of the aponeurosis.
Crease sutures that will be used in closure will repair
Debulking of the Upper Lid Above the Eyelid Crease any dehiscences in the levator, but it is wise to avoid
Debulking involves removal of the marked area of too much disruption in the levator attachments.
skin, muscle, and septum, and removal of eyelid fat. Potential bleeding areas are in the orbicularis and sub-
After the skin incision is marked, pressure on the cutaneous layer of the lower crease incision. The pre-
globe allows the eyelid to tense and an incision is tarsal skin is retracted with cotton applicator sticks,
then made through the upper ellipse incision line; and the bipolar cautery is used to cauterize the ves-
cutting Bovie cautery is then used to cut through the sels in this area.
The eyelid is again retracted downward, exposing
the preaponeurotic fat, junctional fat (transitional fat),
and nasal fat pads (Fig. 10–34). With forceps traction,
the loose preaponeurotic fat is excised with a coagu-
lation Bovie needle tip (Fig. 10–35). Some traction on
the preaponeurotic pad in a nasal direction will allow
removal of the “tail” extension of the pad. An addi-
Transitional fat tional rake retractor is placed in the inner canthus,
interpad septum and with pressure on the globe, an incision is made
with a cutting Bovie needle through the capsule cov-
ering the white nasal fat. The nasal fat pad is teased
out with the forceps and the cotton applicator stick,
avoiding vessels. With forceps traction on the nasal
fat, the coagulation Bovie is used to excise the nasal
fat pad. Vessels can be selectively cauterized with
Nasal fat pad bipolar cautery. Touch-up cautery along the edges is
FIGURE 10–34 Diagrammatic representation of the fat used on all the fat to sculpt the fat and to cauterize the
compartments in the upper lid. The preaponeurotic fat is vessels. Any liquefied fat should then be irrigated
dissected free with the coagulation Bovie needle. Inset away. The fat is reinspected to cauterize any poten-
shows relationship of the nasal fat, transitional fat, and tial bleeding vessels. There is a separate area of fat in
preaponeurotic fat and the interpad septum. the transitional zone between the preaponeurotic fat
CHEN10-125-146.I 3/22/01 1:41 PM Page 141
Whitnall’s ligament
(superior transverse ligament)
Interpad
septum
Muscular levator Medial

horn
Lateral levator
horn
levator
Musculoaponeurotic
junction
FIGURE 10–36 Diagramatic representation of the leva-

tor, Whitnall’s transverse ligament, and the interpad
septum.
FIGURE 10–35 Operative view showing preaponeurotic

fat on the surface of the levator.
Browplasty
Excessive lateral brow fullness or prominence can
sometimes be a major complaint of the patient pre-
and the white nasal fat. This transitional fat (junc- senting for an upper lid blepharoplasty. This excessive
tional fat) invests the conjoined septum and extension fullness may not corrected by the usual excision of
of Whitnall’s ligament that forms the interpad septum skin and muscle using the standard upper lid blepha-
(Fig. 10–36). Removal of this fat will produce a roplasty technique. This fullness can be caused by a
depression in the eyelid crease nasally, and thus it prominent bony superior rim, but is most commonly
should not be removed. In the prominent eyed patient caused by superabundance of the retro-orbicularis
(particularly the thyroid patient), there should be a oculi brow fat (ROOF).4, 16
reduction in the amount of preaponeurotic fat When the retro-orbicularis brow fat layer hyper-
removed so as not to accentuate the height of the trophies, it may extend downward into the eyelid
upper crease and make the eye appear even more proper where it becomes preseptal fat (Fig. 10–37). In
prominent. these patients, sculpting and surgical excision of the
The lacrimal gland is examined and, if it is pro- retro-orbicularis brow fat can allow reduction in this
lapsed, can be repositioned and secured using a sur- overly prominent area.
face cautery with a coagulation Bovie to seal it in
position. It can also be sutured to the periosteum Surgical Technique
inside the orbital rim with 4-0 chromic sutures if
The upper edge of the blepharoplasty incision is
needed.
retracted to expose the brow fat at the superior orbital
rim (Fig. 10–38). Two Blair rake retractors are inserted
OPTIONAL LATERAL BROW PROCEDURES to retract the skin-muscle edge. The area of fat on the
rim to be removed is marked with methylene blue
If there are certain aging changes in the brow that and is then excised by grasping the fat with Adson
will not be corrected by upper lid blepharoplasty forceps and dissecting it free of the periosteum using
and lateral brow procedures are appropriate, the the Bovie coagulating needle. Dissection should not
following can be used at this stage of the upper lid extend nasally to the superior orbital notch so as to
blepharoplasty. avoid damaging the nerves and vessels in that area. A
segment of fat usually measuring 1 to 1.5 cm in verti-
Internal Browpexy cal dimension and then tapering nasally and tempo-
If there is enough laxity in the temporal third of the rally is removed (Fig. 10–39). The resection should
brow so that there is concern that residual skinfolds extend laterally to the frontozygomatic suture. The
may persist laterally or that the lateral eye shadow periosteum should be left intact to prevent the occur-
space may not form well postoperatively, an internal rence of postoperative adhesions that may tether
browpexy should be performed laterally as previ- brow movement. Additional redundant skin may be
ously described. produced after brow fat excision, and any redundant
CHEN10-125-146.I 3/22/01 1:41 PM Page 142
Postseptal
preaponeurotic
fat
FIGURE 10–37 The positioning of

the retro-orbicularis oculi fat (ROOF) or
brow fat and its progression with age.
This fatty layer, when extended into the
lid, has been called preseptal fat. Brow-preseptal (retro-orbicularis) fat
A B
FIGURE 10–38 Operative view of browplasty or brow fat removal. (A) Usual extent of removal of brow fat.
(B) Exposure of orbital rim periosteum following removal of overlying brow fat.
A B
FIGURE 10–39 (A, B) Interoperative views of patients showing excised brow fat.
fold should be excised to prevent double folding in Skin Closure The excision and debulking technique
the crease area. Figure 10–40 shows a patient before described above exposes the levator aponeurosis so
and after browplasty performed with upper lid that additional procedures can be performed on the
blepharoplasty. levator if needed. Shortening of the levator for the
CHEN10-125-146.I 3/22/01 1:41 PM Page 143
A B
FIGURE 10–40 Patient undergoing upper lid blepharoplasty with browplasty. (A) Before surgery. (B) Following
surgery.
correction of eyelid ptosis and lengthening of the lev- stretching the skin laterally to create even incision sides.
ator for dysthyroid eyelid retraction can be performed The first suture is placed at the lateral canthus and
before final skin closure. attaches the skin edges to the levator to ensure crease
formation laterally (Figs. 10–44 and 10–45).
SUPRATARSAL FIXATION To ensure crease position and
to prevent postoperative ptosis, sutures are used to fix-
...
ate the pretarsal skin to the levator aponeurosis
(Fig. 10–41).15, 17 This corrects any dehiscence of the lev-
ator that could have occurred with excision of the skin-
P EARL It is important to close
both skin and muscle to reduce visible
scarring.
muscle septal flap. An absorbable suture (usually 6-0
Vicryl) is used to attach the pretarsal skin-muscle edge
to the levator aponeurosis centrally (Fig. 10–42). The central crease incision is closed with continu-
INCISION CLOSURE Before final skin closure the inter- ous 6-0 nylon.
pad septum is lysed to reduce tethering of closure of the The flowchart in Figure 10–46 outlines my approach
upper lid (Fig. 10–43). The lateral portion of the incision to the treatment of patients with upper eyelid derma-
is closed with interrupted sutures of 6-0 nylon after first tochalasis and brow ptosis.
CONCLUSION
I generally perform an internal browpexy for the lat-
eral one third of the brow in almost every patient
Levator aponeurosis
(Fig. 10–46). In women, ptosis of the nasal two thirds of
Pretarsal skin
FIGURE 10–41 The attachments of the central fixating

suture placed through pretarsal skin and levator is used
before final skin closure. This fixation suture secures levator FIGURE 10–42 Operative slide showing central fixating
attachment, preventing ptosis, and adjusts the position of suture placed transcutaneously attaching the levator to the
the upper lid crease. skin muscle edge.
CHEN10-125-146.I 3/22/01 1:41 PM Page 144
FIGURE 10–43 Operative slide showing elevation of the FIGURE 10–44 Operative slide showing attachment of
interpad septum before lysis. the skin muscle edges to the levator aponeurosis at the lat-
eral canthus with 6-0 nylon.
the brow, whether severe or mild, should be corrected For men, I do an endoscopic assisted eyebrow-
with an endoscopic eyebrow-forehead lift. In many forehead lift if they have a low hairline. Most men do
women, there may be little or no ptosis of the nasal two not have a low hairline. Commonly, men will have
thirds of the brow, but laxity in the lateral third is pre- very mild brow ptosis over the nasal two thirds,
sent. In those patients, I routinely perform internal which I generally ignore, but I always perform an
browpexy. I always do an internal browpexy in com- internal browpexy with the male blepharoplasty. If
bination with the endoscopic eyebrow-forehead lift men have significant brow ptosis in the nasal two
because I do not perform a lateral dissection in my thirds of the brow, I perform a direct or suprabrow
technique. The endoscopic eyebrow-forehead lift in lift. This is performed before the upper lid blepharo-
women is performed prior to performing the upper lid plasty during the same surgical session.
blepharoplasty at the same surgical session.
A B
FIGURE 10–45 Close-up showing attachment of lateral and skin muscle edges to levator aponeurosis. (A) Lower
skin edge attached to levator. (B) Completed passage of suture through lower skin muscle edge, levator aponeurosis,
and upper skin muscle edge.
CHEN10-125-146.I 3/22/01 1:41 PM Page 145
Upper Lid Dermatochalasis and Brow Ptosis
Women Men
Mild or severe Lateral 1/3 Nasal 2/3 Brow Ptosis Lateral 1/3
Nasal 2/3 Brow Ptosis Brow Ptosis Brow Ptosis
Severe Moderate Mild
Endoscopic Brow Forehead Lift Internal Browpexy Direct Suprabrow Lift (Ignore)
(Always + Int. Browpexy)
Upper Blepharoplasty Upper Blepharoplasty plus Internal Browpexy
FIGURE 10–46 Decision tree for management of upper eyelid dermatochalasis and eyebrow ptosis.
REFERENCES
1. Kinze DM: An anatomically based study of the mecha- 9. Loomis MG: Endoscopic brow fixation without brow
nism of eyebrow ptosis. Plast Reconstr Surg 1996; 97: fixation or miniscrews. Plast Reconstr Surg 1996;
1321–1332. 98:373–374.
2. Kinze DM: Limited incision forehead lift for eyebrow 10. Pakkanen M, Salisbury AV, Ersek RA: Biodegradable
elevation to enhance upper blepharoplasty. Plast Recon- positive fixation for the endoscopic brow lift. Plast
str Surg 1996;97:1334–1342. Reconstr Surg 1996;98:1087–1090.
3. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA: 11. Daniel RK, Tirkantits B: Endoscopic forehead lift: an oper-
Anatomy of the frontal branch of the facial nerve the ative technique. Plast Reconstr Surg 1996;98:1148–1157.
significance of the temporal fat pad. Plast Reconstr Surg 12. Steinsapir KD, Shorr N, Hoenig J, Goldberg RA, Baylis
1989;83:265–271. HI, Morrow D: The endoscopic forehead lift. Oph-
4. McCord CD, Doxanas MT: Browplasty and browpexy: thalmic Plast Reconstr Surg 1998;14:107–118.
an adjunct to blepharoplasty. Plast Reconstr Surg 1990; 13. McCord CD: Brow surgery. In: McCord CD, ed. Eyelid
86:248–254. Surgery: Principles and Techniques. New York: Lippin-
5. Vasconez LO: Coronal facelift with endoscopic tech- cott-Raven, 1995:166–170.
niques. Plast Surg Forum 1992;15:229. 14. McCord CD: Techniques in blepharoplasty. Ophthalmic
6. Isse NG: Endoscopic facial rejuvenation: endoforehead, Surg 1979;10:40–55.
the functional lift, case reports. Aesth et Plast Surg 1994; 15. McCord CD: Upper blepharoplasty. In: McCord CD,
18:21–29. ed. Eyelid Surgery: Principles and Techniques. New York:
7. Bostwick J, Eaves FF, Nahai F: Endoscopic Plastic Lippincott-Raven, 1995;179–195.
Surgery. St. Louis: Quality Medical Publishing, 1995. 16. Lempke BN, Stasior GO: The anatomy of eyebrow pto-
8. Codner MA: Endoscopic forehead lift. In: McCord CD, sis. Arch Ophthalmic 1982;100:981–986.
ed. Eyelid Surgery: Principles and Techniques. New York: 17. Sheen JH: Supratarsal fixation in upper blepharoplasty.
Lippincott-Raven, 1995;368–379. Plast Reconstr Surg 1974;54:424–431.
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CHEN11-147-164.I 3/26/01 8:36 AM Page 147
Chapter 11
LOWER BLEPHAROPLASTY
AND MIDFACE DESCENT
Norman Shorr and Julian D. Perry
The anatomic configuration of the eyelids and peri- the dynamic forces that govern lower eyelid position
orbital region makes it one of the most important and contour requires knowledge of lower eyelid,
sites of human expression. The complex forces that cheek, and nasolabial anatomy.
govern periorbital aging include congenital bony and The lower eyelid anterior lamella is composed of
soft tissue anatomy, photo-damage, gravitational skin and orbicularis muscle, which continues inferi-
effects, and changes at the cellular level. Lower eyelid orly onto the face. The posterior lamella is composed
blepharoplasty attempts to create a rejuvenating of tarsus and conjunctiva. The orbital septum may be
appearance through manipulation of the soft tissues; considered the middle lamella. It extends from the
generally, this requires sculpturing and contouring arcus marginalis along the inferior orbital rim and
of the lower eyelid space. Although removal of skin fuses with the inferior border of tarsus. The lower eye-
and fat is sometimes necessary, it is not the only goal lid orbital fat compartments lie just posterior to the
of the procedure. A more natural contour may be orbital septum (Fig. 11–1).
best achieved with concomitant fat repositioning, and The orbital fat is bordered posteriorly and superi-
skin texture may be best addressed with resurfacing orly by the lower eyelid retractors, which fuse with
techniques. the orbital septum approximately 5 mm inferior to the
Lower eyelid blepharoplasty is an individualized inferior tarsal border before inserting on the tarsal
process and it begins with a discussion of the patient’s plate. The lower eyelid retractors adhere closely to the
desires and technical realities. The surgeon and palpebral conjunctiva of the lower eyelid.
patient must first determine the desired and possible
aesthetic results, then decide which techniques may
EARL ... An incision through con-
achieve those results. To successfully plan and exe-
cute lower blepharoplasty, the surgeon must under-
stand the underlying anatomy and the concept of the
P junctiva and the lower eyelid retractors
exposes the orbital fat without violating the
lower eyelid–midface continuum.
orbital septum; this reduces the likelihood of
postoperative middle lamellar cicatricial lid
ANATOMY retraction.
The blepharoplasty surgeon should consider the
lower eyelid as a continuum that begins at the lid Many fine fibroconnective tissue septae (of Koorneef)
margin and extends to the upper lip. Understanding surround the orbital fat.
147
CHEN11-147-164.I 3/22/01 1:49 PM Page 148
Inferior tarsus
Inferior eyelid retractors
Capsulo-palpebral fascia
Orbital septum
Orbital fat
Inferior orbital rim
Sub-orbicularis oculi fat
FIGURE 11–1 Line drawings illustrate the relationship of the orbital fat compartments to the orbital septum and
lower eyelid retractors.
the medial edge of the orbicularis. The SOOF engulfs

...
P EARL The arcuate expansion, a
fascial extension of the inferior oblique
muscle sheath and Lockwood’s ligament, inserts
the levator labi superioris alaeque nasi, levator labi
superioris, and zygomaticus muscles, and lies super-
ficial to the periosteum. At the level of the nasolabial
fold, the levator labi superioris and zygomaticus mus-
on the anterior portion of the inferolateral cles pierce the SOOF and insert into dermis.
orbital rim and separates the central fat com-
partment from the lateral fat compartment.
EARL... By grasping the SOOF at
The inferior oblique muscle originates at the ante-
P the level of the infraorbital rim, the entire
cheek can be mobilized.
rior medial orbital floor and separates the medial fat
compartment from the central fat compartment as it
passes posteriorly and laterally beneath the equator The SOOF is analogous to the retro-orbicularis
of the globe. The arcuate expansion and the inferior oculi fat (ROOF) located in the brow area, and is con-
oblique muscle serve as important surgical landmarks tinuous with the superficial musculoaponeurotic sys-
during lower eyelid blepharoplasty. tem (SMAS). The SMAS is a discrete fascial layer that
The suborbital orbicularis oculi fat (SOOF) is is an extension of the superficial cervical fascia. Dur-
located immediately deep to the orbital portion of the ing the aging process, the forehead and ROOF ptosis
orbicularis oculi muscle. Cadaveric dissections reveal contribute to fullness in the supraorbital region. Many
that the SOOF is located immediately inferior to the surgeons sculpt this fat during routine upper eyelid
inferior orbital rim and is situated directly posterior to blepharoplasty. Similarly, the inferior orbicularis mus-
the orbicularis oculi muscle (Fig. 11–2). Its thickness cle and SOOF become increasingly ptotic with age.
varies from medial to lateral, being most prominent in Normally, the orbicularis oculi muscle attaches
the central and lateral portions. Medial to the infraor- firmly to lower eyelid tarsus and the lateral raphe,
bital nerve, the SOOF is quite thin. This corresponds to resulting in a youthful single contour extending from
CHEN11-147-164.I 3/22/01 1:49 PM Page 149
LOWER BLEPHAROPLASTY AND MIDFACE DESCENT • 149
SOOF
Orbicularis oculi m.
A B
FIGURE 11–2 (A) Cadaver dissection reveals the orbicularis oculi muscle superficial to the suborbicularis oculi fat.
(B) The suborbital orbicularis oculi fat (SOOF). The SOOF extends across the midface and is continuous with the
superficial musculoaponeurotic system (SMAS) of the face.
the lower lid margin to the nasolabial fold. The infe- region. Superior to the orbital rim, the attenuated sep-
rior border of the orbicularis, on the other hand, tum and preseptal tissues allow bulging of the orbital
attaches only to the SOOF and SMAS. fat. Thus, the single contour of the youthful eyelid
develops into two convexities (bulging orbital fat and
malar bags) separated by a concavity of tissue paucity
...
P EARL With age, the SOOF and
SMAS attachments to the zygomaticus
muscles deteriorate and the orbicularis oculi
over the orbital rim. The aging configuration created
by this bulging orbital fat superior to the orbital rim,
the paucity of soft tissue over the orbital rim, and
fibers become stretched. The orbicularis muscle malar bags inferior to the orbital rim is termed the
migrates inferolaterally and becomes crescent double convexity deformity (Fig. 11–3).
Traditional lower eyelid blepharoplasty addresses
shaped, contributing to malar bags and festoons.
only the superior aspect of the double convexity
deformity. Although lower blepharoplasty may
The ptotic SOOF and stretched orbicularis fibers reduce areas of fat bulging superior to the orbital rim,
over the orbital rim result in a paucity of tissue in this it does not address the area of tissue paucity over and
Youth Aged Excess fat removed After malar

augmentation
FIGURE 11–3 Line drawing illustrates the normal youthful single contour of the lower eyelid and the aging changes that
create the double convexity deformity.
CHEN11-147-164.I 3/22/01 1:49 PM Page 150
inferior to the rim, nor the malar bags. The underlying skin wrinkles or folds. When redundant skin must be
bony structure may contribute to the concavity along excised, the transconjunctival approach may be com-
and just inferior to the orbital rim. A bony groove bined with anterior skin excision to preserve the
extending from the anterior lacrimal crest toward the orbital septum and decrease the risk of postoperative
infraorbital foramen may be present. This is termed a lower eyelid retraction. Skin quality issues such as
tear trough abnormality, which may exaggerate the rhytides should be addressed using concomitant
double convexity deformity. The area of tissue resurfacing techniques. The transconjunctival
paucity may be treated with concomitant fat reposi- approach is our first choice for nearly all patients
tioning, and the tear trough abnormality may be undergoing lower blepharoplasty.
treated with implant material to fill the bony defect. The degree of horizontal lower eyelid laxity and
SOOF and orbicularis ptosis may also be addressed skin quality will determine whether concomitant hor-
through midface elevation techniques. The blepharo- izontal tightening or resurfacing should be considered.
plasty surgeon must understand the concepts of the
lower eyelid–midface continuum and the double con-
vexity deformity to appreciate the role of blepharo-
plasty in upper facial rejuvenation.
PITFALL
Patients with horizontal eyelid laxity are at

EVALUATION increased risk of postblepharoplasty lower
eyelid retraction.
Lower eyelid blepharoplasty diminishes the fullness
of the lower eyelids and maintains lower eyelid posi-
tion and contour. Lower blepharoplasty does not
address the area of tissue paucity at and beneath the The snap test and the distraction test are useful in
level of the orbital rim, nor does it address malar the preoperative identification of patients with lower
bags. The choice of which procedures to perform eyelid laxity. The distraction test is performed by
should be made preoperatively. The surgeon should grasping the lower eyelid and pulling it anteriorly
assess the amount of deformity in each layer of the away from the globe. If the lower eyelid can be pulled
lower eyelid–midface continuum, including skin, more than 7 mm from the globe, the distraction test is
muscle, SOOF, orbital fat, and bone. The degree of positive, and horizontal laxity exists. The snap test is
deformity in each individual layer will determine performed by pulling the lower eyelid inferiorly. If
the optimal combination of procedures to create the the eyelid does not spontaneously return to its nor-
desired change. mal anatomic position before the next blink, the snap
The transconjunctival technique produces less test is positive, which signifies that the eyelid has
overcorrection than the traditional transcutaneous diminished tone (Fig. 11–4).
approach, and it avoids an external scar. Transcuta- In general, if there is no horizontal laxity and skin
neous blepharoplasty frequently alters lower eyelid is removed, we perform lateral canthal tendon plica-
margin contour and may cause frank lower eye- tion (Webster suture) to decrease the chance of signif-
lid retraction while only modestly reducing lower icant postoperative eyelid retraction. Frank horizontal
A B
FIGURE 11–4 (A) Snap test. (B) After release, the eyelids do not return flush with the globe; this demonstrates
diminished eyelid tone and horizontal laxity.
CHEN11-147-164.I 3/22/01 1:49 PM Page 151
lid laxity should be addressed through lateral canthal

resuspension. Removal of redundant skin, whether in
combination with transcutaneous approach or with
simultaneous transconjunctival fat repositioning or
removal, does not address skin quality. Fine rhytides
and other skin quality issues may be addressed with
concomitant resurfacing.
BLEPHAROPLASTY PROCEDURES
Transcutaneous Blepharoplasty
Surgical Technique
Local anesthesia and vasoconstriction are achieved
with regional injection of 1% lidocaine solution con- FIGURE 11–5 The infraciliary incision extends across the
taining 1 : 100,000 epinephrine and hyaluronidase (one eyelid approximatley 2 mm inferior to the lash line.
vial of hyaluronidase per 50 mL bottle of lidocaine).
Because the sensory nerves of the conjunctiva and unnatural crease may occur. The infraciliary incision
orbital fat originate in the orbit, the injection is deliv- begins several millimeters temporal to the punctum
ered through the conjunctiva. The surgeon directs the and follows the lid margin toward the lateral canthus.
needle toward the inferior orbital rim, walks the nee- This incision is created with a no. 15 Bard-Parker
dle posteriorly until it touches the orbital floor, and blade and extends laterally toward the orbital rim in a
injects approximately 1 mL of anesthetic. The process preexisting rhytid (Fig. 11–5). When performing
is repeated to anesthetize each individual fat pocket. simultaneous upper and lower eyelid blepharoplasty,
Approximately 2 mL of the same solution is injected the lateral aspect of the lower lid incision should
transcutaneously within the orbicularis muscle. The remain at least 6 mm inferior to the upper incision line
surgeon should allow 10 to 15 minutes for the hemo- to prevent lymphatic flow obstruction. The lateral
static properties of the epinephrine to take effect. extent of the lower eyelid incision depends on the
The periorbital region is prepared and draped in amount of skin resection necessary, but usually ends
sterile, open-face fashion. The lower eyelid incision is near the lateral orbital rim.
placed approximately 2 mm inferior to the lashes. If A 4-mm skin flap is created by undermining infe-
the incision is placed too close to the lash line, an riorly, along the entire extent of the incision
(Fig. 11–6). The pretarsal orbicularis muscle is pre-
served to minimize lower eyelid sphincter damage
(Fig. 11–7). Minimal cautery of the underlying orbic-
ularis should be employed to minimize damage to the
nutrient supply under the skin advancement flap. The
orbicularis muscle is incised approximately 4 mm
FIGURE 11–6 Preserving a strip of pretarsal oribicularis

muscle will allow adequate postoperative sphincter func-
tion.This is achieved by initially fashioning only a skin flap FIGURE 11–7 The skin flap is created using Stevens’
from the lower edge of the infraciliary incision. scissors.
CHEN11-147-164.I 3/22/01 1:49 PM Page 152
FIGURE 11–8 Orbital fat bulging into the field upon FIGURE 11–9 Graded removal of orbital fat using West-
incision of the orbital septum. cott scissors.
inferior to the cutaneous incision (6 mm from the lid using scissors (Fig. 11–10). The cutaneous incision is
margin, 2 mm below the inferior tarsal border) and repaired using a running absorbable or nonab-
bluntly dissected from the underlying orbital septum. sorbable suture (Fig. 11–11).
The orbital septum is incised along the entire extent of
the eyelid, which allows the redundant orbital fat to Repair of Eyelid Laxity All patients undergoing
bulge into the field (Fig. 11–8). lower eyelid skin excision will develop some degree
The thin septa dividing the orbital fat are divided of ectropion. All patients undergoing transcutaneous
with scissors, monopolar cautery, or incisional laser. lower eyelid fat excision with violation of the orbital
Gentle pressure on the globe aids in exposing the septum will develop some degree of lower eyelid
redundant fat. The surgeon should minimize traction retraction. If special precautions are taken, the
on the orbital fat to avoid inadvertent hemorrhage. amount of lower eyelid malposition may be accept-
The fat is removed with monopolar cautery, laser, or able. Intraoperatively, a strip of pretarsal orbicularis
cold steel, and hemostasis is achieved by cauterization should be preserved, and manipulation of the orbital
under direct visualization (Fig. 11–9). Although the septum should be minimized. Only the truly redun-
relative amount of fat to be removed in each of the dant skin should be excised; the previously described
three fat pockets is determined preoperatively, intraoperative maneuvers designed to stretch the
the surgeon frequently redrapes the skin-muscle redraped skin before excision should be performed
flap to check the contour intraoperatively. Care is on every patient undergoing skin excision. The pre-
taken to avoid the inferior oblique muscle as it passes operative evaluation should identify those patients
between the medial and central fat compartments.
PITFALL
Cauterization of the orbital septum may lead

to postoperative cicatricial eyelid retraction,
and should be avoided.
The previously undermined skin is redraped over

the lower eyelid. The patient is asked to look upward
and open the mouth while the surgeon gently bal-
lottes the globe to stretch the redraped skin. These FIGURE 11–10 Redraping the skin flap before marking
maneuvers decrease the risk of excessive skin the excess eyelid skin minimizes the likelihood of postoper-
removal. The amount of redundant skin will be supe- ative eyelid retraction and ectropion. Scissors are used to
rior to the infraciliary incision, and may be excised excise the skin.
CHEN11-147-164.I 3/22/01 1:49 PM Page 153
Lateral
canthal tendon
Orbital
rim
FIGURE 11–11 Closure of transcutaneous lower ble-

pharoplasty incision Note the lack of tension on the wound.
with preexisting lower eyelid laxity, and the surgical

plan should be adjusted accordingly.
...
P EARL In patients undergoing
lower eyelid skin excision who have little
or no horizontal eyelid laxity, concomitant lateral
canthal plication may decrease the chance of sig-
nificant postoperative lower eyelid malposition.
The lateral canthal tendon is grasped with toothed

forceps and advanced laterally until the desired hori-
zontal tension in the lower eyelid is achieved. This
will be the amount of lateral canthal tendon that is pli- FIGURE 11–12 Webster suture provides postoperative
support for the lower eyelid, and decreases the likelihood of
cated. An absorbable suture on a small half circle nee-
postoperative retraction in those patients undergoing tran-
dle is used to engage the medial aspect of the lateral scutaneous lower blepharoplasty with borderline preexist-
canthal tendon. The suture then plicates the lat- ing horizontal laxity.
eral canthal tendon by affixing the medial aspect of
the tendon to the inner aspect of the lateral orbital rim Local anesthesia and sterile preparation with open-
periosteum just superior to the Whitnall’s tubercle face draping are performed in a fashion similar to the
(Fig. 11–12). transcutaneous approach. The assistant retracts the
In patients undergoing lower eyelid skin excision medial third of the lower eyelid with a small Desmar-
who have frank lower eyelid laxity, a concomitant lat- res retractor to expose the cul-de-sac. A nonconduc-
eral canthal resuspension should be performed to tive eyelid plate is placed over the globe into the
decrease postoperative lower lid malposition. inferior fornix and ballottes the globe posteriorly. This
prolapses the orbital fat over the orbital rim. The sur-
Transconjunctival Blepharoplasty geon palpates the medial aspect of the inferior orbital
Lower eyelid blepharoplasty is intermingled with rim with a needle-tip monopolar cautery.
midface lifting and SOOF repositioning according to The conjunctiva and lower lid retractors are incised
the lower eyelid–midface continuum dictum. Within with the needle tip directed 1 to 2 mm posterior to the
the eyelid proper, lower blepharoplasty is primarily inferior orbital rim (Fig. 11–13). The incision begins at
about repositioning or removing orbital fat. This is the apex of the caruncle and extends laterally toward
performed through a conjunctival approach. Transcon- the lateral canthus. The incision should be made at
junctival blepharoplasty may be combined with direct least 4 mm inferior to the inferior punctum to avoid
excision of lower eyelid skin or with resurfacing tech- damage to the canaliculus. After incising the conjunc-
niques to address lower eyelid rhytides. tiva and lower eyelid retractors, yellow orbital fat
CHEN11-147-164.I 3/22/01 1:49 PM Page 154
compartments widely. The closer each fat compart-

ment is opened to the orbital rim, the easier the expo-
sure and the less chance of encountering bleeding or
damage to the inferior oblique muscle.
EARL ...
P Incision of the arcuate
expansion at its attachment to the
orbital rim joins the central fat pad with the lat-
eral fat pad, and permits exposure of the lat-
eral fat pocket.
The lateral fat pad is covered with more septa than

the central fat pad, and the fat may not spring for-
ward as easily. After the superficial portion of the lat-
eral fat pad is excised, the posterior fat comes forward
FIGURE 11–13 Line drawing illustrates that the orbital more freely.
fat may be accessed through the conjunctiva and lower eye- The inferior oblique muscle separates the central
lid retractors without violating the orbital septum. and medial fat compartments. It is important to iden-
tify this structure, especially when learning this tech-
bulges into the field (Fig. 11–14). The connective tissue nique, to ensure identification of the medial fat
septa can then be dissected with the needle tip or compartment and to avoid injury to the inferior
toothed forceps until tufts of fluffy yellow fat are oblique muscle. Partial resection of the central fat
exposed. The assistant removes the glass lid plate and may improve identification of the medial fat, which
uses 0.5-mm Castroviejo forceps to grasp and lift the appears whiter and more membranous than the cen-
lower lid retractors over the globe. This maneuver tral and lateral fat. The medial fat compartment may
protects the globe and further prolapses the fat into not be postseptal at all, but may come around the
the field. The Desmarres retractor can now be reposi- edge of the lower lid retractors from the muscle cone.
tioned so that its blade is in the wound itself, provid- Just as in the upper eyelid, the medial prominence of
ing wider exposure. With the connective tissue septa the lower lid probably represents the medial aspect
on stretch, the cutting cautery can then expose the fat of the central fat pad rather than a prominent medial
fat pad. Unlike the upper eyelid, however, where the
palpebral vessels lie on the surface of the medial fat
pad, the palpebral vessels travel directly through the
medial fat pad in the lower eyelid.
Meticulous hemostasis is important during the
entire procedure. The blood vessels associated with
each fat compartment should be cauterized under
direct visualization. After each fat pocket is exposed,
excision is carried out in a graded fashion with the
monopolar cautery instrument, incisional laser, or
cold steel (Fig. 11–15). Intraoperatively, the lower lid
is redraped and the contour examined. The end point
of fat excision is reached when a slight concavity of
the lower lid exists in the supine position. Slight pres-
sure on the globe simulating upright posture should
restore a single, smooth contour from the eyelid mar-
FIGURE 11–14 Surgical photograph shows bulging of
orbital fat into the field after incision of conjunctiva and gin to the orbital rim.
lower eyelid retractors during transconjunctival lower eye- After fat removal, the lower lid margin is pulled
lid blespharoplasty. The medial, central, and lateral fat com- superiorly to realign the tissue planes (Fig. 11–16).
partments can be visualized after dissecting the intervening With the lid on stretch, gentle pressure on the globe
connective tissue septae. reveals any residual fat bulges. If necessary, further
CHEN11-147-164.I 3/22/01 1:49 PM Page 155
15 minutes four times per day are instituted. Antibi-

otic ointment is applied to the wounds and conjuncti-
val cul-de-sac as appropriate. Patients return the
following week for suture removal and evaluation.
Complications
Postoperative hemorrhage with resulting blindness is
the most feared complication following lower eyelid
blepharoplasty. While the bleeding may occur within
the fat compartments, orbicularis bleeding can lead to
hematoma formation as well. The patient may com-
plain of severe pain and decreased visual acuity.
Examination reveals a firm orbit, proptosis, and sub-
FIGURE 11–15 After each fat pocket is exposed, exci- conjunctival hemorrhage associated with decreased
sion is carried out in graded fashion. vision and an afferent pupillary defect. Treatment is
based on the severity of the hemorrhage and the
degree of visual compromise. The wound is opened,
fat may be excised. In our experience, it is not neces- and blood clots are evacuated. If the signs of orbital
sary to close the conjunctiva and lower eyelid retrac- compression persist, the lateral canthal tendon is
tors at all; however, two or three interrupted 6-0 immediately lysed. As a last resort, surgical orbital
absorbable sutures may be used to close the conjunc- decompression may allow increased arterial perfusion
tiva if the tissues do not appear well opposed. pressure to the eye and optic nerve. The risk of post-
operative hemorrhage can be minimized by meticu-
Postoperative Care lously achieving hemostasis during surgery, avoiding
Antibiotic ointment is applied to the wounds and in traction of the fat pedicles during excision, and dis-
the eyes at the conclusion of the procedure. Patients continuing all anticoagulants prior to surgery.
are given acetaminophen 650 mg with or without oxy- A far more common complication is postoperative
codone 5 mg for pain relief. The patient stabilizes in cicatricial lower eyelid retraction. This is most com-
the recovery room for approximately 1 hour and is monly the result of excessive surgical injury to the
observed for signs of hemorrhage. Upon discharge, orbital septum. This manifests as lagophthalmos with
patients are cautioned to call the surgeon immediately the associated signs and symptoms of corneal expo-
if severe pain, bleeding, swelling, or decreased vision sure. If skin is removed and no horizontal lower eye-
develops. They are instructed to apply ice packs as lid laxity exists, we typically perform Webster suture
often as possible for 2 days following surgery. On the placement at the time of skin excision. If frank lower
third postoperative day, warm compresses for eyelid laxity exists, as determined by the snap and
distraction tests, then concomitant lateral canthal
resuspension should be performed. Surgical tech-
nique may also help prevent lower eyelid retraction.
In the past, surgeons advocated creating a dogleg
inferiorly as the lower lid incision progressed later-
ally. This predisposes to lower lid retraction. If lower
eyelid incision is extended toward the lateral orbital
rim, it should proceed in a horizontal fashion. Leav-
ing a strip of intact pretarsal orbicularis muscle will
preserve sphincter function and decrease the risk of
postoperative lower eyelid retraction.
Other eyelid malpositions may develop after lower
eyelid blepharoplasty. Ectropion may develop after
excessive anterior lamella excision. This complication
can be prevented if the surgeon asks the patient to
FIGURE 11–16 The end point of fat excision is reached look up and open the mouth, while the surgeon bal-
when a slight concavity of the lower eyelid exists in the lottes the globe before excising skin. Careful attention
supine position. The lower lid margin is pulled superiorly to technique should prevent postoperative eyelid
to realign the tissue planes. malposition.
CHEN11-147-164.I 3/22/01 1:49 PM Page 156
Occasionally, too much or too little fat is removed Anatomy of Lower Eyelid Retraction
or repositioned. This complication can be minimized The normal position of the lateral canthal angle is gen-
by frequent intraoperative redraping and assessment. erally 1 to 2 mm superior to the medial canthal angle.5
Despite what the surgeon believes to be an adequate The lower eyelid margin runs tangentially to the infe-
postoperative result, some patients may be dissatis- rior corneal limbus. Following satisfactory blepharo-
fied. Typically, this occurs when the physician does plasty, the position of the lateral canthal angle should
not understand the underlying concepts, and remain superior to the medial canthal angle; similarly,
unknowingly offers the patient unrealistic expecta- the lower eyelid margin should remain tangential to
tions. Detailed knowledge of the underlying anatomy, the inferior limbus. Inferior displacement of the lat-
an understanding that lower blepharoplasty will not eral canthal angle manifests as round eye, whereas
treat skin texture abnormalities, and knowledge of the inferior displacement of the lower eyelid margin man-
lower eyelid–midface anatomic continuum should ifests as lid retraction and scleral show.
prevent this unfortunate complication. The anterior lamella of the lower eyelid is the skin
and orbicularis muscle, which may be thought of as a
continuum from the corner of the mouth to the lower
eyelid margin. The middle lamella is the orbital sep-
MANAGEMENT OF POST- tum,which is pliant in the natural state. Its attach-
BLEPHAROPLASTY COMPLICATIONS ments are at the arcus marginalis at the inferior orbital
OF THE LOWER EYELID rim and the inferior tarsal margin. The posterior
lamella consists of conjunctiva and lower lid retrac-
Every blepharoplasty surgeon will occasionally
tors. The normal lower eyelid should be sufficiently
encounter a postblepharoplasty patient with round
elastic that it may be pushed superiorly to the supe-
eye and scleral show (Fig. 11–17). Unacceptable lat-
rior limbus.
eral canthal dystopia with inferior displacement and
lower eyelid retraction predictably occurs in a small
but significant percentage of lower eyelid transcuta-
neous blepharoplasty cases. Blepharoplasty should be PITFALL
considered an operation to first maintain or regain the
proper eyelid structure and function and then to Lower eyelid malposition may follow any
redrape and remove excess tissue.1 lower eyelid surgery. Entropion may result if
We describe a procedure that has the potential to the posterior lamella is vertically shortened.
routinely and predictably correct lower eyelid posi- Ectropion may result if the anterior lamella is
tion even after multiple surgeries.2–4 This method vertically shortened, and retraction may result
can provide excellent canthal and lower eyelid
if the middle lamella is vertically shortened.
structure, function, and position without the use of
a skin graft.
Excessive skin excision does not cause lid retrac-

tion; it causes ectropion. The most common compli-
cation of lower lid blepharoplasty is retraction.
Retraction occurs when the orbital septum contracts
after healing in an inferior position, or following
hematoma or cauterization of the middle lamella.
There are four possible etiologies of lower eyelid
after blepharoplasty: horizontal lower eyelid laxity,
and vertical inadequacy of the anterior, middle, and
posterior lamellae. Frequently, a combination of these
factors is responsible.
Traditionally, two types of surgical procedures
have been used to treat postblepharoplasty round eye
and scleral show. The first type, lateral canthal resus-
pension, horizontally tightens the posterior lamella of
FIGURE 11–17 Typical unhappy postblepharoplasty the lower eyelid.6 The lower eyelid is horizontally
patient. Lateral canthal dystopia, lower eyelid retraction, shortened in its lateral most aspect by suturing the
and vertical inadequacy of the lower eyelid are seen. remaining tarsus to the periosteum of the orbital rim
CHEN11-147-164.I 3/22/01 1:49 PM Page 157
at the proposed new site of the lateral canthal angle. oculi. It is continuous with the SMAS and may actu-
The second procedure tightens the anterior lamella ally represent the deep undersurface of the SMAS.8
(orbicularis and skin). Both types of procedures hori- With age, the orbital orbicularis oculi muscle, the
zontally tighten the entire eyelid but do not address SOOF, and its continuum, the cheek fat pad, descend.
vertical inadequacy of the eyelid.7 Horizontally tight- These changes become obvious in the fourth decade.
ening, pulling, or stretching a lower eyelid with a ver- During lower eyelid reconstruction, undermining and
tically inadequate middle lamella will not elevate the elevation of the periosteum and SOOF will carry supe-
eyelid margin to the inferior limbus. The more promi- riorly the overlying orbital orbicularis oculi muscle
nent the globe, the less likely horizontal tightening and skin. The subperiosteal SOOF advancement facil-
will benefit the final eyelid position and the more itates the anterior lamellar augmentation in the man-
likely it will worsen the final eyelid position. agement of postblepharoplasty lower lid retraction.
Proptosis predisposes to lower eyelid retraction.1
Gravity, swelling, and scar contracture tend to pull Evaluation and Planning
the eyelid down. The only support for the eyelid is the
Patients requesting surgery for round eye and scleral
horizontal tightness of the eyelid and the stretch of the
show often complain of aesthetic concerns with
pretarsal orbicularis. The more prominent the globe,
regard to the shape of the eye, and functional con-
the greater is the demand on these lifting forces to
cerns such as blurred vision, redness of the eyes, ocu-
hold the eyelid up against the convexity of the globe.
lar discomfort, and tearing. The patient’s aesthetic
If the lower eyelid is horizontally lax during the
concerns usually include loss of the almond shape
postblepharoplasty healing phase, it is much more
and a tired, fatigued appearance, caused by the infe-
likely to assume an inferior position. If the lower eye-
rior displacement of the lateral canthus and lower
lid is horizontally too tight during the postoperative
eyelid. Despite insufficient vertical lower eyelid skin,
healing period, it is also more likely to move inferi-
patients often complain of excess tissue, especially
orly. Excessive tightening of the lower eyelid in the
when they smile. Apparent excess skin is usually due
patient with a prominent eye increases the incidence
in part to loss of elasticity of the skin from scarring of
of postoperative retraction.
lower lid tissues.
The incidence of postblepharoplasty lower eyelid
Lower eyelid retraction is measured by two para-
retraction is directly proportional to the relative prop-
meters. The first is the extent of lateral canthal infe-
tosis of the globe, amount of overcorrection or under-
rior displacement relative to the medial canthus. The
correction of horizontal eyelid laxity, amount of
second is the amount of lower eyelid inferior dis-
orbicularis surgery, and intraoperative and postoper-
placement relative to the inferior limbus. As men-
ative bleeding. These same concerns must be care-
tioned earlier in this chapter, the distraction and snap
fully considered in surgery to correct lower eyelid
tests are performed to determine the presence and
retraction.
degree of horizontal eyelid laxity.
The patient is asked to squint and smile to deter-
Anatomy of the SOOF mine if the eyelid elevates without restriction. The
Through the transeyelid subperiosteal midface lift, patient is then asked to open the mouth to determine
necessary vertical augmentation of the anterior if stretching the anterior lamella pulls the eyelid ante-
lamella may be obtained without the use of a skin riorly or inferiorly (ectropion). The lower eyelid is
graft. The skin and orbicularis muscle that rests infe- manually pushed superiorly to determine whether
rior to the inferior orbital rim may be considered the middle lamella is tethered to the inferior orbital
“cheek,” while the skin and orbicularis muscle superim. The patient is asked to simultaneously raise the
rior to the inferior orbital rim is lower eyelid. It is, eyebrows and close the upper eyelids to determine
however, the continuity of the cheek and lower eyelid the presence and degree of lagophthalmos. These clin-
that allows lower eyelid anterior lamellar augmenta- ical tests allow the surgeon to determine the degree
tion through superior advancement of the cheek. of vertical and horizontal inadequacy in each of the
The orbicularis oculi muscle is divided into three three lamellae.
portions: a pretarsal, palpebral (or preseptal), and an In addition to determining the adequacy of each
orbital portion that overlies the bone that surrounds lamella, particular concern is given to the identifica-
the orbit. The tissue layers just inferior to the inferior tion of globe prominence. The degree of relative prop-
orbital rim from anterior to posterior are skin, orbital tosis is assessed using exophthalmometry. In cases
orbicularis oculi, SOOF,8 periosteum, and bone. involving a prominent globe, the lower eyelid must
The SOOF is located just inferior to the inferior often be horizontally lengthened rather than short-
orbital rim and is directly posterior to the orbicularis ened. The shortest distance between two points is a
CHEN11-147-164.I 3/22/01 1:49 PM Page 158
straight line. As the globe becomes more prominent, of the mucosal surface of the hard palate graft. The
the distance from the medial canthus around the rule of thumb for determining the vertical height of
globe to the lateral canthus becomes greater. Hori- the hard palate graft is to add 1 mm to the amount of
zontal tightening of the lower eyelid will result in fur- vertical inadequacy between the existing and the
ther inferior positioning of the lower eyelid margin. desired eyelid margin positions. In the more proptotic
patient, an additional 1 to 2 mm of vertical height may
Surgical Concept be added to compensate for the anticipated loss of
The approach begins by first defining the problem support due to the lesser horizontal tension that is
with regard to the horizontal and vertical inadequa- present when the globe is proptotic.
cies in each of the three eyelid lamellae.9–11 The sur-
geon must lyse all cicatrix that tethers the eyelid to Surgical Technique
the inferior orbital rim, then augment each individual
This procedure involves performing a midface lift and
vertically shortened layer.
a total full-thickness lower eyelid reconstruction. Ver-
The anterior lamella is augmented by an advance-
tical reconstruction of an eyelid may be performed
ment flap technique. The entire cheek, which is con-
using an autogenous hard palate graft or any of sev-
tinuous with the eyelid, is advanced superiorly and
eral graft materials.10 The hard palate graft is a com-
supported by suturing the periosteum and SOOF to a
posite graft composed of a mucous membrane surface
periosteal cuff at the orbital rim.
and a deeper layer of dense connective tissue that is
similar to tarsus. (The surgical technique for harvest-
EARL... When the tarsus (posterior
P
ing hard palate graft is not addressed in this chapter.)
lamella) and anterior lamella are advanced
Incision, Lysis of Adhesions, and Mobilization
superiorly as an advancement flap, the vertically
Prior to making the incision, the lower eyelid margin
tethering middle lamella is horizontally divided is grasped with Castroviejo forceps and retracted
from the inferior tarsal margin. superiorly. The superior traction test is used to deter-
mine the position and amount of restriction of supe-
rior movement, and it is repeated frequently
The middle lamella is then lengthened and splinted throughout the procedure. A lateral canthotomy
using a hard palate spacer graft, which is sutured into divides the superior and inferior limbs of the lateral
the posterior lamella. The hard palate graft is sutured canthal tendon to the depth of periosteum and is
such that the superior edge of the hard palate graft is extended laterally for approximately 15 mm. The infe-
opposed to the inferior tarsal margin. The inferior rior limb of the lateral canthal tendon is lysed
edge of the hard palate graft interfaces with the supe- (Fig. 11–18) and a plane is dissected from the lateral
rior edge of the recessed middle lamella. The recon- canthus inferiorly between the orbicularis and perios-
structed eyelid is then temporarily stabilized with teum. Skin and soft tissues immediately lateral to the
sutures and a bandage “cast.” This fixes the layers of lateral canthal angle are now freely mobile. The lower
the eyelid into position and allows for primary inten- eyelid is swung anteriorly away from the globe,
tion healing of the middle lamella.
This stabilization is achieved by suspending the
totally reconstructed lower eyelid from the eyebrow,
which maintains the lower eyelid on an upward
stretch. This suture stabilization is critically impor-
tant. The hard palate graft becomes an inferior vertical
extension of the existing tarsal plate. It acts not only as
a spacer, but also as a buttress to support the lower
eyelid. This buttress support of the lower eyelid is
particularly useful and important in maintaining a
superior position of the reconstructed eyelid, which
may lie over a prominent globe.
This procedure results in total lower eyelid recon-
struction. The anterior lamella is reconstructed by
advancement SOOF lift. The middle lamella is recon-
structed by separation and spacing with the cartilagi-
nous portion of the hard palate graft. The posterior FIGURE 11–18 Lysis of the inferior limb of the lateral
lamella is reconstructed by the vertical augmentation canthal tendon.
CHEN11-147-164.I 3/22/01 1:49 PM Page 159
FIGURE 11–19 The posterior lamella is pulled superi- FIGURE 11–20 Middle lamella cicatrix is exposed.
orly to determine if it is vertically inadequate. If it is, cicatrix
is lysed until it can be elevated freely.
then retracted superiorly (Fig. 11–21). If this maneuver
exposing the tarsus, palpebral conjunctiva, and infe- fully releases all middle lamellar restricting cicatrix, no
rior cul-de-sac. Conjunctiva and the lower eyelid further middle lamellar lysis is necessary. If it does not,
retractors are incised immediately inferior to the infe- then the middle lamella may be dissected free from the
rior tarsal margin from the lateralmost to the medial- arcus marginalis along the inferior orbital rim.
most aspect of the eyelid, ending in the caruncle
medially. Care is taken to avoid the inferior canalicu- Cheek Elevation: Subperiosteal Myocutaneous Flap
lus and the semilunar fold. Injury to the canaliculus Once the middle lamella tether has been freed, atten-
may result in epiphora, and scarring of the semilunar tion can be turned to mobilizing the skin, orbicularis,
fold may result in diplopia. and cheek. The skin, orbicularis, SOOF, and maxillary
Superiorly directed lower eyelid traction still periosteum must be free and mobile to allow cheek
reveals restriction to superior movement, because elevation. This is achieved through a subperiosteal
only the posterior lamellar attachments to the inferior dissection. A monopolar cutting cautery instrument
tarsal margin have been divided. The posterior is used to incise the periosteum just below the infe-
lamella (conjunctiva and lower lid retractors) is rior orbital rim, leaving a cuff of periosteum onto
grasped at its leading edge and retracted superiorly which the subperiosteal myocutaneous flap sutures
to determine if it is vertically inadequate. If it is, cica- will be anchored later (Fig. 11–22). Alternatively, the
trix is lysed until it can be elevated freely (Fig. 11–19). periosteal incision can be made with a no. 15 blade.
The freed posterior lamella may be pulled superiorly A periosteal elevator is used to dissect the subpe-
without restriction. riosteal plane along the anterior face of the maxilla.
The assistant continues to distract the eyelid mar- The subperiosteal plane has the advantage of being
gin (middle and posterior lamella) superiorly and
anteriorly. A dissection is performed along the poste-
rior surface of the septum as far inferiorly as the arcus
marginalis of the inferior orbital rim. At this point,
superior traction is limited only by middle lamellar
cicatrix (Fig. 11–20) or anterior lamellar vertical inad-
equacy, or both.
To determine whether the restriction to superior
motion is due to the middle lamella or the anterior
lamella, the cheek (anterior lamella) is digitally pushed
superiorly. If this maneuver fully relieves the restric-
tion, then the restriction is within the anterior lamella.
However, if this fails to relieves the restriction, then
the restriction is midlamellar (septum). If the restric-
tion is determined to be midlamellar, the septum is
divided from the inferior tarsal margin across its entire FIGURE 11–21 Superior traction test reveals residual
horizontal extent with scissors. The eyelid margin is middle lamellar tethering cicatrix, which must be lysed.
CHEN11-147-164.I 3/22/01 1:49 PM Page 160
FIGURE 11–22 Periosteum opened along entire hori- FIGURE 11–23 Subperiosteal dissection is performed
zontal length of lower eyelid below the inferior orbital rim. with special care to avoid damaging the infraorbital neu-
Castroviejo forceps point to cuff of periosteum remaining rovascular bundle.
along the inferior orbital rim.
relatively avascular and is deep to the branches of the can be easily pulled superiorly as far superior as the
seventh cranial nerve, thereby decreasing the risk of superior limbus with the globe in the primary posi-
damage to the nerve. Care is taken to avoid injury to tion. The vertical aspect of the anterior lamellar layer
the infraorbital neurovascular bundle (Fig. 11–23). portion of the total lower eyelid reconstruction is
The inferior edge of the elevated periosteum is then now complete.
incised with a cutting cautery to permit mobilization
and elevation of the entire cheek. Horizontal Dimension Eyelid Reconstruction
The level of the periosteotomy must be individu- Attention is turned to determining the appropriate
alized and is usually determined preoperatively. horizontal length of the eyelid. Neither the conjunctiva
Four to six 4-0 Prolene are then placed in a horizon- nor the skin is horizontally shortened. The continuum
tal mattress fashion (Fig. 11–24) through the perios- of the tarsus and the lateral canthal tendon is either
teum and SOOF flap and anchored to the periosteum horizontally shortened or horizontally lengthened.
at the orbital rim, thereby elevating the orbicularis, Horizontal shortening is performed by vertical exci-
cheek, and overlying skin (Fig. 11–25). Once the sion perpendicular to the eyelid margin. Lengthening
sutures are tied, the subperiosteal SOOF lift is com- is performed by passing the horizontal mattress suture
pleted. The entire cheek has been elevated to accom- through the inferior crus of the lateral canthal tendon
plish anterior lamellar reconstruction, and the eyelid several millimeters lateral to the tarsus. The appropri-
margin now crosses the pupil. The anterior lamella ate horizontal length is determined by draping the
FIGURE 11–24 A 4-0 Prolene suture is passed in a hor-

izontal mattress fashion through the periosteum and SOOF FIGURE 11–25 Line drawing showing the four subpe-
and is attached to the cuff of periosteum at the inferior riosteal myocutaneous flap sutures passing through the
orbital rim to allow elevation of the myocutaneous flap. arcus marginalis.
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FIGURE 11–26 The periorbita lining the inner (orbital) FIGURE 11–27 Sutures are passed through periorbita
aspect of the lateral orbital rim is exposed. on the orbital (inside) surface of lateral rim.
lower eyelid across the proposed site of the new lat- ing lower lid shortening. The lateral canthal tendon
eral canthal angle under appropriate tension. The point of the upper lid is now disinserted from the perios-
at which the eyelid crosses the lateral orbital rim is teum, draped across the new lateral canthal angle
marked on the eyelid with a marking pencil. This point position and horizontally shortened such that satis-
delineates the appropriate horizontal length of the factory tarsal/tarsal interface will be achieved. A
lower eyelid. horizontal mattress suture is now passed through the
The more proptotic the globe, the less horizontal upper eyelid lateral tarsal tongue, then through
shortening needs to be done. In a proptotic patient the lateral orbital rim periorbita, just as described
who has previously undergone horizontal shortening, for the lower eyelid.
it may be necessary to lengthen the lower eyelid to A suture is now passed through the upper and
make it long enough to drape superiorly around the lower gray line to ensure perfect approximation of the
prominent globe. In such a case, great care must be eyelid margins in the lateral canthal angle (Fig. 11–28).
used in dissecting the lower eyelid from the lateral The upper and lower eyelids are now of exactly equal
orbital rim to leave significant excess soft tissue lat- length to ensure satisfactory tarsal/tarsal and
eral to the tarsus to be used in horizontal lengthening tarsal/corneal interface. The gray line suture is drawn
of the eyelid. up and tied. The upper and lower eyelid tarsal tongue
horizontal mattress sutures are drawn up and tied.
Lateral Canthal Reconstruction Excellent lateral canthal angle position and tarsal/
Following placement of the composite graft, lateral tarsal interface is confirmed. This completes the
canthal reconstruction is performed. The periorbita lateral canthal angle reconstruction.
lining the inner aspect of the lateral orbital rim
(Fig. 11–26) is exposed. A double-armed 5-0 suture on
a half-circle needle is passed through the lateral tarsal
tongue and then through the periorbita on the inner
aspect of the lateral orbital rim at the point of the pro-
posed new lateral canthal angle (Fig. 11–27). The
suture is tied temporarily, and the patient is placed in
a sitting position on the mechanized operating table.
The surgeon inspects the lower eyelid and lateral can-
thal angle position and decides whether the lateral
canthal angle needs to be moved superiorly, inferi-
orly, posteriorly, or anteriorly. Exact placement of this
lateral canthal angle tarsal tongue horizontal mattress
suture ensures success.
Before finally tying the lateral canthal suspension
suture, the upper eyelid must be examined. Deter-
mination must be made as to whether the upper lid FIGURE 11–28 A gray line suture ensures perfect
needs horizontal shortening. An opposing upper approximation of the upper and lower eyelid margins in the
eyelid horizontal length disparity may occur follow- lateral canthal angle.
CHEN11-147-164.I 3/22/01 1:49 PM Page 162
Vertical Dimension Anterior Lamella Eyelid, margin, back through the upper eyelid margin, then
Cheek, Canthus Augmentation by Advancement through the eyebrow, and tied upon themselves
The eyelid, canthus, and cheek now have fallen into (Fig. 11–30). These three sutures are drawn up to ade-
place so that the reconstruction appears to be very quate tension to support the lower eyelid such that
adequate. If this large flap is not further supported, the margin rests at the superior pupil during the
however, it will move inferiorly by gravity. If all cica- 5-day casted healing period. The patient must wear
trix has been adequately freed, support of the orbicu- the patch (cast) for 5 to 7 days.
laris and cheek at several lateral points is usually The superior splinting of the lower eyelid allows
adequate. Horizontal mattress sutures of Dexon are for each of three reconstructed lamellae to be apposed
passed through the deep tissues of the flap and then to the appropriate vertical position of the other two
up through the external periosteum over the lateral lamellae during the healing period. It also avoids cor-
orbital rim. The tension and the position of these rugation during healing. In cases of extensive scarring
sutures is adjusted until satisfactory support is of the middle lamella, triamcinolone acetonide injec-
achieved (Fig. 11–29). After all sutures have been tions may be administered (up to 0.5 cc of 5 mg/cc).
placed, each suture is tied in turn and cut on the knot. The area of the eye and eyelids is dressed with an
The lateral canthus incision is then closed with run- ophthalmic antibiotic steroid ointment and patched
ning 6-0 mild chromic suture. It is important to with two eye patches and paper tape. It can be com-
remember that the postblepharoplasty lateral canthal fortably worn for 5 to 7 days without replacement.
dystopia and lower eyelid retraction resulted from Consideration may be given to the use of postopera-
surgery and manipulation of the anterior lamella. tive oral antibiotics and steroids.
Although this procedure specifically avoids an A sound understanding of the lower eyelid/cheek
infralash skin incision, careful closure of the lateral continuum anatomy, coupled with this problem-
canthal cutaneous incision is necessary to avoid rede- solving approach to the treatment of lower eyelid
velopment of anterior lamellar cicatrix and produc- retraction, can routinely and predictably correct lower
tion of a visible scar. eyelid position, even after complex and multiple surg-
Perhaps the most important step in the procedure, eries (Fig. 11–31). This technique can provide excel-
however, is the suture stabilization and casting of the lent canthal and lower eyelid structure, function, and
reconstructed eyelids. position without the use of a skin graft.
Placing the Cast

CONCLUSION
The surgeon may place a 24- to 48-hour dissolving
bandage contact lens over the cornea to keep the Lower blepharoplasty is an individualized process and
patient comfortable during the first postoperative it begins with a discussion of the patient’s desires
day or two. Three 6-0 Prolene horizontal mattress and technical realities. This requires a detailed knowl-
sutures are passed from the eyebrow, through the edge of the underlying anatomic changes that govern
upper eyelid, along the gray line of the lower eyelid the aging process in the lower eyelid–midface region.
Because this anatomic region represents one of the most
important sites of human expression, the competent
FIGURE 11–29 Horizontal mattress sutures from orbic-

ularis to periosteum advance and support the cheek. This
provides vertical augmentation and reconstruction across FIGURE 11–30 Sutures splint the totally reconstructed
the total horizontal eyelid. lower eyelid superiorly during the healing period.
CHEN11-147-164.I 3/22/01 1:49 PM Page 163
A B
FIGURE 11–31 A 41-year-old patient with lower eyelid retraction after blepharoplasty and two failed reconstruc-
tive efforts. Note relative prominence of the globes. (A) Preoperative photograph demonstrates full-thickness vertical
inadequacy of lower eyelids. (B) After total lower eyelid reconstruction.
surgeon can create a pleasing, rejuvenating, and lasting 2. For lateral canthal dysfunction (rounding of lateral
patient experience through lower eyelid blepharo- canthal angle); phimosis of eyelid fissure: lateral
plasty. canthoplasty with periosteal strip procedure.
3. For mild (vertical) skin shortage: vertical recruit-
ACKNOWLEDGEMENTS ment of skin (vertical orbicularis flap with upward
re-draping of inferior orbicularis arc.15)
Julian D. Perry is an American Ophthalmological 4. For moderate skin shortage: add sub-periosteal
Society-Herman Knapp Testimonial Fund Fellow, and “cheek-lift.”
a recipient of the Abe Meyer Scholarship. 5. For moderately severe skin shortage: vertical skin
recruitment with periosteal strip or fascia lata
EDITOR’S SUPPLEMENT sling procedure.
6. For severe eyelid retraction: vertical skin recruit-
To summarize the system for management of lower ment, periosteal strip procedure, lateral cantho-
eyelid malposition, McCord constructed an algorithm14 plasty, or fascia lata sling, plus graft(s):
that can be expanded to the following six stages: for anterior lamella shortage: skin graft;
for middle lamella shortage: spacer—fascia lata or
1. For horizontal laxity that is asymptomatic or bor- temporalis fascia, ear cartilage, or MEDPOR;
derline symptomatic: lateral canthoplasty (lower for posterior lamella shortage: nasochondral
lid tightening) with tarsal strip procedure. mucosal graft, or hard palate graft.
REFERENCES
1. Shorr N, Enzer Y: Considerations in aesthetic eye 5. Wolff E: Anatomy of the Eye and Orbit, 7th ed. Philadel-
surgery. J Dermatol Surg Oncol 1992;18:1081–1095. phia: WB Saunders, 1976.
2. Shorr N, Fallor MK: “Madame Butterfly” procedure: 6. Anderson RL, Gordy DD. The tarsal strip procedure.
combined with cheek and lateral canthal suspension Arch Ophthalmol 1979;97:2192–2196.
procedure for post blepharoplasty “round eye” and 7. Cohen MS, Shorr N: Eyelid reconstruction with hard
lower eyelid retraction. Ophthalmic Plast Reconst Surg palate mucosa graft. Ophthalmic Plast Reconstr Surg
1985;1:229–235. 1992;8:183–195.
3. Shorr N, Fallor MK: Repair of post blepharoplasty 8. Aische AE, Rimeriz OH. Suborbicularis oculi fat pad:
“round eye” and lower eyelid retraction, combined anatomy and clinical study. Plast Reconst Surg 1995;
cheek lift and lateral canthal resuspension. In: Ward 95:37–42.
PH, Berman WE, eds. Plastic and Reconstructive Surgery 9. Shorr N: Management of post blepharoplasty lower
of the Head and Neck, vol 1: Aesthetic Surgery. St. Louis: eyelid retraction with palate mucosal graft. In: Eyelid
CV Mosby, 1984:279–290. Aesthetics: 21st Annual Scientific Symposium of the Amer-
4. Shorr N, Goldberg RA: Lower eyelid reconstruction fol- ican Society of Ophthalmic Plastic and Reconstructive
lowing blepharoplasty. J Cosmetic Surg 1989;6:77–82. Surgery; October 26, 1990; Atlanta, GA:62.
CHEN11-147-164.I 3/22/01 1:49 PM Page 164
10. Shorr N: Versatile Hard Palate Mucosal Graft. American 13. Shorr N: “Madame Butterfly” procedure: Total lower
Academy of Ophthalmology Instruction Section eyelid reconstruction in three layers utilizing a hard
Course. Chicago: American Academy of Ophthalmol- palate graft: management of the unhappy post-
ogy, 1993. blepharoplasty patient with round eye and scleral
11. Shorr N, Cohen MS: Cosmetic blepharoplasty. Ophthal- show. Int J Aesthet Restor Surg 1995;3(1):3–26.
mol Clin North Am 1991;4:17–33. 14. McCord CD: The correction of lower lid malposition
12. Shorr N: Madame Butterfly procedure with hard following lower lid blepharoplasty. Plast Reconstr Surg
palate graft: management of post-blepharoplasty 1999;103(3):1036–1039.
round eye and scleral show. Facial Plastic Surg 1994; 15. McCord CD, Codner MA, Hester TR: Redraping the infe-
10:90–118. rior orbicularis arc. Plast Reconstr Surg 1998; 102(2):171.
CHEN12-165-178.I 3/26/01 8:37 AM Page 165
Chapter 12
LASER BLEPHAROPLASTY
Jemshed A. Khan
Eyelid plastic surgery represents the most complex technique, and an ability to prevent and manage
surgical laser dissection performed today. Incisional potential complications. Incisional CO2 laser tech-
CO2 laser eyelid surgery may well revolutionize the nique closely parallels monopolar incisional eyelid
way complex dissection is performed in other surgical blepharoplasty and is often combined with laser skin
fields. In coming years, laser techniques may become resurfacing.1, 2 There are a few serious risks that are
the norm for eyelid surgery because they offer the specific to incisional laser blepharoplasty. This chap-
surgeon a rapid and bloodless dissection and benefit ter emphasizes the avoidance and management of
the patient by providing rapid recovery with dimin- complications through a review of basic principles
ished swelling and bruising. Furthermore, traditional of laser surgery, technique, postoperative care and
eyelid surgery is tedious and lengthy because the flow complications, and laser safety.
of the procedure is frequently disrupted by the need
to stop and cauterize bleeding tissues. By comparison,
laser surgery is a much more continuous process OVERVIEW
wherein surgery becomes an instantaneous extension
of the surgeon’s conscious thought processes. Skill- Laser blepharoplasty does not differ fundamentally
fully performing this type of surgery creates for the from other blepharoplasty techniques. However,
surgeon an unparalleled sense of satisfaction, which is certain surgical skills and safety precautions must
absent with other surgical modes. be assimilated to reduce the hazards peculiar to
Though incisional laser surgery holds great laser surgery. Foremost among these considerations
promise, one should keep in mind that the laser is are embracing a new knowledge base, seeking a
merely a tool that simultaneously incises tissue and mentor, mastering a new set of surgical maneuvers,
creates a controlled hemostatic zone of thermal injury. learning safe laser technique, and acquiring laser-
In this regard, the CO2 laser may be eventually sup- safe instrumentation. CO2 laser surgery is a learned
planted by gentler and smarter technology that incor- surgical discipline that is both demanding and
porates tactile feedback and automatic control of unforgiving. Hence, the importance of observing a
wound depth, and provides pinpoint rather than skilled laser eyelid surgeon cannot be overempha-
indiscriminate hemostatic thermal injury. Certainly, sized because one picks up many of the finer points
there is nothing magic about the laser; it will not of laser surgery that cannot be communicated effec-
transform poor surgical skills into better surgical tively in other venues. For example, one can observe
results. Indeed, the improved aesthetic results of laser where the assistant positions his/her hands, the
surgery depend almost entirely on the surgeon’s skill placement of the plume evacuator, or the amount of
and judgment. laser defocusing that results in a cautery effect.
Incisional laser eyelid blepharoplasty requires These small details allow for a smooth transition to
thoughtful preoperative analysis, meticulous surgical laser surgery.
165
CHEN12-165-178.I 3/22/01 1:51 PM Page 166
uniform hand speed and consistent focus and energy

settings, one soon learns to anticipate incisional depth
and adjust parameters based on visual inspection of
the incision.
Beam Focus and Incident Angle

Incisional CO 2 laser handpieces deliver a focused
high-energy ablative spot (usually 0.1 to 0.2 mm diam-
eter) that is moved to create a linear division of tissue.
EARL... Because the angle of inci-

P sion is coincident with the path of the
laser beam, the laser handpiece must be held
precisely perpendicular to the tissue surface to
create a perpendicular incision. Maintaining
FIGURE 12–1 A special-finish laser blepharoplasty beam precise focus diminishes the likelihood of
instrument set designed to reduce laser energy reflection. thermal injury.
Left side, top to bottom: ambidextrous Khan-Sutcliffe “pro-
peller” laser shield used as a backstop during incisional ble-
pharoplasty and to mask off areas during resurfacing, Maintaining precise beam focus and perpendicu-
Khan-Jaeger metal globe guard for transconjunctival expo- lar alignment while moving the handpiece across the
sure of fornix and globe protection, matte-finish titanium intended incision site at a uniform handspeed is diffi-
Khan laser eye shield with unique antirotational posts and
cult at first, both because the laser lacks tactile feed-
eyelash traction bar, and Khan-Baker protective eyelid
clamp. Right side: Khan combination laser backstop and
back and because surgeons are used to making an
Desmarres retractor. (Source: Storz Instrument Co., St. incision with an angled blade. However, with con-
Louis, MO.) scious effort these movements can be mastered.
Hemostasis
Instrumentation for Incisional Eyelid Surgery Clinically useful hemostasis requires 50 m or more
Specialized laser-impenetrable metal instrumentation of thermal injury.3 Pulsed CO2 laser incisions gener-
is necessary during laser surgery to protect underly- ally create a zone of thermal injury which is 110 m or
ing structures such as the eyeball from accidental greater (Fig. 12–2). This injury zone appears to be clin-
injury (Fig. 12–1). Such instruments sets are usually ically tolerable and is not associated with a significant
matte-finished so as to reduce the risk of reflected risk of hypertrophic scarring.
laser energy. Common to most laser instrument sets
are an upper eyelid clamp, which interposes a metal
shield between the undersurface of the eyelid and the
globe; a metal globe protector, which is placed in the
palpebral fissure; a Desmarres retractor, which
exposes the inferior fornix during transconjunctival
blepharoplasty; a modified laser-safe Jaeger “bone”
plate, which retracts the globe and prolapses the infe-
rior fornix and fat during transconjunctival blepharo-
plasty; and a flat metal guard, which acts as a
backstop when dividing the upper eyelid orbital sep-
tum or fat pads.
Judging and Controlling Incision Depth

With scalpel surgery one experiences tactile feedback,
which assists in judging and controlling incision
depth. With the CO2 laser, incision depth is influ- FIGURE 12–2 An approximately 100-mm zone of ther-
enced by precise handpiece focus, tissue hydration, mal injury is evident along the edges of this pulsed CO2
operator hand speed, and energy settings. By using laser incision. (Image courtesy of Brian Beisman, M.D.)
CHEN12-165-178.I 3/22/01 1:51 PM Page 167
LASER BLEPHAROPLASTY • 167
EARL ...
P When vessels of up to
0.5 mm diameter are encountered, the
beam may be deliberately defocused to reduce
the ablative fluence and create larger zones of
thermal hemostasis.
However, defocusing should be approached cau-

tiously because subablative fluences may result in
either charring or tissue heating without vaporization.
In either circumstance, larger zones of thermal injury
that may lead to scarring are produced. Lasing FIGURE 12–3 Skin removal amountis determined.
charred tissue results in further heating of carbonized
tissue to up to 600°C and resultant large zones of ther-
• Metal globe guard for globe protection
mal injury as the heat is slowly conducted from the
• Protective eyelid clamp
glowing red-hot embers of carbonized tissue to
• Combined laser backstop and Desmarres retractor
the surrounding areas.3
• 0.5 mm toothed forceps
• Cotton tip applicators
Wound Healing
• Hemostat (fine curved)
Continuous wave CO2 laser incisions have less tensile • Bipolar forceps
strength than scalpel incisions for the first 1 to • Needle driver
3 weeks after surgery, but final wound strength is • Suture scissors
equivalent. The delay in wound healing probably
results from laser-induced thermal injury along the Surgical Technique
incision edges and the adjacent epidermis. CO2
The sequential performance of laser upper eyelid ble-
lasered epidermal wounds show a delay of 3 days in
pharoplasty is demonstrated in Figures 12–3 to 12–12
the onset of epidermal migration. This delay is
for the right upper eyelid. Determine the amount
believed to result from the eschar of injured tissue
of skin removal using pinch or other techniques
that physically impedes epithelialization. Further-
(Fig. 12–3). The inferior resection margin is the antic-
more, injured epidermal cells in the zone of reversible
ipated new eye lid crease. Pinch the skin to determine
injury may also require time to recover before migrat-
amount for removal and be certain that the lids can
ing. The eschar of thermal damage in the dermal and
passively close. Medial extent of removal is superior
deeper edges of the incision probably impedes heal-
to the punctum and lateral extent of removal is often
ing of the deep wound as well. The efflux of blood-
determined by hooding and may be limited by the lat-
borne macrophages and wound healing factors is
eral orbital rim. Ink the margins for resection and then
reduced because of the laser’s hemostatic effect, and
remeasure with calipers to ensure perfect symmetry.
further delay is occasioned by the necessity for
Incise the skin and orbicularis (Fig. 12–4). Keep the
macrophage influx to clear devitalized tissue.
beam perpendicular to the skin surface and repeat
EARL ...
P For the aforementioned
reasons, eyelid skin sutures are left in
longer, usually 10 days or longer for my patients,
to avoid wound dehiscence.
Upper Eyelid Laser Blepharoplasty

Instruments
The following instruments are those recommended
for upper eyelid blepharoplasty:
• Ambidextrous “propeller” laser shield used as a
backstop during incisional blepharoplasty FIGURE 12–4 Skin and orbicularis are incised.
CHEN12-165-178.I 3/22/01 1:51 PM Page 168
FIGURE 12–5 Skin-muscle ellipse is incised. FIGURE 12–6 The orbital septum is opened laterally.
passes with wound gently spread until the beam is across a closed hemostat, or divided against a back-
through the orbicularis. Be very careful of the levator stop. Avoid the lacrimal gland laterally.
aponeurosis, which may be directly beneath the orbic- Bluntly spread the fascia over the nasal fat pad
ularis at the inferior incision. with hemostats (Fig. 12–10). Ballotte the globe to bring
Excise the skin-muscle ellipse (Fig. 12–5). Apply the fat pad forward. Make an X-shaped incision over
strong traction and countertraction to develop surgi- the nasal fat pad. Deepen the incision until fat pro-
cal plane. Stay in the plane of the postorbicularis fas- lapses. Grasp and immobilize the fat and then use a
cia, being careful to avoid transecting the levator cotton tip applicator to bluntly strip away tissues
inferiorly. retaining the nasal fat pad. The base of the nasal fat
Open the orbital septum laterally, keeping the laser pad may require local anesthesia injection. At this
pointed tangential or away from the globe (Fig. 12–6). point, the retro-orbicularis oculi fat (ROOF) may be
Ballotte the globe and inspect to visualize the under- excised. To do so, grasp the orbicularis of the upper
lying postseptal fat pocket. Buttonhole the septum wound edge. Place a propeller protector between the
until fat prolapses freely. orbital rim and the levator. Trim the orbicularis and
Divide the entire horizontal width of the exposed underlying ROOF flush with the skin edge. Reflect the
septum over the backstop (Fig. 12–7). Identify the ROOF from the deep connective tissue overlying
exposed upper eyelid fat pad and underlying levator the orbital rim. Do not expose bare periosteum.
muscle (Fig. 12–8). Ballotte the globe to prolapse any residual fat
Grasp the fat pad with forceps (Fig. 12–9). Bluntly (Fig. 12–11A). Close the skin incision with inter-
strip it free of the levator muscle and aponeurosis. rupted 6-0 Prolene nasally and running 6-0 Prolene
Excise the fat pad to the level of the orbital rim or for the remainder (Fig. 12–11B). Take only superficial
Whitnall’s ligament. The fat pad may be excised dermal bites (0.5-mm depth) only to reduce bleeding.
FIGURE 12–7 The entire horizontal width of the FIGURE 12–8 The exposed upper eyelid fat pad and
exposed septum is divided. underlying levator muscle are identified.
CHEN12-165-178.I 3/22/01 1:51 PM Page 169
FIGURE 12–9 The fat pad is grasped with a forceps. FIGURE 12–10 The fascia is spread over the nasal fat
pad and incised.
Other options include re-creating the eyelid crease by taken lateral to the canthal angle to prevent dehis-
placing three stitches through the dermis of the cence. Use a taper needle to reduce bleeding. Oint-
upper skin edge or the orbicularis and then through ment is applied to the inferior cul-de-sac if the patient
the surface of the levator aponeurosis along the supe- is not blinking fully. Stitches are left in for 9 to
rior tarsal border. Deeper (1.5-mm depth) bites are 15 days (Fig. 12–12).
A B
FIGURE 12–11 (A) The globe is ballotted to prolapse any residual fat. (B) Incision is closed.
A B
FIGURE 12–12 Preoperative (A) appearance and immediate postoperative (B) appearance.
CHEN12-165-178.I 3/22/01 1:51 PM Page 170
• The lateral fat pad is easier to remove once sepa-

EARL ...
P The levator muscle and rated from the underlying lower eyelid retractors.
• If the fat is restrained between the central and lat-
aponeurosis are on the undersurface of
eral fat pads, look for and divide the anteriorly
the preaponeurotic fat pad. Precise measure- located fibrous band of tissue (arcuate expansion
ments are critical. arising from the inferior oblique muscle).
Transconjunctival Blepharoplasty of the Surgical Technique

Lower Eyelids The sequence for transconjunctival lower eyelid
blepharoplasty is shown in Figures 12–14 to 12–27
Patient Evaluation and the accompanying legends. Ballotte the globe
The main problem to be addressed in a candidate for posteriorly with Jaeger plate or metal guard while
transconjuctival blepharoplasty of the lower eyelid is an assistant retracts the lower eyelid margin with
inferior fat pad herniation without significant dermal two fingers (Fig. 12–14). This prolapses the inferior
rhytids (wrinkles) of the lower eyelids (Fig. 12–13). If fat pads and fornix.
the patient has significant dermal rhytids, then these Incise the conjunctiva beginning at the inferior bor-
must be addressed via a traditional transcutaneous der of the lateral tip of the caruncle, and continue lat-
blepharoplasty or by adjuvant laser skin resurfacing erally but stay 4 mm below the base of the tarsal plate
or chemical peeling. Horizontal eyelid laxity should (Fig. 12–15). Continue to within 2 mm of the lateral
also be addressed with the cutaneous approaches as it canthal angle. Always angle the beam toward the
cannot be solved with transconjunctival surgery. inferior orbital rim.
Expose the orbital septum by carrying the incision
Instruments (Storz Instrument Co. St Louis, MO) deeper until the incision spreads open, exposing the
The following instruments are recommended for septum (Fig. 12–16). Place a Desmarres retractor.
transconjunctival blepharoplasty of the lower eyelids: Grasp the posterior/inferior conjunctival wound
• Protective metal globe shield edge with 0.5-mm toothed forceps. Spread the
• Khan-Jaeger laser eyelid plate wound farther open by sweeping a cotton tip inferi-
• 0.5 mm toothed forceps orly across the septum.
• Desmarres retractor (dull finish) Incise the septum over the nasal fat pad by bal-
• Bipolar cautery lotting the globe to bring the fat pad forward
• Hemostat (fine curved) (Fig. 12–17). Make an X-shaped incision over the nasal
fat pad and deepen the incision until a knuckle of pale
Anatomic Landmarks and Surgical Tips yellow fat prolapses. Notice the relative differences in
the incisions used to release the nasal, central, and lat-
The following points are important references for the
eral fat pads.
transconjunctival blepharoplasty procedure:
Remove the nasal fat pad (Fig. 12–18). Grasp and
• The inferior oblique muscle can always be located immobilize the nasal fat and then use a cotton tip
between the nasal and central fat pads. applicator to bluntly strip away tissues retaining
A B
FIGURE 12–13 Patient before (A) and after (B) bilateral upper eyelid blepharoplasty and transconjunctival lower
eyelid blepharoplasty.
CHEN12-165-178.I 3/22/01 1:51 PM Page 171
the nasal fat pad. Do not tug on the fat pad. The Laser transect the nasal fat pad flush with the infe-
base of the nasal fat pad may require local anesthe- rior orbital rim, utilizing a hemostat or backstop
sia injection. (Fig. 12–19). Expose and remove the central fat pad
FIGURE 12–14 The inferior fat pads and fornix are pro- FIGURE 12–15 The conjunctiva is incised.
lapsed.
FIGURE 12–16 The orbital septum is exposed.

FIGURE 12–17 The septum is incised over the nasal fat
pad.
FIGURE 12–18 The nasal fat pad is removed. FIGURE 12–19 The nasal fat pad is laser transected.
CHEN12-165-178.I 3/22/01 1:51 PM Page 172
(Fig. 12–20). To incise the septum over the central fat transect the central fat pad flush with the inferior
pad, ballotte the globe to bring the fat pad forward orbital rim utilizing a hemostat or backstop.
and then make a horizontal 10- to 12-mm incision over Identify and release the lateral fat pad from the
the central fat pad. Place the incision 2 to 3 mm poste- lower eyelid retractors (Fig. 12–21). This fat pad is
rior and superior to the inferior orbital rim. Grasp and constrained by the lower eyelid retractors and may
immobilize the central fat pedicle and then use a cot- need to be sharply divided from the retractors. The
ton tip applicator to bluntly strip away tissues, expos- orbital septum, arcuate expansion (fibrous anterior
ing the central fat pad. Do not tug on the fat pad. Laser band arising from the inferior oblique muscle and
separating the central and lateral fat pads), and lat-
eral canthal tendon also may create hindrances. The
septum must be incised and one may also need to
release the arcuate expansion (described below).
If you have difficulty exposing and releasing the
lateral fat pad, identify whether the arcuate expan-
sion is creating a hindrance and should be divided
(Fig. 12–22). The laser tip has been passed beneath the
expansion in the photo.
Divide the arcuate expansion, if necessary
(Fig. 12–23). Notice how the arcuate expansion acts as
a sling and constrains the release of the central and
temporal fat pads. The expansion may be divided to
release the fat pads.
FIGURE 12–20 The central fat pad is exposed and Divide the lateral fat pad over a backstop, such as
removed. a wet cotton tip applicator or hemostat (Fig. 12–24).
FIGURE 12–21 The lateral fat pad is identified and

released from the lower eyelid retractors. FIGURE 12–22 Identify whether the arcuate expansion
is creating a hindrance and should be divided.
FIGURE 12–24 The lateral fat pad is divided over a

FIGURE 12–23 Arcuate expansion is divided. backstop.
CHEN12-165-178.I 3/22/01 1:51 PM Page 173
FIGURE 12–25 Anatomic relationships are inspected, FIGURE 12–26 The eyelid is repositioned, and inspect-
and hemostasis is checked. ed for residual fat.
The lateral fat may come out in two layers. Inspect focuses on only those complications that are specific
the anatomic relationships and check for hemostasis to laser upper or lower eyelid blepharoplasty. The
(Fig. 12–25). Reposition the eyelid and ballotte to look interested reader is referred to a stepwise hypertext
for any residual bulging fat (Fig. 12–26). To achieve summary of such techniques.6
closure, tug upward on the lower eyelid margin to
prevent inversion or overriding of the wound
(Fig. 12–27). No suture is used, but place ointment
and reassure the patient. PITFALL
For all practical purposes, the only significant

EARL... Always protect globe with
P an impenetrable metal shield.
blepharoplasty complications specific to laser
eyelid surgery are those related to thermal
injury, wound healing, combustion hazard,
or inadvertent laser penetration of tissue.
COMPLICATIONS OF LASER UPPER
EYELID BLEPHAROPLASTY Direct CO2 laser injury to the globe is one of the
The reader is advised to consult more general texts most dreaded complications of laser surgery. The risk
regarding the prevention of complications of ble- of such injuries may be reduced by placement of a
pharoplasty in general.4, 5 For brevity, this discussion metal shield between the eyelids and globe. How-
ever, even when such precautions are employed, the
device may dislodge during surgery and not provide
adequate protection as shown by the CO2 corneal
injury in (Fig. 12–28). The newer generation Khan-
Baker eyelid clamp (Storz Instrument Co., St. Louis,
MO) has been devised and provides larger clamping
teeth and a means of determining the extent of supe-
rior fornix protection, and is designed to be less likely
to dislodge. Nonetheless, all current eyelid clamps are
essentially friction fixated devices and subject to dis-
location. Protective metal contact lenses may rotate
and expose the globe. A device developed by the
author (Storz Instrument Co., St. Louis, MO) consists
of a relatively large titanium scleral shield which is
maintained in position by medial and lateral antiro-
tational posts (Fig. 12–1). It is not always possible to
FIGURE 12–27 Ideal position of lower eyelid at com- judge the exact location of the underlying shield dur-
pletion on transconjunctival laser blepharoplasty. ing eyelid surgery, and injury may occur when deep
CHEN12-165-178.I 3/22/01 1:51 PM Page 174
rubbed against the pillow during sleep. Therefore, the

suture bites in this area are 2.0 mm in width and
depth and purposely include orbicularis oculi
and deeper tissues. With this technique, the author
usually removes skin stitches between the 9th and
14th postoperative day. No stitches are used for
transconjunctival lower eyelid blepharoplasty.
Upper eyelid hematomas may occur postoperatively
from laser blepharoplasty despite adequate intraop-
erative hemostasis. This seems reasonable since the
zone of hemostasis is only approximately 110 m and
therefore rebleeding may occur as the vessel reper-
fuses. In the author’s opinion, such bleeding usually
emanates from vessels larger than 0.25 mm that are
FIGURE 12–28 A CO2 laser corneal injury from Paris, located on the undersurface of the upper aspect of the
France. (Courtesy of Oculoplastik, Montreal.) wound, often close to the eyebrow or in the nasal
aspect. Whenever such vessels are encountered, the
dissection is performed beyond the edge of the author makes a special point of deliberately cauteriz-
protective device. This is especially concerning when ing a several-millimeter segment of such vessels using
working superior to the insertion of the septum on bipolar cautery. Hematomas do not seem to be asso-
to the levator aponeurosis. Therefore, additional ciated with transconjunctival laser techniques in the
guards such as the Khan-Sutcliffe shield or moistened lower eyelid, possibly because—relative to skin—
cotton tip applicators are used during upper eyelid significant heat conduction occurs during CO2 laser
blepharoplasty. division of fat. Significant hematomas will require
If globe perforation occurs, the globe must be pro- drainage, and one can expect prolonged swelling of
tected from undue pressure, which might result in the involved eyelid.
expulsion of ocular contents, and the patient should A theoretical risk of laser surgery is an increase in
be referred for intraocular evaluation. If corneal injury wound infection rates. This is because necrotic thermal
occurs, a corneal specialist should be consulted. debris, until it is cleared from the wound, could act
as a nutrient bed for infection.
...
P EARL When closing the eyelid
skin following upper or lower eyelid tran-
scutaneous laser blepharoplasty, a modified
PITFALL
wound closure technique will help to reduce the Group A streptococcal necrotizing fasciitis
incidence of dehiscence and bleeding. has been reported following combined laser
blepharoplasty and skin resurfacing, which
was performed without prophylactic oral
Bleeding occurs more commonly during laser antibiotics.
wound closure because the hemostasis provided by
laser is only 110 m (Brian Biesman, ophthalmologist,
personal communication) versus up to 2.0 mm or
more seen with bipolar cautery techniques. Therefore, However, in the author’s experience with over
the author recommends (1) the use of a taper rather 2000 incisional laser eyelid procedures performed
than cutting needle for suturing; (2) nonabsorbing over a 4-year period, infection is uncommon and pro-
(i.e., 6-0 Prolene) suture, which will retain its tensile phylactic oral antibiotics are unnecessary. However,
strength; and (3) 0.5-mm bites of skin only (avoiding for resurfacing, the author routinely prescribes pro-
orbicularis oculi) in the non–tension-bearing portion phylactic oral antibiotics.
of the incision that is within the area from the medial Even among patients who are prone to keloid for-
to the lateral canthal angles. mation, hypertrophic scarring is unusual in the thin eye-
Wound dehiscence usually occurs in the segment of lid skin. The risk of hypertrophic or noticeable
the incision lateral to the lateral canthal angle because scarring may be reduced by maintaining precise focus
this area not only supports the gravitational weight and perpendicularity even in complex topographic
of the cheek but can also be stressed when the face is areas, avoiding incision placement into adjacent
CHEN12-165-178.I 3/22/01 1:51 PM Page 175
resurface directly over or directly adjacent to fresh

blepharoplasty incisions. If one is resurfacing directly
across a fresh eyelid skin incision, this should be per-
formed prior to wound closure to allow better judg-
ment of the amount of skin removal and to avoid
lasering stitches. Although resurfacing close to face-
lift incisions may result in scarring or delayed epithe-
lialization, such problems are unusual with bleph-
aroplasty incisions because of the excellent local blood
supply.
PITFALL
FIGURE 12–29 Hypertrophic nasal webbing and scar
tissue following CO2 laser blepharoplasty with incision car- Early or delayed scarring is an unusual com-
ried medial to the upper punctum. Condition resolved over plication of laser resurfacing. It may be attrib-
several months with massage and intralesional triam- uted to an exuberant healing response or
cinilone acetonide. deep resurfacing into the reticular dermis.
thicker skin (Fig. 12–29), avoiding placement of the

incision in areas where webbing may occur, and by Very mild scarring may be treated with topical
layered wound closure when one anticipates that steroids or intralesional triamcinolone (Kenalog) at a
wound tension may lead to a wide atrophic scar. concentration of 5 mgmL (the higher potency oph-
thalmic preparation may induce dermal atrophy).
Application of a silicone gel or sheeting, alone or in
COMPLICATIONS OF combination, or Cordoran tape, may also be helpful.
TRANSCONJUNCTIVAL LOWER EYELID When hypertrophic scarring is minimal to moderate
and still vascular, it may respond to 585-nm pulse dye
BLEPHAROPLASTY laser treatment. True keloid formation may respond
When pyogenic granulomas of the conjunctiva occur, to intralesional steroids plus 585-nm pulsed dye laser
they often respond to a 6-week course of topical irradiation. Persistent hypertrophic incisional scars
prednisolone acetate 1% given as 1 drop q.i.d. If this is may be excised after waiting for 6 months.
unsuccessful, one should remove the granuloma.
Retraction of the tarsal plate and the lower eyelid is
an occasional complication of laser transconjunctival Ectropion
blepharoplasty. This may be avoided by placing the Significant preoperative lower eyelid laxity also pre-
transconjunctival incision at least 4.0 mm away from disposes to ectropion and may be anticipated preop-
the base of the inferior tarsal plate such that any scar eratively by performing eyelid distraction tests.
tissue contracture does not have direct purchase on During resurfacing, the patient is in repose and the
the base of the tarsal plate. If such a complication effect of gravitational cheek descent may be underes-
occurs, it may be treated initially by vigorous upward timated. When significant laxity is detected, one
massage of the eyelid and 0.2 mL (1 mg) of triamci- should either refrain from resurfacing close to the eye-
nolone (5 mgmL) injected into the cicatricial tissue lid margin or prophylactically tighten the lower
at 3-week intervals, for two to three treatments, until eyelid margin. Tarsal strip procedures, lateral canthal
past the cicatricial phase (usually 3 to 8 weeks post- tightening, or orbicularis oculi suspension procedures
operative). Surgical correction is by lysis of all adhe- may be employed in such cases.7–9
sions and interposing hard palate mucosa or any Mild ectropion often resolves spontaneously or
other appropriate graft. Ectropion due to a cutaneous responds to upward eyelid massage. When mild
procedure is discussed in Chapter 13. ectropion persists, consideration should be given to a
Laser skin resurfacing of the face and eyelids may horizontal lower eyelid tightening procedure. With
be routinely combined with upper eyelid blepharo- more advanced ectropion or eyelid retraction, hori-
plasty and transcutaneous or transconjunctival lower zontal tightening must be supplemented by either a
eyelid blepharoplasty. The author does not routinely free skin graft or a malar suspension.7–9
CHEN12-165-178.I 3/22/01 1:51 PM Page 176
CONCLUSION ACKNOWLEDGMENTS
Laser blepharoplasty represents an improvement The author acknowledges the permission granted by
over traditional blepharoplasty in terms of surgical the publishers to reproduce and update material
operating times, hemostasis, intraoperative bruising, from Khan JA: CO2 laser facial resurfacing and inci-
and intraoperative visualization of anatomic detail. sional blepharoplasty. In: Mauriello J, ed. Unfavor-
Nonetheless, laser blepharoplasty requires significant able Results of Eyelid and Lacrimal Surgery. Woburn,
surgical skill. This procedure may be approached in a MA: Butterworth-Heinemann, 1999:27–44; and Khan
stepwise manner as outlined in this chapter, to avoid JA: The transition to laser incisional surgery. In:
complications (Figs. 12–30 and 12–31). Specialized Biesman B, ed. Lasers in Facial Aesthetic and Recon-
instrumentation is also helpful in minimizing risk structive Surgery. Philadelphia: Williams & Wilkins,
and improving surgical exposure. Because significant 1998:1–13, 91–97; and from the author’s Web site
educational efforts have been undertaken to teach http:\\www.Geocities\FashionAvenue\3072. The
safe laser techniques, complications specific to laser author has a financial interest in some of the instru-
blepharoplasty are infrequent. ments discussed in this chapter.
Upper blepharoplasty
Herniated Excess skin Underlying Asymmetric ROOF Brow Glabellar

fat and muscle ptosis folds descent ptosis furrow
Skin, muscle, fat Skin, muscle Müllerectomy Reset both ROOF Forehead/ Botox or
blepharoplasty blepharoplasty or levator lid folds at debulking or brow lift procerus/corrugator
resection same height forehead/brow lift excision/denervation
FIGURE 12–30 Clinical pathway for laser blepharoplasty of upper eyelid.
Lower blepharoplasty
Herniated Skin Festoon and/or Horizontal laxity Tear-trough Lower lid retraction, Crow's
fat only wrinkles malar bags or rounded deformity malar fat descent feet
lateral canthus on cheek
Transconjunctival Resurfacing Skin/muscle bleph. Lower lid Tear trough SOOF lift Botox and/or
blepharoplasty or skin/muscle and/or resurfacing tightening implant or fat and/or hard resurfacing
blepharoplasty and/or direct excision (e.g. tarsal-strip repositioning palate mucosal and/or filler
procedure) graft and/or
skin graft
FIGURE 12–31 Clinical pathway for laser blepharoplasty of lower eyelid.

CHEN12-165-178.I 3/22/01 1:51 PM Page 177
REFERENCES
1. Khan JA: The transition to laser incisional surgery. In: 4. Peck GC, ed: Complications and Problems in Aesthetic
Biesman B, ed. Lasers in Facial Aesthetic and Reconstruc- Surgery. New York: Gower, 1992.
tive Surgery. Philadelphia: Williams & Wilkins, 1998: 5. Putterman AE, ed: Cosmetic Oculoplastic Surgery. New
91–97. York: Grune & Stratton, 1982.
2. Khan JA: CO2 laser skin resurfacing in the near-mil- 6. Http:\\www.Geocities\FashionAvenue\3072.
lisecond domain. In: Albert DM, Jakobiec FA, eds. Prin-
ciples and Practice of Ophthalmology, 2nd ed, vol 3. 7. Jordon DR, Anderson RL: The lateral tarsal strip revis-
Philadelphia: WB Saunders, 1998:2000,3529–3550. ited. Arch Ophthalmol 1989;107:604.
3. Fitzpatrick RE: Ultrapulse CO2 laser resurfacing of the 8. Mladick RA: Updated muscle suspension and lower
facial skin. In: Rabkin MD, ed. CO2 Laser Cosmetic Ble- blepharoplasty. Clin Plast Surg 1993;20:311–315.
pharoplasty and Skin Resurfacing [CD-ROM]. Boston: 9. Furnas DW: Festoons, mounds, and bags of the eyelids
Ophthalmology Interactive, 1997. and cheeks. Clin Plast Surg 1993;20:367–385.
CHEN12-165-178.I 3/22/01 1:51 PM Page 178
CHEN13-179-194.I 3/26/01 8:38 AM Page 179
Chapter 13
LASER SKIN RESURFACING

Jemshed A. Khan
Erbium:yttrium-aluminum-garnet (YAG) and CO2 cial because they promote an advantageous laser tis-
laser resurfacing systems create a controlled depth sue interaction that results in ablation and wrinkle
cutaneous ablation and associated injury zone that is reduction without scarring.1–3 Because the “chro-
followed by a healing response that produces the mophore” for the 10.6-m CO2 and 2.94-m
desired improvement. Laser resurfacing introduces a erbium:YAG laser is water, these lasers have many
host of possible complications, most of which are for- advantages when incising or heating biologic soft tis-
tunately minor. This chapter discusses the avoidance sues (Fig. 13–1).
and management of complications through a review
of basic principles of laser resurfacing technique, post-
operative care and complications, and laser safety.
EARL... To laser resurface human
FUNDAMENTALS OF LASER SKIN

P skin without significant scarring, the laser
must be capable of removing the epidermis and
RESURFACING some papillary dermis as well as ejecting most
Laser-Tissue Interactions of the generated heat out of the wound to avoid
To understand laser resurfacing, one should keep in creating significant damage to the deep dermis
mind that certain CO2 and erbium:YAG laser para- (Fig. 13–2).
meters (wavelength, pulse duration, etc.) are benefi-
FIGURE 13–1 Laser absorption

curve for various wavelengths.
179
CHEN13-179-194.I 3/22/01 1:55 PM Page 180
CO2 laser
First pass Second pass
Epithelium removed
Thermal injury
Epidermis
Papillary dermis
Reticular dermis
Erbium laser
First pass Second and third passes
Epithelium removed Pass 1
Pass 2
Thermal injury Pass 3
Epidermis
Papillary dermis
Reticular dermis
Subcutaneous
layer
FIGURE 13–2 Human skin layers and structures include the epidermis and dermis. The dermis is divided into a
superficial papillary layer and a deep reticular layer. Re-epithelialization proceeds from a reservoir of pluripotential
keratinocytes associated with hair follicles and appendages.
To precisely vaporize the epidermis, the laser tissues by heating and vaporizing the intracellular
must deliver a sufficient energy pulse to almost water.
instantaneously raise the intracellular epidermal fluid With regard to tissue penetration, 90% of the radiant
to its boiling point, at which time a steam plume is CO2 laser energy is absorbed within 30 m of water
ejected out of the wound, quickly carrying away with penetration, thus allowing very precise vaporization
it the generated heat before significant dermal dam- of target tissue with little lateral thermal damage. For
age can occur. Subsequent passes with the CO2 laser erbium:YAG lasers there is even greater absorption:
must induce thermal, conformational, and other 90% of the radiant laser energy is ab-sorbed within
changes in the dermal collagen to induce shrinkage 1 m of water penetration. Rapid tissue heating is also
and wrinkle reduction. Because these thermal effects necessary to avoid the lateral spread of heat to sur-
are thought to prolong healing, erbium:YAG lasers rounding tissues. Unfortunately, the low energy lev-
have more recently been marketed as an alternative els and lengthy exposure duration associated with the
“cool” method of epidermal ablation and wrinkle early and underpowered continuous wave CO2 lasers
improvement. resulted in significant tissue charring, unwanted col-
One can best understand ablative laser-tissue inter- lateral thermal damage, and secondary scarring. This
actions by considering that there are only three laser scarring occurred because there was significant lateral
features needed for laser skin resurfacing: appropriate thermal spread (as much as 5 mm) during the time
wavelength, limited tissue penetration, and rapid that it took the low power laser to heat the target tis-
tissue heating. With regard to wavelength, the 10.6-m sue to boiling point.
CO2 laser wavelength and the 2.94-m erbium:YAG However, by increasing the CO2 laser fluence (to
lasers are both highly absorbed by water, making above 4 to 5 Jcm2), one can heat the target tissue
them ideal lasers for destroying cell-based biologic to 100°C rapidly enough that the vapor plume ejects
CHEN13-179-194.I 3/22/01 1:55 PM Page 181
LASER SKIN RESURFACING • 181
the heated tissue out of the wound before there is sig-

nificant lateral thermal injury. This time interval
within which human skin must be heated to prevent
significant collateral thermal injury (known as the
thermal relaxation time) is 6 950 sec. This observation
led Coherent Medical Lasers (Palo Alto, CA) to
develop the first clinical CO2 lasers capable of energy
fluences of 7 4 to 5 Jcm2 delivered in pulse durations
of less than 1 msec. Studies have confirmed that pulse
durations greater than 1 msec are associated with
greater localized thermal damage. CO2 laser energy
may also be delivered to human skin with 1 msec
“dwell” exposure utilizing a less expensive continu-
ous wave beam that rapidly moves across the tissue
(Sharplan Lasers, Allendale, NJ).
Because erbium:YAG laser pulses are generally of
250-sec duration, thermal damage is not a significant
factor. Ablative fluences are achieved at settings
7 1.6 Jcm2, thus allowing laser resurfacing with rela-
tively inexpensive and less powerful laser tubes. With
FIGURE 13–3 Desiccated epidermal debris must be
single-pulse erbium:YAG laser there is little thermal removed between CO2 laser passes. The forehead and
effect and bleeding is routinely encountered in the cheeks have both been treated with one pass, but in the fore-
superficial papillary dermis. head the debris has been wiped away. The perioral area has
Clinical experience confirms that, unlike not been treated.
erbium:YAG, second and third CO2 laser passes exert
a significant thermal effect on the dermis character-
EARL... The vessel-sealing activity
ized and differentiated from the epidermal vaporiza-
tion by immediate dermal shrinkage and scant
desiccated debris. The thermal effects of the CO2 laser
P of the CO2 laser results from the approx-
imately 100-m zone of coagulative thermal
also results in a relatively bloodless field because damage that accompanies pulsed CO 2 laser
small vessels are sealed by the laser energy. durations of approximately 1 sec.
PITFALL This benefit is counterbalanced by delayed wound

healing and, perhaps, infection risk associated within
Following CO2 vaporization of the epidermis the 100-m zone of devitalized tissue. This dead and
there is a significant residue of desiccated epi- injured tissue, which can act as a nutrient bed for bac-
dermal debris that must be removed prior to terial infection, must be cleared from the epithelial
further laser passes (Fig. 13–3). Failure to surface before healing can proceed.
The first CO2 laser resurfacing pass vaporizes the
remove this debris may result in tissue heat-
epidermis, leaving a residual desiccated debris that is
ing above 100°C, small visible combustion wiped away. By contrast, several passes with the
flashes, and significant thermal injury. erbium:YAG laser are required to reach equivalent
depth. No more resurfacing passes are necessary
when the goals of treatment are limited to the epider-
Recent studies indicate up to a twofold increase in mis, such as improvement of epidermal skin tone,
collagen denaturation and fibroblast death when ablation of actinic keratoses, elimination of superficial
debris is not wiped away between CO2 laser passes. hyperpigmentation, and reduction of pore size. At
Debris is ejected from the wound during erbium:YAG least one commercial CO2 laser as well as most
resurfacing and need not be wiped away. erbium:YAG lasers are designed with pulse durations
short enough that there is an almost pure vaporiza-
Tissue Response tion effect without significant thermal effect. The clin-
An important benefit of CO2 laser resurfacing is the ical benefits of such very short-pulsed lasers may be
relatively bloodless field that results from the laser’s comparable to medium depth Jessner–trichloroacetic
ability to seal blood vessels of 6 0.5 mm diameter. acid peeling in that there is less erythema and more
CHEN13-179-194.I 3/22/01 1:55 PM Page 182
rapid re-epithelialization and less likelihood of pig- or when attempting to erase very deep wrinkles
ment disturbance during the healing period. Unfor- whose bases may lie at the same depth as the reticular
tunately, such parameters may also limit the laser’s dermis of the adjacent tissue shoulder. Scarring may
wrinkle-removing and hemostatic benefits. [Propri- also be more likely in keloid-prone patients or over
etary erbium:YAG laser technology (Sciton Corp.) the edges of facelift flaps.
introduced in 1998 allows the option of rapid erbium Following resurfacing, but prior to re-epithelialization,
pulsing in a manner that creates thermal effects simi- the barrier function of the skin is disturbed and there
lar to CO2 laser.] Subsequent CO2 laser passes are is leakage and oozing of serum and protein onto the
applied to the papillary dermis so as to induce an raw dermal surface. Unsightly crusting, scabbing, and
immediately noticeable thermal shrinkage and stimu- exudate often accumulate on the skin surface.
late a long-term healing response characterized by
deposition of new subepidermal collagen (Grenz
zone) and elastin fibers. This tightening of the dermis PITFALL
creates the wrinkle reduction. The immediate ther-
mally induced conformational changes in the papil- The accumulation of significant debris may
lary collagen are not well understood, but probably serve as a nutrient bed for bacterial infection,
involve contraction of the extracellular matrix. The and the trauma of surgery may reactivate her-
injury underlying the laser-ablation zone may vary petic infections, which can spread rapidly on
from discrete zones of collagen denaturation to a compromised epidermal surface.
patchy or absent thermal denaturation.
Wound Healing Hence, antibiotic and antiviral prophylaxis and

Epithelialization may be aborted and healing by scar- wound hygiene are important when resurfacing
ring may occur when the pilar complexes have been large areas.
inactivated by isotretinoin (Accutane) use, heavy Complete epithelialization is characterized by the
x-ray irradiation, or destroyed (i.e., very deep resur- cessation of weeping and oozing and a smooth, pink,
facing into the dermis). Hence, caution is prudent, dry skin surface. In general, re-epithelialization is
especially when resurfacing the very thin eyelid skin completed within 7 days for erbium:YAG (Fig. 13–4)
A B
FIGURE 13–4 (A) Patient prior to full-face erbium:

yttrium-aluminum-garnet (YAG) resurfacing. (B) Four days
after resurfacing. (C) Seven days after resurfacing. Patient
C has re-epithelialized and has applied concealer.
CHEN13-179-194.I 3/22/01 1:55 PM Page 183
A-C
FIGURE 13–5 (A) Patient prior to full-face CO2 laser resurfacing. (B) Intraoperative view. (C) Twelve days after
resurfacing. Patient has epithelialized and is ready to begin use of concealer.
and 10 to 14 days for CO 2 resurfacing (Fig. 13–5). year or longer in the typically fair skin of patients of
Milia or acne may erupt following re-epithelialization. Northern European ancestry.
Between 3 and 5 weeks, postinflammatory hyperpig-
mentation may begin (Fig. 13–6). Following CO2 laser
EARL ...
skin resurfacing, the healed skin is usually red or pink
for 6 to 12 weeks, although redness may last up to a P With erbium:YAG laser
resurfacing, depending on treatment
depth, recovery is usually much more rapid than
is seen with deeper CO2 laser treatments.
Even after the skin has returned to a normal

appearance, epidermal-dermal adhesion is at least
temporarily reduced, as evidenced by the ease with
which the scant epidermis is denuded upon repeat
resurfacing. In a recent study, CO2 laser irradiated
specimens showed a subepidermal dermal repair
zone consisting of compact new collagen fibers over-
lying collagen with evidence of solar elastosis. It is
believed that new dermal collagen and elastin fiber
production continues for up to 6 months after resur-
facing and contributes to wrinkle reduction.
PREOPERATIVE EVALUATION AND

PREPARATIONS
The prevention of complications begins with evalua-
tion of the laser resurfacing candidate. One should
document which areas of the face are of concern to the
FIGURE 13–6 Hyperpigmentation of treated areas is patient, special occupational considerations, when
clearly evident 5 weeks after resurfacing over the forehead, the patient would want to have any procedures done,
eyelids, and crows’-feet areas general medical history, allergies, and medications.
CHEN13-179-194.I 3/22/01 1:55 PM Page 184
A careful dermatologic and medical history will out facial rhytids and other features and photographs
help screen for conditions that may be associated with the patient. During the sketching, the patient is asked
a poor resurfacing result or complications. Specific to point out any other areas of concern and counseled
features to elicit in the history include immune system as to whether or not this problem is amenable to resur-
compromise, and racial origins of African, Far-East facing versus other options. Lower eyelid tone is
Asian, or Native American background. A personal assessed with the “snap back” test. Estimates of pho-
or family history of keloid formation may increase the toaging, loss of skin tone, actinic keratosis, pigmentary
likelihood of keloid formation or hypertrophic scar- changes, telangiectasia, wrinkling, fine facial hairs,
ring after resurfacing. Postinflammatory hyperpig- and acne or scarring are performed and documented.
mentation after resurfacing is believed to occur more The author then discusses preoperative medica-
commonly in patients with darker skin. tions (see Prophylaxis, below); anesthesia options; the
risks of surgery, including postinflammatory hyper-
pigmentation, hypopigmentation, herpetic or bacterial
EARL ...
P Isotretinoin (Accutane)
treatment within the past 2 to 3 years or
past facial x-ray treatments may impair follicle
infection, ectropion, pain, scarring; the need to post-
pone most public and social activities during the 10- to
14-day period prior to complete re-epithelialization as
and sweat gland activity, thus resulting in well as skin appearance during that time; and the
usual 6- to 12-week period of postoperative erythema.
delayed or absent re-epithelialization after
About a 50% measured improvement in wrinkle
resurfacing. depth, which correlates with a significant clinical
improvement, has been reported.
Active acne may be accelerated by the intense heal-
Prophylaxis
ing response and trigger further scarring. Patients
with acne rosacea or telangiectasia may have more The large raw exposed facial areas following resurfac-
noticeable vessels after resurfacing. Patients’ litigious ing may invite devastating bacterial cellulitis, primary
personality should also be considered by the surgeon. herpes simplex, or reactivation of latent herpes simplex
Pregnancy is a contraindication because of an in- with disseminated facial scarring. Therefore, some
creased risk of hyperpigmentation. physicians prescribe prophylactic antibiotic and antivi-
The physical examination begins with assessment ral medications prior to resurfacing to achieve thera-
of the patient’s skin type. Fitzpatrick class IV or darker peutic levels at the time of treatment, and are continued
skin is prone to hypertrophic scarring or pigmentary for 12 days thereafter or until re-epithelialization is well
problems (Table 13–1). In the author’s opinion, pro- established.
longed postoperative erythema is more likely in
extremely fair skin. In his practice, the author sketches
EARL ...
P Topical antivirals and
antibiotics are avoided because of the
extremely high incidence of contact dermatitis
TABLE 13–1 FITZPATRICK’S SKIN TYPE
CLASSIFICATION SYSTEM when such drugs are applied to large raw resur-
faced areas.
Type Color Reaction to first sun
exposure yearly
All resurfacing patients, except those undergoing
I White Always burn/never tan very small treatment areas, receive a preoperative oral
II White Usually burn/tan with antibiotic, usually ciprofloxacin hydrochloride (Cipro)
difficulty 500 mg orally b.i.d. for 14 days, begun 48 hours prior
III White Sometimes mild burn/tan to surgery. Ciprofloxacin hydrochloride is a broad-
average spectrum fluoroquinolone that provides good skin
IV Medium coverage for both gram-negative and gram-positive
brown Rarely burn/tan with ease skin pathogens, Staphylococcus aureus, Streptococcus
V Dark pyogenes, and Pseudomonas aeruginosa. An alternate
brown Rarely burn/tan very easily
regimen consists of azithromycin (Zithromax), a
VI Black Never burn/tan very easily
macrolide antibiotic, which provides good coverage
for the major gram-positive skin pathogens, for exam-
Data from Fitzpatrick RE, Goldman MP, Satur NM, Tope WD:
Pulsed carbon dioxide laser resurfacing of photoaged facial skin. ple, S. aureus and S. pyogenes. Azithromycin is pre-
Arch Dermatol 1996;132:395–402. scribed as a 500 mg single dose, followed the next day
CHEN13-179-194.I 3/22/01 1:55 PM Page 185
by 250 mg once daily for 12 days, begun at least 2 creams may be too strong for the delicate eyelid
days prior to surgery. Both of these antibiotics should skin—the patient can determine this through careful
be avoided or used cautiously in patients taking theo- trial and error. Common bleaching agents applied
phylline medications or warfarin. In addition, signif- once or twice daily include hydroquinone 2 to 4% or
icant drug interactions may occur between azithro- kojic acid 2%. Many authorities espouse that preop-
mycin and many drugs including digoxin, ergot erative bleaching creams are of no benefit in reducing
drugs, and triazolam as well as other drugs metabo- the incidence of postresurfacing hyperpigmentation
lized by the cytochrome P-450 system such as pheny- in Fitzpatrick I to III skin types because the treated
toin, carbamazepine, and cyclosporine. melanocytes are vaporized during the resurfacing,
The antiviral drug acyclovir (Zovirax), a thymidine although Randal Pham, M.D. (personal communica-
kinase inhibitor that is active against human herpes tion, 1996) has indicated a reduction of hyperpigmen-
viruses, may be prescribed as 400 mg orally every tation from 50 to 20% in a predominantly Asian-
8 hours for 14 days, begun at least 2 days prior to American population.
surgery. Some physicians have substituted Valtrex Tretinoin (Retin-A®) is often prescribed preopera-
500 mg orally twice daily, or oral Famvir. If a herpes tively because of its anticomedogenic effect. Retin-A
infection develops, the acyclovir dose may be interferes with keratinization of the follicular duct
increased to achieve therapeutic levels for an active and reduces the comedone plug, hence reducing both
infection to 800 mg orally five times per day. acne and milia formation; 1.0% hydrocortisone may
Preoperative application of topical bleaching be added to pretreatment formulas to counter irrita-
agents is a common but unproven practice intended tion caused by other pretreatment agents. The author
to reduce the incidence of postresurfacing hyperpig- occasionally employs a compounded cream of hydro-
mentation. Pretreatment is usually begun 1 to 2 weeks quinone 3%, hydrocortisone 1%, kojic acid 2%, and
preoperatively in Fitzpatrick I to III skin types (Table tretinoin 0.025% applied once or twice daily for 1 to
13–1), and up to 4 to 8 weeks preoperatively in darker 2 weeks prior to resurfacing. Some patients find this
skin types. Creams are applied by squeezing a dab combination irritating and discontinue it. This cream
onto the palm of the nondominant hand. Two fingers may be resumed at 3 to 5 weeks postoperatively if
of the dominant hand are dipped into the cream and hyperpigmentation occurs. -Hydroxyacids have
it is spread over the face. Care should be employed also been used for skin pretreatment. The author
around the eyelids where the cream may enter the does not routinely pretreat Fitzpatrick III or fairer
tear film and irritate the eyes. In some patients, skin (Table 13–2).
TABLE 13–2 PRE- AND POSTOPERATIVE WOUND CARE
Immediate Late
Skin type Race/ethnicity Preoperativea postoperativeb postoperativec
I Very fair Standard Standard Standard

European
II Fair European Standard Standard Standard
III European/ Standard Standard Standard
Mediterranean
IV Mediteranean/ Standard plus Standard Standard,
Asian/Hispanic bleaching agent hydroquinone,
sunscreen kojic acid
V Asian/Hispanic Standard plus Standard Standard,
bleaching agent hydroquinone,
VI Black Standard plus Standard Standard,
bleaching agent hydroquinone,
a
Preoperative standard for all patients: ciprofloxacillin, Zovirax; Retin-A, as needed.
b
Immediate postoperative standard for all patients: ciprofloxacillin, Zovirax, Vaseline or Aquaphor, 2.5% hydrocortisone
cream, vinegar, and water soaks. Diflucan as needed.
c
Late postoperative standard for all patients: 2.5% hydrocortisone cream, SPF 30± sunscreen, skin concealer. Temovate
cream, triamcinolone, as needed.
CHEN13-179-194.I 4/24/01 8:28 AM Page 186
Laser Safety and Regulatory Compliance

EARL ...
In the United States, the American National Stan-
dards Institute has issued guidelines for the safe
operation of medical lasers. Occupational Safety and
P Specialized instruments
used during resurfacing include laser-
impenetrable protection of the patient’s eyes, as
Health Administration (OSHA) regulations require
the protection of health care workers from occupa- well as a laser-impenetrable device for masking
tional laser injury. Similarly, some states have also the edges of treatment zones and protecting
instituted laser safety standards. High-powered eyelashes and eyebrow cilia (Fig. 13–7).
resurfacing lasers may directly injure the eye, teeth,
or skin, present combustion hazards, cause electrical
injury, and produce a hazardous vapor plume. OSHA standards require posting a sign outside the
Because the resurfacing wavelengths are invisible, a procedure room door indicating that the laser is in
HeNe red aiming beam is used to indicate the laser use; and protective eyewear may be made available
beam’s position. Hence, ensuring alignment of the to personnel entering the operating room.
beam is critical. The laser plume, if inhaled, may deliver hazardous
CO2 laser energy may reflect off smooth metallic particulate matter to the respiratory system. Further-
surfaces, but is absorbed by water, biologic tissues, more, the presence of human papillomavirus DNA
glass, and plastic. All persons within the treatment has been documented in the plume after CO2 laser
area should don protective eyewear—usually laser treatment of warts. Studies also show that there is a
safety glasses. Erbium:YAG lasers require wave- risk of contamination of the operator by human papil-
length-specific protective goggles. lomavirus DNA (detectable with the polymerase
The patient’s eyes may be protected with steel eye chain reaction technique) during CO2 laser treatment.
shields (Fig. 13–7), laser safety glasses, or water- These hazards should be reduced by the use of a com-
soaked gauze pads. Of special note, plastic corneal mercial smoke evacuator designed for use with sur-
protectors melt when exposed to the CO2 laser. gical lasers, and by donning laser masks. Laser masks
A B
FIGURE 13–7 (A) A special-finish five-piece laser blepharoplasty and resurfacing instrument set designed to
reduce laser energy reflection. Left side, top to bottom, ambidextrous Khan-Sutcliffe “propeller” laser shield used as
a backstop during incisional blepharoplasty and to mask off areas during resurfacing; Khan-Jaeger metal globe guard
for transconjunctival exposure of fornix and globe protection; matte-finish titanium Khan laser eye shield with unique
antirotational posts and eyelash traction bar; and Khan-Baker protective eyelid clamp. Right side: Khan combination
laser backstop and Desmarres retractor. (Source: Storz Instrument Co., St. Louis, Missouri.) (B) Titanium Khan laser
eye shield with antirotational posts and eyelash traction bar.
CHEN13-179-194.I 3/22/01 1:55 PM Page 187
(Tecnol, Fort Worth, TX), unlike general surgical cannula fed into a nasal trumpet. We have found that
masks, effectively filter out 95% of contaminants of local infiltrative anesthetic may be completely
0.1-m size. avoided, even during full-face laser resurfacing.
One should never operate resurfacing lasers in the Propofol (Diprivan) is used intravenously to maintain
presence of flammable anesthetics, alcohol-based skin intraoperative deep sedation (also termed total
preparation solutions, or other flammable materials. venous anesthesia) and amnesia. Propofol may be
Avoid alcohol or other flammable skin preparation administered by the anesthetist as an initial 20 mg
solutions because even when the skin surface appears slow intravenous bolus followed by 10 mg every 5 to
dry there may be invisible flammable alcohol vapors 10 minutes depending on the desired depth of seda-
present. The area surrounding the surgical site should tion. If a micropump delivery is preferred, then seda-
be draped with wet towels or aluminum foil. Plastic tion is usually maintained with 25 to 50 gkgmin.
instruments or shields may melt when irradiated and At the completion of resurfacing, topical 2% lido-
dry paper or cloth drapes may ignite. caine jelly is applied to the treated areas for pain relief.
Oxygen use increases the laser combustion hazard. Patients recover sufficiently from anesthesia, often
The author does not administer supplemental oxygen within 20 minutes of surgery, and are discharged to
while the laser is in use unless the delivery system is the care of a competent adult driver. Patients are
protected by wet towels. Special airway precautions advised to begin postoperative oral analgesics imme-
are necessary when endotracheal tubes are employed diately. To reduce nausea, control pain, and induce
because of the toxic combustion by-products released drowsiness after full-face resurfacing, patients are
from the burning endotracheal tube plus the risk of prescribed meperidine HCl (Demerol) 50 mg 1 tab
laser-ignited endotracheal tube fires. Red rubber or orally q 4–6 hours. PRN and promethazine HCl 25 mg
silicone tubes are wrapped with Food and Drug PO q 6 hours PRN. Most patients require pain relief
Administration (FDA) approved wrapping and fur- medications for only the first 12 hours.
ther protected with moist gauze. The cuff may be
inflated with methylene blue tinted saline so that per-
foration is readily detectable.
LASER DELIVERY AND OPERATIVE
TECHNIQUES
Anesthesia
Laser resurfacing is commonly practiced in an office Laser resurfacing is performed as a series of passes
or ambulatory surgery setting using either local or with the laser. Treatment depth should not extend
monitored intravenous anesthesia. In an office setting, into the reticular dermis because of the increased
periocular, forehead, or perioral treatments may be risk of scarring. For treatment of large facial areas,
performed with a combination of local anesthesia and one employs an attached computerized pattern gen-
sublingual 5 mg diazepam (Valium). Office resurfac- erator or spiral delivery system to ensure rapid uni-
ing of the cheeks, full face, or more than a single cos- form treatment.
metic zone is difficult because of significant
discomfort unless semiconscious sedation or even
EARL... Rhytids caused by actinic
unconscious sedation with a laryngeal mask airway
can be provided safely. Topical Emla cream (lidocaine
2.5% and prilocaine 2.5%) may be a useful adjunct in
P damage or simple dermal plasticity (i.e.,
cheeks) respond best to resurfacing, followed by
some patients, but is too unpredictable to be routinely
and solely employed. The author monitors blood rhytids of thin dermis caused by underlying mus-
pressure, pulse, and blood oxygen levels when per- cle activity skin (i.e., crow’s-feet, lower eyelids).
forming laser resurfacing in an office setting.
Ambulatory surgical facilities allow for conscious
or unconscious intravenous sedation in a controlled Rhytids due to major muscles underlying a thick
environment. Propofol, a short-acting intravenous dermis respond the least, for example, glabella, fore-
sedative-hypnotic agent, is titrated by an anesthetist head, nasolabial fold, etc. With the erbium:YAG laser,
to maintain deep sedation during treatment. Supple- judging treatment depth is much more difficult.
mental oxygen is continued during laser resurfacing Bleeding is usually a signal that one has reached the
treatment because of the respiratory depression asso- superficial papillary dermis. Further treatment is
ciated with profound propofol sedation. To maintain largely a matter of judgment and experience.
arterial oxygen levels despite deep sedation and res- Laser resurfacing of the face may be performed
piratory depression, oxygen must be delivered sequentially by completing one cosmetic zone before
directly to the posterior nasopharynx via a flexible moving on to another. The division of the face into
CHEN13-179-194.I 3/22/01 1:55 PM Page 188
cosmetic zones is based on visible topographic The laser tip should be held perpendicular to the
boundaries and skin thickness. These zones vary con- plane of the target skin to ensure uniform energy
siderably in thickness, appearance, and sebaceous delivery and minimize skew. If the laser handpiece is
character, as indicated in Table 13–3. The depth and focal, then the laser must be held at the exact focal
effectiveness of resurfacing can be varied by chang- length to ensure correct and uniform irradiance.
ing the number of passes and/or the tissue irradiance Many CO2 and newer erbium:YAG laser handpieces
(Fig. 13–8). are designed to treat larger areas by either scanning a
TABLE 13–3 AVERAGE THICKNESS OF FACIAL SKIN IN MICRONS AT VARIOUS

LOCATIONS AND RANKED BY DERMAL THICKNESS (IN MICRONS)
Location Epidermis Dermis Hypodermis Total
Neck 115 138 544 797

Eyelids 130 215 248 593
Root of nose 144 324 223 691
Cheek 141 909 459 1509
Lobule of nose 111 918 735 1764
Forehead 202 969 1210 2381
Lower lip 113 973 829 1915
Upper lip 156 1061 931 2148
Mental region 149 1375 1020 2544
Source: Gonzalez-Ulloa M, Castillo A, Stevens E, et al: Preliminary study of the total restoration of the facial
skin. Plast Reconstr Surg 1954;13:151–161.
Very light
Light
Medium
FIGURE 13–8 Treatment density

and depth is varied depending on skin Very light
thickness and richness of dermal
appendages. The neck area is usually
not treated with CO2 laser because of
significant scarring risk. Other thin
areas of facial skin that should be
treated cautiously include the eyelids
and along the jaw line.
CHEN13-179-194.I 3/22/01 1:55 PM Page 189
continuous beam in a spiral pattern or laying down a The medial third of the pretarsal and preseptal eye-
sequential pattern of adjacent pulsed spots. If a pat- lid skin is most prone to scarring and should be treated
tern or spiral delivery system is used, then the hand- very cautiously; the lateral two thirds are also thin.
piece is held motionless during the delivery to
prevent overlapping and underlapping. The laser is
EARL... The pretarsal skin should
then moved to a directly adjacent tissue area and the
treatment repeated until the entire cosmetic zone has
been treated. Further passes may be performed in a
P be left untreated in patients with signifi-
cant lid laxity and risk of ectropion.
similar manner. For CO2 laser, debris must be wiped
away between passes, but for erbium resurfacing this
is not necessary. A record is made of the treatment. The upper eyelid is treated like the lower eyelid
This record is referred to during postoperative visits with one pass or at most two low-density CO 2
and will guide the surgeon in learning how treatment passes, placed superior to the upper eyelid crease.
parameters affect outcome for various facial areas and The crow’s-feet area and associated rhytids are much
skin types. more resilient and may be treated nearly as heavily
The eyelids present special considerations because as the forehead. Associated malar bags and festoons
of the risk of blindness and the extreme thinness of may be treated with one or two CO2 passes and usu-
eyelid skin. The pretarsal and preseptal eyelid skin is ally show up to a 50% improvement.
among the thinnest of the human body and is subject Laser skin resurfacing of the face and eyelids may
to the dual risks of scarring and ectropion (Fig. 13–9). be routinely combined with upper eyelid blepharo-
Although the lower eyelids and crow’s-feet are con- plasty, transcutaneous or transconjunctival lower
sidered a single cosmetic unit, for resurfacing pur- eyelid blepharoplasty, or forehead lift. The author
poses this area should be subdivided into three does not routinely resurface directly over fresh ble-
specific zones: the medial one third of the pretarsal pharoplasty incisions, although some surgeons make
and preseptal skin; the lateral two thirds of the a point of doing so in the belief that an improved
pretarsal and preseptal skin; and the remaining peri- incision results. Resurfacing directly across a fresh
orbital and crow’s-feet skin. eyelid skin incision should be performed prior to
wound closure to allow better judgment of the
amount of skin removal and to avoid lasering
EARL... One pass or at most two
P low-density CO2 passes are sufficient for
the eyelid skin. Scarring may develop if this
stitches. Though resurfacing close to facelift or fore-
head lift incisions may result in scarring or delayed
epithelialization, such problems are unusual with
extremely thin skin is treated like thicker facial blepharoplasty incisions because of the excellent
skin and the reticular dermis is breached. local blood supply.
Laser skin resurfacing of the forehead may be rou-
tinely performed in conjunction with endoscopic or
coronal forehead lift procedures in which there has
been no disruption of supraorbital or superficial tem-
poral arterial blood supply. Caution should be
employed if one is resurfacing close to a pretrichial
hairline incision or close to a large-access incision.
POSTOPERATIVE WOUND CARE AND

COMPLICATIONS
When embarking on resurfacing, a formal comanag-
ing relationship with an interested dermatologist and
plastic surgeon will help to allay and answer many
physician and patient concerns. Later on, a formal
comanagement arrangement may be unnecessary,
but a friendly professional relationship will be helpful
for those patients with unusual results or seeking fur-
ther opinions.
FIGURE 13–9 Lower eyelid ectropion following laser Regardless of the specific postoperative protocol
resurfacing. (Photograph courtesy of Sterling Baker, M.D.) used, most practitioners agree on the five principles of
CHEN13-179-194.I 3/22/01 1:55 PM Page 190
sone markedly reduces both the duration of erythema

TABLE 13–4 FIVE BASIC PRINCIPLES as well as the incidence of hyperpigmentation. It is
OF RESURFACING WOUND CARE normal for wound crusting and weeping to occur.
Patients are instructed not to pick at crusts because
Keep it moist (until it has re-epithelialized) they may incite bleeding or scarring.
Hydroquinone for hyperpigmentation
Antiviral and antibiotic prophylaxis
No picking at scabs or crusts
EARL... Gauze sponges soaked in
Sunscreen and sun avoidance
P white vinegar and ice water, mixed as 1
tablespoon of white vinegar to 1 pint of chilled
distilled water, are applied three times daily for
resurfacing wound care outlined in Table 13–4.
Although occlusive dressings may accelerate wound a soothing antipruritic effect and for antibacter-
healing and reduce immediate postoperative discom- ial and antifungal activity.
fort, the author advises against postoperative dress-
ings because of the risk of infection and toxic shock.
Other practitioners have abandoned the use of dress- Re-epithelialization is usually completed by day
ings after day 4. New semipermeable dressings such 7 to 14 depending on the patient’s age. Once re-
as Flexzan-Extra have been developed because of con- epithelialization occurs, petrolatum, Aquaphor, and
cerns about poor adherence of earlier dressings. Post- white vinegar treatments are discontinued and
operative care usually consists of white petrolatum, hydrocortisone cream 2.5% is applied hs for several
or Aquaphor mixed 1 : 1 with hydrocortisone cream weeks until erythema has resolved. Table 13–5 lists
2.5%, applied three times daily to reduce drying or the dermatologic and other products useful in man-
crusting. In the author’s opinion, topical hydrocorti- aging resurfacing.
TABLE 13–5 PRODUCTS USED IN RESURFACING WOUND CARE
Indication/Class Generic Name Brand Name Recommended
Resurfacing preoperative care

Antibiotic Ciprofloxacillin Cipro Most cases
Antiviral Acyclovir Zovirax Most cases
Antifungal Fluconazole Diflucan Not recommended
Bleaching agent Hydroquinone Various Fitzpatrick IV,V,VI
Bleaching agent Kojic acid Generic Fitzpatrick IV,V,VI
Anticomedogenic Tretinoin Retin-A Neutral
Steroid Hydrocortisone Various Use with Retin-A
Sunscreen Various Various Neutral
Resurfacing immediate postoperative care—prior to complete epithelialization
Antibiotic Ciprofloxacillin Cipro Most cases
Antiviral Acyclovir Zovirax Most cases
Antifungal Fluconazole Diflucan As needed
Occlusive dressing Various Various Not recommended
Occlusive topical Petroleum jelly Vaseline Recommended
Occlusive topical Various Aquaphor Recommended
Steroid cream 2.5% hydrocortisone Various Recommended
Wound care Acetic acid None Recommended
Late postoperative care—after complete epithelialization
Steroid cream 2.5% Hydrocortisone Various Recommended
Sunscreen SPF 7 25 Various Various Recommended
Concealer Various Various Recommended
Bleaching agent Hydroquinone Various If pigmenting
Bleaching agent Kojic acid Generic If pigmenting
High potency steroid Clobetasol propionate Temovate-E If prolonged erythema
CHEN13-179-194.I 3/22/01 1:55 PM Page 191
Topical application of Cellex-C antioxidant has Infection

been reported to decrease postoperative erythema,
although it may cause skin sensitization in some
patients. Topical antibiotics or other sensitizing topi-
cal agents should be avoided because 65% of patients Satellite lesions Raw erosive Pain, erythema,
erythema lesions odor, discharge
will develop contact dermatitis.
Impetiginization Gm stain
KOH prep
Impetiginization of the skin should be suspected (fungal)
Herpes culture
(bacterial)
when painless honey-like skin crusting occurs.
Impetiginization is a superficial infection due to the
gram-positive cocci S. pyogenes or, less commonly,
S. aureus. Pretreatment oral antibiotics should provide Rx: Diflucan Rx: Zovirax etc. IV antibiotics
adequate gram-positive coverage and prevent frank
erysipelas or cellulitis. Alternatively, erythromycin
250 to 500 mg PO four times/day or dicloxacillin FIGURE 13–10 Management of postoperative wound
infection following facial resurfacing.
250 mg PO four times/day may be prescribed.
Cellulitis Herpetic Infections

If cellulitis occurs, immediate cultures and Gram Herpetic infections should be treated by increasing
stains should be obtained and intravenous antibiotic the Zovirax, Valtrex, or Famvir dose to the levels used
therapy should be considered. Infectious disease spe- to treat herpes zoster, possibly including intravenous
cialty consultation may be considered. Cellulitis fol- therapy. Infectious disease specialty consultation may
lowing resurfacing usually appears within 2 to 10 be considered. The lesions associated with laser resur-
days of surgery and may be characterized by redness, facing may appear atypical because there may be no
discomfort, exudate, and often an accompanying foul characteristic vesicular stage if the epidermis has not
odor (Tina Alster, M.D., personal communication, yet regenerated. Prior to epidermal regeneration,
1996). In one series, culture-proven infection was early lesions appear as a crop of small raw red lesions
reported in 4.3% of 395 resurfacing procedures per- (more raw looking than the surrounding resurfaced
formed without antibiotic prophylaxis. Symptoms skin) clustered as a small grouping. These erosion-like
began between postoperative days 2 to 10 in all lesions may progress to typical discrete white punc-
patients. Over half of patients had infections with tate lesions, and more lesions may appear if the out-
multiple organisms. Pseudomonas was most common break is left unchecked. If active herpes lesions are
(41%), followed by S. aureus (35%), S. epidermidis allowed to proliferate they may cause scarring.
(29%), and Candida (24%). Multiple drug resistant
gram-negative organisms were found in four cases. Candida
Periocular streptococcal necrotizing fasciitis has been Candida may superficially colonize the moist skin
reported following combined laser blepharoplasty surface, usually prior to re-epithelialization. The
and resurfacing (Fig. 13–10). appearance may be quite variable and difficult to
diagnose without KOH staining. Soft whitish plaques
Acne and Milia similar to leukoplakia or milia-like lesions as well as
Acne or milia may present around the time epithe- characteristic satellite lesions may be present. The
lialization is well established or thereafter and is asso- underlying skin is often erythematous and appears
ciated with topical white petrolatum application. irritated. Some surgeons in humid locales routinely
Acne is treated with oral antibiotics. Milia frequently treat all patients prophylactically with a single oral
follow laser resurfacing and appear clinically as a dose of fluconazole (Diflucan) 200 mg orally prior to
painless crop of small white dome-shaped elevations. resurfacing. However, the author has not found this
These epidermal cysts probably result from occlusion necessary and avoids routine prophylaxis because of
of eccrine duct openings, which may explain why the significant drug interactions associated with flu-
they are more common in patients who apply topical conazole, a fungal cytochrome P-450 inhibitor.
petrolatum-based products. Observation, mild
chemoexfoliation, incision with a no. 11 blade or a Hyperpigmentation
small curette and discontinuation of oil-based prod- Postinflammatory hyperpigmentation occurs in up to
ucts as soon as re-epithelialization occurs should elim- 30% of patients, typically appearing 3 to 4 weeks fol-
inate milia. lowing resurfacing, and resolves within 6 months
CHEN13-179-194.I 3/22/01 1:55 PM Page 192
(Fig. 13–6). Postinflammatory hyperpigmentation Erythema

usually results from increased epidermal melanin as Noticeable erythema normally follows laser resurfac-
well as the accumulation of melanin in subepidermal ing and may persist for 6 to 12 weeks or longer. Once
macrophages. Fortunately, such discoloration is usu- re-epithelialization is complete, the intense erythema
ally transient and responds to several weeks of topical may be disguised with a topical skin concealer con-
4% hydroquinone USP cream applied at bedtime, or sisting of a dense yellow or green base covered by a
twice daily if combined with sunscreen (Eldopaque flesh tone. Newer mineral crystal concealers provide
Forte 4% cream); 2.5% hydrocortisone application will better coverage than the older pigment concealers.
also help reduce inflammatory hyperpigmentation. In Failure to use a green or yellow base beneath the flesh
patients with higher melanin production [e.g., Fitz- tone produces an unsightly muddy purple/brown
patrick type IV–VI; Hispanic (usually Fitzpatrick type hue. As the redness fades, less of an underlying base
IV–VI); Asian (usually Fitzpatrick type IV–VI); or is necessary. Sunscreen of SPF 30 or greater should be
black skin (usually Fitzpatrick Type VI)] postinflam- incorporated in the concealer. Concealer may be pur-
matory hyperpigmentation may be very problematic. chased from department store cosmetics counters, or
Such patients often require 4 to 8 weeks of preopera- prepared for the patient during consultation with a
tive bleaching agents and several months of postop- makeup artist, skilled beautician, cosmetic consultant,
erative therapy. or aesthetician.
Although prolonged erythema beyond 3 months is
occasionally noted in extremely fair individuals with
...
P EARL It is the author’s impres-
sion that use of 2.5% hydrocortisone
cream nightly for 6 weeks after epithelialization
clear skin, it eventually resolves in most instances
(Fig. 13–11). If more rapid intervention is desired,
then one may consider low-potency topical steroid
has reduced the incidence of hyperpigmentation preparations such as 0.05% desonide (Desowen)
to less than 15%. applied two or three times/day or 1% hydrocortisone
(Hytone) applied two to four times/ day. The use of
medium- and high-potency topical steroids, for exam-
ple, 0.05% clobetasol propionate cream (Temovate),
While laser skin resurfacing may be performed any
has been reported in the management of prolonged
time of year, North-American patient preferences,
erythema, and such agents have been effective in the
outdoor summer activities, seasonal holidays, and
author’s limited experience. Because of the significant
social schedules conspire to produce a seasonal
risk and manufacturers’ warnings that such potent
demand that is greatest in early fall and mid-winter
through mid-spring. Patients who opt for resurfacing
during summer months may be more likely to hyper-
pigment from sun exposure. Therefore, they are coun-
seled to frequently apply SPF 30 or greater sunscreen,
don a wide-brimmed hat when outdoors, and assidu-
ously avoid sun exposure.
Itching
Itching is usually transient and secondary to an
inflammatory healing response. Symptoms are often
most intense along the mandibular border or pret-
richial forehead. Patients may present with concerns
regarding telltale petechiae or excoriations and may
be unaware that they scratch and abrade this area
while asleep. Mild pruritus may be controlled by top-
ical application of mild antiinflammatory steroids, ice
packs or cool soaks, and an oral antihistamine such as
oral Benadryl 50 mg, which may be taken before
going to sleep. For the anxious or apprehensive
patient in whom pruritus interferes with sleep, dox-
epin hydrochloride (Sinequan capsules) 25 mg taken
orally at bedtime should induce drowsiness, reduce FIGURE 13–11 Prolonged erythema 5 months follow-
anxiety, and diminish itching. ing laser resurfacing.
CHEN13-179-194.I 3/22/01 1:55 PM Page 193
steroids may induce atrophic changes or permanent Ectropion

telangiectasia, they should be used cautiously and for Because laser resurfacing results in tightening of the
extremely brief durations on the face, that is, 1 to 7 skin and may produce cicatricial scarring, ectropion
days. There are anecdotal reports of using the pulse may complicate lower eyelid laser resurfacing
dye laser with a 1-mm spot size to treat persistent ery- (Fig. 13–9). Significant preexistent lower eyelid laxity
thema. Recurrent erythema may result from sensiti- predisposes to ectropion and may be anticipated pre-
zation to aerosolized sprays, makeup, or other operatively by performing eyelid distraction tests.
airborne antigens encountered by dermal Langer- During resurfacing, the patient is in repose and the
hans’ cells before epithelialization was complete. effect of gravitational cheek descent may be underes-
timated. When significant laxity is detected, one
Hypopigmentation should either refrain from resurfacing close to the eye-
Hypopigmentation may not manifest until 6 to 12 lid margin or prophylactically tighten the eyelid mar-
months following laser resurfacing and is believed to gin. Tarsal strip procedures, lateral canthal tightening,
be due to a reduction in melanocytes. It is more com- or orbicularis oculi suspension procedures may be
mon in patients who have received prior dermabrasion employed in such cases.4, 5
or deep chemical peel. Hypopigmentation is perma- Mild ectropion following resurfacing often resolves
nent and has been reported in up to 3% of patients. spontaneously or responds to upward eyelid massage.
However, it may be camouflaged with makeup. When mild ectropion persists, consideration should
be given to a horizontal eyelid tightening procedure.
Scarring With more advanced ectropion or eyelid retraction,
Scarring, early or delayed, is an unusual complica- horizontal tightening must be supplemented by either
tion of laser resurfacing. It may be attributed to an a free skin graft or a malar suspension.
exuberant healing response, keloid tendency, treat-
ment of higher risk zones such as the jaw line, upper
lip or medial lower eyelid, accidental lasing of char,
SUMMARY
or deep resurfacing into the reticular dermis. Very Laser skin resurfacing will continue to evolve at a
mild scarring may be treated with topical steroids or technology driven rate. Compared to chemical peel-
intralesional triamcinolone (Kenalog) at a concentra- ing methods, laser resurfacing appears to offer finer
tion of 5 mgmL (the higher potency ophthalmic precision and control of ablation depth (Fig. 13–12).
preparation may induce dermal atrophy). Applica- Nonetheless, as outlined in the preceding discussion,
tion of a silicone gel or sheeting, alone or in combi- laser resurfacing is every bit as complex an undertak-
nation, or skin application of Cordoran tape, may ing as is traditional deep chemical peeling, and
also be helpful. When hypertrophic scarring is mini- requires thoughtful preoperative, intraoperative,
mal to moderate and still vascular, it may respond to and postoperative judgment.
585-nm pulse dye laser treatment. True keloid for-
mation may respond to intralesional steroids plus ACKNOWLEDGMENTS
585-nm pulsed dye laser irradiation. Persistent
hypertrophic incisional scars may be excised after The author acknowledges the permission granted by
waiting 6 months. the publishers to reproduce and update material
A B
FIGURE 13–12 Patient before (A) and 6 weeks following (B) CO2 laser skin resurfacing and laser blepharoplasty.
CHEN13-179-194.I 3/22/01 1:55 PM Page 194
from Khan, JA: CO2 laser facial resurfacing and inci- man B, ed. Lasers in Facial Aesthetic and Reconstruc-
sional blepharoplasty. In: Mauriello J, ed. Unfavor- tive Surgery. Philadelphia: Williams and Wilkins,
able Results of Eyelid and Lacrimal Surgery. Woburn, 1998:1–13, 91–97; and from the author’s Web site
MA: Butterworth-Heinemann: 1999:27–44; Khan JA: http:\\www.Geocities\FashionAvenue\3072
The transition to laser incisional surgery. In: Bies-
REFERENCES
1. Khan JA: The transition to laser incisional surgery. In: 3. Fitzpatrick RE: Ultrapulse CO2 laser resurfacing of the
Biesman B, ed. Lasers in Facial Aesthetic and Reconstruc- facial skin. In: Rabkin MD, ed. CO2 Laser Cosmetic Ble-
tive Surgery. Philadelphia: Williams and Wilkins, pharoplasty and Skin Resurfacing [CD-ROM]. Boston:
1998:91–97. Ophthalmology Interactive, 1997.
2. Khan JA: CO2 laser skin resurfacing in the near-mil- 4. Putterman AE, ed. Cosmetic Oculoplastic Surgery. NY:
lisecond domain. In: Albert DM, Jakobiec FA, eds. Prin- Grune & Stratton, 1982.
ciples and Practice of Ophthalmology, 2nd ed, vol. 3. 5. Furnas DW: Festoons, mounds, and bags of the eyelids
Philadelphia: WB Saunders, 1998: 2000, 3529–3550. and cheeks. Clin Plast Surg 1993:20:367–385.
CHEN14-195-210.I 3/26/01 8:38 AM Page 195
Chapter 14
LASER FACIAL RESURFACING:

DUAL MODE
Cary E. Feibleman
Laser facial resurfacing is less than one decade old, pattern matches the inherent resonating pattern of the
but has already become one of the most popular pro- structure. Argon laser energy is maximally absorbed
cedures in cosmetic surgery. Super- and ultrapulsed by hemoglobin, but relatively ignored by water. CO2
CO2 lasers were introduced for facial resurfacing in laser energy is well absorbed by water, but erbium
the early 1990s and then followed by erbium:yttrium- energy is absorbed 20 times more completely. Because
aluminum-garnet (YAG) lasers. The latest develop- most of the energy is absorbed, relatively little is trans-
ment is the Derma K, which features simultaneously mitted to the surrounding tissue. This produces little
firing CO2 and erbium lasers that achieve epithelial thermal damage beyond the target structure.
resurfacing, substantial wrinkle reduction, and Argon lasers were first used and found early
quicker healing than if either laser were used alone. acceptance in ophthalmology for retinal vessel
The Derma K laser provides unparalleled flexibility coagulation, cauterization in general surgery, and
because it offers three resurfacing therapeutic modes hemangioma treatment in cosmetic surgery and derm-
in one unit: pure CO2 , pure erbium:YAG, and com- atology. Early equipment was large, energy con-
bined CO2–Erbium:YAG. suming, and heat producing, which limited its use
LASER stands for light amplification by stimulated to research laboratories.
emission of radiation. The first laser used in derma- As argon lasers became more practical, they were
tology was a ruby laser used by Leon Goldman in joined by continuous wave, low-energy CO2 lasers
1961. The first use of an argon laser was by L’Esper- used for surgical cutting and ablation. Other
ance in 1968. The principle underlying the use of lasers were developed, including krypton, excimer,
lasers in medicine is that each laser emits a specific YAG, diode, alexandrite, ruby, and erbium lasers.
wavelength of light energy that is determined by the Each of these lasers has specific emission wavelength
crystal or gas through which its energy passes. Car- and peak absorbance patterns and differs in its
bon dioxide lasers emit at 10,600 nm and erbium:YAG energy, heat output, and absorbance pattern in tissue.
lasers emit at 2,910 nm. Laser light is coherent, and all Of these, the erbium:YAG laser has joined the CO2
the photons travel in phase with one another. The laser as the most commonly used in skin resurfacing.
beam is collimated, and all the energy travels in a very
uniform, nondiverging manner.
Within the body each specific molecule has a unique TYPES OF LASERS USED IN FACIAL
absorbance pattern for transmitted energy. The target RESURFACING
substance that maximally absorbs a particular wave-
length of energy is known as the chromophore. This is The CO2 Laser
similar to the distinctive resonance that physical struc- The first low-energy continuous wave CO2 lasers
tures show for a unique wave pattern of sound that were moderately effective for cutting and ablation.
produces a vibratory ringing when the absorbed wave The laser’s energy was maximally absorbed by water.
195
CHEN14-195-210.I 3/22/01 1:59 PM Page 196
As the water boiled in the skin, thermal energy was lining layers of the adnexal structures—the hair folli-
absorbed by the surrounding tissue. Once the water cles and sweat gland ducts—and quickly resurface the
content disappeared, a charred, desiccated layer skin and reconstitute the basement membrane. Sec-
developed, which continued to absorb energy. This ond, thermally damaged dermal collagen heals with a
left a large area of char and a peripheral zone of ther- thin, lamellar, horizontally oriented layer of new col-
mal burn. In warts this was desirable. But the width of lagen that forms a flattened foundation for the upper
thermal injury in incisive surgery often led to delayed layers of skin. This tightens and smoothes wrinkles
healing and dehiscences. and gives the skin a more youthful appearance.
The development of superpulsed and ultrapulsed
lasers capable of delivering high energy in millisec- The Erbium:YAG Laser
ond and microsecond bursts allowed ablation with Erbium:YAG energy is absorbed in the skin by water
minimal thermal damage to the skin. This was accom- 20 times more efficiently than CO2 laser energy. As the
plished by either having the laser fire at one point, laser fires on the skin, water molecules boil and vapor-
very briefly, or by having the laser quickly move to ize. The rapidly expelled gas literally blows up the
the next target so that no one site built up heat. cell. Much of the absorbed heat is carried away in the
Greater than 5 joules (J)/cm2 is needed for ablation. steam produced, leaving insignificant amounts of
The theory behind this advancement is that skin, transmitted heat and no desiccated char in the skin.
epidermis, dermis, blood vessels, and adnexal struc- Pass after pass can be made with the laser, and this
tures each have unique thermal relaxation times (time removes layers of dermis and epidermis. The draw-
for significant cooling). It is thought that a pulse backs are that there is no hemostasis, a serious detri-
width between 650 and 1000 sec will limit heat ment once the superficial plexus vessel layer in the
diffusion in tissue. Beyond 1000 sec, heat will con- dermis has been exposed, and there is little thermal
duct to surrounding tissues and thermal injury will heating of the reticular and papillary dermal collagen
increase. The thermal relaxation time is the time it that is required for deep wrinkle reduction. Controlled
takes heat to diffuse out of a structure and into sur- thermal injury to the dermis is a desired benefit.
rounding structures by thermal conduction. Many The efficiency of the erbium:YAG laser is also its
very brief blasts delivered in 1 second can ablate the Achilles heel, because it produces insignificant ther-
skin with limited thermal injury, because the heat mal damage to the dermis to stimulate development
remains confined to the structure when the length of of a new layer of lamellar collagen. Also, it is quite
the pulse is shorter than the time it takes for heat to possible to ablate down to bone if the operator is not
spread out from the target.1 observant.
The effect of the laser on the skin is broken down The erbium laser is best reserved for young
into three distinct zones. The first zone consists of patients with superficial rhytides who need little col-
ablated epidermis and dermis that vaporizes into the lagen regeneration. It is also useful for resurfacing
air as smoke or as water vapor. The next zone is an necks and dorsa of hands. These sites contain few
area of thermal burn, a coagulation zone, which is adnexal structures, heal poorly, and often scar when
replaced in the healing process. The third zone con- treated by superpulsed and ultrapulsed CO2 lasers.
sists of heated collagen that if brought to approxi- Erbium lasers can take off layers as fine as 5 m with
mately 65°C will have its cross-linked bonds broken, each pass. This allows exquisitely controlled ablation
but will re-form in a lamellar manner without having that can be stopped at the basement membrane under
to be totally replaced by a cicatrix. direct visual control. Bleeding is the reference point
Ultra- and superpulsed lasers require two to four that ablation has reached the papillary dermis.2
passes of the laser beam to ablate through the papil-
lary dermis and produce thermal effects in the reticu-
lar dermis. Areas of the face with deep wrinkles— The Derma K Dual Mode CO2 and
rhytids—may require an extra pass. The limiting fac- Erbium:YAG Laser
tor is that the skin desiccates and heat builds up in the The Derma K dual mode laser was introduced in 1997
surface crust unless it is continually wiped away. and released worldwide the following year. It offers
Eventually the dermis dehydrates enough that further three different modes of laser resurfacing: CO 2 ,
laser firings burn rather than ablate. At this point the erbium, or combined mode. In the combined mode,
end point has been exceeded and there is a high risk the Derma K’s CO2 and erbium lasers fire simultane-
of scarring.2 ously. The erbium:YAG laser is maximally powered
Modern laser facial resurfacing achieves two goals. at 1.7 J and fires in millisecond bursts that do not
First, epidermal ablation removes irregular scaling exceed the thermo-relaxation threshold of the skin.
and pigmentation. Replacement cells arise from the The CO2 laser is capable of firing at 12 watts (W) in a
CHEN14-195-210.I 3/22/01 1:59 PM Page 197
LASER FACIAL RESURFACING: DUAL MODE • 197
continuous mode, but when coupled with the erbium ablates the residual surface char. Healing is thought to
laser it is generally set at between 3 and 5 W. proceed more quickly with this technique than if the
In this mode the CO2 laser is used in a different erbium laser were not used. The presumed explana-
manner than super- and ultrapulsed lasers. The set- tion is that less proteinaceous, necrotic debris pro-
ting is derived from early laser research of the effects vides less opportunity for bacterial growth.3
of CO2 laser energy on dermal collagen. Age and sun
damage cause collagen and elastic fibers to become
twisted and haphazardly arranged. When collagen is FACTORS TO CONSIDER IN LASER
heated to approximately 65°C, certain chemical bonds RESURFACING
break and the fibers lose their intertwined structure.
As they heal, they form a flattened, new layer of col- Regional Anatomy of the Face
lagen that is present in the papillary dermis. The clin- The relative thickness of epidermis and dermis, the
ical effect is that the skin is smoothed and tightened, density of adnexal structures, and different regions of
and wrinkles are diminished. When this is combined the face influence laser settings and the number
with the superficial ablation of the erbium laser, pig- of passes. Eyelid, periauricular, and neck skin are the
mentary alterations like lentigines and ephelids dis- thinnest. Nasal, lip, and submental skin are the thick-
appear and small keratotic lesions such as seborrheic est. As a rule, the thicker portions of the face can tol-
and actinic keratoses are removed.1 erate more passes than the thinnest. Power settings
Unlike super- and ultrapulsed lasers, thermal dam- on the laser are usually lower for eyelid skin.
age is usually limited to the papillary dermis. Because
the dermal injury is caused by heating to 65°C rather Skin Types
than by burning temperatures exceeding 100°C, nec- Thomas B. Fitzpatrick, M.D., the retired chairman of
essary repair is comparatively limited. Erythema dermatology at Harvard Medical School, devised a
fades quickly and dermal remodeling is prompt. Tra- system of categorizing people into six different
ditional CO2 lasers produce erythema that lasts from groups depending on skin pigmentation and the
3 to often more than 6 months, because the body is ability to tan (see Chapter 13, Table 13–1). Skin types
healing a second-degree burn. Erythema in patients I to III represent the best candidates for laser resur-
treated with the Derma K in the combined mode usu- facing, because they have the lowest chance of
ally resolves within 1 to 2 months (Fig. 14–1). noticeable pigmentary alterations in healing. The
Recently, clinicians have experimented with com- older, super- and ultrapulsed CO2 lasers produced
bining two different lasers in a “piggyback” sequence. up to a 40% incidence of posttreatment, permanent
Patients first receive two to three passes with an ultra- hypopigmentation in patients at 12 months. Hyper-
pulsed CO 2 laser, and then an erbium:YAG laser pigmentation occurs early in recovery and usually
A B
FIGURE 14–1 (A) Prelaser. (B) Absence of erythema at three months postlaser.
CHEN14-195-210.I 3/22/01 1:59 PM Page 198
responds to bleaching agents. Hypopigmentation in PROCEDURE FOR LASER SKIN

fair-complected individuals is seldom noticed, but in RESURFACING
skin types IV and V pigmentary problems can be
quite cosmetically bothersome. In very dark com- Evaluation
plected individuals, permanent pigmentary alteration
can be emotionally devastating. Rhytid Assessment and Actinic Damage
The mechanism of these alterations in pigmenta- Aging produces gradual thinning of all three layers
tion is not totally understood. Initially, in darker of the skin—the epidermis, dermis, and subcutaneous
skinned persons there is transient hyperpigmentation fat layer. With time sebaceous and eccrine secretions
that can be stimulated by ultraviolet light. Fortu- decrease and hairs become finer and more diffuse.
nately, it is also suppressible with the bleaching Ultraviolet injury from sun exposure, both UVA and
agents hydroquinone, kojic acid, and azaelic acid. Per- UVB, hasten aging and cause hyperkeratotic lesions
manent posttreatment hypopigmentation is possibly within the epidermis and elastotic degeneration
the result of a lethal reaction in the melanocytes to the within the papillary dermis. Biopsies show irregularly
thermal effects of the laser combined with the body’s rounded, globular, collagenous, and elastotic degen-
healing inflammatory response. Because most of the eration throughout the dermis. Although previously
melanocytes reside in the basal layer of the epidermis, it was thought that UVB was the major damaging fac-
replacements come from dermal adnexal melano- tor, it is now appreciated that UVA also contributes to
cytes. If the laser heat extends deep enough, many of degeneration, and it penetrates deeper into the der-
those cells will be destroyed or rendered incapable of mis. This actinic damage produces thinning of the
producing pigment. epidermis and dermis and decreases dermal elastic-
The erbium:YAG laser is much gentler to the skin ity. Thinner skin requires less laser energy for abla-
and melanocytes, because there is limited thermal tion and in the eyelids may be predisposed to scarring
damage that extends beyond the zone of ablation. and ectropion.
Hyperpigmentation can occur transiently. Postin- For the patient to have realistic expectations about
flammatory hypo- and hyperpigmentation do occur, what can be achieved, it is important to discuss the
but in far smaller numbers than with the CO2 laser. difference in response between static and dynamic
Using both lasers simultaneously with a CO2 laser rhytids, which are wrinkles. Dynamic rhytids are
power setting reduced to 3 W, long-term pigmentary those that form in the skin overlying large muscle
changes are as low as the numbers observed with the groups such as the nasolabial creases, marionette lines
erbium:YAG laser alone. Most patients accept these around the mouth, and the glabellar and forehead
changes if they are forewarned. In most cases of sun- region wrinkles. Static rhytids form at the lateral can-
damaged skin, the gentle lightening of the skin that thi, the crepe-paper changes in the lower lids, and the
occurs following laser resurfacing is welcome and wrinkles in the lateral cheeks. The wrinkles in the lips
complementary to the face’s overall appearance.4 and forehead have both static and dynamic compo-
Individuals with skin type IV can be treated with nents. Dynamic wrinkles are usually genetic in etiol-
the combined laser, but they must be forewarned of ogy, whereas static wrinkles are influenced by
the significant probability of pigmentary change in patients’ activities (Fig. 14–2).
the healing process and begin bleaching agents in the Smoking and pursing one’s lips lead to early peri-
weeks following the procedure. West et al5 have oral creases. Excessive sun and wind exposure, par-
recently observed that there is no benefit of pretreat- ticularly without use of sunglasses, leads to
ing patients with bleaching agents for several weeks premature wrinkling around the eyes. Sun and aging
prior to the procedure. This is not surprising as the also cause the forehead and cheeks to “weather”
laser destroys most of the melanocytes during the early. Fair-complected people tend to wrinkle the ear-
ablation. Dark-skinned people with Mediterranean liest. In addition, there is great variability in different
origins, Latin Americans, individuals with Indian individuals’ ability to repair damage to the epidermis,
ancestry, Asians, as well as light-skinned African- dermal elastic tissue, and collagen.
Americans can all be treated, but they must under- Laser resurfacing is very effective at treating static
stand the risk of hyper- and hypopigmentation and wrinkles, but has limited effect on dynamic wrinkles.
be willing to accept the risk that those pigmentary Dynamic wrinkles in the upper half of the face are
changes may not totally resolve. Patients with types V best treated with Botox, diluted botulinum toxin, and
and VI skin have a high risk of unwanted pigmentary by filling materials, such as Zyderm collagen in the
changes in healing and are not good laser therapy lower half of the face. Deep lines in the forehead and
candidates with current ablative lasers.6 smile lines around the eyes and bridge of the nose
CHEN14-195-210.I 3/22/01 1:59 PM Page 199
A B
FIGURE 14–2 (A) Prelaser wrinkles. (B) Three months postlaser.
respond very well to Botox. This is now the treatment diabetes and peripheral vascular arteriosclerosis are
of choice for deep lines and creases in the upper half not good candidates because of problems in healing.
of the face and is complementary to laser therapy as Patients who continue to smoke cigarettes and those
part of facial regeneration. Full and partial face lifts with small vessel disease will heal more slowly.
and blepharoplasties can also be done in conjunction Patients with photosensitive diseases such as lupus
with laser resurfacing. and those taking photosensitizing medications are
probably safe, because it is usually ultraviolet that
Expectations activates their skin lesions. Resurfacing lasers do not
As with all reconstructive procedures, it is impor- operate in that spectral range. It is important to eval-
tant that the patient has realistic expectations uate patients both serologically and by history for evi-
about what can be achieved. Generally, fine and dence of herpes simplex, HIV, or hepatitis. Every
medium static rhytids improve 60 to 90%, whereas patient is given antiherpetic drug prophylaxis.
deeper static rhytids, such as around the mouth, Because blood and ablated tissue is briefly aerosolized
eyes, and in the cheeks, may improve 50 to 75%. during therapy, patients with HIV or antigen-positive
Dynamic lines such as the marionette lines and fore- hepatitis are not treated.
head rhytides may improve from 20 to 50%, but it is It is important to evaluate patients who state they
best to caution the patient not to have high expecta- develop keloids. Most patients’ “keloids” are actually
tions for lines caused by the overlap and intersection hypertrophic scars, which are a result of normal ten-
of two major muscle groups. sion on a scar caused by its position or orientation
Pretreatment photographs are mandatory docu- on the body. Sternotomy, cesarean, elbow, and knee
ments, and those taken during recovery are very help- incisions are common sites of hypertrophic scar devel-
ful in assessing the gradually unfolding improvement opment. Patients with thick scars in these areas are
that takes place during healing. not precluded from laser surgery. True keloid formers
will develop a keloid at the site of any incision or sim-
Medical History ple trauma where the skin has broken through into
It is important to review the patient’s medical history the dermis. Although the face is relatively immune
and current health status. Although the sophistication from keloids even in these patients, it is not wise to
of the dual mode laser allows office treatment done treat them with the laser.
under local anesthesia, a review of the patient’s car- Patients should be off Accutane for at least 12
diovascular and pulmonary status is important, months prior to laser surgery, as Accutane can cause
because Valium and Demerol are given by mouth and either delayed healing or scar formation within the
lidocaine is used both topically and subcutaneously. laser-treated field.
Patients are monitored in the pretreatment phase and The decreased vascularity and paucity of adnexal
during therapy with a computerized blood pressure, structures in radiation treated fields make patients
pulse oximetry, and heart rate monitor. Clearance who have undergone facial radiation treatment poor
from the cardiologist is obtained for any patient with laser candidates. Previous facial surgery procedures
heart problems. Although facial skin is the most richly can affect the decision to treat a patient or to alter the
vascularized of any region on the body, patients with technique. Patients who have undergone phenol peels
CHEN14-195-210.I 3/22/01 1:59 PM Page 200
A B
FIGURE 14–3 (A) Prelaser. (B) Three months postlaser.
and dermabrasion may have thin skin, and a substan- treatment to the shoulders of rhytids. This decreases
tial number have marked hypopigmentation. These the chance of scarring and produces a more pleasing
patients should be photographed prior to treatment appearance of facial relaxation.7, 8
to document pigment loss, and one may choose to
make fewer passes with the laser, because the skin is
thinner due to the unpredictable depth of dermabra- PITFALL
sion compared to computerized laser ablation. Areas
of dermal scarring and adnexal loss may affect heal- Repeated Botox injections may lead to muscle
ing. Caution in treating these patients is suggested. atrophy.
Previous blepharoplasty surgery can predispose a
patient to ectropion if care is not taken to assess how
much lax eyelid tissue is present and how much elas-
ticity has been lost in the lower lid. Laser therapy of Dilutions and injection techniques differ. One vial
the eyelids may produce 1 to 2 mm of tightening, and of Botox distributed by Allergan contains 100 units of
because the lids’ epidermis and dermis are so thin botulinum A toxin. Throughout most of the 1990s, a
care must be taken not to cause scarring (Fig. 14–3). single source of constant strength toxin was available.
In 1998 a new source was released that was felt to be
Pretreatment more potent.
Botulinum A toxin is freeze dried and reconsti-
Botox Injection for Wrinkles tuted in chilled normal saline. The original recom-
Botox injections are now an important part of laser mended dilution with 1 cc of saline was probably
pretreatment. This treatment, which is familiar to influenced by its use for injections into the small peri-
ophthalmologists for the treatment of benign essen- ocular muscles. Cosmetic surgeons have experi-
tial blepharospasm, strabismus, nystagmus, and mus- mented with differing dilutions. In our practice we
cle spasms was observed by Carrurthers and have had very good results with diluting the toxin
Carruthers7 to be very effective treatment for degen- with 4 cc of nonpreserved, normal saline. Even
erative lines that form at the lateral canthi, nasal though we use a 30-gauge injection needle, some
bridge, glabella, and the forehead. The muscular diluted Botox leaks out from the injection site. We feel
groups underlying these regions cause wrinkles to that the larger diluted volume gives an enhanced like-
form when excessive contraction is accompanied by lihood of delivering adequate doses of the medication
loss of elasticity due to age and sun.7, 8 to the target muscles.
Dilute quantities of botulinum toxin injected into The diluent and diluted solution are kept between
the muscles irreversibly block acetylcholine release 33° and 40°F. Once diluted, the toxin remains active
from presynaptic neurons at the neruomusclar junc- for over 4 days in the vial. The toxin is fragile, so shak-
tion and cause paralysis that lasts from 3 to 6 months. ing and rapid inversion of the bottle should be
The onset of action can vary from 1 day to 2 weeks. avoided. A 1-cc Luer lock tuberculin syringe with a
Wrinkles disappear as the underlying muscles Teflon-coated, 12 -inch, 30-gauge needle is used for
become flaccid. Botox injections are usually done at treatment. The diluted toxin is drawn up with a
least 2 weeks before laser therapy, and relaxation of 23- or 26-gauge needle. The approximate positions of
the injected muscle groups prevents unnecessary laser the muscles to be treated are noted when the patient
CHEN14-195-210.I 3/22/01 1:59 PM Page 201
frowns or raises the eyebrows. The needle is inserted

into the skin to just above the periosteum and then
withdrawn very slightly, at which point it should be
within the belly of the target muscle; 0.05 to 0.1 cc is
injected in each site. This corresponds to 1 to 2 units
2–3 units
per injection when one vial is diluted with 4 cc of dilu- per site
ent. Several injections are made at 12 - to 1-cm distances 5 units
along the muscle depending on its caliber. Large mus- 10 units divided into
cles require more injections. The glabellar region usu- divided into several sites
ally takes 10 units, 0.4 cc, and a heavily wrinkled several sites
forehead may take 20 to 25 units, 0.8 to 1.0 cc. The lat-
eral canthi each receive 4 to 5 units, 0.2 cc. The ante- FIGURE 14–4 Clinical application of Botulinum toxin
rior muscles of the neck may require as much as 50 injection in the forehead and periorbital like region.
units, 2.0 cc.
Some physicians use a nerve stimulator to deter-
mine the site of muscle position, but experienced aged to prevent the development of antibodies. Care
physicians get very good results without this aid. should be taken to control the volume of solution
About 80% of patients get a very good result from injected and particularly to avoid toxin injected
the treatment. within the orbital rim. Ptosis has occurred when extra
Botox has drifted into the eyelid muscles. This usu-
ally resolves in two weeks (Figs. 14–4 and 14–5).
EARL ...
P Always inject Botox at
least 1 cm beyond the orbital rim.
Skin
Patients begin using tretinoin, retinol, or a 12% -
It is very important for the physician to explain to hydroxy acid cream on the skin 2 to 4 weeks before
patients that successful Botox treatment will make laser therapy. This stimulates the regenerative
them unable to contract the treated muscles. This is machinery within the cells and hydrates the cells.
not a problem in most circumstances, but the inabil- There are no studies that compare this pretreatment
ity to frown and show surprise by raising one’s eye- plan to one without pretreatment preparative creams.
brows may be important to some expressive Many laser physicians also begin hydroquinone 4 to
individuals. 6 weeks before treatment in patients who easily tan.
Recently, West et al5 have shown in a small series that
this does not seem to prevent hyperpigmentation.
The day before laser therapy, patients begin pro-
PITFALL phylactic antiviral therapy (valcyclovir or famcy-
clovir), cephalosporin, and methylprednisolone for
It is important not to inject Botox into the 7 days. The morning of their laser treatment, patients
muscles of the lateral third of the forehead to do not eat or drink anything.
prevent a droopy, heavy eyelid appearance. Almost all of our patients are treated with simulta-
neous Derma K erbium:YAG and CO2 laser therapy.
The majority of patients have significant wrinkling in
Allergies to the toxin are rare and treatments more their face and will not get a satisfactory dermal
frequently than every 2 months should be discour- response without CO2 laser therapy. The Derma K
A B
FIGURE 14–5 (A) Pre-Botox injection. (B) One month post-Botox.

CHEN14-195-210.I 3/22/01 1:59 PM Page 202
dual mode laser allows a combined modified approach much of this as is possible from the operative
that couples erbium laser energy with an attenuated region.9–11
CO2 laser that gently heats superficial collagen with-
out causing the deep burn produced by other CO2
lasers. Most patients in their 40s and older can benefit PITFALL
from the combined modalities of the Derma K.
The mechanism of action is that heating of papil- In contrast to the CO2 laser smoke plume, the
lary dermal and superficial reticular dermal collagen erbium plume contains cellular debris that
is necessary for a fine layer of lamellar collagen to be
can harbor virus particles.
generated in the papillary dermis. This produces a
new foundation for the epidermis and is essential to
eliminate and soften wrinkles.
The decision of which laser mode will be best Medications
suited to the individual patient needs to be made One hour prior to therapy the patient is given
prior to therapy. Most patients in their 30s probably diazepam 10 mg and Zofran, an antiemetic. A Welch-
do not need traditional CO2 laser therapy. Patients in Allyn digital blood pressure, pulse rate, and pulse
their 30s and 40s with very fine perioral and perior- oximetry monitor checks the patient’s vital signs from
bital lines can be treated with the erbium laser alone. this point until the end of the procedure. Forty-five
Older patients treated with the erbium alone will minutes prior to therapy we rub into the facial skin a
experience a recurrence of lines and wrinkles with in topical anesthetic, Betacaine LA (Medical Center
1 or 2 years and will be unhappy. They are therefore Pharmacy, 4600 N. Habana Ave., Tampa, Florida
good candidates for dual-mode treatment. 33614, 1-800-226-7094), a proprietary ointment con-
taining approximately 12% Xylocaine, 12% prilocaine,
and a small amount of a sympathomimetic. We find it
Laser Skin Resurfacing more potent and effective than Emla and it does not
need to be occluded. We delay applying the analgesic
Laser Safety ointment to the neck until 40 minutes before it is
It is important that everyone in the doctor’s office have treated. Ela-max (4% lidocaine cream in a liposome
a rudimentary knowledge of laser safety. Whenever base) has recently been released by Ferndale Labora-
the laser is being operated, there should be an tories; it has wide availability and can be substituted
approved laser caution sign placed prominently out- for the above-mentioned anesthetic creams.
side the treatment room, and the door should always Following the Betacaine application, we give the
be closed during laser operation. Within the laser treat- patient oral Demerol 50 mg. We give the patient a
ment room, the most important concerns are to pre- repeat dose of diazepam and Demerol 50 mg 15 min-
vent fire and to protect the eyes from direct or reflected utes before the procedure unless speech is slurred or
laser light. Everyone in the laser room should wear the patient is asleep. Because pain perception is vari-
protective lenses that are specific for the wavelength able and the medication may have a more potent effect
of the laser being used. A large container of water in the elderly or very slight patients, the second dose
should be prepoured and placed close to the laser of Demerol is held until the laser treatment is begun
operators for use in the case of accidental fire. Moist and may not be given at all if analgesia is sufficient.
gauze rather than dry gauze should be used around The depth of analgesia achieved can vary consid-
the patient to prevent fire and burns. Any oxygen erably between patients. Quick-acting, proparacaine
source in the room should be turned off. Reflective 0.5% eye drops are instilled into the eyes. Lacri-lube,
surfaces should be eliminated in the room, and any an ophthalmic lubricant, is applied to the inner sur-
metal instruments should have a burnished surface. face of metallic, laser eye shields that are inserted into
If there is a window, an opaque covering should be each eye. CD head sets with calming music are placed
drawn. Moist toweling should be used around the on the patient’s head, and the patient’s hand is held to
perimeter of the treatment area, and the laser should counter the isolation perceived when the ocular
always be switched to the standby position when not shields are in place. We usually begin treatment on
being used for treatment. A very powerful smoke the forehead and proceed caudally.
evacuator is necessary for any erbium laser, because Eighty percent of our patients tolerate the entire
the particulate debris that is produced from the procedure without further anesthesia. Twenty percent
ablated surface literally explodes into the air and is need a combination of nerve blocks and field anes-
not completely vaporized. It is prudent to evacuate as thesia. If the patients complain of excessive heat or a
CHEN14-195-210.I 3/22/01 1:59 PM Page 203
burning sensation during the course of therapy, we during the procedure. The laser beam is delivered
stop the procedure and block the supraorbital, infra- through a hollow metal cylinder with a fixed extended
orbital, and mental nerves. Anesthesia is achieved arm that is positioned directly on the skin’s surface.
with 2 cc at each site of an equal mixture of lidocaine For almost all of our patients, the erbium laser
2% with epinephrine 1:200,000 and bupivacaine 0.5% parameters are set at 1.2 J, 3-mm spot size with 10%
buffered with 0.4 cc 8.4% sodium bicarbonate. The overlap. The CO2 setting is 3 W, 75% duty cycle (the
intraoral approach to the infraorbital and mental actual length of time between erbium exposures that
nerves gives the best results. Mucosal topical anes- the CO2 laser is firing), and both lasers are set at
thesia can make it an almost painless induction. It is 10 Hz. The computer pattern generator is first set for
best to do the nerve blocks in a sequential manner the largest square, 2 by 2 cm. The laser fires 10 suc-
from cephalad to caudal and delay induction until 10 cessive 3-mm spots per second in rows that precisely
to 15 minutes before each area is treated. Buffering form a 2 by 2 cm square and have a programmable
with bicarbonate seems to shorten the life of the anes- overlap capability. A 10% overlap in both horizontal
thesia, so if one blocks all the nerves at the beginning and vertical directions yields a pattern suggesting the
of the procedure, a region may be coming out of anes- interlocking Olympic rings (Fig. 14–6). The intense
thesia just as it is being treated. laser heat causes tissue shrinkage due to water vapor-
Field blocks are necessary for regions not covered ization and protein contraction. When multiple passes
by the nerve blocks. The eyelids, nose, and perimeter are made, the contracting tissue is evenly lased and
of the face are best treated in this manner. We use a prevents a branded effect. We generally do three
100 cc IV bag of normal saline and add the following passes in the preauricular, periocular, and immediate
to it: 10 cc Xylocaine 2% with epinephrine 1:200,000, submental regions. Four passes are made over the
10 cc bupivacaine 0.5%, 2 cc sodium bicarbonate, and remainder of the face.
one vial of Wydase (hyaluronidase) 100 units. Some The computer pattern generator (CPG) can adjust
physicians add Solu-Medrol to the infiltrating solution to smaller squares as well as other useful shapes such
rather than give the patient oral steroids. The Wydase as triangles and rectangles for use around the eyes,
allows the injection fluid to be massaged around the nose, and mouth. Our modifications of the above for
face better and is particularly helpful in areas such as special regions of the face are as follows: Three passes
the eyelids. Seldom is more than 50 cc of this mixture are made on the portion of the eyelids covering the
necessary for the entire procedure, even when nerve globe and the duty cycle is reduced to 50% in elderly
blocks are partially effective. Thus, there is no risk of patients, because of the thinness of the tissue. In con-
anesthetic toxicity. We have not had any patients who trast, six or seven passes of the laser beam are made
were unable to tolerate the procedure with this prepa- on the deep lip lines and the shoulders of deep lines
ration, and we are able to treat the entire face and neck almost anywhere on the face. If the patient is elderly
in 90 minutes with the above preparation. A small and the preauricular skin is very thin, only three
number of patients metabolize anesthetic very passes are made (Fig. 14–7).
quickly; therefore, one must be prepared to reinfiltrate
areas if the patient experiences pain.
Some physicians prefer IV sedation or general
anesthesia for their patients. Treatment time can be
shortened to 1 hour, but there is the added cost of the
operating room or surgi-center, the anesthesiologist,
as well as the increased risk to the patient that this
deeper anesthesia entails. Recent legislation in the
state of California has had the effect of making illegal
any IV or inhalation anesthesia done outside an
approved Medicare surgi-center or operating room
facility. Other states are currently considering similar
legislation.
Laser Settings
Laser settings and technique vary greatly with each
physician. This is a very operator sensitive therapy FIGURE 14–6 Computer pattern generator (CPG) 3-mm
and may require continuous, subjective modification spot pattern.
CHEN14-195-210.I 3/22/01 1:59 PM Page 204
FIGURE 14–7 (A) CPG 2 cm square,

3-mm spot size, one pass. (B) CPG 2 cm
A, B square, 3-mm spot size, three passes.
At the end of the procedure, the CPG is replaced

with the 3-mm handpiece and used freehand to touch
PITFALL
up or feather areas that due to their shape or location
are not easily treated with the CPG. The distal eye-
lids, columella, canthi, vermillion border, eyebrow
Immediate skin tightening is due to dehy-
margins and hairline are better treated this way. dration and heat-induced desiccation. Long-
Some physicians with extensive experience with term skin tightening is due to papillary
older machines that predate CPGs are very comfort- dermal lamellar fibrosis.
able doing the entire procedure freehand with the
3-mm handpiece set at 12 Hz. It is harder to maintain
consistent overlap with this technique. We employ As one is treating the skin, it is easy to observe pro-
this technique for treating the neck because it is the gressive skin tightening with each pass. This does not
fastest way to treat large flat areas with minimal necessarily correspond with the degree of eventual
topographic changes. skin tightening, because it is an immediate reaction
The above recommendations work very well with probably related most closely to dehydration of epi-
our patients and give consistent results. Some physi- dermis and dermis. The permanent tightening that
cians claim success increasing the CO2 to 5 W, reduc- takes place evolves over several months as lamellar
ing to two passes, and increasing the 3-mm beam collagen is laid down in the healing papillary dermis.
overlap of successive passes to 50%. Other physicians Nevertheless, this immediate tightening does give one
reduce the CO2 setting to 2 W. It is our belief that a a rough estimate of the tightening that will take place.
CO2 setting of 3 W is the absolute minimum for treat- It is most noticeable on the eyelids and gives one an
ing the face, to induce lamellar collagen formation indication of how much effect one is having on tissue.
that is necessary for long-term wrinkle reduction. One can usually expect 1 to 2 mm of eyelid tightening
Healing in all regions of the skin is dependent on and an approximate 5% tightening in the overall facial
the concentration of adnexal structures, and seba- skin. This is quite variable but very pleasing to the
ceous and sweat glands whose epithelial lining cells patient. The firming of skin is never the wind tunnel-
form the reservoir for new surface skin cells. These like effect seen in excessive face lifts.
structures are far fewer on the neck than on the face; With the older CO2 lasers the appearance of a
thus, reduced laser settings are necessary. When we chamois-like tan color supposedly heralds entry into
treat the upper neck, we reduce the CO2 to 1 W, the the reticular dermis and is the reference point for stop-
duty cycle to 50%, and the number of passes to three. ping treatment. This color is probably the result of der-
For the lower half of the neck, we do only two passes mal dehydration, residual crust, and thermal damage
with a 25% duty cycle, and sometimes eliminate the to collagen and adnexae. Because the Derma K
CO2 altogether. employs an erbium:YAG laser, there is no crust forma-
tion and the attenuated CO2 profile does not thermally
burn or dehydrate dermis to the same excessive degree
EARL... Use erbium and very low
P CO2 settings when treating the neck.
as do super- and ultrapulsed lasers. Thus, one must not
rely on a sudden color change or dermal appearance
as the visual reference point for ending the procedure.
CHEN14-195-210.I 3/22/01 1:59 PM Page 205
Counting the number of passes is the best way to oper- ice pack lubricates its surface and lessens this prob-
ate the laser in a safe manner and avoid going too lem. Done properly, most patients experience pain the
deeply and ultimately scarring the patient.12–15 night after the procedure that is in the range of a mild
to moderate sunburn. Occluding the exposed nerve
Immediate Postoperative Phase endings with petrolatum markedly diminishes dis-
There are two ways to care for the patient in the comfort. Aquaphor emollient is continued for at least
immediate postoperative phase: open and closed a week until the epithelium has re-epithelialized to
techniques. At 1 month postoperative it is impossi- the degree that the skin does not feel easily dried.
ble to tell which method was employed. If instruc- The closed technique usually employs the use of
tions are well followed, each technique produces moistened, form-fitting bandages that are either
excellent results. Posttreatment pain is very minimal opaque or employ a moist, transluscent biomembrane
with the Derma K. More than 95% of our patients covered with occlusive gauze. This needs to be form-
treated with the Derma K do not need to take codeine fitted to the patient’s face and must have holes cut for
for pain relief. the mouth, nose, and eyes. Flexan and Vigilon are two
We employ the open technique, which involves common brands. They require daily changing by a
thick applications of Aquaphor or Crisco to the skin nurse for the first 2 days, and then they are discontin-
every 3 to 4 hours accompanied by frequent applica- ued and replaced with moisturizing salves16.
tions of ice packs for the first 24 hours (Fig. 14–8). This The closed technique is easier for the patient, but the
helps to control soft tissue swelling that can occur opaque, total facial dressings give the patient a robot-
with extensive field injections of anesthetic. The open like appearance and can produce claustrophobia. The
technique is much cheaper for the patient and dressings are expensive. Originally, these dressing
requires much less office personnel time. It also were used for the entire first week and the incidence of
allows the surgeon to see through to the healing skin infection was noted to increase with each successive
without removing a cumbersome expensive bandage day. If there is any discomfort or concern about the
in case the patient is having a problem. Aquaphor is emergence of an infection or bleeding, the physician
essentially petrolatum, and reactions to it are exceed- must remove the bandaging.16 The initial phases of
ingly rare. This technique does require diligence on healing seem to be faster with the closed technique,
the part of the patient to make certain that the emol- and there is diminished, immediate erythema, but at 2
lient is applied thickly. It needs to be reapplied after weeks both patient groups are at the same stage of
each ice pack application as the cold temperature healing and one cannot differentiate between them.
tends to solidify the petrolatum on the skin and it eas- If patients do not follow directions, a thick crust
ily comes off. Salad oil applied to the surface of the will form on the skin that can produce scarring as it
A, B C
FIGURE 14–8 (A) Prelaser. (B) Two days postlaser, open technique. (C) Four months postlaser.
CHEN14-195-210.I 3/22/01 1:59 PM Page 206
heals. Keeping the skin moist is very important, Long-Term Follow-Up

because it provides the proper environment for In the first months following treatment, a small per-
the re-epithelializing keratinocytes to grow from the centage of patients may develop hyperpigmentation.
adnexal orifices and resurface the skin. Erythema In our experience less than 5% of skin types I and II
occurs to a variable degree and is caused by vasodi- experience this. Skin types III and IV may have tran-
latation of the dermal capillaries. A dermal inflam- sient hyperpigmentation rates varying from 10 to 50%,
matory infiltrate is present and subsides with depending on the type of laser used and the number
resolution of the erythema. Fibroblasts are present for of passes done. Strict sun avoidance and 4% hydro-
months. quinone twice a day usually make this disappear in a
After 48 hours we begin dilute vinegar com- few months. Additional or alternative bleaching
presses starting with one teaspoon of household agents are azaelic acid or kojic acid. Tretinoin and
vinegar in a cup of cool or room temperature water retinol can be added, but are not in themselves as
and gradually increase the strength to one table- effective as hydroquinone. The observation that this
spoon per cup. Patients apply this to the face for 5 pigmentation resolves so predictably and quickly
minutes and then gently debride the desquamating with this regimen suggests that it is almost certainly
epithelial surface. Patients find this soothing and the epidermal in origin, because bleaching agents rarely
mild acidification of the surface probably helps to have much effect on dermal hyperpigmentation.
control bacterial and candida growth. This treatment Resolution of erythema is variable. It usually fades
continues at least four times a day until the seventh by the end of the second month, but was observed in
postoperative day. Patients also continue their antivi- one rosacea-prone patient to last until the end of the
ral medications and antibiotics for the entire first third month. The quickest resolution was 3 weeks in
week. Steroids are tapered over the same length of one 40-year-old patient.
time. We recommend vitamin supplements, includ- Hypopigmentation is seldom seen before the fourth
ing vitamins A (25,000 IU), E (400 IU), C (500 mg), as month and often is not observed until 6 to 10 months
well as zinc and other minerals to be taken daily for after the procedure. This is irreversible and probably
the next 2 months. Other physicians have had good represents toxic effects of the laser on the melanocytes.
experience with calendula cream in the first weeks This type of reaction is most frequently noted in
after laser therapy. This is a homeopathic antiinflam- patients who undergo ultrapulsed or superpulsed
matory product. All these non-Aquaphor topical CO2 laser therapy and less frequently found in
products have a risk of inducing contact or irritant patients who are treated with the erbium laser alone.
dermatitis. The potential for irritation or allergic sen- This finding is most likely caused by heating
sitization decreases with each successive week as the melanocytes deep within the adnexae, although toxic
skin heals. inflammatory activity in healing may play a factor in
At the end of 7 days, many younger patients are able some cases of hypopigmentation. Ultra- and super-
to apply green-tinted concealing makeup which sub- pulsed CO2 lasers produce an area of thermal necrosis
stantially hides most of the posttreatment erythema. and heating that extends into the reticular dermis. All
Older patients may not have sufficient re-epithelializa- patients experience a mild lightening of their skin. The
tion to apply makeup until the 10th or 14th day. Mois- hypopigmentation that can occur is often very local-
turization is encouraged throughout this period. Up ized and not apparent to the patient. Many physicians
until the third week, patients are told to stay indoors do not consider an area of lightened skin as hypopig-
most of the day, cover the face with a scarf if sitting in mentation unless it is quite noticeable or vitiligo-like
a room with open windows, and to avoid fluorescent in totally lacking pigment (Fig. 14–9). This predictable
fixtures, for they are a significant source of ultraviolet lightening of the skin is why we avoid treating only
radiation. After 2 weeks patients are told to continue selective regions of the face, rather than the whole
to avoid direct sunlight for the next 2 months, to face. Patients may develop pronounced raccoon-like
always use a SPF 30 to 50 sun block with UVA protec- eyes or an accentuation of the perioral marionette
tion, and to wear large sunglasses when outdoors. lines if just these regions are treated.17
Periorbital and perioral edema is most noticeable Following therapy and healing, lifelong minimal
in the first few weeks, but remains subtle for several sun exposure and daily sun block application are
months. Rhytids in these regions gradually reappear practices that need to be followed. It is sometimes sur-
in the months following therapy, albeit markedly prisingly difficult to change the behavior patterns of
diminished. patients who have completed the healing process.
Hair that is temporarily lost due to laser ablation
gradually regrows unless damage was done deep into Complications
the reticular dermis where the bulb of the hair follicle Most complications can be avoided by using the tech-
is located. niques that we employ. Staphylococcal, streptococcal,
CHEN14-195-210.I 3/22/01 1:59 PM Page 207
sient hyperpigmentation and need to be warned of

this. It is usually treatable with hydroquinone, which
may need to be formulated in concentrations as high
as 8%. Tretinoin and topical steroids are synergistic
complements to hydroquinone in treating hyperpig-
mentation. Mild lightening of the skin usually occurs,
but extreme hypopigmentation and depigmentation
are rare with the Derma K; however, patients should
be warned that they can occur. These complications
are a greater problem for darker skinned patients. For
the above reasons, skin types I through III are the best
laser candidates.17
Laser Treatment of Benign and Malignant

FIGURE 14–9 Postlaser hypopigmentation. Facial Tumors
The decision as to which Derma K laser mode to use
and pseudomonas are the bacterial infections most for treating facial lesions depends on an understand-
frequently reported in the literature. Candida and ing of the biologic activity of the lesion. Benign lesions
fungal infections are also reported. Most of these that are very slow growing or of limited growth
infections are transferred from other parts of the body potential can be treated with pure erbium laser
to healing skin. Occlusive dressings alter the surface energy. Lesions are ablated through the epidermal
dynamics and can predispose to infections. Herpes level or papillary dermis and then treatment is
simplex can occur as late as 2 weeks after the laser stopped. Re-epithelialization occurs, the surface is
procedure. Contact dermatitis to one of the elements flat, and the cosmetic appearance is good. Tumors
found within occlusive masks can occur, and for this that can be treated in this manner are syringomata,
reason we never use topical antibiotics because all of trichoepitheliomata, angiofibromata, actinic keratoses,
them have been observed to cause contact dermatitis and lentigines (Fig. 14–10). The treatment of rhino-
in susceptible patients. phyma is best done in the mixed laser mode with the
CO2 set between 8 and 10 W to maximize its coagula-
tion effect on bleeding vessels in the nose (Fig. 14–11).
PITFALL Without use of CO2 laser energy, treatment of this
condition, or any other where there is a significant
If tenderness suddenly occurs, suspect herpes vascular component, is impossible. Lentigines and
or streptococcal infection. If itching occurs, melasma can be treated with the erbium laser, but
suspect contact dermatitis or impetigo.17 there is a significant recurrence rate, and both lesions
might be better treated with a krypton, copper vapor,
alexandrite, or other laser whose maximal absorbance
Hyperpigmentation, hypopigmentation, and is closest to that of melanin. Melasma recurs at least
depigmentation have been previously discussed. 50% of the time regardless of what laser energy wave-
Darker skin patients will almost always have tran- length is used.18
A B
FIGURE 14–10 (A) Syringomata of right lower eyelid prelaser. (B) 8 months postlaser.
CHEN14-195-210.I 3/22/01 1:59 PM Page 208
The CO2 laser can be used with the smallest hand- resurfacing. The patented laser combination includ-
piece available for surgical cutting. This can be used ing full-strength erbium laser with attenuated CO2
for any type of benign or malignant lesion. Healing is laser energy produces full wrinkle reduction, skin
slower because the blood vessels have been coagu- smoothing, and tightening with quick healing and
lated, but the surgical field is comparatively blood- fast resolution of erythema (Fig. 14–12). Addition-
less. Delay suture removal a few extra days to ally, the patients receive a complementary lighten-
compensate for the slower healing. ing of chronic aging and sun-damaged skin, removal
of actinic keratoses, and reversal of sun-induced
CONCLUSION lentigines. Crepe-paper lines around the eyes are
removed and blepharoplasty can often be delayed
Dual wavelength laser treatment of the face using for years.
the Derma K is the next evolutionary step in laser
FIGURE 14–11 (A) Rhinophyma

prelaser. (B) 6 months postlaser. A, B
FIGURE 14–12 (A) Prelaser Derma

K treatment. (B) Postlaser. A, B
CHEN14-195-210.I 3/22/01 1:59 PM Page 209
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9. Freitag L, Chapma G, Sielczak M, et al: Laser smoke 17. Nanni CA, Alster TS: Complications of carbon dioxide
effect on the bronchial system. Lasers Surg Med 1987; laser resurfacing. Am Soc Dermatol Surg 1998; 24: 315–320.
7:283–288. 18. Manaloto RMP, Alster T: Erbium:YAG laser resurfac-
10. Oosterhuis JW, Verschuerlin RC, Eibergen R, Oldhoff J: ing for refractory melasma. Dermatol Surg 1999; 25:
The viability of cells in the waste products of CO2 laser 121–123.
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Chapter 15
ASIAN BLEPHAROPLASTY
William P. Chen
There is a great deal of myth and misconception in crease, and the anatomy of Caucasian lids that are
discussions of eyelid surgery in Asians. It is impor- without a lid crease. In discussing “Asian” eyelid, it
tant to realize that the conventional view that Asian is understood by this author’s definition, as those
eyelid surgery started only after WWII with industri- Asians with “Han” features (the Han dynasty of
alization and westernization of Asia is inaccurate. China dates from 206 B.C. to 220 A.D.)—namely, the
There has always been a demand for this type of cos- Chinese, Japanese, Koreans, and certain ethnic
metic surgery in Asia, and the first 20 descriptions of groups in South East Asia, including Vietnam, Cam-
the double eyelid crease procedure were published in bodia, Malaysia, Singapore, etc. It does not include
Japanese medical literature from 1896 to 1940. Over the Indians in the Asian subcontinent of India, nor
the last 30 years in the Western Hemisphere there has does it include the Russians. Their anatomy falls
been concurrent rise in demand as more Asians settle more into the Caucasian category. It has been esti-
abroad. The Asians seeking an eyelid crease proce- mated that of the 56 officially recognized ethnic
dure are a relatively young, affluent, and educated groups in China today, just one of them—the Han—
group. But their understanding of what they want makes up the bulk of the population, comprising
and of what can be achieved may not be synchronous about 1.1 billion people. The other 55 ethnic minor-
with the surgeon’s own beliefs. They may not be ity groups encompass about 100 million people
aware of what the normal wound healing processes spread throughout China. I prefer the term “Asian”
will be. Additionally, the operating surgeon may not over “Oriental.” The latter, I believe, is a rather non-
be fully informed of what is involved in this special- specific, racially stereotypic, and ethnically biased
ized and peculiar aspect of aesthetic eyelid surgery. term.
Almost all the complications and suboptimal results Among the misconceptions and myths is the con-
may be related to a lack of communication between cept that most Asians do not have an upper eyelid
the patient and the surgeon, and the inability of the crease. This could be because usually only those
surgeon to observe certain fundamental concepts and patients who do not have a crease would seek consult
pitfalls. and be seen by the surgical practitioners. The lid
crease occurs in varying incidence among different
ANATOMY AND TERMINOLOGY ethnic subsets of Asians,1 whether Chinese, Japanese,
Koreans, etc. It even shows provincial and geograph-
In recent years, studies in the ophthalmic and plastic ical variance, for example, northern versus southern
surgery literature have compared the anatomic dif- Chinese; Japanese who are from Hokkaido versus the
ferences of those Asians without a lid crease versus more southern province of Kyushu. Overall, one may
Caucasians with a lid crease (Figs. 15–1 and 15–2). state that among Han ethnic groups (Chinese, Japan-
We are, however, still unclear about the anatomic ese, and Koreans), the average incidence of having a
details of those Asians’ eyelids that possess a lid crease is 50%.
211
CHEN15-211-224.I 3/22/01 2:00 PM Page 212
Sub-brow fat
(ROOF)
Orbital septum
Submuscular fat
FIGURE 15–1 Schematic drawing
showing cross-sectional view of an Asian
upper eyelid without lid crease. The
orbital septum tends to fuse with the lev- Pretarsal fat
ator aponeurosis in a variable fashion
from down over the anterior tarsal sur-
face up to 5 mm above the superior tarsal
border. Besides the typical preaponeu-
rotic (post-septal or orbital) fat pad, sub-
muscular (suborbicularis oculi muscle, or
pre-septal) islands of fat pads and pre-
tarsal fat globules are often present. The
submuscolar fat may appear as an infe-
rior extension of the sub-brow fat (or
retro-orbicularis oculi fat).The upper
tarsal plate measures from 6.5 to 8.0 mm
in Asians.
Sub-brow fat
(ROOF)
Orbital septum
FIGURE 15–2 Schematic drawing

showing cross-sectional view of a typical
Caucasian eyelid with a natural upper
eyelid crease. Aponeurotic fibers form
interdigitations to the pretarsal orbicularis
oculi muscle and a subdermal attachment
along the superior tarsal border. The lid
crease is often a composite of the vector
forces from several creases. The pretarsal
region is firmer and more anchored
because of the presence of interdigitations
of terminal aponeurotic fibers. The orbital
septum fuses with the levator aponeurosis
at a higher level, compared with most
Asians. There is less preaponeurotic fat
inferiorly. There may be less submuscular
and pretarsal fat. The upper tarsus is often
8.0 to 11.0 mm in Caucasians.
CHEN15-211-224.I 3/22/01 2:00 PM Page 213
ASIAN BLEPHAROPLASTY • 213
My view is that the pretarsal fat relates to “presep-

EARL ...
P Fifty percent of Asians
have an upper eyelid crease.
tal” or submuscular (suborbicularis) fat that is an
extension of the sub-brow fat found in the pretarsal
region of the tarsus (preseptal is a poor term at this loca-
tion as there may not be any septum here at all). Asians
This means that one in two Asians is likely to have may have pretarsal fat anterior and inferior to the point
an upper eyelid crease, and this ratio holds true even of fusion of levator aponeurosis and orbital septum;
among parents and siblings (e.g., two out of four the pretarsal fat does not arise purely from the fact that
brothers and sisters will have an upper eyelid crease, preaponeurotic fat pads have gravitated inferiorly to
or one of the two parents will have a crease). The the pretarsal area as a result of a lowered point of
crease occurs in direct correlation to the height (verti- fusion of septum-levator or from a “loose” or “leaky”
cal size) of the superior tarsal plate (as measured over septum. It is different in texture and configuration,
the central portion above the pupillary aperture). more microlobular and amorphous than the preapo-
Asians are in general smaller in physical stature. Their neurotic fat that is seen above the septum-levator point
tarsal plate height averages 6.5 to 8.0 mm and the of fusion. These findings are not unique to Asians and
crease, when present, is usually not more than this dis- may be seen in Caucasians as well. Figure 15–3 shows
tance from the ciliary margin (eyelid margin). The the presence of pretarsal fat anterior to the orbital sep-
crease is not any less prominent in Asians as compared tum, overlying the anterior surface of the upper tarsus,
to non-Asians with respect to the depth of inward and is not a part of the preaponeurotic fat pads that are
folding of the crease line. One of the reasons that the posterior to the orbital septum.
lateral canthus appears more up-slanted may be Further confusion in terminology undermines the
the presence medially of a fold of skin over the crease, communication between patients and physicians.
partially blocking the upper medial half of the palpe- The terms outer double eyelid and inner double eyelid
bral fissure. refer not to the higher crease found in a Caucasian
We still come across the term Westernizing bleph- (Fig. 15–4) versus the lower crease seen in those
aroplasty being used for the crease procedure that Asians who possess a crease, but to the relative con-
Asians elect to undergo.2 This could be complicating figuration (shape) of the crease as seen in an Asian.
and misleading to the patient and physician alike. The term outer double refers merely to a crease that
The Asians really do not want to elect the height and does not converge to the medial canthus—parallel is a
crease configuration of a Caucasian’s or a West-
erner’s eye.
EARL ...
P Asians seldom prefer a
“Westernizing” crease (shape or height).
They prefer an Asian crease.
Invariably, they want to look like other Asians who

have a crease, a very different crease as compared to
those of a Caucasian. If the surgeon has a less than per-
fect concept of this Asian crease, one will encounter
difficulty along the way.
There has been much debate and conflicting find-
ings regarding the fat compartments and location of
various fat pads in the upper eyelid of Asians. Various
theories have been invoked to explain the presence of
FIGURE 15–3 This left upper eyelid incision shows three
fat pads in the pretarsal region of the upper lid—from
zones of fat pads in this Asian patient: the pure yellowish
postulating a lower point of fusion of the orbital sep-
pretarsal fat pads located in the anterior surface of the
tum, to having a “leaky septum” allowing isolated fat upper tarsus, anterior to the opened orbital septum above it;
pads to migrate downward even though the orbital the orange-pinkish vascularized preaponeurotic (postsep-
septum-levator fusion point is stated to be above the tal) fat pads with capillaries running horizontally through
superior tarsal border. Uchida3 was the first author to them; and the sub-brow fat pads above it, which appear
describe the findings of pretarsal fat in some Japanese pale yellowish, and are located anterior to the opened
patients. orbital septum.
CHEN15-211-224.I 3/22/01 2:00 PM Page 214
rior tarsal border area. The distal terminations of the

levator aponeurosis fibers blends into the intermus-
cular septal and connective tissue fibers of the pre-
tarsal orbicularis oculi muscle,4 resulting in an
infolding when the levator is contracting the upper
lid upward.
Asian blepharoplasty is a term that was first used in a
paper published in 1987 by this author that described
a distinctive surgical procedure tailored specifically for
those Asians without a crease who want to have a
crease.1 The paper discussed the height and shape of
the crease and the surgical techniques to use to form a
crease that appears continuous, is symmetrical in con-
tour, and that achieves permanency.
In the external incision approach, the goal of the
surgery is to clear the trapezoidal block of preaponeu-
rotic tissues along the superior tarsal border, which
includes the skin, orbicularis, orbital septum, as well
FIGURE 15–4 A typical semilunar crease for Caucasian. as minimal preaponeurotic fat, in an equidepth and
The crease is high by Asian norm and appears more sepa- uniform fashion to allow for optimal surgical apposi-
rated from the lid margin over the central one-third of the tion of the terminal fibers of the levator aponeurosis
eyelid. to the undersurface of the skin along the superior
more appropriate term anatomically (Fig. 15–5). The tarsal border.5–8 In a nasally tapered crease, one would
term inner double eyelid refers to a medially converg- design the crease to converge medially. In a parallel
ing crease—here “nasally tapered crease” is less crease, one would stay more level and even along the
ambiguous (Fig. 15–6). The terms inner and outer dou- lid margin.
ble eyelids make sense only if one understands the
Chinese origin of these terms as they are translations
from Kanji (literal meaning: “words of the Han
SURGICAL METHOD
race”), the language of the Han people. Generally it is In previous publications,5, 6 I have discussed the
quite confusing for others who are not native to the concept of upper eyelid crease configurations and the
Chinese written language. I prefer to avoid using essential steps required for predictable placement of a
them for medicolegal reasons, as both Chinese and lid crease among those Asians without a crease. My
non-Chinese Asians may be using them inaccurately. method is based on accurate measurement of the cen-
The lid crease results from the presence of subcu- tral height of the upper tarsus, using it to guide the
taneous terminal interdigitations of the levator placement of the external incision line for formation of
aponeurosis in the pretarsal as well as along the supe-
FIGURE 15–5 A parallel crease configuration running FIGURE 15–6 A nasally tapered crease configuration.
equidistant from the lid margin as its course from medial The crease converges to the medial canthus and may either
to lateral canthus. merge into it or stay converging but separated.
CHEN15-211-224.I 3/22/01 2:00 PM Page 215
the crease. It was mentioned that the ideal creases the surgeon is planning to preserve or enhance it, is
tend to be of either the nasally tapered type or of the indeed the correct crease line to use.
parallel configuration. Medial upper lid fold is often If the crease is to be nasally tapered, with either a
present in the medial portion of the upper eyelid of laterally leveled or flared configuration, mark the
Asians, whether they have a crease or not, and should medial one-third of the incision line to taper toward
not be considered pathologic, nor should it be auto- the medial canthal angle or to merge with the medial
matically removed. upper lid fold. The lateral one-third is marked in
either a leveled or flared configuration.
For the parallel crease, the measured height of the
SURGICAL TECHNIQUE superior tarsal border is drawn across the width of
Marking of the Crease the eyelid skin.
I use the shaved off tip of a wooden cotton tip appli- To recapitulate, the height of the tarsus determines
cator dipped with methylene blue to mark the pro- the overall central position of the surgical crease; the
posed crease; 1 to 1.5 mL of anesthetic are used to shape is determined by how you design the medial
achieve sensory anesthesia of the upper lid. I evert the one-third and lateral one-third of this crease (lower
upper lid and measure the vertical height of the tarsus line of incision), according to the patient’s preference.
over the central portion of the lid with a caliper. This
measurement is usually between 6.5 and 8 mm. It is
Skin Incision
carefully transcribed onto the external skin surface, To create adequate adhesions, it is necessary to
again over the central part of the eyelid skin (Fig. remove some subdermal tissue. A strip of skin mea-
15–7). This point directly overlies the superior tarsal suring approximately 2 mm is then marked above
border and will serve as a reference point for the over- and parallel to this lower line of incision (Fig. 15–8). In
all crease height along the central one-third of the eye- the patient who desires a nasally tapered configura-
lid, whether the crease shape is to be nasally tapered, tion, taper this upper line of incision towards the
parallel, or laterally flared. medial canthal angle, or merge with any medial
upper lid fold that may be present. As a result, the
segment of skin to be excised is often less than 2 mm
EARL... Measure the central tarsal
P height (in mm) to determine the proper
over the medial portion of the crease.
EARL ...
P
height of the crease over the central one-third In Asian blepharoplasty
of the upper eyelid. involving skin excision, the lower line of
incision will determine the shape and height of
For those patients who have a crease, I also mea- the surgically created crease.
sure the tarsus to confirm that the apparent crease, if
FIGURE 15–7 The upper eyelid is everted and a caliper FIGURE 15–8 Construction of a nasally tapered crease.
used to measure the central height of the tarsus. This point is The medial one-third of the incision lines tapers toward the
transcribed onto the external surface of the skin and serves medial canthal angle. The lateral one-third may be either
as a central reference point for the lower line of incision. leveled or flared upward.
CHEN15-211-224.I 3/22/01 2:00 PM Page 216
FIGURE 15–9 Upper and lower lines of incision has FIGURE 15–10 After traversing the supratarsal orbicu-
been opened with a no. 15 surgical blade, with Wetfield laris in a bevelled fashion, the orbital septum is reached and
bipolar cautery applied to vascular oozing that may arise opened horizontally, exposing the underlying preaponeu-
from orbicularis muscle. rotic fat pads.
The incision is then carried out using a no. 15 ed, exposing the underlying preaponeurotic fat pads
surgical blade (Bard-Parker) along the upper and (Fig. 15–10).
lower lines, incising just below the subcutaneous
plane (Fig. 15–9). I control any fine capillary oozing Preaponeurotic Fat Pads
using a bipolar Wetfield cautery. Although the strip of Depending on the degree of fullness of the upper lid,
skin bounded by the upper and lower lines of incision the surgeon may use a pair of sharp scissors or
may be excised with scissors; preferably, it is excised monopolar bovie cautery in a low, cutting mode to
after the orbital septum is opened along the superior excise a very small amount of the preaponeurotic fat
line of incision and the skin-orbicularis-orbital sep- pad. I control any bleeding points with a bipolar Wet-
tum flap is turned inferiorly along the superior tarsal field cautery.
border (see next sections).
The excision of a strip of skin is not necessary in
every case; however, it is the author’s belief that it ...
facilitates the removal of subsequent layers of the lid
tissues, thereby allowing adequate crease formation.
P EARL Use bipolar Wetfield
cautery in all hemostatic maneuvers and
reserve the monopolar bovie cautery solely for
Opening of Orbital Septum cutting and dissection purposes because Wet-
At this point the superior tarsal border is still covered field cautery results in a lower level of thermal
by pretarsal and supratarsal* (preferred over the term tissue injury.
preseptal) orbicularis oculi muscle, with possibly some
terminal portions of the septum orbitale, and the ante-
riorly directed terminal fibers of the levator aponeu- The fat excision often requires a small local sup-
rosis beneath the septum. To open the septum, retract plement of lidocaine in the space underneath the pre-
the incision wound superiorly and use a fine-tipped aponeurotic fat pad. If a patient with dermatochalasis
monopolar bovie cautery, in the cutting mode, to and obliteration of crease should manifest even a very
incise through the orbicularis and orbital septum in a minimal concavity in the supratarsal sulcus, do not
beveled fashion along the upper skin incision line. remove any fat as it will worsen the hollowness and
In Asians, the orbital septum may be only 2 to 3 mm result in multiple redundant folds superior to where
above the superior tarsal border. It is readily open- one wants the crease to be.
* Semantically, in Asians the supratarsal area is an area directly above the tarsus, whereas the true preseptal region may be quite a few mil-
limeters superior to this because the orbital septum may fuse with the levator aponeurosis a variable distance from the superior tarsal border.
CHEN15-211-224.I 3/22/01 2:00 PM Page 217
FIGURE 15–11 The skin-orbicularis-septal flap may be FIGURE 15–12 A 1- to 2-mm strip of pretarsal orbicu-
rotated inferiorly to facilitate exposure to the preaponeu- laris muscle is trimmed along the lower skin incision.
rotic fat pads and underlying levator aponeurosis. It is then
trimmed horizontally along the superior tarsal border.
Excision of Skin, Preseptal Orbicularis, PITFALL

and Orbital Septum
Vigorous dissection over the pretarsal plane
After the septum is opened horizontally, the strip of
skin, supratarsal orbicularis and orbital septum will create prolonged postoperative edema
hinged along the superior tarsal border are excised. It and the risk of undesirable formation of mul-
consists of approximately 2 to 3 mm of skin, a greater tiple creases.
amount of supratarsal orbicularis muscle, and a vari-
able amount of the orbital septum (Fig. 15–11) (trape-
zoidal debulking of preaponeurotic tissues).
Formation of Lid Crease/Closure of Wound
Excision of Pretarsal Orbicularis To form a dynamic crease, the terminal fibers of the
To facilitate the infolding of the new crease, I excise a levator aponeurosis above the superior tarsal border
1- to 2-mm strip of pretarsal orbicularis muscle along should be directed to the subdermal plane of the
the lower skin incision edge (Fig. 15–12). lower line of skin incision.
Some surgeons routinely debulk the entire pre-
tarsal subcutaneous tissue, believing that it is better
to have only skin over the anterior surface of the tar-
EARL ...
sus. My experience differs, and I remove pretarsal tis-
sue only if pretarsal fat is quite apparent and
threatens the surgical formation of the desired upper
P Dynamic crease of the
upper eyelid is a surgically created crease
that fades on downgaze. A static crease remains
lid crease. In the pretarsal plane of a creaseless Asian obvious on downgaze.
eyelid, there are few if any terminal interdigitations
of the levator aponeurosis to the dermis. I refrain from
vigorous dissection along the pretarsal plane, as I feel I use 6-0 nonabsorbable suture (6-0 silk or nylon)
that it creates prolonged postoperative edema and can to pick up the lower skin edge and subcutaneous tis-
risk undesirable formation of more than one crease. sue, the levator aponeurosis along the superior tarsal
Furthermore, it is quite natural for Asians born with a border, and then the upper skin edge, and tie each of
natural crease to have some degree of pretarsal full- these with an interrupted suture.
ness along the area between the crease and the Besides the stitch over the center of the crease, I
eyelashes. place two or three sutures medially and two laterally
CHEN15-211-224.I 3/22/01 2:00 PM Page 218
FIGURE 15–13 The wound is closed with five inter-

rupted 6-0 sutures and a continuous 7-0 nylon suture.
(Fig. 15–13). With these five or six crease-forming FIGURE 15–14 Cross-sectional drawing of an Asian upper
sutures in place, the rest of the incision may be closed eyelid without upper lid crease. Black dots correspond to lines
using 6-0 or 7-0 nylon in a continuous or subcuticular of skin incision. Solid arrows correspond to the transorbicu-
fashion. laris vector from skin to orbital septum. Dotted arrows show
possible plane of dissection through the preaponeurotic fat-
TRIANGULAR, TRAPEZOIDAL, pads. Trapezoidal debulking of preaponeurotic tissues in
Asian blepharoplasty may include all tissues bounded by the
AND RECTANGULAR DEBULKING upper and lower transorbicularis vectors, and that between
OF EYELID TISSUES the skin and the orbital septum. Minimal fat excision may also
During a double eyelid procedure by way of the external be included.
incision method, leaving behind a platform of tissues
anterior to the superior tarsal border will interfere with neurotic tissues, including at times a minimal amount
the definition and formation of the proposed crease. The of preaponeurotic fat, the orbital septum, supratarsal
various attempts in removing skin,9 skin with orbicu- orbicularis, subcutaneous fat, and overlying skin
laris, skin with pretarsal fat, skin with muscle and sep- (62 mm), all of which hinges along the superior tarsal
tum, and preaponeurotic fat are all attempts at creating border, may be debulked. The anterior surface of this
a clear platform for the formation of adhesions between conceptual trapezoid consists of the skin, whereas the
fibers of the levator aponeurosis and the subcutaneous posterior portion of the trapezoid is wider and
structure of the surgically created crease.10–14 includes all preaponeurotic tissues from the opened
Triangular and trapezoidal debulking allows a sys- orbital septum down to the superior tarsal border.
tematic and uniform cleaning of the preaponeurotic 3. A small strand of the pretarsal orbicularis along the
space along the superior tarsal border and the pretarsal inferior skin incision may be trimmed off.
plane. As Figure 15–14 shows: 4. The trapezoidal debulking allows easy inward
1. When skin excision (6 2 mm) is carried out in con- folding of the skin edges toward the underlying
junction with the lid crease placement, retracting aponeurosis, facilitating the surgical formation of
the upper skin incision edge allows an upwardly the crease. Collin et al’s 4 electron microscopic
beveled plane of dissection to proceed across supra- study described insertions of distal strands of the
tarsal orbicularis oculi muscle and the lower por- levator aponeurosis into the septa in between pre-
tion of the orbital septum. (In Asians who do not tarsal orbicularis oculi muscle fibers, rather than
have a crease in the upper lid, the orbital septum is into any subdermal tissue along the lid crease in
frequently fused to the levator aponeurosis at 2 to 4 those eyelids that had crease. Should this be the
mm above the superior tarsal border, and it can be case, formation of a crease may be facilitated by
as low as halfway down the anterior surface of the the above surgical maneuver as it links the
tarsus.) The septum and underlying preaponeurotic aponeurosis to the upper border of the pretarsal
fat pads are easily identified. platform. Vigorous dissection and debulking of
2. The septum orbitale is opened horizontally. This pretarsal tissues is to be avoided for reasons men-
trapezoid (viewed from cross section) of preapo- tioned in previous discussions.
CHEN15-211-224.I 3/22/01 2:00 PM Page 219
If debulking is carried out without including any In triangular debulking (without skin removal):
skin excision, the block of tissue removed resembles a
triangular configuration in cross-sectional view. Amount of Orbicularis
If the patient has a great deal of skin redundancy, Amount of Skin
the amount of skin included for excision is increased = Infinity (or n, with n W 1)
by moving up the upper line of skin incision. The (Vertical measurement of tissues)
plane of dissection through the orbicularis becomes
less beveled and the trapezoidal debulking gradually As you proceed to trapezoidal and rectangular
turns into more of a rectangular configuration. debulking, the ratio of orbicularis to skin removal, as
Figure 15–15 shows the transorbicularis vector measured vertically, approaches a 1 : 1 ratio (n = 1).
(step 2) for the dissection plane rotating counter- The ratio will be less than 1.0 only when the
clockwise and leveling off as one removes more skin amount of skin redundancy is truly excessive, as in
and the upper line of skin incision A1[U]B moves fur- an elderly individual, allowing the removal of exces-
ther from the superior tarsal border. sive skin without compromising wound closure and
predisposition to ectropion and lagophthalmos of the
Triangular S Trapezoidal S Rectangular
upper lid. In this situation a “reverse” trapezoidal
Debulking Debulking Debulking
block of tissue is removed, with the height over the
S As more skin needs to be removed S skin side greater than the height of the preseptal
orbicularis excised. Even in this case with a great deal
of skin removal, the path through the orbicularis mus-
cle (transorbicularis vector) should still be perpendic-
ular to the levator palpebrae superioris muscle.
Therefore,
In young individuals,
d Amount of Orbicularis
W 1.0
d Amount of Skin
In elderly individuals,
d Amount of Orbicularis
d Amount of Skin
= 1:1, and occassionally 6 1.0
(d = difference)
In conclusion, the applications and advantages of

trapezoidal debulking in Asians blepharoplasty are as
follows:
1. It is an easier approach through the orbital septum

when the plane of dissection is beveled. It lessens
potential injury to levator aponeurosis when there
FIGURE 15–15 Schematic drawing showing anterior is a buffer of preaponeurotic fat pad underneath the
lamella of upper eyelid, with orbicularis of the supratarsal septum.
region and skin lying anterior to the orbital septum. The 2. It allows for a controlled, uniform debulking of the
first surgical step involves upper and lower lines of inci- junctional platform in the supratarsal and pretarsal
sions, 1(U) and 1(L) above the superior tarsal border (STB). region.
The second step involves an oblique transection through the 3. It allows optimal formation of adhesions between
orbicularis (2) via the transorbicularis vector line. The third the levator aponeurosis and the inferior subcuta-
step (3), upon reaching and opening of the orbital septum,
neous tissues, or to intermuscular septa within pre-
one dissects inferiorly toward the superior tarsal border.
tarsal orbicularis oculi muscle fibers (pretarsal
Step 4 shows a leveled excision of orbicularis and redun-
dant skin above the superior tarsal border. The transorbic- platform).
ularis vector rotates and levels off as more skin needs to be 4. It allows crease formation to be based on the indi-
removed, such that the cross section of soft tissues that are vidual’s tarsus height.
debulked changes from a triangular, to a trapezoidal, and 5. It reduces the complication rate—including prob-
finally to a rectangular configuration. lems with asymmetry, shape, height, continuity,
CHEN15-211-224.I 3/22/01 2:00 PM Page 220
permanency, segmentation of crease due to uneven on the individual’s tarsal height using Asian bleph-
planes of dissection, fading and late disappearance aroplasty, performing only skin excision plus
of crease, multiple creases, and persistent edema. levator aponeurotic repair (resection and/or
advancement).
SPECIAL CONSIDERATIONS
When Elderly Asian Patients
Do not Have a Preexisting Crease,
The concept of triangular, trapezoidal and They Have an Option of Having a Crease Added
rectangular debulking of the preaponeurotic 1. Dermatochalasis alone is corrected by Asian ble-
platform is applicable universally to upper pharoplasty with excision of the dermatochalasis and
eyelid surgery in Asians and Caucasians, creation of a lid crease (if the patient desires one).
and in cases with challenging lid crease 2. Dermatochalasis with fatty prolapse is corrected by
management problem. Asian blepharoplasty with excision of the derma-
tochalasis and creation of a lid crease (if the patient
desires one), with trimming of only enough fat to
CLINICAL APPLICATION allow creation of a crease. (Note: excess fat exci-
sion will result in enhancement of the supratarsal
Elderly Asian patients, with or without a prior
sulcus.)
upper lid crease, may present with dermatochalasis
3. Dermatochalasis with ptosis is corrected by skin
alone (Fig. 15–16), dermatochalasis with fatty pro-
excision–only Asian blepharoplasty, with creation
lapse (Fig. 15–17), or dermatochalasis with ptosis.
of a lid crease, plus levator aponeurotic repair
When the Elderly Asian Patient (resection and/or advancement).
Has a Preexisting Crease
(See Pathway in Fig. 15–18) THE SUTURE LIGATION METHOD
1. Dermatochalasis alone is corrected by preserving
the crease, and performing a skin-excision ble- Along the same spectrum, the surgical goal of the con-
pharoplasty. junctival ligation (suturing) approach is to create a
2. Dermatochalasis with fatty prolapse is best han- surgical adhesion between the soft tissues just above
dled by preserving the crease, and performing a the tarsal plate to the overlying skin whether the sur-
blepharoplasty with trimming of only enough fat gical ligature is first inserted through the conjunctival
above the superior tarsal border to allow preserva- side or from the skin side, and whether it is ligated
tion of the crease. (Note: excess fat excision will with the suture knot buried under the subcutaneous
result in deepening of the supratarsal sulcus.) side or the subconjunctival side. There are usually
3. In dermatochalasis with ptosis, the crease has often three to five stitches used with variations of this
migrated upward; the crease should be reset based method. The method does not involve any excision or
removal of soft tissue and therefore will not correct
for any anatomic soft tissue redundancy. It works rel-
atively well only for young adults in their early twen-
ties. Beyond this age group, the natural increase in
soft tissue mass over the preaponeurotic platform,
whether arising from aging or from gravitational sag-
ging, will make the suture ligation method (without
tissue excision) less effective.
FIGURE 15–16 Asian patient showing dermatochalasis FIGURE 15–17 Asian patient showing dermatochalasis
of the upper eyelid. with fatty prolapse over the upper eyelid.
CHEN15-211-224.I 3/22/01 2:00 PM Page 221
Upper lid of elderly Asian patient
With crease Without crease
Dermatochalasis Dermatochalasis Dermatochalasis

+ fat + ptosis
Skin excision Skin + minimal Aponeurotic repair,

blepharoplasty, fat removal, reset crease to Asians'
preserve crease preserve crease tarsal height
Patient wants crease Stay with no crease

+ fat + ptosis
Asian blepharoplasty Asian Asian

plus crease formation blepharoplasty blepharoplasty
minimal fat aponeurotic repair,
excision, plus crease
plus crease formation
formation

+ fat + ptosis
Asian blepharoplasty Asian Asian

blepharoplasty blepharoplasty
minimal fat plus aponeurotic
excision repair
FIGURE 15–18 Surgical solutions for Asian blepharoplasty in elderly patients.
Patients’ complaints may include persistent foreign

body sensation; irregularity in the contour of the PITFALL
crease (for example, “bamboolike” truncation of por-
tions of the crease); unevenness in the depth of the
Removal of preaponeurotic fat pads in Asian
crease in the medial, central, or lateral third of the eye-
lid; granuloma formation; and “static” appearance of
blepharoplasty should be avoided, especially
the crease on downgaze. in older patients, to reduce the possibility of
enhancing the supratarsal sulcus, a feature
that is aesthetically undesirable in Asians.
SUBOPTIMAL RESULTS
AND COMPLICATIONS
For Asians who request placement of a conservative Often, physicians are coerced by the patients into
upper lid crease, removal of preaponeurotic fat is creating a high crease. Asians in general have smaller
often unnecessary and should be avoided because it physiques not only in terms of weight and height but
may lead to a prominent supratrasal sulcus. also in the size of their tarsus, eyelid width, distance
CHEN15-211-224.I 3/22/01 2:00 PM Page 222
from upper lid margin to the lower border of the will create for him/her on the upper eyelids. A line
brow, etc. Since Western physicians often consider 9 is described by several parameters in mathematics
to 10 mm as the average upper eyelid crease height, a and geometry: It can be described by its length (the
crease that they would consider “high” will therefore horizontal extent or width along the superior tarsal
be greater than 9 to 10 mm and much higher than the border), shape (the geometric configuration), height
superior border of the upper tarsus in an Asian. When (the relative separation from the eyelash margin and
a “high crease” as requested by an Asian patient is its spatial relationship to the medial and lateral can-
then executed by Western physicians, it is anatomi- thi), continuity (whether the crease is continuous or
cally inappropriate and aesthetically undesirable as it broken apart), and permanency (whether it stays per-
tends to lead to lagophthalmos from any placement manent in appearance). Symmetry between the two
of skin-levator-skin fixation sutures or inferior subcu- lids can occur only if all of the above parameters are
taneous orbicularis muscle-to-levator aponeurosis accurate, correct, and equally well executed on both
sutures. It is almost always undesirable to create a sides.
high crease in Asians; the visual impact is an image By now one understands that aesthetic Asian
of a crease bisecting the zone between the eyebrow eyelid surgery is not as easy as it seems. The surgery
and the upper eyelid margin. demands nothing short of perfection in performing
these points. To take the simplest: if the shape is not
properly chosen, either as a parallel crease or a nasally
PITFALL tapered crease, one can end up with a semilunar
crease and a “Westernized” look, which is not what
an Asian prefers. The Asian patient wants to look like
It is always undesirable to create a high
his/her Asian friend who is born with a natural,
crease in Asians. Asian-looking crease. One can also get a bifid crease
medially, or one with an exaggerated upward flare
laterally. Asymmetry may occur between the two
To reduce fullness in the pretarsal space, some sur- creases simply because they are different in shape
geons advocate aggressive excision of pretarsal fat (Fig. 15–19).
and some orbicularis to ensure that the pretarsal skin If the height is not properly executed based on the
lies flat against the tarsus postoperatively. central tarsal height, you can get an excessively high
Fullness in the pretarsal area is not always undesir- crease (Fig. 15–20). It can occur from incorrect place-
able. When the pretarsal area is abnormally oversized, ment of the incision line, from poor suture placement
it is usually a result of a crease that is placed too high (on to tarsus, orbital septum, levator aponeurosis, or
to start with, leaving more tissue in between this orbicularis oculi), or persistent edema. A low crease
high crease and the lid margin. Aggressive dissection may occur, although it is rare. Excessive fat removal
or excision of pretarsal tissues tends to lead to persis- will lead to a “famined” look with an exaggerated and
tent lymphedema and risks formation of multiple
pseudo-creases in the pretarsal region. It is more effec-
tive to create a crease fit for that individual that is based
on the height of his or her tarsus (measuring 6.5 to
8.0 mm), and to excise no more than 2 to 3 mm of the
pretarsal orbicularis oculi muscle along the inferior cut
edge of the skin incision.
...
P EARL The evaluation and man-
agement of suboptimal results in Asian
eyelid surgery is best performed by subspecialty-
trained oculoplastic ophthalmologists.
Almost all suboptimal results and complications

arise from failure to observe the following points:
In those patients who do not have a crease and
desire an Asian blepharoplasty, the only thing that FIGURE 15–19 Circle of complications in Asian bleph-
matters to that patient is the new crease line that you aroplasty.
CHEN15-211-224.I 3/22/01 2:00 PM Page 223
FIGURE 15–20 The crease over the left upper eyelid

appears high, semilunar, and asymmetric. Contributing fac-
tors may include inadvertent high placement of incision
line, excessively high placement of crease-forming sutures,
excessive dissection in the preaponeurotic plane, and exces-
sive fat excision.
hollowed supratarsal sulcus (Fig. 15–21), which is a

very undesirable feature on an Asian face. Multiple
creases (Fig. 15–22) are more prone to occur if the inci-
FIGURE 15–21 Excessive fat removal has resulted in a
sion is too high above the superior tarsal border, or if
prominent supratarsal sulcus. Note the lack of separation
excessive dissection has been carried out along the
from the superior orbital rim of the brow and the visual con-
pretarsal plane or within the preaponeurotic (post- fusion with a faint rudimentary crease beneath it.
septal) space.
Problems with continuity can give rise to a frag-
mented (discontinuous) crease, a shallow rudimentary skin and soft tissue above it. This results in hooding
crease, or a partially (Fig. 15–23) or completely oblit- of eyelid tissue above the crease in essence shielding
erated crease. An otherwise properly formed crease the real crease when the individual is viewed face on
may look obliterated due to inadequate removal of looking straight ahead.
Permanency problems include late disappearance
of crease (which is seen more with the conjunctival
suturing method widely practiced in Japan and
China), and downward shifting and progressive shal-
lowing of the crease (Fig. 15–24). The latter arise from
inadequate subdermal attachment of the distal fibers
of the levator aponeurosis at the level of the superior
tarsal border. Fading of the medial one-third of the
crease is also a fairly common occurrence and is often
due to an inability to adequately fixate the most
FIGURE 15–22 Multiple creases occurred in this patient; medial portion of the levator aponeurosis to the skin
the most likely cause is excessive dissection in the pre- edges. The result is a crease that runs over only the
aponeurotic space and the supratarsal sulcus. Similarly, lateral two-thirds of the palpabral fissure.
multiple creases can occur in the pretarsal plane from exces-
sive dissection in the pretarsal plane.
FIGURE 15–23 Partial crease formation seen in a young FIGURE 15–24 A young woman who had undergone
Asian woman following a double-eyelid crease procedure conjunctival suturing procedure for creation of lid crease.
utilizing the suture ligation method. The left upper lid crease had disappeared after 1 year.
CHEN15-211-224.I 3/22/01 2:00 PM Page 224
CONCLUSION ing disorders, and use of herbal medicines and antico-

agulants), propensity for scar formation, variation in
If one can achieve correct length (width), correct shape, skin types, and poor patient compliance.
correct height, keeping it continuous and permanent, Lastly, a corollary to this discussion is that any cor-
and equally on both sides, then one has eliminated all rection of suboptimal results in Asian eyelid surgery
identifiable surgical inconsistencies and can hope to requires accurate identification as to which of the
achieve symmetry and optimal results, barring unfore- above parameters are involved, followed by coopera-
seen variables like bleeding (from hypertension, bleed- tive blending and reversal of those causes.
REFERENCES
1. Chen WP: Asian blepharoplasty—anatomy and tech- Surgery, 3rd ed. Philadelphia: WB Saunders, 1999;
nique. J Ophthalmic Plast Reconstr Surg 1987;3(3): 101–111.
135–140. 8. Chen WPD: Eyelid and eyelid skin diseases. In: Lee D,
2. Chen WP: A comparision of Caucasian and Asian ble- Higginbotham E, eds. Clinical Guide to Comprehensive
pharoplasty. Ophthalmic Pract, 1991;9(5):216–222. Ophthalmology. New York: Thieme, 1998:137–182.
3. Uchida J: A surgical procedure for blepharoptosis vera 9. Sayoc BT: Plastic construction of the superior palpebral
and for pseudo-blepharoptosis orientalis. Br J Plast Surg fold. Am J Ophthalmol 1954;38:556–559.
1962;15:271–276. 10. Hayashi K: The Double eyelid operation. Jan Rev Clin
4. Collin JR, Beard C, Wood I: Experimental and clinical Ophthalmol 1938;33:1000–1010,1098–1110.
data on the insertion of the levator palpebrae superi- 11. Fernandez LR: Double eyelid operation in the Oriental
oris muscle. Am J Ophthalmol 1978;85:792–801. in Hawaii. Plast Reconstr Surg 1960;25(3):257–264.
5. Chen WPD: Asian Blepharoplasty (A Surgical Atlas). 12. Inoue, S: The double eyelid operation. Jpn Rev Clin Oph-
Newton, MA: Butterworth and Heinemann, 1995. thalmol 1947;42:306.
6. Chen WPD: Concept of triangular, rectangular and trape- 13. Mitsui Y: Plastic construction of a double eyelid. Jpn
zoidal debulking of eyelid tissues: application in Asian Rev Clin Ophthalmol 1956;44:19.
blepharoplasty. Plast Reconstr Surg 1996;97(1):212–218. 14. Sayoc BT: Anatomic considerations in the plastic con-
7. Chen WP: Upper eyelid blepharoplasty in the Asian struction of a palpebral fold in the full upper eyelid.
patient. In: Putterman A, ed. Cosmetic Oculoplastic Am J Ophthalmol 1996;63:155–158.
CHEN16-225-242.I 3/26/01 9:13 AM Page 225
Chapter 16
PERIOCULAR SKIN LESIONS AND

COMMON EYELID TUMORS
Gloria M. Bertucci
Lesions of the eyelid include a variety of conditions that carcinoma and sebaceous carcinoma. These stains
may be of cosmetic concern, cause functional impair- allow for the determination of ultrastructural (elec-
ment, or be locally destructive or life-threatening. This tron microscopic) characteristics at the light micro-
chapter discusses the common, and some of the less scopic level. The use of any of these special stains may
common, eyelid tumors and inflammatory processes. result in a delay in final diagnosis.
Clinically, lesions are often described as solid or This chapter divides lesions into benign, preinva-
cystic, flat or elevated, ulcerated or intact, single or sive, and malignant categories. Many times the clini-
multiple, and pigmented or nonpigmented, and their cal impression is accurate, and histopathology is
clinical behavior is predicted based on an appraisal of merely confirmatory. However, the clinical appear-
these features. ance can be deceptive, sometimes significantly so
Assessing pigmented lesions is a special challenge (Table 16–1), which is why histologic examination
clinically. These lesions include both benign and
malignant conditions, such as nevomelanocytic TABLE 16–1 DISCORDANT CLINICAL AND
lesions, pigmented seborrheic keratosis, pigmented PATHOLOGIC DIAGNOSES
basal cell carcinoma, and cysts that appear pig-
mented.1 Melanomas are the most significant of the Clinical impression Final pathologic diagnosis
pigmented lesions clinically, but are infrequent com-
pared to other pigmented lesions, and histopathologic Blepharitis; chalazion Sebaceous carcinoma
confirmation is always required.2 Cyst Cystic basal cell carcinoma
Hemangioma; boil Merkel cell carcinoma
Histopathologic study involves a process of tissue
Melanoma Pigmented basal cell
fixation (usually formalin), paraffin embedding, and
carcinoma
cutting and staining of slides. The standard stain is Nevus; melanoma Pigmented seborrheic
hematoxylin and eosin (H&E), which provides infor- keratosis
mation about the nuclear and cytoplasmic character- Basal cell carcinoma Amelanotic nevus
istics that facilitates reaching a definitive diagnosis in Basal cell carcinoma Trichoepithelioma
the vast majority of cases. For cases in which a fungal Hemangioma Spitz nevus
or mycobacterial (acid-fast bacterial, AFB) etiology Cyst; angioma Pilomatricoma
needs to be excluded, special stains for these organ- Seborrheic keratosis Intradermal nevus
isms can be used. For these cases submission of a sep- Squamous papilloma Polypoid nevus
arate piece of fresh tissue for culture is the best Keratosis Hyperkeratotic nevus
approach. Immunoperoxidase stains and other spe-
cial stains are available to the pathologist, but these Clinical characteristics such as size, pigmentation, color, eleva-
tion, and cystic appearance can sometimes be misleading, giving
stains are rarely used in the diagnostic evaluation of an incorrect clinical impression. The listed lesions are not infre-
eyelid lesions, except in the diagnosis of Merkel cell quently misdiagnosed based on clinical features.
225
CHEN16-225-242.I 3/22/01 2:25 PM Page 226
should always be obtained on biopsied or excised eye- contrast to most malignant tumors, benign tumors
lid and periorbital lesions. When the clinical impres- favor the upper lid.4 Benign lesions do not interfere
sion of malignancy is strong, and the biopsy is benign, with normal lash growth. There may be a history of sta-
rebiopsy is recommended.3 bility, although some are brought to attention because
of recent growth. Most studies reveal that the com-
BENIGN LESIONS monest benign noninflammatory tumors are squamous
papillomas, vascular tumors, nevi, cysts, and neural
Benign eyelid lesions include neoplastic tumors and tumors.4–6 But a variety of other epithelial lesions such
inflammatory conditions (Table 16–2). Benign tumors as seborrheic keratosis, certain adnexal tumors, and the
usually affect patients younger than 20 years of age. In inflammatory conditions are also not uncommon.
TABLE 16–2 BENIGN LESIONS
Condition Distinguishing clues
Squamous papilloma Papillary growth

No atypia
Lacks adnexal structures
Seborrheic keratosis Acanthosis with bland basaloid cells
Flat-based lesion
Horn cysts
Capillary hemangioma Proliferation of small capillaries
Fibrosis and vascular obliteration (if regressed)
Cavernous hemangioma Large dilated vascular spaces
Flattened endothelial lining cells
Pyogenic granuloma Radiating blood vessels
Surface ulceration
Glomus tumor Vascular proliferation
Surrounding glomus cells
Common acquired nevi Bland nevus cells
Symmetrical lesion
Multinucleated nevus cells
Blue nevus Intradermal spindled nevus cells
Heavy pigmentation (usually)
Fibrosis
Spitz nevus Reddish-colored nodule
Atypical melanocytes
Epithelial inclusions (Kamino bodies)
Divided nevus of the eyelid (“kissing nevus”) Involves upper and lower eyelids equally
Features of common acquired nevus
Nevus of Ota Increased deep dermal melanocytes in periocular skin
Associated with clinical ocular melanosis
Trichoepithelioma Basaloid cells
Abrupt keratinization
Trichilemmoma Clear cells
Hair follicles (occasionally)
Pilomatricoma Basaloid cells
Ghost cells
Giant cells
Calcification
Syringoma Small ducts with central cystic spaces
Comma-shaped tails
Fibrous stroma
Chondroid syringoma Tubules
Myxoid or chondroid stroma
(continues on next page)
CHEN16-225-242.I 3/22/01 2:25 PM Page 227
PERIOCULAR SKIN LESIONS AND COMMON EYELID TUMORS • 227
TABLE 16–2 (continued)
Sebaceous hyperplasia Dilated duct

Surrounding mature sebaceous lobules
Sebaceous adenoma Varying-sized sebaceous lobules
Varying stages of maturation
Hidrocystoma Cystic space(s)
Double-layered living cells
Epidermal inclusion cyst Squamous-lined cyst
Keratin contents
Dermoid cyst Squamous-lined cyst
Associated adnexal structures
Keratin and hair or sebaceous contents
Neurofibroma Disorganized proliferation of peripheral nerve
elements with wavy cytoplasm
Nonencapsulated
Hordeolum Tender lesion
Acute inflammation
Chalazion Chronic granulomatous inflammation
Empty spaces
Sarcoidosis Noncaseating granulomas
Giant cells
Special stains (and culture) negative for organisms
Xanthelasma Yellow appearance
Foamy histiocytes
Localized dystrophic periocular calcification Subcutaneous calcification
Partial surface erosion
History of steroid injection
Classification of Epithelial Tumors Microscopically, there are several subtypes. The

commonest subtype is the acanthotic seborrheic keratosis,
Squamous Papilloma (Acrochordon, Skin Tag,
which shows abrupt acanthosis formed of a prolifer-
Fibroepithelial Polyp)
ation of uniform basaloid cells. The base of the acan-
Squamous papillomas are papillary lesions that usu- thotic epidermis is flat.9 Keratin-filled cysts (horn
ally present no problem in clinical diagnosis. They are cysts) and entrapped keratin (pseudohorn cysts) are
considered in some reports to be the most common characteristic.10 There is no atypia (Fig. 16–1).
benign eyelid lesion.7, 8 They often are multiple, and
can involve the lid margin.8 Microscopically, they are
characterized by a papillary growth consisting of a
fibrovascular stalk lacking adnexal structures, covered
by a benign acanthotic epidermis that may show over-
lying hyperkeratosis.
Seborrheic Keratosis
Seborrheic keratoses are lesions of the epidermis.
They are age-related lesions, appearing sponta-
neously in the middle-aged and elderly, and
increasing in number with age. 9 They are well-
demarcated plaques ranging in size from a few
millimeters to several centimeters, and are light to
dark brown in color, with a velvety to granular, cob- FIGURE 16–1 Seborrheic keratosis, acanthotic variant.
blestoned surface. 10 They show a characteristic This plaque-like lesion is flat-based, with a proliferation of
“stuck-on” appearance, thus the previous designa- bland epidermal cells and formation of horn cysts. (H&E,
tion of stucco keratosis. 20*)
CHEN16-225-242.I 3/22/01 2:25 PM Page 228
Variants Hyperkeratotic seborrheic keratosis is char-

acterized by marked surface papillomatosis and
hyperkeratosis.
Irritated seborrheic keratosis, also known as inverted
follicular keratosis, occurs when a seborrheic keratosis
involves hair follicle structures. Microscopically, it
shows small squamous eddies and can be confused
with a squamous carcinoma.
Pigmented seborrheic keratosis, which can clinically
be confused with a benign nevus or even a melanoma,
microscopically shows the usual appearance, but with
the additional finding of abundant melanin in the
basaloid cells.
Classification of Vascular Tumors FIGURE 16–2 Capillary hemangioma. There is a prolif-

eration of small and medium-sized thin-walled vascular
Capillary Hemangiomas channels with flattenned lining cells. (H&E 100*)
These benign lesions, sometimes referred to as straw-
berry nevus, are usually congenital but can occur in fibrous stroma with scattered chronic inflammatory
adults as acquired lesions.11 In the congenital form, cells. Occasional calcifications or possible phlebolith
the lesions are usually obvious at birth or within a few may be seen.12
weeks of life. A red-purple, slightly elevated, soft
mass that enlarges over the first 6 months is charac- Pyogenic Granuloma
teristic. The lesion then undergoes regression with The term pyogenic granuloma is a misnomer in that this
fading. It has been estimated that 30% of lesions lesion is neither pyogenic (pus-producing) nor gran-
regress by age 3, and 75 to 90% by age 7.8 In adults it ulomatous. It is a rapidly growing polypoid lesion of
can present as a blue nodular mass that grows for sev- blood vessels, which may easily bleed. The growth
eral months before stabilizing.11 usually follows minor trauma or surgery.8
Microscopically, there is a granulation tissue–like
proliferation of radiating blood vessels with associ-
EARL... Congenital capillary heman-
P giomas are not usually biopsied, but are
allowed to regress.9
ated inflammation and overlying ulceration.
Glomus Tumor
The glomus tumor is usually a painful lesion, primar-
ily of the digits, but has rarely been reported on the
Incompletely regressed lesions occasionally may be eyelid.13 When present, it is described as an enlarging
removed and will show the regressive features violaceous to blue mass.13 These lesions occur in two
described below. Others may be treated. Those clinical settings: solitary sporadic lesions and multi-
treated with steroids can develop changes of localized ple familial lesions.13 The blood vessels of the latter
dystrophic periocular calcification (see below). type are larger and less painful.9
Histologically, the early lesions are lobulated Histologically, glomus tumors are composed of
masses of small tight capillaries with plump endothe- blood vessels with a surrounding proliferation of glo-
lial lining cells. Soon the lining cells flatten as blood mus cells, which are uniform small dark cells7 that
flow is established (Fig. 16–2). With regression, inter- normally function to control blood flow to the capil-
stitial and septal fibrous tissue become more promi- lary bed.
nent, and the vessels may obliterate. Fat can replace
the periphery of the lobules.8 Classification of Nevi
Common Acquired Nevi
Cavernous Hemangiomas Common acquired nevi include junctional, com-
These lesions are less frequent than capillary heman- pound, and intradermal nevi. Nevi are lesions char-
giomas, and usually present from ages 10 to 30. They acterized by the accumulation of nevus cells in the
grow slowly and do not regress. The color depends skin or mucosal surfaces. They can occur virtually
on the location of the vessels within the skin: blue if anywhere on the body and show different degrees of
superficial, to no appreciable color change if deep.12 pigmentation. On the eyelid they frequently involve
Microscopically, the lesion shows large blood-filled the margin, without loss of the eyelashes. A typical
spaces lined by flattened endothelium, within a nevus can be flat, elevated, or polypoid. It is well
CHEN16-225-242.I 3/22/01 2:25 PM Page 229
demarcated, evenly pigmented, symmetrical, and epidermis, which is histologically normal. The clini-
nonulcerated. cal blue coloration is attributed to the presence of
Microscopic exam shows nevus cells that are small melanin pigment deep in the dermis.9 Patients with
and bland with uniform nuclei. Those at the dermal- periorbital cellular blue nevus present with a bluish
epidermal junction are nested, whereas those in the discoloration of the eyelid in the preteen years. Rare
dermis can be nested or sheetlike. Some cells may cases of melanoma arising in the nevus and intracra-
demonstrate intranuclear pseudoinclusions, which nial melanoma in association with the nevus are
are pale-staining areas within the nucleus.7 Others described.14
may be multinucleated giant nevus cells, which are
benign. The three types of acquired nevi are classified
Spitz Nevus
based on the location of the nevus cells.
The Spitz nevus is a benign lesion that histopatholog-
ically can be confused with melanoma. Spitz nevi are
EARL... In junctional nevi, the nests
P
very vascular lesions with sparsely pigmented spin-
dled and epithelioid nevus cells that show significant
of nevus cells are limited to the tips of epi-
atypia, but with an overall constellation of features
dermal rete ridges along the dermal-epidermal that to the experienced pathologist is recognized as
junction. In compound nevi, nevus cells are pre- benign. Eosinophilic epithelial inclusions known
sent both at the junction and in the dermis. In as Kamino bodies are characteristic.9 Spitz nevi usu-
intradermal nevi, the nevus cells are exclusively ally occur in young children, accounting for its previ-
within the dermis (Fig. 16–3). ous designation as juvenile melanoma. On the eyelid,
it can present as a rapidly growing red nodule and be
clinically misinterpreted as a hemangioma.15 The high
There is some clinical correlation with these histo- vascularity and the low melanin content give the
logic features. Junctional nevi are flat and hyperpig- lesion a reddish hue.8
mented. Compound nevi are typically pigmented
papules. Intradermal nevi are papular or polypoid Divided Nevus of the Eyelid (“Kissing Nevus”)
and may be only lightly pigmented or skin-colored.7
The divided nevus is a rare lesion peculiar to the eye-
Polypoid compound or intradermal nevi can be clini-
lid. It is somewhat of a clinical curiosity. It is a nevus
cally confused with squamous papillomas. Hyperk-
that develops on the eyelid during fetal growth
eratotic nevi can grossly appear as keratoses.
when the upper and lower eyelids are still fused
together.16 Later in fetal life, at about the fifth gesta-
Blue Nevus tional month, the lids separate.8 At birth, nevi are
The blue nevus is a benign variant of the intradermal noted to equally involve both the upper and lower
nevus in which the nevus cells are spindled and usu- lid (Fig. 16–4). The histologic features are of a com-
ally heavily pigmented. There is associated dermal mon acquired nevus.
fibrosis.9 There is no involvement of the overlying
FIGURE 16–4 Divided (“kissing”) nevus. Nevi are pre-

FIGURE 16–3 Intradermal nevus. Nests and sheets of sent on upper and lower lids. This curiosity results from the
nevus cells fill the dermis. In this variant, no junctional nests development of a nevus during fetal life on the fused fetal
are present. (H&E 100*) eyelid.
CHEN16-225-242.I 3/22/01 2:25 PM Page 230
Nevus of Ota (Oculodermal Melanosis)

The nevus of Ota is a congenital melanosis12 also
known as oculodermal melanosis.17 In contrast to
pure ocular melanosis,12 the nevus of Ota is a condi-
tion of increased melanocytes not only in the uvea,
sclera, and episcleral tissues, but also associated with
increased melanocytes in the deep dermis of the eye-
lid and facial skin.12 The involvement has a trigeminal
distribution.7 On skin, the lesion appears brownish or
bluish, depending on the depth of the melanocytes in
the dermis.17 In the eyelid, the melanocytes are mid-
or deep dermal, spindled, and pigmented.7 Those on
the cheek are more superficial.17
FIGURE 16–5 Trichoepithelioma. This adnexal tumor of

EARL... The nevus of Ota is impor-
P tant because of its association with pri-
mary meningeal melanoma,18 and reports of
follicular (hair) differentiation can be difficult to distinguish
from a basal cell carcinoma. There are nests of basaloid cells,
but several show abrupt central keratinization, indicating
an attempt at hair formation. (H&E 20*)
melanomas arising in the brain, orbit, and uveal
autosomal-dominant condition that also includes
tract in association with a nevus of Ota are well
multiple hamartomas of the gastrointestinal tract,
known. acral keratoses, and early-onset breast cancer in
women.
Microscopically, trichilemmoma consists of lob-
There are also a few cases of primary cutaneous ules of clear cells that contain glycogen, and there
melanoma arising in the nevus of Ota.19 may be areas of hair follicles or even of squamous
differentiation.12 The periphery of the lobules can
Classification of Adnexal Tumors show basaloid cells with palisading. 7 The surface
The skin of the eyelid contains adnexal structures, and may be hyperkeratotic. The features can be confused
therefore adnexal tumors similar to those elsewhere with those of basal cell carcinoma or squamous
on the body can occur on the eyelid. Adnexal tumors carcinoma.12
show differentiation toward the normal appendage
structures, which can be divided accordingly into four Pilomatricomas (Calcifying Epitheliomas of
groups: follicular (hair) differentiation, eccrine sweat Malherbe)
gland differentiation, sebaceous differentiation, and Pilomatricomas are uncommon lesions of hair follicle
apocrine sweat gland differentiation. origin that occur on the face (cheek, eyelid, and fore-
head), neck and scalp,20 usually in young patients,9
Trichoepitheliomas with 60% younger than 20 years.8 They are hard,
Trichoepitheliomas occur on any hair-bearing area. slow-growing nodules that can cause pain or inflam-
They are small, firm nodules, 2 to 8 mm, that can clin- mation and ulceration.20 They present as 0.5- to 3-cm
ically resemble basal cell carcinoma, and even lesions.7 They are deep-seated but freely movable der-
histopathologically the distinction can be difficult. mal lesions. In the eye area, they favor the upper eye-
Multiple trichoepitheliomas are inherited as a genetic lid and brow.8 They may have a red-pink or blue-red
trait and occur in the young, but solitary trichoep- appearance, and clinically can resemble a cyst or
itheliomas appear late in life.12 angioma.8 The diagnosis can be suggested by extru-
Histologically, they show nests of basaloid cells sion of tiny hard granular material,9 which represents
with central abrupt keratinization.12 The pattern reca- calcifications.
pitulates developing hairs. Unlike basal cell carci- Histologic study shows a lobulated mass with a
noma, there is no mitotic activity or individual cell characteristic combination of small darkly staining
necrosis (Fig. 16–5). islands of basaloid cells showing abrupt transition to
other “shadow cells” or “ghost cells,” which are pale-
Trichilemmomas staining and lack nuclei. Basaloid cells tend to favor the
Trichilemmomas arise from the outer hair sheath. periphery of the lobules.8, 12 Variable amounts of calci-
These are usually solitary and small; however mul- fication and even ossification are present. A focal or
tiple lesions can occur in Cowden disease, 12 an florid foreign-body giant cell reaction can be present.
CHEN16-225-242.I 3/22/01 2:25 PM Page 231
FIGURE 16–6 Pilomatricoma. Anucleated “ghost” cells FIGURE 16–7 Syringoma. A proliferation of small duc-
are partially surrounded by darkly staining basaloid cells, tules with curved “comma-shaped” tails is present in the
and by foreign-body giant cells. (H&E 100*) dermis. A normal hair structure is present upper right.
(H&E 100*)
The appearance of the basaloid cells alone can be wor- Classification of Cysts
risome, but the unique combination of features is
Hidrocystomas
diagnostic of this benign process8 (Fig. 16–6).
These are actually cystic adnexal lesions. They may be
Syringomas of either eccrine or apocrine origin, and are small
These lesions are considered of eccrine sweat gland (1–3 mm) bluish cystic nodules. On the eyelid they
origin.8 Syringomas can present as solitary or as coa- originate from the blocked ducts of the glands of Moll
lesced plaquelike lesions. They may be limited to the and therefore are concentrated along the lid margin.7
lower eyelid,10 or they can also involve other parts of Histologically, there are single or multiple cystic
the body.21 They are usually seen in young women as spaces with pale-staining contents lined by a double
yellow, waxy small nodules 1 to 2 mm in size.8 There layer of cells, which in the apocrine variety shows
is a characteristic microscopic appearance of small an inner layer with papillary projections12 and cells
ductal structures with central cystic lumina, with sev- with decapitation secretion. Differentiation between
eral of the ducts having curved, comma-shaped tails. the eccrine and apocrine types may be difficult. 9
The surrounding stroma is fibrous12 (Fig. 16–7). Incomplete removal of the cyst epithelium can lead
to recurrence.
Chondroid Syringomas (Mixed Tumors of Skin, Epidermal Inclusion Cysts (Epidermoid Cysts,
Pleomorphic Adenomas) Sebaceous Cysts)
These are 0.5- to 2-cm lesions present in the dermis, These very common lesions may result from minor
formed of tubules within a myxoid or chondroid trauma or after surgery. They are firm and painless
stroma. These tumors are histologically similar to cysts within the dermis and the subcutaneous tissues.7
tumors that occur in the lacrimal or salivary gland, They grossly contain pasty contents.
where they are referred to as pleomorphic adenomas.12 Microscopically, the cyst is lined by keratinizing
squamous epithelium and is filled with keratin mate-
Sebaceous Hyperplasia rial (Fig. 16–8). There may be a giant cell reaction if
These lesions typically occur in the elderly, and are the lining has ruptured. Connection to the overlying
common on the face, scalp, and eyelids. They are fre- epidermis is occasionally demonstrated, leading to
quently multiple, small (2–3 mm), soft, and yellow. the concept of origin from an inclusion of the surface
Microscopically, there is a single sebaceous gland epidermis. Most cysts show no such connection. An
with a dilated duct surrounded by mature seba- alternate explanation is that they may arise from
ceous lobules.12 infundibular (upper hair follicle) epithelium. These
cysts show no associated sebaceous element, and the
Sebaceous Adenomas term sebaceous cyst is a common misnomer.
These are usually solitary lesions that are larger than
the hyperplasias—up to 1 cm. Microscopically, there Dermoid Cyst
are several varying-sized sebaceous lobules at differ- The eyelid area and especially the superior temporal
ent stages of maturity.12 area are sites for this cyst. It typically occurs at the
CHEN16-225-242.I 3/22/01 2:25 PM Page 232
FIGURE 16–8 Epidermal inclusion cyst. A keratin-filled FIGURE 16–9 Neurofibroma. There is a proliferation of
squamous-lined cyst is present in the dermis. Here there is cells with small nuclei and abundant pink-staining wavy
no connection to the surface epidermis. (H&E 20*) cytoplasm, representing a disorganized growth of periph-
eral nerve type tissue. (H&E 100*)
zygomaticofrontal suture. These cysts are believed to
be congenital, but may not present until several years peripheral nerve.12 In cases in which the histopathol-
later due to slow growth.7 ogy needs to be differentiated from other soft tissue
Histopathologic study shows a cyst lined by kera- lesions, an immunoperoxidase stain for S-100 protein
tinizing squamous epithelium, but with adnexal can be performed and should be positive.
structures in the cyst wall. The cyst contents include
not only keratinaceous debris, but also the products of Classification of Inflammatory Lesions
the adnexal component, which may be sebaceous
material or hairs.7 Hordeolum
Hordeolum is an acute infection of the lid. It can be
Classification of Neural Lesions external or internal. External hordeolum (stye) is a puru-
lent inflammation of infected eyelash follicles and sur-
Neurofibromas rounding sebaceous (Zeis) and apocrine (Moll) glands
Neurofibromas can involve the soft tissues of the eye of the lid margin. It is usually due to staphylococcal
area as part of the clinical manifestation of neurofi- infection. Internal hordeolum involves the sebaceous
bromatosis (NF) or as an isolated finding. Those that (meibomian) glands of the tarsus. These present as
are part of NF present in the first decade.22 Neurofi- painful lesions. They usually localize and drain spon-
bromatosis type I (von Recklinghausen’s disease) has taneously. The inflammation can spread to other adja-
a frequency of 1 : 3000 and is characterized by multi- cent glands 7, 8 or to the apposing or contralateral
ple neurofibromas with cutaneous café-au-lait spots eyelid. The inflammation can also recur. When
and pigmented iris hamartoma (Lisch nodules). 10 inflammation persists or does not completely resolve,
There is frequent ocular involvement. A variant of a chalazion can secondarily form.
neurofibroma known as plexiform neurofibroma occurs
only in NF type I and involves the orbital soft tissues Chalazion
in a diffusely infiltrative way.12 This feature is impor- A chalazion is a localized lipogranulomatous inflam-
tant not only because of the local problems associated matory response involving the sebaceous glands (mei-
with the diffuse infiltration, but because of the ten- bomian or Zeis) of the eyelid. It occurs secondary to
dency of this variant to recur after surgery.23 Isolated obstruction of the gland duct. The obstruction can be
neurofibroma can involve the orbital area. It tends to the result of inflammation or infection, or of neoplastic
be a more localized although still unencapsulated lesions of the lid margin.8 Most chalazia resolve spon-
mass. This lesion is usually unassociated with neu- taneously after conservative treatment. Some require
rofibromatosis and occurs later in life, usually in incision and drainage. Intralesional injection with syn-
young and middle-aged adults.12 thetic glucocorticoids has been tried.24 Few require
Microscopically, neurofibroma shows a proliferation surgical removal.
of peripheral nerve elements in a loose disorganized Microscopically, there is chronic inflammation and
pattern that is nonencapsulated. The neural elements a granulomatous response, which may be loose or
tend to have abundant wavy cytoplasm (Fig. 16–9). The rather well formed, and which may surround empty
plexiform variant has a more organoid appearance spaces that are the residua of released fatty gland con-
with a proliferation of the terminal branches of the tents (Fig. 16–10).
CHEN16-225-242.I 3/22/01 2:25 PM Page 233
FIGURE 16–10 Chalazion. An empty space, which rep- FIGURE 16–11 Sarcoidosis. Noncaseating granulomata
resents released fatty gland contents, is surrounded by formed of epithelioid histiocytes and rimmed by chronic
chronic inflammation and a granulomatous reaction. (H&E inflammatory cells are present. Special stains for organisms
200*) should be negative. (H&E 100*)
Sarcoidosis the medial canthal area. They are soft yellow plaques
Sarcoidosis is a systemic condition that can affect skin. of varying size. Microscopic exam shows foamy histi-
The etiology is unknown. However, recently mycobac- ocytes in the dermis (Fig. 16–12). These lesions may
terial DNA has been identified in 80% of a small series be related to increased blood lipid (cholesterol or
of cutaneous lesions of sarcoidosis that were tested.25 It triglyceride) levels, but not always.7
has been reported that 23% of individuals with sar-
coidosis have eyelid lesions, which present as gray- Localized Dystrophic Periocular Calcification
white papules and nodules that may coalesce.7, 8 This is an acquired lesion secondary to treatment of
Microscopically, there are epithelioid granulomas, infantile hemangioma with intralesional steroids.26
nearly always noncaseating, in the superficial and Several months elapse from the time of the treatment
deep dermis (Fig. 16–11). There are associated giant to the clinical appearance of hard subcutaneous calci-
cells, some with inclusions of asteroid bodies and fications with partial surface erosion.26
Schaumann bodies. Special stains for acid-fast bacilli
and fungus should be negative. Cultures should ide-
ally also be done and be negative. Sarcoidosis is a
PREINVASIVE LESIONS (TABLE 16–3)
diagnosis by exclusion.7 Classification
Further Classifications Actinic Keratoses (Solar Keratoses)
Xanthelasma Actinic keratoses are intraepithelial squamous dys-
plasias that can range from mild atypia to squamous
These lesions of the middle-aged or elderly are usu-
carcinomas in situ. They occur on sun-damaged skin
ally bilateral on the upper and/or lower eyelids near
of middle-aged or older patients. They are scaly, flat,
TABLE 16–3 PREINVASIVE LESIONS
Actinic keratosis Atypical squamous cells in the

epidermis
Sparing of hair follicles
Dermal elastosis (sun-damaged
skin)
Lentigo maligna Atypical melanocytes along the
basal layer
Sun-damaged skin
FIGURE 16–12 Xanthelasma. Sheets of foamy histio- Dermal melanophages and
cytes fill the dermis. Residual compressed skin appendage inflammation
structures are apparent upper right. (H&E 100*)
CHEN16-225-242.I 3/22/01 2:25 PM Page 234
light brown pigmented, or erythematous, and mea-

...
P
sure from a few millimeters to up to 1 cm. There may EARL Approximately 20% of
be marked overlying hyperkeratosis (cutaneous
cases showing only lentigo maligna on
horn). Actinic keratoses only rarely become invasive,
and may actually regress.9, 12 biopsy will show areas of invasive lentigo maligna
Histologically, there are atypical squamous cells melanoma on excision.30 Lesions too large to
within the epidermis, which may be limited to the excise may be treated with cryosurgery 31 or
lower levels of the epidermis (mild) or involve the full radiotherapy.32
thickness (severe). The atypical cells tend to spare the
hair follicles.12 There is overlying alternating hyperk-
eratosis and parakeratosis.9, 10 Sun-damaged skin is Lentigo maligna that involves the conjunctiva
evidenced by dermal elastosis, a degenerative change responds well to cryotherapy. Microscopic exam of
of the dermal collagen that results in altered staining early lentigo maligna shows a flattened epidermis
characteristics (Fig. 16–13). with hyperplasia of atypical melanocytes present
singly and in groups along the basilar layer.9 These
Lentigo Maligna cells have enlarged, irregularly shaped and hyper-
(Melanotic Freckle, Hutchinson’s Freckle) chromatic nuclei. The atypical cells can extend down
Lentigo maligna is a flat pigmented lesion composed hair follicles. Later lesions show nested cells that are
of atypical melanocytes occurring on sun-exposed spindled.10 The dermis shows actinic damage, and
skin of the elderly.9 Ninety percent occur on the also contains melanophages and an inflammatory
face.27 It is slow-growing, often large, with irregular infiltrate (Fig. 16–14).
borders, and frequently extends beyond its clinically
apparent margins.28
MALIGNANT TUMORS
EARL... Lentigo maligna is a nonin-
P vasive form of melanoma, and can be con-
sidered the radial growth phase of melanoma.9
The frequency of eyelid malignancies is on the rise.33
In a review of 111 patients hospitalized from 1991 to
1995, malignant tumors of the eyelid accounted for
Excision is recommended because left untreated, 15% of malignant tumors of the face.34 Patients with
30 to 50% of cases will progress to invasive malignant eyelid tumors are generally over 40 years
lentigo maligna melanoma.29 old, 5 and typically over 60 years old.34 Males and
females are equally affected.35, 36 The tumors occur
nearly exclusively in whites, with only three of 206
Invasive melanoma may be heralded by the onset malignant neoplasms occurring in blacks in one
of nodularity; however, the invasive component may series.36, 37 The tumors usually involve the lower lid
not always be clinically apparent. and medial canthus. The most common malignant
FIGURE 16–13 Actinic keratosis. Atypical cells are pre- FIGURE 16–14 Lentigo maligna. Atypical melanocytes
sent in the lower portion of the epidermis (large arrow). are present along the basilar portion of the epidermis
These spare the hair follicles (arrowhead). Dermal elastosis (arrowheads). These involve the appendages (arrows). Der-
is present (between medium-size arrows). (H&E 200*) mal elastosis is present (asterisks). (H&E 100*)
CHEN16-225-242.I 3/22/01 2:25 PM Page 235
eyelid tumor is basal cell carcinoma. At a distant sec- Classification

ond is squamous carcinoma, followed by
melanoma,5, 34, 36 sebaceous carcinoma, and lym- Basal Cell Carcinoma
phoma37 (Table 16–4). Malignant eyelid tumors can
sometimes appear clinically benign. Therefore, all
EARL ... Basal cell carcinoma is
excised lid lesions should be examined histologically.3
P the most common malignant tumor of
the eyelid and periocular tissues,38 accounting
TABLE 16–4 MALIGNANT TUMORS
for about 90% of all eyelid malignancies.36, 39
Basal cell Dark basaloid tumor cells Only rare cases of basal cell carcinoma (BCC) involv-
carcinoma Buds from the overlying ing the lacrimal gland are reported, and these are
basal layer probably due to spread from skin after inadequate
Peripheral palisading control of the margins.38 Reviews of several hundred
Retraction spaces periocular basal cell carcinomas reveal that there is
Squamous cell Atypical squamoid cells preferential occurrence on the lower lid vs. upper lid
carcinoma Keratin pearls (sometimes) (35 to 66% vs. 10.7 to 16%) and medial canthus vs. lat-
Many mitoses eral canthus (13 to 48.5% vs. 3 to 5.6%).36, 38–41 BCC is
typically a tumor of fair-skinned adults. There is a
Melanoma Invasive nests of atypical
melanocytes strong association with ultraviolet (UV) radiation
Intraepidermal spread exposure. However, UV radiation exposure does not
Variable melanin pigment fully explain the preferential location of these tumors,
Mitoses as studies show that the upper and lower lids are sim-
ilarly exposed to UV radiation.41
Sebaceous Vacuolated cells
BCCs arise from the basilar layer of the epidermis,
carcinoma Pagetoid (intraepithelial) spread
which is the lowest layer. The lesion is slow-growing
Merkel cell Cords and clusters of immature, but can become extremely locally invasive if allowed
carcinoma small tumor cells to progress (Figs. 16–15 and 16–16). When on the lid
Necrosis margin, there is madarosis—loss of normal lashes—
Many mitoses
which is a clue to the malignant nature.7
No epidermal involvement
(usually)
Kaposi Atypical angulated slit-like
sarcoma vascular spaces
Plump lining cells
Hemosiderin
FIGURE 16–15 Basal cell carcinoma. Gross appearance FIGURE 16–16 Basal cell carcinoma. Most unusual case
of nodulo-ulcerative basal cell carcinoma with central ulcer- of neglected basal cell carcinoma showing extensive local
ation and elevated rim. destruction.
CHEN16-225-242.I 3/22/01 2:25 PM Page 236
accounting for about 3 to 9% of eyelid malignan-

cies.35, 36 It also affects elderly fair-skinned individu-
als.8 The incidence is higher in the immunosup-
pressed.10 Squamous carcinoma usually occurs on the
margin of the lower lid,8 but it can involve the upper
lid and outer canthus, and does so more frequently
than does BCC. Clinically, SCC presents as a plaque
or nodule with irregular borders. It is gray-white and
granular and can ulcerate.8
Microscopically, there are invasive nests of
squamoid cells. Well-differentiated tumors show
polygonal cells with large nuclei, prominent nucleoli,
and abundant pink cytoplasm, which may appear
keratinized. Formation of keratin pearls, which are
FIGURE 16–17 Basal cell carcinoma. Tumor nests com- concentric layers of tumor cells with increasing kera-
posed of small darkly staining cells invade the dermis. The tinization towards the center,10 are characteristic. Less
cells along the periphery of the nests show a picket-fence well-differentiated tumors show greater pleomor-
arrangement, termed peripheral palisading (arrow). A clear phism and less keratinization with few or no keratin
retraction space between the tumor nest and the dermis is
pearls. Mitoses are easy to find. The surrounding skin
characteristic (arrowhead). (H&E 100*)
usually shows evidence of sun damage, with actinic
Microscopically, there are nests of basaloid tumor keratosis (Fig. 16–18).
cells, which are small dark cells with scant cytoplasm,
budding from the overlying epidermis. The periph- Melanoma
ery of the tumor cell nests shows characteristic pal- Melanoma is generally believed to be the most com-
isading, which is the pseudostratified or picket fence mon of the non–basal cell, non–squamous cell eyelid
arrangement of the cells. Retraction spaces, an arti- malignancies.36, 37 Recognition of malignant melanoma
factual separation of the tumor nests from the sur- is especially important because it is one of the skin
rounding dermis, are typically present (Fig. 16–17). cancers that is potentially fatal.9 Most melanomas of
Variants Nodular (nodulo-ulcerative) basal cell carci- the orbital region represent primary tumors and usu-
noma is the commonest subtype. This subtype shows ally involve the uveal tract, but the eyelid is also occa-
a gross appearance of a pearly nodule with superim- sionally affected.44 One study of 32 patients with
posed vessels. Central ulceration occurs as the lesion eyelid melanoma showed two-thirds of cases occur-
enlarges, and the edges become elevated and rolled.7 ring on the lower lid.45 Clinical signs include a change
Sclerosing (desmoplastic, morpheaform) basal cell car- in pigmentation, ulceration or hemorrhage, and
cinoma is clinically flat and ill-defined, and micro- growth.45 A melanoma that is primary in the conjunc-
scopically shows thin strands of tumor cells within tiva may not be noticed until it involves the adjacent
fibrotic stroma. Detection of the tumor strands is at eyelid skin.44
times challenging, and margin evaluation can be espe-
cially difficult. This variant is frequently incompletely
EARL ...
excised, which probably explains why this variant
recurs more often than other variants, with a recur-
rence rate of over 35%.42
P Some reviews suggest
that melanomas that involve the con-
junctiva and eyelid skin have a worse prognosis
Pigmented basal cell carcinoma is of significance only
than eyelid melanomas that do not involve the
in the fact that it can mimic other pigmented lesions
clinically, and can be confused with melanoma. conjunctiva.46
Microscopically it shows the features of the usual
BCC, but with excess melanin pigment within the
tumor cells. Other reviews suggest that conjunctival melanoma
Cystic basal cell carcinoma is important because it behaves the same as cutaneous melanoma.12 Progno-
can clinically mimic benign cysts, and requires sis depends on depth of invasion, determined as
histopathology for diagnosis.43 either the level of invasion relative to dermal struc-
tures (Clark’s levels) or as the tumor thickness as mea-
Squamous Cell Carcinoma sured from the granular layer to the deepest extent of
Squamous cell carcinoma (SCC) is a distant second to involvement (Breslow’s depth).9, 27 Breslow measure-
BCC in frequency of occurrence on the eyelid,5, 34, 36 ment is a better predictor of prognosis. A Breslow
CHEN16-225-242.I 3/22/01 2:25 PM Page 237
A B
FIGURE 16–18 Squamous cell carcinoma. (A) (Left) Showing massive squamous carcinoma of left upper eyelid.
(B) Nests of squamoid tumor cells invade the dermis (arrows). There is an attempt at concentric layering of the cells
(asterisk). (H&E 100*)
measurement of 6 0.76 mm correlates with a 99% Microscopically, melanomas exhibit both architec-
5-year survival. A measurement of 0.76 to 1.50 mm tural and cytologic atypia. There are poorly circum-
predicts a 95% 5-year survival.9 Both cutaneous and scribed and varying-sized invasive nests of tumor
conjunctival melanomas can invade lymphatics and cells in an asymmetric arrangement. There is intraepi-
metastasize, usually first to preauricular and intradermal pagetoid spread of tumor cells. Individual
parotid lymph nodes, and then to submandibular or cells are loosely cohesive, epithelioid, or spindled, and
cervical nodes.12 have large nuclei, prominent nucleoli, and occasional
intranuclear inclusions. Pigmentation is variable.
Mitoses can be found (Fig. 16–19).
EARL ...
P Eyelid melanomas with
orbital invasion have a poor prognosis,
despite irradiation and chemotherapy.47
Variants Lentigo maligna melanoma is an invasive
melanoma arising within a preexisting lentigo
maligna. It has been reported that this variant has a
slower growth rate than other invasive melanomas.10
However, the behavior of this tumor is similar to
Metastatic melanoma infrequently presents in the that of other melanomas after controlling for tumor
eyelid. However, melanoma should be in the clinical thickness.27
differential diagnosis of new eyelid lesions in patients Nodular melanoma occurs on mucous membranes or
with a known history of melanoma elsewhere.44, 48 skin. 7 It is a melanoma with a prominent vertical
A B
FIGURE 16–19 Malignant melanoma. (A) Low-power view showing disorganized pattern of varying-sized nests
of tumor cells. Some nests move upward into the epidermis, a feature known as “pagetoid spread” (arrows). (H&E
100*) (B) High-power view of melanoma cells showing nuclear pleomorphism, with some cells exhibiting intranuclear
inclusions (large arrow), others with nucleoli (small arrow), and scatterred mitoses (arrowhead). (H&E 500*)
CHEN16-225-242.I 3/22/01 2:25 PM Page 238
growth phase. The surrounding epithelium shows lit- termed pagetoid spread. Well-differentiated tumors
tle involvement by tumor cells. show lobules of tumor cells, with characteristic vac-
Superficial spreading melanoma occurs in younger uolated cells located near the centers of the nests.
individuals than does lentigo maligna melanoma, and Moderately or poorly differentiated tumors show
can arise from a preexisting nevus.7 greater pleomorphism and fewer diagnostic cells,
with a cord-like pattern resembling basal cell carci-
noma12 (Fig. 16–21). A special stain for fat is positive
Sebaceous Carcinomas (Meibomian Gland in these lesions and facilitates diagnosis. It is impor-
Carcinomas, Zeis Gland Carcinomas) tant to note that this stain can be done only on unfixed
Sebaceous carcinomas are considered rare; however, tissue; therefore, consultation with the pathologist
nearly all cases arise on the skin of the eyelid area,12 before biopsy and the submission of fresh tissue to
where they account for 2 to 5% of all malignant eyelid pathology with the indication to rule out sebaceous
epithelial tumors.7 In the eyelid they arise from mei- carcinoma with use of this stain should be considered.
bomian (tarsal) glands or Zeis glands (sebaceous Immunohistochemical stains might also be necessary
glands of the eyelashes).7, 12 They can also arise from for diagnosis.49 Correct diagnosis is important
the sebaceous glands of the periocular skin.7 They are because the prognosis is poor, with mortality second
extremely rare elsewhere on the body.7, 8, 12 Because only to melanoma.50
the upper lid contains twice the number of meibo-
mian glands as the lower lid, the incidence is greater Merkel Cell Carcinomas
on the upper lid.7, 12 Most affected patients are elderly (Trabecular Carcinomas; Neuroendocrine
and female.12 A higher incidence in China than the Carcinomas; Small Cell Carcinomas of Skin)
United States or Western Europe has been reported.8 Overall, Merkel cell carcinomas are relatively rare, but
There is a varied clinical presentation. The tumor half occur in the skin of the head and neck,10 and
may present as a nodule or a diffuse thickening, and about 1 of 10 occur in the eyelid and periocular tis-
frequently mimics a benign inflammatory condition sues. They usually occur in elderly patients. Predis-
such as chalazion or blepharoconjunctivitis, leading posing factors include sun exposure and immunosup-
to delay in diagnosis (“masquerade syndrome”). One pression.51 Those on the eyelid present near the eyelid
clinical sign of malignancy is loss of the eyelashes as margin and are tender, bulging lesions that may
the tumor invades the hair follicles (madarosis). This ulcerate.7, 10, 52 The color is pink to red, and may cause
tumor has a tendency for multifocal sites of origin on confusion with hemangioma, boil, or lymphoma.7
the same eyelid or on the upper and lower lids simul- These are aggressive tumors, with one in three recur-
taneously, making complete excision difficult 7 ring and two in three causing lymph node metas-
(Fig. 16–20). tases.52 Although long-term survival is possible even
Histologically, the characteristic cell shows abun- after recurrence,53 death from widespread metastases
dant vacuolated or foamy cytoplasm due to accumu- has been reported in 17%.10
lated lipids. Individual tumor cells with this Histologically, these tumors involve dermis and
appearance present in the overlying epithelium is subcutaneous tissues. There is usually no connection
FIGURE 16–20 Sebaceous carcinoma. Plaque-like thick- FIGURE 16–21 Sebaceous carcinoma. Tumor cells
ening of the upper lid, with loss of eyelashes (“madarosis”) include several with pale-staining and vacuolated cyto-
is typical. plasm. (H&E 200*)
CHEN16-225-242.I 3/22/01 2:25 PM Page 239
FIGURE 16–22 Merkel cell carcinoma. Poorly differen- FIGURE 16–23 Kaposi sarcoma. Proliferation of narrow,
tiated, immature-appearing tumor cells with hyperchro- angulated vascular channels, some of which are slit-like
matic nuclei and scant cytoplasm (large arrow) and (arrows). These are lined by cells with plump nuclei (arrow-
occasional mitoses (arrowhead). Tumor cells contrast with head). (H&E 200*)
smaller darker lymphocytes (small arrow). (H&E 500*)
to or involvement of the overlying epidermis.10 The Kaposi Sarcoma

pattern is of cords, trabeculae, and groups of cells.10 The incidence of Kaposi sarcoma of the eyelid, while
The malignant cells are small, uniform, and imma- rare, has increased in frequency along with the
ture-appearing, with scant cytoplasm. There are many increase in cases of acquired immunodeficiency syn-
mitoses and areas of necrosis.7 The appearance can drome (AIDS). Clinically, a high index of suspicion is
mimic other small cell tumors including lymphoma, necessary to make the diagnosis. The lesions can be
metastatic small cell (oat cell) carcinoma of the lung, patches or plaques, and may resemble a variety of
some types of melanoma, and even basal cell carci- other benign vascular or malignant lesions. Micro-
noma (Fig. 16–22). Electron microscopy reveals dense scopically a classic lesion shows proliferation of atyp-
core granules similar to other neuroendocrine cells. A ical vascular channels, which are angulated and
panel of immunoperoxidase stains may be needed for slit-like, with plump lining cells. Hemosiderin is usu-
definitive diagnosis.54, 55 ally present (Fig. 16–23).10
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20. Duflo S, Nicollas R, Roman S, et al: Pilomatrixoma of
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40. Arlette JP, Carruthers A, Threlfall WJ, et al: Basal cell
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41. Lindgren G, Diffey BL, Larko O: Basal cell carcinoma of
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the eyelids and solar ultraviolet radiation exposure. Br
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ties and problems in eyelid neurofibromas. Ophthalmic
42. Pieh S, Kuchar A, Novak P, et al: Long-term results
Paediatr Genet 1993;14(1):43–50.
after surgical basal cell carcinoma excision in the eyelid
24. Black RL, Terry JE: Treatment of chalazia with intrale- region. Br J Ophthalmol 1999;83(1):85–88.
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1990;61(12):904–906. basal cell carcinoma of the orbit and eyelids. Ophthalmic
25. Li N, Bajoghli A, Kubba A, et al: Identification of Plast Reconstr Surg 1998;14(2):134–140.
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26. Carruthers J, Jevon G, Prendiville J: Localized dys- 45. Grossniklaus HE, McLean IW: Cutaneous melanoma of
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ular hemangiomas. Pediatr Dermatol 1998;15(1):23–26. 46. Tahery DP, Goldberg R, Moy RL: Malignant melanoma
27. Cox NH, Aitchison TC, Sirel JM, et al: Comparison of the eyelid. A report of eight cases and a review of
between lentigo maligna melanoma and other histoge- the literature. J Am Acad Dermatol 1992;27(1):17–21.
netic types of malignant melanoma of the head and 47. Dithmar S, Meldrum ML, Murray DR, et al: Desmo-
neck. Scottish Melanoma Group. Br J Cancer 1996;73(7): plastic spindle-cell melanoma of the eyelid with orbital
940–944. invasion. Ophthalmic Plast Reconstr Surg 1999;15(2):
28. Cohen LM, Zax RH: Recurrent lentigo maligna invad- 134–136.
ing a skin graft successfully treated with Mohs’ micro- 48. Hartstein ME, Biesman B, Kincaid MC: Cutaneous
graphic surgery. Cutis 1996;57(3):175–178. malignant melanoma metastatic to the eyelid. Oph-
29. Gaspar ZS, Dawber RP: Treatment of lentigo maligna. thalmic Surg Lasers 1998;29(12):993–995.
Australas J Dermatol 1997;38(1):1–6; quiz 7–8. 49. Sinard JH: Immunohistochemical distinction of ocular
30. Somach SC, Taira JW, Pitha JV, et al: Pigmented lesions sebaceous carcinoma from basal cell and squamous cell
in actinically damaged skin. Histopathologic compari- carcinoma. Arch Ophthalmol 1999;117(6):776–783.
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50. Zurcher M, Hintschich CR, Garner A, et al: Sebaceous 53. Allen PJ, Zhang ZF, Coit DG: Surgical management of
carcinoma of the eyelid: a clinicopathological study. Br Merkel cell carcinoma. Ann Surg 1999;229(1):97–105.
J Ophthalmol 1998;82(9):1049–1055. 54. Metz KA, Jacob M, Schmidt U, et al: Merkel cell carci-
51. Miller RW, Rabkin CS: Merkel cell carcinoma and noma of the eyelid: histological and immunohisto-
melanoma: etiological similarities and differences. Can- chemical features with special respect to differential
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52. Coskuncan N, Kazokoglu H, Sav A, et al: Merkel cell 236(8):561–566.
tumour of the eyelid and reconstruction with the Cut- 55. Scott MP, Helm KF: Cytokeratin 20: a marker for diag-
ler-Beard technique: a clinicopathologic case report. Eur nosing Merkel cell carcinoma. Am J Dermatopathol
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CHEN17-243-262.I 3/26/01 8:42 AM Page 243
Chapter 17
FULL-THICKNESS EYELID
RECONSTRUCTION
Ralph E. Wesley, Kimberly A. Klippenstein, Samuel A. Gallo, and Brian S. Biesman
The surgeon who learns a system of eyelid and peri- closure without resulting deformity. Younger patients
orbital reconstruction will also find these skills applic- with firm tight tissue provide less opportunity for
able to cosmetic surgery. Knowing the consistency direct closure and more scrutiny for the cosmetic
and limitations of periorbital tissue will benefit the effect of any reconstructive effort.
surgeon not only in reconstructing eyelid defects, but
also in avoiding complications or corrections in cos-
EARL... Lateral canthal defects are
metic surgery.
Most eyelid defects come from cancers, such as
basal cell carcinoma, in which tissue is missing. In
P generally much easier to correct than
medial canthal defects. The medial canthus
traumatic defects, careful inspection of the tissue will involves a concavity with limitations of tissue
often reveal that slowly piecing the remnants that can be brought in due to the brow, the
together, like one solves a puzzle, will correct the
lacrimal system, and the nose.
defect. Other causes of eyelid defects include necrotic
lesions (such as herpes zoster), necrotizing fasciitis,
and brown recluse spider bites in which the underly- The lateral canthus has a wide range of skin tissues
ing systemic condition must be treated prior to recon- that can be brought in with skin muscle flaps all of the
struction. In rare instances, congenital colobomas or way over to the temporal area, down the cheek, and
radiation burns may be responsible for the defect. even from the neck.
This chapter describes the techniques that cover Upper eyelid reconstruction1 is more critical than
upper or lower eyelid defects, medial or lateral can- lower eyelid reconstruction. When an upper eyelid
thal defects, and associated combinations. The goal is defect is closed primarily and pulled extremely tight,
to perform direct closure if at all possible. Factors that a permanent ptosis may result. In the lower lid, the
affect the accomplishment of this goal are discussed. tightness simply loosens. The tightness may tem-
porarily displace the globe superiorly, but usually
FACTORS TO CONSIDER IN EYELID resolves without any secondary procedures. The lid
margin is more critical in the upper lid. Cicatrization
RECONSTRUCTION of the lid margin on the lower lid may be well toler-
Before performing eyelid reconstruction, it is impor- ated in apposition to the lower conjunctiva. In the
tant to consider the factors that may affect the proce- upper lid, keratinization or trichiasis of the lid mar-
dure and its success. Certain factors will affect the gin may be intolerable because the upper lid con-
success of achieving direct closure in eyelid recon- stantly opens and closes with blinking, which can
struction. For instance, older patients with laxity of cause intolerable corneal irritation. Irregularity or
skin and surrounding tissue provide a much better aberrant lash well tolerated in the lower lid may be a
opportunity to stretch remnant tissue over a defect for severe disability in the upper lid.
243
CHEN17-243-262.I 3/22/01 2:26 PM Page 244
substitute for experience in working with periorbital

EARL ...
P The upper lid provides tissues. This chapter describes standard, reliable tech-
niques that can be enhanced by the surgeon’s artistic
tarsus of 8.0 to 10.0 mm for adjacent or
aptitude for both an excellent functional and cosmetic
opposite lid reconstruction, whereas the lower result.
lid tarsal plate has a height of only 4.0 mm,
which severely limits it as a donor site.
FULL-THICKNESS EYELID REPAIR
Upper eyelid defects generally require immediate The most important techniques to master in eyelid
reconstruction, whereas lower lid defects can be reconstruction involve direct closure, which includes
deferred for a longer period, depending on the not only closing the medial and lateral portions of an
patient’s tear film and Bell’s protective phenomenon. upper or lower eyelid defect together, but also the
The lacrimal system creates particular concerns in ability to loosen the medial or lateral canthal tendons
eyelid reconstruction. Although the lateral canthal for closure, or to extend them with a Tenzel semicir-
tendon can be loosened to mobilize remnants of the cular flap in the upper or lower eyelid to permit the
eyelid medially, the reverse is generally not carried defect to close directly. With these important tech-
out. Cutting the upper and lower medial canthal ten- niques, the surgeon can close the vast majority of
dons will interrupt the lacrimal secretory area. How- upper or lower eyelid defects. A later section dis-
ever, there are instances in which that technique may cusses techniques specific to the upper or lower eyelid
be applied. In older patients with decreased tearing, to be used for larger defects or instances in which hor-
severing the medial canthal tendon and destroying izontal sliding cannot be carried out.
the lacrimal canalicular system may have an insignif-
icant effect on lacrimal drainage and allow a remnant Direct Closure of Upper and Lower Eyelid Defects
of an eyelid to be mobilized laterally. In direct closure, the horizontal tarsoligamentous
sling should be reestablished, which involves clos-
ing the tarsal plate or tarsal plate to canthal tendons,
EARL... Medial canthal reconstruc-
P
and very precisely closing the eyelid margin. Some
surgeons prefer to place the tarsal stitches first,
tion is more critical than lateral canthal
whereas others prefer to line up the lid margin and
reconstruction because a small amount of then close the tarsal plate. Generally, less experi-
medial ectropion can result in intolerable enced surgeons find it much easier to close the lid
epiphora, whereas a slight out-turning of the margin first, whereas those more experienced in ocu-
lateral tarsal plate might have only a slight loplastics feel comfortable preplacing their tarsal
cosmetic effect. stitches.
Surgical Technique
The most important and critical portion of any eye- Magnification with loupes or a microscope is highly
lid reconstruction is the upper eyelid margin. Surgi- recommended to obtain the most meticulous reap-
cal techniques can be used to reconstruct an entire proximation of tissues. Local anesthesia with Xylo-
upper eyelid that cosmetically looks good but, as fine caine including epinephrine for hemostasis can be
skin and hairs rotate around the lid margin and con- extremely helpful in providing a dry surgical field.
stantly abrade the cornea, the result over time may be Hemostasis with bipolar cautery is our preferred
much less satisfactory for the comfort of the patient. method, but other types of cautery, such as unipolar
Techniques that can stretch and utilize existing lid and thermal, can be used judiciously. Bipolar offers
margin are more likely to give a better long-term the advantage of being extremely precise in avoiding
result than those that bring in periorbital skin and any electrical current damage to surrounding tissue.
muscle, particularly in the upper eyelid. Fortunately, Surgeons should be aware that cauterization near a
periorbital oculoplastic tissues tend to be forgiving lid margin should avoid the lash follicles to prevent a
with a good blood supply readily available to support gap in lashes at the lid margin.
other grafts and flaps and a low risk of infection. Prior to closing a wound under direct closure, we
Exceptions to this include patients who smoke tobacco will often separate the orbicularis muscle from the
and those with systemic conditions, such as those tarsal plate. This allows the sutures that close the
treated with radiation, or those with diabetes or other tarsal plate to be placed as accurately as possible. Sep-
systemically compromised conditions. There is no arating the orbicularis muscle may cause some initial
CHEN17-243-262.I 3/22/01 2:26 PM Page 245
FULL-THICKNESS EYELID RECONSTRUCTION • 245
bleeding, but the ability to see and work more pre- additional suture may be required below the tarsal
cisely with the tissue will be especially helpful. How- plate in the lower lid or possibly above in the soft
ever, the lid margin should be inspected to see how it tissues of the upper lid. The more internal (gray line
goes together, rather than uniformly placing the suture) is draped through the two limbs of the more
stitches through the gray line or the lash line because external suture, and then the external suture is tied
one remnant may be thicker than the other. down so that both 7-0 silks are directed away from
Next, the tarsal plate should be closed with the cornea. The sutures can then be trimmed closer
lamellar 6-0 vicryl sutures (Fig. 17–1). This is aided to the lid margin. An alternative is to leave the 7-0
by using a fine needle, such as an S-28 (Ethicon silks long and simply drape them over some ointment
sutures). The bites should be lamellar so that the once the closure is carried out. Finally, the skin and
Vicryl does not go through the tarsal conjunctival muscle can be closed with either 7-0 silks or 6-0
edge, which would irritate the cornea. The knots are Vicryl, and a small dog-ear may be excised.
then tied externally on the tarsal plate and will lie The sutures should be left in place longer than
under the orbicularis muscle. With the closure of most eyelid or facial sutures so that the lid will be well
greater defects and more tightness on the lid mar- healed and will avoid the late formation of a lid notch.
gin, the 6-0 Vicryl sutures should be placed first We prefer to leave the lid sutures in place 10 to 14
prior to closure of the lid margin with the 7-0 silks. days. The buried 6-0 Vicryls will add strength to the
At least two and possibly three 7-0 silk sutures substance of the wound and help to avoid late eyelid
should be placed through the tarsal plate, and an notching. The edges of the defect should be perpen-
dicular to the lid margin. Irregular Mohs’ defects will
not close well. They require the surgeon to use a
no. 15 Bard-Parker blade or scissors to create a wound
Incision that is perpendicular to the eyelid margin and all
planes. Wounds that are off-angle may create a mis-
directed force that can cause notching or buckling of
Tarsus the eyelid.
Lateral Cantholysis for Larger Eyelid Defects

A Lateral cantholysis can be used in both the upper and
lower eyelids to permit direct closure of larger defects.
B
EARL ...
Tarsus P Defects in the more
medial portion of the lower eyelid will
respond better to lateral cantholysis than those
in the more lateral portion. The reason involves
the fact that cantholysis mobilizes the lateral
segment.
C D Thus, if the lateral segment is larger (which will be

the case with a more medial defect), then the canthol-
ysis will allow more tissue to rotate inward. In rare
FIGURE 17–1 Direct closure upper eyelid defect. instances, a medial cantholysis may be carried out,
(A) Incision is designed with pentagonal shape, vertical sec- particularly in the upper lid.2 This is applicable for
tions running through the height of the tarsus. (B) After full- closure of defects in older patients or those in whom
thickness resection, edges of remaining tarsus are aligned sacrificing the lacrimal drainage system would not be
using intratarsal placement of 7-0 silk or 6-0 Vicryl. Each a problem due to the lack of tear production
interrupted suture is tied with knot placed anteriorly.
(Fig. 17–2).
(C) Lid margin is then aligned with 6-0 silk over mucocuta-
neous junction and anterior lid margin. (D) Skin closure is
carried out using 7-0 silk sutures. Lid margin sutures are Surgical Technique
then laid over the anterior skin surface and tied down with Lateral cantholysis is carried out by splitting the
ends of some skin closure sutures, preventing any contact of upper and lower lids3, 4 at the lateral canthus with a
the lid margin sutures with the cornea. scissors, and then nibbling into either the lower limb
CHEN17-243-262.I 3/22/01 2:26 PM Page 246
FIGURE 17–2 (A) A lower eyelid

defect too large for direct closure may
be closed with the aid of inferior can-
tholysis. (B) Inferior cantholysis allows
lateral portion of remaining lid margin
to be transferred medially, allowing clo-
sure with lessened tension on wound
edges. A B
of the lateral canthal tendon or the upper limb of the required for closure. The lower lid will tolerate
lateral canthal tendon. Simply cutting the upper and extremely tight closures without any subsequent
lower lids does not release the tendon, and this sec- defect, as the lid will loosen quite a bit. However, the
ondary action of nibbling at the upper or lower limb upper lid may experience either early postoperative
of the lateral canthal tendon is essential to allow the ptosis that subsequently relaxes and resolves, or per-
lateral remnant full mobility. To perform a semicircu- manent ptosis that may require ptosis surgery. As
lar flap, the angle of splitting the lid for lower eyelid more tissue is rotated in laterally, there is less chance
reconstruction should be directed upward from the of upper eyelid ptosis.
lateral canthus; in upper eyelid reconstruction the
angle should be directed downward, as described Tenzel Semicircular Flap
below, in case cantholysis is not adequate to close the The Tenzel semicircular flap can be used when lateral
defect. As the lower lid is mobilized direct closure can cantholysis will not permit direct closure. The Tenzel
be carried out, as described above. Once the closure semicircular flap was originally described to close
of the main portion of the defect has been completed, lower eyelid defects in a horizontal manner, but the
the lateral canthus may or may not need to be closed. reverse can also be used with the upper eyelid. The
The lateral canthus should be inspected to see if clo- Tenzel semicircular flap is essentially an extension of
sure is required there. Sometimes a 6-0 Vicryl buried the lateral cantholysis described above, and brings in
stitch will bring the lower lid up into position, or even skin and muscle from the lateral area into the upper
6-0 plain skin muscle stitches may be all that is or lower eyelid (Fig. 17–3).
FIGURE 17–3 (A) Reversed semicir- A B

cular flap of Tenzel can be used to repair
a potential upper eyelid defect. (B) After
excision of eyelid lesion, a semicircular
flap is fashioned with facilitation of a
superior cantholysis. (C) Upper eyelid
defect is closed. Lateral segment of
lower lid or lateral portion of inferior
tarsus is ankored to external periosteum
near lateral orbital tubercle. This suture
may be externalized and helps anchor
lateral portion of upper lid to lateral
orbital rim. (D) Completion of closure of
semicircular flap. C D
CHEN17-243-262.I 3/22/01 2:26 PM Page 247
Surgical Technique ADVANCED LOWER EYELID

The important principle of a semicircular flap is to RECONSTRUCTION
perform a cantholysis and to have a flap in the lower
lid that arches upward in a semicircular manner, or Hughes Tarsoconjunctival Flap
in the upper lid that arches downward. This allows When the horizontal sliding techniques above do not
the tissue brought in from the temporal area to fol- appear to be satisfactory, the vertical upper lid to
low the natural contour of the lid, avoiding a lateral lower lid sharing procedure of an advancement
ectropion of the lower lid or retraction of the upper Hughes flap provides one of the most stable, pre-
lid. The flap should arch up from the lower lid, con- dictable eyelid reconstructions possible for lower eye-
tinuing the continuity of the lower eyelid margin. lid defects in oculoplastic surgery. The internal
Once this is marked with methylene blue, a no. 15 portion of the lower eyelid is reconstructed with the
Bard-Parker blade can be used to incise down tarsoconjunctival flap from above, and the anterior
through the skin and muscle. The lateral canthal portion is reconstructed with either a skin graft or an
tendon is severed with the Westcott scissors, and advancement of skin from the lower eyelid. In gen-
then skin and muscle is dissected off so that it will eral, one will do better bringing in a free skin graft,
rotate as a flap. In the cases in which a lateral can- which can easily be done from the lateral portion of
tholysis was first attempted, the flap is simply the upper lid or from behind the ear, as opposed to
drawn as an extension (shown above), which can be advancing skin. Many of the skin advancement flaps
rotated into the defect. will later tilt the lid out slightly, and the safer choice,
especially in surgeons with less experience in eyelid
reconstruction, is to go ahead and use a free skin graft
EARL... One of the important prin-
P ciples of any flap is extensive undermining
and then hemostasis. The more a flap is under-
for the very best result.
Tarsoconjunctival flaps can be used to recon-
struct large defects, even including an entire eyelid
when some additional medial or lateral tissue is
mined, the less critical becomes the flexibility rotated inward.
and the geometry of a flap.
...
The skin and muscle flap should then be rotated
into the defect, and the defect closed as described
above. Next, the lateral canthus should be reformed.
P EARL Important principles in the
tarsoconjunctival flap are to leave a good
4.0 mm of normal lid margin in the upper eyelid
This can be carried out by picking the appropriate to avoid cicatricial ectropion, and to fully mobi-
place on the flap that matches the upper canthus, lize the flap down to conjunctiva so that it is eas-
using a buried 6-0 Vicryl to bring the orbicularis ily moved into the defect and will not create
muscle of the lower flap into the upper lid, in cases
secondary retraction of the upper eyelid once
of lower eyelid reconstruction, and just the reverse
when the upper eyelid is being reconstructed. An the flap is released.
additional 6-0 Vicryl suture or two, depending on
the size of the flap, may be required out laterally.
The flap closes amazingly well without much dog- A second stage is required to separate the flap,
ear. Then 6-0 nylon or another appropriate skin which can be done in almost all instances within 7 to
suture can be used to close the lateral portion of the 10 days because the vascularity occurs rather rapidly.
flap. Patients at risk are primarily those whose capillaries
In designing upper eyelid flaps, a more generous are affected by smoking tobacco. Diabetics and other
amount of tissue should be included, as only the patients, generally at risk for flaps, seem to do quite
bare minimum is needed for the lower eyelid. By well with Hughes flaps. Because this flap is a vertical
including more tissue for the upper eyelid, retraction eyelid-sharing flap, there is virtually no tendency for
is less likely to occur, as is the reverse problem of a late contraction of the flap, as long as adequate exter-
restrictive ptosis. The upper eyelid semicircular flap nal skin has been placed.
should be drawn even more steeply inferiorly than
the angle used in lower eyelid flaps. This additional Surgical Technique
tissue is critical to upper eyelid mobility and recon- Under local or general anesthesia, the upper eyelid is
struction. inverted and a flap marked with methylene blue
CHEN17-243-262.I 3/22/01 2:26 PM Page 248
A B
C D
FIGURE 17–4 (A) Large right lower eyelid basal cell tumor. (B) Multiple frozen section excision eventually resulted
in loss of entire eyelid margin. (C) Defect is repaired using a combination of Hughes tarsoconjunctival flap from upper
eyelid to lower lid defect (forming posterior layer) and a full-thickness skin graft (forming anterior layer). Appearance
one week postoperatively. Two months later, a Quickert groove director is applied between flap and globe during
release of flap. (D) Appearance of the reconstructed lower eyelid 3 months later.
(Fig. 17–4). The flap should be somewhat smaller the inferior portion of the flap to the conjunctiva
than the defect so that closure of the defect horizon- lower lid retractors in the lower lid. Any protective
tally into the flap will result in good tightness of the lens should be removed prior to closure of the
eyelid. A horizontal incision is then made 4.0 mm advancement flap.
behind the lid margin, full thickness through the tar- Next, an advancement of skin from the lower lid
soconjunctival unit. The planes are quite distinct and can be brought in or a free full-thickness skin graft
the surgeon can easily tell when he penetrates the tar- brought in and closed with 7-0 silk or 6-0 plain. The
soconjunctival tissue with the no. 15 Bard-Parker flap can be separated a week to 10 days later by care-
blade. Then vertical incisions are made from the ini- fully anesthetizing the lower lid with Xylocaine with
tial edge up to the top of the tarsal plate. Now with epinephrine, as well as the upper lid. The flap is sep-
forceps and Westcott scissors, the tarsoconjunctival arated by instilling Ophthaine (proparacaine) drops
flap is dissected superiorly and Müller’s muscle on into the area around the flap and then lifting the flap
conjunctiva encountered. The Müller’s muscle should up off the cornea with Westcott scissors, cutting the
be carefully dissected off of the conjunctiva and flap 1.0 mm or so higher than the desired lower eyelid
relaxing incisions made on the conjunctiva when the margin to allow the tissue to be trimmed downward
flap can be brought into the lower lid. (In a later sec- to fine-tune the eyelid contour.
tion, this will be described when the flap is actually The patient should open and close the lid to make
moved horizontally as an adjacent tissue flap for sure there is no retraction of the upper lid. If there
upper eyelid reconstruction.) The medial and lateral is no upper eyelid retraction, the remaining flap can be
borders should be sewn with lamellar 6-0 Vicryl trimmed off even with the upper lid. Should there
sutures and a running 6-0 Vicryl suture used to fix be retraction, then the upper remnant of the flap is
CHEN17-243-262.I 3/22/01 2:26 PM Page 249
A B
C D
FIGURE 17–5 (A) Mustarde cheek rotation flap used to reconstruct large medial lower eyelid skin defect in a sin-
gle stage. Lateral canthus was left intact. (B) Rotational cheek flap is fashioned. (C) An added full-thickness skin graft
was applied over lateral nasal region. (D) Appearance 3 months postoperatively.
grasped and, anterior to the attachment in the upper allow this to rotate in place down on the cheek. The
lid from the original donor site, one dissects up into the flap lacks functioning orbicularis muscle, which is not
upper lid and slowly releases the retractors until the of major consequence in the lower eyelid. The lack of
lid comes down into a normal, nonretracted position. tone to the lacrimal pump mechanism may result in a
The remnant of tissue from the upper lid is then sagging lateral lower lid and epiphora. This rotational
trimmed. Finally, the lower lid is inspected and the flap is used more often for large defects with a deep
flap trimmed down flush with the lower lid to match nasal defect when keeping the eye closed for a week or
the contour of the lower eyelid margin. two with a Hughes flap is undesirable, as with a
patient with monocular vision, amblyopia in a child,
active corneal disease, or glaucoma.
Mustarde Cheek Flap
Our preference in large defects is to use a vertical shar-
ing tarsoconjunctival flap, but the Mustarde cheek flap Surgical Technique
can be used to bring in tissue from laterally. The Mus- The flap should be drawn with an upward slope,
tarde flap can cover any lower eyelid defect in a single much like a Tenzel flap, but with the incision rotating
operative procedure (Fig. 17–5). A Mustarde flap is around in front of the ear. This requires good hemo-
especially useful for vertically deep defects that extend stasis and undermining of the skin and some orbicu-
down onto the cheek. The flap utilizes a long scar line laris muscle to rotate the flap into position. This flap
across the face, which usually is of minimal notice in does not create facial palsy because the nerves to the
patients with the skin type that develops skin cancers. facial muscles enter from the deep side of the facial
A triangle of normal tissue may need to be excised to muscle.
CHEN17-243-262.I 3/22/01 2:26 PM Page 250
Excised tissue
4-o polydek
FIGURE 17–6 (A) Mustarde cheek

flap used in reconstruction of full-
thickness lower eyelid defect. Rotational
flap may require excision of some nor-
Lat. rim
mal cheek tissue over the infero-lateral
periosteum
corner for the flap to close properly.
(B) Fixation of the underside of rota-
tional flap over lateral orbital rim is Nasal chondro-
important to avoid postoperative lower- mucosal graft
lid retraction or ectropion. Nasal chon-
dromucosal graft or ear cartilage graft
may be added to provide support and
rigidity to newly created lower-lid
margin. B
The medial triangle varies according to the tissue

...
P EARL The flap is primarily skin
and subcutaneous tissue that is rotated
into the defect rather than skin muscle flap, with
that needs to be rotated into the defect.
Surgeons with less experience in performing these
flaps will do well to wait until the end of the mobiliza-
tion before excising any tissue. The semicircular flap
the exception of the tissue brought in right should be undermined completely in a subcutaneous
at the lateral canthus, which does involve skin plane to avoid injury to the facial nerve. A small trian-
and orbicularis muscle.5 gle at the lower lateral edge of the flap may be excised
to allow the flap to close smoothly. Before rotating the
undermined tissue, a naso-chondromucosal graft can
A triangle of tissue is excised with a large nasal and
be obtained to provide support and mucosal elements
superiorly based area with the medial edge in the
for the inner portion of the reconstructed lid. The nasal
nasolabial fold. The semicircular flap begins at the lat-
septum contains cartilage with its own mucosal back-
eral canthus and extends upward and around to the
ing, which can be used for donor graft. The mucosa,
auricular area as shown in Figure 17–6.
however, will be much thicker and boggier than that of
normal conjunctiva. In taking a nasochondromucosal
graft from the septum, extreme care must be exercised
EARL... To prevent late lateral con-
P traction, the superior limit of the semicir-
cle for a Mustarde flap should be at least as high
to make sure that the mucosa on the opposite side is
not perforated. Otherwise, a nasal septal perforation
will occur. Alternately, Alloderm, preserved cadavaric
as the brow. skin, can also be sewn on the back side of the flap and
allowed to epithelialize with the adjacent conjunctiva.
CHEN17-243-262.I 3/22/01 2:26 PM Page 251
This avoids the need for mucosal grafts. Ear cartilage is ADVANCED UPPER EYELID
another source that can be used to line the surface, RECONSTRUCTION
though a considerable amount of morbidity occurs
while the ear cartilage heals during the period of Sliding Tarsoconjunctival Flap
epithelialization. This may include corneal abrasion When direct closure and lateral cantholysis are not
and ocular pain. possible for closure of upper eyelid defects, the slid-
The inferior margin of the mucosa is sutured to ing tarsoconjunctival flap, utilizing the techniques
the conjunctiva with a running 5-0 plain catgut described above for the Hughes flap, can be
suture and left free at the lateral and temporal mar- extremely useful. More often, this technique is indi-
gins. With the rotational cheek flap mobilized to fill cated for defects involving the medial or lateral one-
the nasal triangle, the medial canthus can be recon- third of the upper eyelid. The tarsoconjunctival flap
structed with 5-0 Vicryl suture through the dermis is fashioned and moved laterally into the defect and,
to the cheek flap, and secured to the posterior (deep) in fact, should protrude 2.0 mm below the normal
head of the medial canthal tendon or to the perios- lid margin to allow for any necrosis or shortening of
teum in the medial orbital rim. In cases in which the the flap. The external portion should be covered
lower canaliculus has been reconstructed, including with either adjacent skin-muscle flap or with a free
bicanalicular silicone intubation, the medial canthal skin graft.
suture will need to be placed posterior to the intu-
bated canaliculus.
After commitment of the position of the recon-
...
structed medial canthus, the upper border of the
chondromucosal or other graft is sutured to the supe-
rior margin of the cheek flap by running 5-0 catgut
P EARL The tarsal plate of the upper
lid is usually 10.0 mm in vertical height, but
it is usually laterally shifted due to dehiscence of
suture up to form the eyelid margin consisting of
the medical horn of the levator muscle.
the mucous membrane graft internally and the
epidermal border of the Mustarde flap externally.
The sutures are tied externally to avoid irritation
to the cornea. Therefore, laterally located cancers are more likely
Next, the lateral canthus is formed by suturing the to destroy much of the tarsal plate as opposed to
deep layer of the dermis of the rotational graft to the medial lesions. However, even when only a third of
superior and inner aspect of the lateral orbital rim. the tarsal plate remains medially, this remnant can be
The upper inward contour is extremely important, mobilized to provide another one-third of the eyelid
and the dermal sutures should be near the lateral and then the additional portion closed with adjacent
border of the chondromucosal graft. Upward trac- tissue mobilized in from the side. This leaves a more
tion at the apex of the flap can be provided by the stable long-term lid margin than techniques such as
use of 4-0 Vicryl sutures on a P-2 (Ethicon) needle to the Cutler-Beard flap described below. The long-term
avoid contraction of the lower lateral lid. Skin can stability of the lid margin is an important considera-
now be closed with running 6-0 nylon suture. The tion in upper eyelid reconstruction.
eyelids may be sutured together with a tarsorrhaphy
stitch to provide additional upward tension on both Surgical Technique
the flap and to evert the mucosa during the healing Once the tarsoconjunctival flap has been developed
period. Sutures are usually removed at approxi- (Fig. 17–7), it should be free to rotate laterally or medi-
mately 1 week. ally into the defect. Lamellar intratarsal 6-0 Vicryl
Other sources of lining of the back side of the flap sutures are used to fix the tarsoconjunctival flap to the
include a tarsoconjunctival flap from the upper lid, lid margin and then often to either the medial or lat-
which can be brought down in a Hughes flap but eral canthal tendon with 6-0 Vicryls. A double-arm
would require a second-stage separation. However, a suture can be used for the medial canthal tendon in a
free tarsoconjunctival graft from the upper lid can be mattress fashion. If a free skin graft is used, it can be
carried out as a single step. brought down to the lid margin or a millimeter or two
The injection of Xylocaine, including epinephrine of the external portion of the tarsoconjunctival flap
for hemostasis, prior to mobilization of the flap will will be simply left bare, as it will epithelialize over
aid greatly in hemostasis. We prefer to mobilize the and the keratinized epithelium of the skin will grow
flap with sharp dissection. Electric cautery can be down within 1.0 mm of the lid margin. This would
used but offers the potential complication of elimi- not normally be in contact with the cornea, ensuring
nating some of the vascularity of the flap. the patient’s comfort.
CHEN17-243-262.I 3/22/01 2:26 PM Page 252
Transposed
tarsus and
conjunctiva
B
FIGURE 17–7 Reconstruction of
upper eyelid defect using sliding tarso- Orbital
conjunctival flap. It consists of a Hughes rim
flap that is mobilized medially or later-
ally rather than down into the lower A
eyelid. (A) Full thickness defect of the
left upper lid involving lateral one third
of lid. (B) Tarsoconjunctival flap is fash-
ioned from the central one-third of C
everted upper tarsus. (C) The flap is
transferred laterally in a horizontal and
slightly oblique fashion. (D) Medial cor-
ner of tarsal flap is sutured to the lateral Skin
extent of eyelid margin, providing the graft
posterior lamella for the defect. The
sutures are placed intratarsally. (E) A
piece of full-thickness skin graft is
D E
applied as the anterior lamella. The flap
and graft are covered for 5 days with
semipressure eye patch.
Cutler-Beard Bridge Flap gut suture, which will not irritate the cornea. Inlay
The Cutler-Beard bridge flap can be used to recon- graft material can be added, such as eye bank sclera,
struct an entire upper eyelid (Fig. 17–8). The larger Alloderm, and morselized lid cartilage, to make a
defect and resultant flap will have the problem that thicker, more stable lid. Finally, the skin and muscle is
there is suboptimal mobility of the eyelid, resulting brought up underneath the bridge of lower eyelid
most likely in some ptosis. However, the lid looks margin and sewn in place with 6-0 Vicryl or 6-0
acceptable cosmetically. In the long run, the larger nylons.
defects are more likely to have problems with lid mar- When the flap is separated a week or so later, the
gin rotation, epidermalization, or even the develop- lower bridge of tissue will need to be de-epithelialized
ment of fine hairs. The Cutler-Beard flap requires the under the bridge of tissue left at the lower eyelid mar-
presence of lower eyelid tissue to share. This is a two- gin, and then the base portion of the flap still attached
stage procedure and the flap can be separated in a to the lower cheek, rotated back into the defect and
week to 10 days. closed with 6-0 nylon sutures. This flap has great vas-
cularization, which comes not only from the expand-
Surgical Technique able conduit of vessels through the conjunctiva
As with any defect, the flap is drawn somewhat internally but also from the skin-orbicularis muscle
smaller than the defect to allow for some narrowing of flap from the lower lid.
the defect as its edges are sutured to the flap. The flap This has been an extremely dependable flap; how-
is marked on the lower eyelid, approximately 4.0 mm ever, over the years, we have tended to use this less
down from the lid margin. A full-thickness incision is and less due to frequent applications of the tarsocon-
made through the lower eyelid, in a horizontal man- junctival flap above. However, this is an important
ner, leaving the entire 4.0 mm of lower lid margin and tool in the armamentarium of the reconstructive sur-
sparing the inferior marginal artery. Then vertical cuts geon for medium to complete defects of the upper
are made both in the conjunctiva and on the skin, eyelid.
widening somewhat as they go down, to allow for the
flap to be mobilized up into the defect. Composite Graft
We prefer to split the flap so that the conjunc- The composite graft involves bringing tissue in from a
tiva–lower lid retractor layer is separate from the skin normal opposite eyelid6 (Fig. 17–9). This is used most
muscle layer. Any protective lens should be removed. often in upper eyelid reconstruction where lid mar-
The conjunctiva–lower lid retractors are sewed in to gin is more critical. Usually, a section of upper eyelid
the upper and lateral limits of the defect with a plain is used from the normal opposite upper eyelid into
CHEN17-243-262.I 3/22/01 2:26 PM Page 253
A B
C D
FIGURE 17–8 (A) Elderly man with basal cell

carcinoma of the central portion of the right upper
lid following resection and clearing of margins
using multiple frozen section studies. A bridge flap
is designed and prepared. (B) The advancement
flap under the bridge tissue of the lower lid is sepa-
rated into a posterior lamella and an anterior skin-
orbicularis lamella. The posterior lamella is passed
under the lower eyelid margin and then advanced
superiorly to fill in the upper eyelid defect. Eye-
bank sclera or ear cartilage graft may be used as a
middle lamella to provide firmness to this compos-
ite lid. The anterior skin-muscle layer is then passed
under the bridge (lower lid margin) to cover the
eye-bank sclera or ear cartilage graft material, which
E is sutured to the underlying posterior lamella.
(C) Appearance of bridge flap 1 week later. (D) Second stage reconstruction of bridge flap. A Quickert groove
director is slid under the flap, which is itself under the bridge. The flap is severed in a beveled fashion such
that redundant conjunctival tissues are available to reconstruct an adequate mucocutaneous junction along
the newly constructed upper lid margin. (E) Postoperative appearance immediately after the flap has been
separated.
253
CHEN17-243-262.I 3/22/01 2:26 PM Page 254
FIGURE 17–9 Full-thickness compos- A

ite eyelid graft for upper eyelid defect. Graft from
(A) A full-thickness eyelid defect of the normal eyelid
left upper eyelid may be closed using a
full-thickness graft from the normal right
upper eyelid. The size of the harvested Skin-muscle
flap
graft should correspond to the defect size.
The donor site is closed over the right Defect
upper lid. The preseptal area of the cen-
tral portion of the left upper lid is under-
mined to create a myocutaneous flap.
(B) The skin-muscle layer of the free graft
is removed and preserved. The posterior
layer consisting of the lid margin and tar- B
sus is sutured into the defect using
intratarsal bites of 7-0 silk sutures. Its C
anterior raw surface is covered with the
skin-muscle flap by adjacent transfer,
thereby bringing in vascular supply.
(C) The remaining skin defect is covered,
using the previously preserved piece of
skin from the composite graft. The under-
lying muscle layer is removed from the
skin first. The eyelid is patched for 5 days.
the defect, and this is covered with skin and muscle

EARL... To release any tension on
from the recipient area. The key to this flap surviving
is bringing in a good skin-muscle flap in the recipient
eyelid to provide for the immediate vascularity of the
P the suture line, a canthotomy can be
performed in the recipient eyelid to minimize
free tarsoconjunctiva-lid margin composite graft
brought in from the opposite side. Figure 17–9 illus- this tension.
trates the graft from the opposite upper eyelid and
closure of the donor defect.
A skin-muscle flap is then brought across to be
Surgical Technique advanced or rotated downward to cover the tarsus of
Composite grafting allows for replacing two impor- the composite graft. The skin-muscle flap is then
tant parts of the lid with normal eyelid tissue: the sutured into place. If some shortage of skin exists in
tarsus and the lid margin. The maximum amount of the recipient upper lid, some of the skin that has been
donor lid tissue that can be taken is approximately removed from the front of the composite graft can be
8 mm, though in an older patient a larger capacity placed in the defect created by mobilization of the flap.
graft could be used. A pentagonal section of normal
eyelid should be removed from the opposite upper
eyelid with parallel vertical lines to the lid margin,
...
extending the entire 10 mm height of the upper tar-
sus. The defect should be closed with the usual tech-
nique, and the anterior skin and muscle of the
P EARL A skin-muscle flap over the
donor composite graft provides the prime
blood supply for this graft to be viable.
composite graft is removed and saved from 2 mm
above the lashes upward. The skin and muscle of
the composite graft must be removed so that the Composite grafts harvested from the lower lid
vascularity of the recipient skin and muscle will can also be used for upper lid defect, but the lashes
nurture this graft. This leaves the lash follicles are shorter and the tarsal plate will be approxi-
undisturbed. mately 3.9 to 4.0 mm, rather than 8 to 10 mm as
The modified composite graft is sewn into the noted in the upper lid.
tarsal defect with interrupted 7-0 silk or 6-0 Vicryl This flap offers the potential of providing normal
sutures. Tension will tend to compromise the vascu- lashes, which cannot be done with the other tech-
larization and viability of the graft. niques for major upper eyelid reconstruction. The
CHEN17-243-262.I 3/22/01 2:26 PM Page 255
disadvantage is that it requires surgery on the oppo- with deep 5-0 Vicryl sutures and 6-0 nylon cutaneous
site normal eyelid, and the possibility of failure of free sutures. The flap can be thinned at the tip edges,
composite graft. Lid margin grafts are not as viable as which will be the most lateral portion of the eyelid
adjacent tissue or vertical lid-sharing grafts. reconstruction, if adjacent skin and muscle is available
to help with the vascularity of the flap. Otherwise, the
Median Forehead Flap subcutaneous area should be left intact because it
The median forehead flap is used primarily when tis- tends to support the flap. Once the flap has vascular-
sue from below the level of the brow is not available ized satisfactorily, a second stage is used to excise
for upper eyelid reconstruction. The flap can also be the excess tissue at the bend of the flap at the root
used at times for lower lid reconstruction, but longer of the nose to allow the tissue to blend in smoothly.
length would be required and usually there is cheek The median forehead flap can also be done as an
tissue available. The application of the flap for lower island myocutaneous flap in a one-stage procedure in
portions of eyelid or orbital reconstruction become which it is tunneled under and the entire donor site
more appropriate as there is less tissue available in the closed initially. This requires considerable experience
lower orbit. The flap is thicker and less mobile than in planning and execution of the flap. Most surgeons
other techniques mentioned above, but this flap is an would do better to carry this out in a two-stage pro-
eye saver when other methods cannot be utilized. cedure with less vulnerability to the vascularity of the
flap. In the second stage, the thickness of the flap may
Surgical Technique be refined and modified. In the initial reconstruction,
The flap is drawn vertically from the glabellar area depending on the size of the defect, a mucous mem-
superiorly in the paramedian area so that the brane graft can be used to line the internal portion of
epitrochlear vessels that run very close to the skin will the eyelid to provide for a fornix.
support the flap.
The base of the flap should come down into the Upper Lid Vertical Split-Level Flap: Brown-
glabellar area so that when it rotates into the medial Beard Technique
canthus and the upper eyelid, the vascularity of the In some instances, there will be vertical loss of tissue
flap will be maintained from the epitrochlear source. such as with cicatricial changes from shingles or
The incision is carried out with a no. 15 Bard-Parker necrotizing fasciitis. The Brown-Beard technique
blade, and the tip of the flap trimmed to the depth of (Fig. 17–10) allows the lid to be split at two different
the subcutaneous area. As the surgeon comes closer levels so that an internal (posterior) graft can be
down to the origin of the flap and the vessels, a deeper placed based on an external (anterior) vascular bed
layer of muscle should be included to rotate with and an external (anterior) graft based on an internal
the flap. Once the flap has been rotated down into the (posterior) vascular bed. This technique is quite effec-
defect, the donor site in the forehead can be closed tive. The amount of vertical lengthening requires that
FIGURE 17–10 The technique of

Undermined Brown-Beard split-level grafting is used
Anterior
incision plane for vertical eyelid reconstruction or
lengthening of the upper eyelid. It uses a
Graft
Tarsus “split-level” technique such that both the
skin graft externally and the muscous
membrane graft internally have a recipi-
Posterior ent vascular bed for survival. (A) The
incision anterior skin incision is typically made
5 mm from the superior border of the
upper tarsus. The posterior tarsotomy is
made 5-mm from the back side of the tar-
sus. Dissection is then carried out in a
epi-tarsal plane to join the two partial
thickness incisions, such that the eyelid is
split in a shelved fashion. (B) The
stepped incisional planes allow vertical
A B C lengthening and placement of anterior
skin graft as well as posterior full thickness buccal mucous membrane graft. (C) Grafts are in place. The skin graft is nourished
by the blood supply of the preseptal orbicularis oculi, while the posterior mucous membrane graft is vascularized by the over-
lying pretarsal orbicularis oculi muscle.
CHEN17-243-262.I 3/22/01 2:26 PM Page 256
the two incisions be separated by at least that dimen- dles are then placed deeply into the medial canthal
sion so that there is a constant vertical bed. The internal tendon and then pointed outward through the skin.
graft can be mucous membrane, such as conjunctiva, Each of the double-arm mattress needles is then
and the external grafts can be skin. This flap has a high brought out through the skin and the suture is sim-
chance of success and increases the amount of vertical ply tied down on the skin and left for a couple of
dimension of the upper eyelid. weeks. When the suture is tied down externally, the
pull on the medial lid remnant is internal where
Free Myocutaneous Grafts the initial bites of the suture were taken.
In instances of vertical shortening of the upper eye- Soft tissue defects around the medial canthus may
lid, particularly in cases such as following enucle- be very deep, including excision of skin and orbicu-
ation with ocular prosthesis where there is good laris muscle down to the periosteum as seen often
vascularity but perhaps a shortage internally, a full- with carcinoma excision. When there are remnants of
thickness incision can be made through the upper the canalicular system in the upper or lower lid, we
eyelid and a skin muscle graft taken from the often pass silicone tubes to stent the remnant. How-
retroauricular area that includes skin, subcutaneous ever, with major resection of most of the canaliculus,
tissue, and retroauricularis muscle. This can be the lacrimal system usually fails. We wait to see if the
sewn in place as a free graft, without a conjunctival lacrimal secretion is a problem for the patient, and
surface, for a good 4.0 mm of correction. The vascu- will place a Jones tube 6 months later if the lacrimal
larity comes basically from the recipient orbicularis system has been obliterated.
muscle of the upper eyelid, which will allow sur-
vival in this range. Larger grafts will develop more
contraction and have less chance of survival. This is Healing by Secondary Intention
a simple, direct technique of lengthening an upper Healing by secondary intention is often overlooked in
eyelid and expanding the socket surface because the the medial canthus.7, 8
conjunctiva will re-epithelialize over the orbicularis
muscle.
PITFALL
MEDIAL CANTHAL DEFECTS
The medial canthus should be closed directly, bring- When the defect is asymmetric and oriented
ing remnants of the upper and lower lids in toward very much superiorly or inferiorly to the
the deep limb of the medial canthal tendon. Most medial canthal tendon, one should avoid
commonly with eyelid reconstruction, routine healing by secondary intention as cicatricial
attachment leads to a gap between the eye and the retraction of the upper lid or a severe medial
eyelid. The common approach, in most texts, is to cicatricial ectropion of the lower lid can
apply the fixation to the deep head of the medial
occur. This defect can be very difficult to
canthal tendon. In actuality, as long as we are closing
correct later.
defects external to the lacrimal apparatus, we are
using the superficial head. Only when the sutures
are placed deep to the canthus do we truly approxi-
mate the deep head of the medial canthal tendon.
Therefore, attention getting as deep an internal bite If the defect is directly medial, the area will heal
as possible will tend to eliminate the gap at the in and re-epithelialize by secondary intention with
medial canthus. an excellent cosmetic result. Defects up to 1.0 cm can
be counted on to close uneventfully. The defect
should be kept clean of debris and constantly cov-
EARL... Direct closure of the me-
P dial canthal defect should emphasize the
inward contour of the upper or lower eyelid.
ered with ointment to speed healing and decrease
contraction.
Full-Thickness Skin Grafts

Full-thickness skin grafts are easily performed using
Often, the direct closure is carried out by using a upper eyelid skin, retroauricular skin, or preauricu-
double-armed 5-0 Vicryl suture in a mattress fashion lar or supraclavicular tissue. The upper eyelid tissue
goes into the medial remnant of the eyelid. The nee- will be thinner than retroauricular. When the defect
CHEN17-243-262.I 3/22/01 2:26 PM Page 257
goes through skin and muscle all the way down to the The flap is drawn as shown in Figure 17–11, under-
periosteum, a full-thickness skin graft may leave a mined extensively around the glabellar area, and then
depression, and other techniques listed below that rotated down into the defect; 5-0 Vicryls are used to
bring in either thicker tissue or skin and muscle may close the donor site at the flap and the edges of the
be required. flap are trimmed so that it fits the defect with an
When a skin graft is placed, it can be stented for a appropriate geometric pattern. Also, the flap is usu-
few days with Xeroform and an eye patch so that ally trimmed to a somewhat thinner nature where it
the graft takes nicely. Sometimes a stitch through the comes down closest to the medial canthus. Deep
middle of the graft to help hold it down onto the exist- suture fixation with 5-0 or 6-0 Vicryl sutures helps to
ing orbicularis muscle will be helpful in obtaining anchor the flap, and then 6-0 nylons can be used for
vascular apposition. In the postoperative care, we the cutaneous area. Extremely large defects can be
often use steroid ointment to prevent late subdermal closed with a glabellar flap, which may also be com-
contraction. Otherwise, the skin graft that initially bined with skin and muscle horizontal rotations from
looked good may actually contract and fold. A month the upper or lower eyelid.
of topical steroid cream can be helpful in eliminating
this late problem.
Island Myocutaneous Flap
An island flap is a myocutaneous flap in which the
Glabellar Flap donor site and the recipient site are not contiguous.
Glabellar flaps work well cosmetically and function- Tissue brought in from the glabellar area can be
ally. 9 They allow the rotation of tissue from the attached simply by orbicularis, procerus, or supercil-
glabellar area down into the medial canthal defect. iary muscle, and brought under skin and rotated into
The flap can be trimmed to match the thickness. This the tissue. The epitrochlear vessels are extremely
is an advantage over a full-thickness skin graft, superficial in this area and provide good vasculariza-
which often, with deep defects, will look hollow tion. Even without the specific vessels, the orbicularis
postoperatively. muscle itself provides a good blood supply.
The flap should be measured to match the defect,
and fashioned so that the blood supply of the orbicu-
laris muscle comes from the inferior portion of the
Undermined area
flap to allow the superior portion to rotate down into
Incision the defect while still maintaining the inferior blood
supply, which will be superiorly located after the
rotation of the flap. Then a tunnel is made in the recip-
A ient site, and the donor skin-muscle flap tunneled
down and fixed at the medial canthus. This is espe-
cially helpful with large medial canthal defects in
which a glabellar flap would not satisfactorily rotate
into the defect.
B
LATERAL CANTHAL DEFECTS

Direct Closure
Lateral canthal defects are more easily reconstructed
than medial canthal defects. Often, direct closure of
the upper and lower eyelid to the deep head of the
lateral canthal tendon will essentially close the major
FIGURE 17–11 (A) Glabellar flap uses redundant tissue portion of the defect, and the free mobility of the lat-
in the area between the eyebrows to reconstruct deep med- eral canthal skin and muscle allows various patterns
ical canthal defects. Its closure required wide undermining
of closure to be brought down (Fig. 17–12). The dia-
of the forehead skin as well as careful attention to the design
and dimensions of the base and the tip of the glabellar flap.
gram shows how skin and muscle can be undermined
The distal tip of the flap may be excised to avoid necrosis. and brought in to reconstruct the lateral canthus.
(B) Appearance of the closure of a medial canthal defect Myriad geometric shapes and techniques can be used
using glabellar flap. Alternative methods include full- to cover the lateral canthus because there is so much
thickness skin graft or healing by natural granulation. free tissue out laterally.
CHEN17-243-262.I 3/22/01 2:26 PM Page 258
A
A
FIGURE 17–13 (A) Defect over lateral portion of upper

eyelid may be repaired by rotation of adjacent tissue. In
this case, a rotational flap from the temporal region down
into the defect is used. (B) Closure of the rotational flap as
well as the flap’s originating site.
C
FIGURE 17–12 Small diamond-shaped lateral canthal reconstruction without distortion of the lateral can-
as well as full-thickness lid defect may be repaired using a thus or creation of cicatricial ectropion.
combination of canthoplasties of the upper lid and the
lower lid, and mobilization of a myocutaneous flap from
the temporal area to the lateral orbital rim. (A) Intratarsal
COMBINATION OF FULL-THICKNESS
bites are taken from lateral edges of the upper and lower EYELID DEFECTS
lids using 5-0 Vicryl. It is then secured to the inner perior-
The principles of closure of combination of full-
bita just superior to the lateral orbital tubercle. (B) Under-
mining of the temporal myocutaneous flap and advance- thickness eyelid defects are the same as those of
ment to cover the lateral orbital rim. (C) Appearance after isolated defects, but special situations should be
closure of the combined upper and lower lateral canthal recognized. With a medial canthal and upper or lower
defects. eyelid defect, often the direct closure or reconstruc-
tion of the horizontal eyelid corrects the majority of
Rotational Flaps the soft tissue medial canthal or lateral canthal defect.
Simple rotational flaps (Fig. 17–13) can be designed The most important combinations are those that
with the abundant lateral canthal tissue, or more pre- involve large-scale removal of both the upper and
cise geometric rhomboid flaps can provide defect cov- lower eyelid (Fig. 17–16). Often one defect is larger
erage (Fig. 17–14). than the other, and horizontal sharing from the rem-
nant of the existing eyelid will greatly aid in the
Rhomboid-Type Flaps reconstruction of the defect. When there is inadequate
In larger defects, modifications such as double- tissue to do that, then tissue needs to be brought in
rhomboid flaps (Fig. 17–15) can provide tissue for from the temporal area or from out of the orbital field
CHEN17-243-262.I 3/22/01 2:26 PM Page 259
A B, C
FIGURE 17–14 (A) Full-thickness eyelid skin defect over the inferolateral portion of left lower lid. (B) Rhomboid
flap is fashioned from healthy tissues above the area of the defect. (C) Rhomboid flap has been rotated downward
and sutured in place using buried sutures.
A B
FIGURE 17–15 (A) Large facial and temporal defect and design of double rhomboid flaps above and below the
defect. (B) Rhomboid flaps rotated and sutured in place.
A B
FIGURE 17–16 (A) Large cheek defect that requires extensive undermining and mobilization. (B) Skin-muscle
layers over the lateral aspect of the cheek as well as the pre-auricular region advanced into the defect. Triangles of tissue
are excised laterally at the base of the flap to allow for smooth closure.
CHEN17-243-262.I 3/22/01 2:26 PM Page 260
in the forehead area, such as the median forehead flap Major Eyelid Defects with Lack of Tissue
described above. In severe cases, the important prin- When there is essentially no upper or lower lid tis-
ciple is to provide coverage for the globe, even if the sue, the areas that can often be utilized are a para-
upper and lower eyelids are completely absent. median forehead flap brought in to reconstruct both
upper and lower lids, or to advance a large Mustarde
Specific Suggestions for Repairing Defects flap that starts at the level of the brow, rather than at
Total Defect of Upper Lid and Inner Canthus the lateral canthus. Sometimes a combination of
these two flaps is used. The massive tissue that can
The defect over the inner canthus may be closed by
be brought in by mobilization is from the cheek and
rotating the lower eyelid via a semicircular flap. A
lateral face.
bridge flap with ear cartilage graft may then be used
When none of this is available due to extreme loss
to reconstruct the total upper lid defect. Other alter-
of tissue or a large defect following a major Mohs’
natives to closure of the inner canthal defect include
cancer excision, then the possibility of free myocuta-
glabellar flap, skin graft, or healing by spontaneous
neous flaps attached to the superficial temporal artery
granulation.
or the vessels at the medial canthal area must be
entertained. The tissues and island flap can also some-
Total Defect of Upper Lid and Outer Canthus times be advanced from the frontal area, without skin,
This defect may require advancement of the lower lid to bring in a vascular supply of tissue to cover the eye-
to the outer canthus and semicircular flap or bridge lid to support mucous membrane grafts internally
flap with ear cartilage, Alloderm, or eye-bank sclera to and skin grafts externally.
the upper lid.
Total Defect of Lower Lid and Inner Canthus

CONCLUSION
The main procedure is advancement of tarsoconjunc- Eyelid reconstruction constitutes the most challeng-
tival flap from the upper lid to the lower lid with a ing and rewarding parts of ophthalmic plastic
full-thickness skin graft (Hughes flap). The inner can- surgery. Understanding an orderly progression of
thus may be repaired via direct closure, a horizontal procedures for reconstruction allows the surgeon to
sliding tarsoconjunctival flap with skin graft, external analyze the defect and then proceed with the appro-
myocutaneous flap, or a small glabellar flap. priate method of reconstruction (Figs. 17–17 and
17–18).
Total Defect of Lower Lid and Outer Canthus
This defect requires canthal fixation with advance- ACKNOWLEDGMENT
ment Hughes flap from the upper to the lower lid and
lateral canthus, with skin graft or skin flap advance- This work is supported in part by a grant from
ment or rotation. Research to Prevent Blindness, Inc.
REFERENCES
1. Wesley RE, McCord CD Jr: Reconstruction of the upper 5. Stasior GO, Stasior OG: Eyelid and canthal reconstruc-
eyelid and medial canthus. In: McCord CD Jr, Tanen- tion. In: Dortzbach RK, ed: Ophthalmic Plastic Surgery:
baum M, Nunery WR, eds: Oculoplastic Surgery, 3rd ed. Prevention and Management of Complications. New York:
New York: Raven Press, 1995: 99–117. Raven Press, 1994: 12.
2. Bergin DJ, McCord CD Jr: Reconstruction of the upper 6. Kwitko GM, Nesi FA: Eyelid and ocular adnexal recon-
eyelid major defects. In: Hornblass A, ed: Oculoplastic, struction. In: Nesi FA, Lisman RD, Levine M, eds:
Orbital and Reconstructive Surgery. Baltimore: Williams Smith’s Ophthalmic Plastic and Reconstructive Surgery,
& Wilkins, 1988: 605–623. 2nd ed. St. Louis: Mosby, 1998: 577–608.
3. Dryden RM, Wulc AE: Reconstruction of the lower eye- 7. Older JJ: Medial canthal reconstruction. In: Hornblass
lid: major defects. In: Hornblass A, ed: Oculoplastic, A, ed: Oculoplastic, Orbital and Reconstructive Surgery.
Orbital and Reconstructive Surgery. Baltimore: Williams Baltimore: Williams & Wilkins, 1988: 14.
& Wilkins, 1988: 630–642. 8. Becker FF: Reconstructive surgery of the medial can-
4. McCord CD Jr, Nunery WR, Tanenbaum M: Reconstruc- thal region. Ann Plast Surg 1981;7:259.
tion of the lower eyelid and outer canthus. In: McCord 9. Dailey RA, Habrich D: Medial canthal reconstruction. In:
CD Jr, Tanenbaum M, Nunery WR, eds: Oculoplastic Boswiak S, ed: Ophthalmic Plastic and Reconstructive
Surgery, 3rd ed. New York: Raven Press, 1995: 119–144. Surgery, 1st ed. Philadelphia: WB Saunders, 1996: 387–399.
CHEN17-243-262.I 3/22/01 2:26 PM Page 261
Upper lid defect
Small size Vertical shortage Horizontal defect Selected small/

Defect ≤30% defect Location medium defect
Free composite
graft
Direct closure Adjacent Brown-Beard Medial defect Central defect Lateral
(± cantholysis) myocutaneous split-level graft 1/3 defect
flap (Adjacent tarsus
present)
Medium to
large
Small to medium Large defect of
defect lid and periorbital
tissue
Cutler-Beard Sliding
“bridge” flap tarsoconjunctival
flap
Reverse Sliding Median
Tenzel's tarsoconjunctival forehead
semicircular flap flap
flap
Defects criterion:
Small <25%
Medium 25–35%
Large >35%
FIGURE 17–17 Clinical pathway—management of full-thickness upper eyelid defects.
Lower lid defect
Small Medium and large

size size defect
Direct closure Medial Possibility for

± cantholysis defect eyelid sharing
Tenzel's Yes (2 stages) No (1 stage)

semicircular flap
Modified Hughes Mustarde

tarsoconjunctival rotational flap
flap and FTSG
Defects criterion:
Small <25% FIGURE 17–18 Clinical path-
Medium 25–35% way—management of full-
Large >35% thickness lower eyelid defects.
CHEN17-243-262.I 3/22/01 2:26 PM Page 262
CHEN18-263-288.I 3/26/01 8:42 AM Page 263
Chapter 18
LACRIMAL SYSTEM
Marc J. Hirschbein and George O. Stasior
Normal tear flow is indispensable for clear and com- The lacrimal gland is well vascularized, and receives
fortable vision. Abnormalities of tear flow can its main blood supply from the lacrimal artery, which
adversely affect the patient’s vision and daily activi- arises as a branch of the ophthalmic artery or the mid-
ties. Severe cases can result in abscess formation, peri- dle meningeal artery. It receives both sympathetic and
orbital cellulitis, and sepsis. Lacrimal problems may parasympathetic innervation. Sympathetic fibers origi-
be congenital or acquired, and may occur at any age. nate in the superior cervical ganglion, and travel with
The tearing patient presents the ophthalmologist the internal carotid artery to reach the gland.2 Parasym-
with a complex diagnostic and therapeutic challenge. pathetic innervation arises in the sphenopalatine gan-
Dominique Arel opened the door to the lacrimal sys- glion, and travels dorsally through the retroorbital
tem in 1713 with his development of the lacrimal nerve plexus to the lacrimal gland.3 It is currently
syringe set.1 In recent years, the surgeon has benefited believed that both systems exert a unique stimulatory
from a number of new diagnostic techniques, and an effect on lacrimal gland secretion.4
even larger number of surgical options. This chapter The lacrimal drainage system begins at the supe-
defines the etiology of lacrimal diseases, and cus- rior and inferior punctum (Fig. 18–1). They are
tomizes the appropriate treatment modality to
improve the surgical outcome and increase the satis-
faction of the patient. Superior canalicus
Common canalicus
ANATOMY Valve of Rosenmüller
Lacrimal sac
Tears are produced by the main and accessory
lacrimal glands. The main lacrimal gland is believed Valve of Krause
to be responsible for reflex tearing. It is located in the Spiral valve of Hyrtl
Inferior canalicus
lacrimal fossa in the superotemporal orbit. It is
Valve of Taillefer
divided by the levator aponeurosis into an orbital and Nasolacrimal duct Inferior turbinate
a palpebral lobe. The ducts from the orbital lobe pass
into the palpebral lobe. The ducts from the palpebral
lobe exit into the superior fornix approximately 5 mm Valve of Hasner
above the superior tarsal border. The accessory
lacrimal glands of Krause and Wolfring are located in FIGURE 18–1 Anatomy of the lacrimal drainage appara-
the forniceal conjunctiva and the conjunctiva adjacent tus. The canaliculi join to form a common canaliculus in 90%
to the superior edge of the tarsal plate, respectively. of the population. The valve of Rosenmüller sits between the
Accessory lacrimal glands are more numerous in the common canaliculus and the lacrimal sac. The valve of Has-
superior fornix. They are felt to be the main contribu- ner, at the distal end of the lacrimal duct, is the most com-
tors to basal tear secretion. mon site of congenital nasolacrimal duct obstruction.
263
CHEN18-263-288.I 3/22/01 2:27 PM Page 264
approximately 0.3 mm in diameter, sit on an elevated

ridge of tissue (the papilla), and are surrounded inter-
nally by a ring of connective tissue. The upper punc- Angular
tum is 6.0 mm from the medial canthus, and the lower vessel
is 6.5 mm. The puncta should sit in apposition to the
globe. The canaliculi proceed vertically for 2 mm and
widen to form the ampulla, then turn horizontally
and proceed for 8 to 10 mm. The internal diameter of
the canaliculi varies from 0.5 to 1.0 mm. Internally,
they are lined with stratified squamous epithelium.
Medial
In 90% of individuals, the canaliculi join to form a
Skin incision
common canaliculus, 3 to 5 mm in length, prior to
entering the lacrimal sac. The valve of Rosenmüller is Lateral
formed by a fold of mucosa at the junction between
the common canaliculus and the lacrimal sac.
The lacrimal sac sits in the lacrimal sac fossa,
formed by the lacrimal bone and the frontal process FIGURE 18–2 The angular artery lies 8 to 10 mm from
of the maxillary bone. The mean thickness of the the medial canthus. It runs between the levator anguli oris
lacrimal bone is 106 m.5 The sac is surrounded by and the levator labii superiosis muscles.
the medial canthal tendon. Both deep and superficial
heads of the pretarsal and preseptal fibers from the PHYSIOLOGY OF THE LACRIMAL PUMP
orbicularis oculi muscle forms the medial canthal ten-
don. The fundus of the lacrimal sac extends for 4 mm Tear production has been estimated to be 1.5 cc25
above the medial canthal tendon and for 10 mm infe- hours or 0.8 to 1.2 Lmin. In the healthy eye, the
riorly, to the nasolacrimal duct. The nasolacrimal majority of the tears produced are cleared by evapo-
duct, contained within the maxillary bone, extends ration, with only a small fraction passing through the
for 12 mm in an inferior, lateral, and posterior direc- lacrimal drainage system. In 1961, Jones7 presented
tion. The valve of Hasner is a mucosal fold at the exit his theory of the lacrimal pump, based primarily on
of the nasolacrimal duct below the inferior turbinate. static anatomic observations. In this model, capillary
The nasolacrimal duct is 30 to 35 mm from the ante- action, negative intrasac pressure gradients, and the
rior opening of the nose in adults, and 20 to 25 mm in lateral to medial pumping action of the lids all com-
children. bine to process tears through the lacrimal system.
Blood supply to the medial canthal region is sup- At the start of the blink, the lids are fully open, and
plied by the angular vessels, an anastomosis between the canaliculi and lacrimal sac are filled with tears
the facial and orbital circulations. The vessels course from the previous cycle. As the blink is initiated, the
between the levator anguli oris and the levator labii puncta each come into opposition with the other lid
superiosis muscles, approximately 8 to 10 mm from margin, effectively occluding the system. As the blink
the medial canthus (Fig. 18–2). Foreknowledge of continues, contraction of the orbicularis oculi muscle,
this vascular complex is to the benefit of the lacrimal particularly in the region of the medial canthal ten-
surgeon. don, squeeze the tears out of the canaliculi and
An understanding of nasal and sinus anatomy is lacrimal sac and into the nose. At the moment the lids
equally paramount. The lateral nasal wall is com- are completely closed, the system is essentially empty.
posed of the superior, middle, and inferior turbinates. As the lids open, pressure is first released from the
The turbinates function to create vortex currents to medial canthal region, creating a partial vacuum
distribute inspired air throughout the nasal vestibule, while the puncta remain occluded. As the lids con-
allowing the air to be warmed, and for filtration and tinue to separate, the puncta reopen, pulling the next
olfaction to proceed. The lacrimal sac sits adjacent to bolus of tears into the canalicular system. The com-
the middle turbinate, and this is the site of anastomo- plete cycle takes an average of 258 msec.8
sis for a dacryocystorhinostomy. The nasolacrimal
duct exits beneath the inferior turbinate, as mentioned EVALUATION
above. The lacrimal fossa sits adjacent to the ethmoid
sinuses, and above the maxillary sinus. Anterior eth- History
moid air cells may extend anterior to the lacrimal sac The most frequent complaint to prompt an evalua-
fossa in 93% of orbits.6 tion of the lacrimal system is tearing. Unfortunately,
CHEN18-263-288.I 3/22/01 2:27 PM Page 265
LACRIMAL SYSTEM • 265
this is also a very nonspecific complaint. Any ocular

process, from eyelid abnormalities to iritis, may pre- TABLE 18–1 DIFFERENTIAL DIAGNOSIS
sent with tearing. The ophthalmologist must first get OF TEARING
a detailed history of the symptoms: When did the
tearing begin? How often does it occur? Is it one eye Excess lacrimation
or both eyes? Are there any associated ocular symp- Supranuclear
toms? Does it only happen when the patient is out- Stimulation of the lacrimal nucleus
Reflex (see below)
doors? Is there a seasonal pattern? Are there any
Emotional
associated medical conditions? Is the patient taking Central norvous system (CNS) trauma
any systemic medications? The answers to these Stroke
questions can often point the examiner toward a non- Reflex tearing
lacrimal cause of the problem. For example, an asso- Pain
ciated sandy or gritty feeling may indicate ble- Corneal abrasion, foreign body, trichiasis,
pharitis, meibomitis, or a dry-eye condition. Dry eye dry eye, conjunctivitis, glaucoma, iritis
is perhaps the most common single cause of tearing. Other ocular surface disease
Its incidence increases with age, is more common in Allergy, anterior corneal dystrophy
females, and may be associated with systemic medi- Retinal stimulation
actions or diseases. Although diagnosis and treat- Infranuclear
Cerebellopontine angle tumors
ment is fairly straightforward, it is the process of
Aberrant regeneration (post–Bell’s palsy)
explaining to patients that their tearing is because Direct lacrimal gland stimulation
their eyes are too dry that proves to be the true chal- Lacrimal gland tumor
lenge. We find it helpful to explain to patients that all Dacryoadenitis (viral, bacterial, inflammatory)
of our eyes produce a basic amount of tears to keep Inflammatory/infiltrative processes
the surface of the eyes lubricated. When these prove
Decreased outflow
insufficient (either through an aqueous or lipid defi-
Lacrimal pump abnormalities
ciency), the body signals our reflex tears to overcom- Eyelid laxity, lid retraction, cicatricial changes,
pensate, resulting in tearing. It is imperative that the seventh nerve palsy
clinician maintain a high index of suspicion for dry Puncta
eyes in all tearing patients, and perform appropriate Agenesis, stenosis, ectropion, iatrogenic
testing on all patients. For another example of a non- (punctal plugs)9
lacrimal cause of the problem, tearing that occurs Canaliculus
only in the cold may be a manifestation of normal Stenosis, scarring, canaliculitis, canalicular
reflex tearing, whereas tearing that occurs indoors in laceration
the winter may be related to forced-air heating. It is Nasolacrimal sac
the patient who describes nearly constant tearing, Infectious (bacterial, fungal, viral, parasitic),
inflammatory disease,10 trauma, neoplasm,
either in one eye or in both, who is more likely to
allergic,11 iatrogenic (after orbital
have true lacrimal pathology. decompression or sinus surgery)12, 13
Table 18–1 presents the differential diagnosis for Nasolacrimal duct
acquired tearing in adults. Although extensive, it can Primary acquired nasolacrimal duct
be broken down into two main groups: those that obstruction, trauma, neoplasm
produce too many tears, and those with insuffi- Valve of Hasner
cient drainage. The former is made up of the non- Congenital obstruction, allergy, inferior
lacrimal drainage causes of tearing, and is predomi- turbinate hypertrophy
nated by three main subgroups: ocular surface Neoplasm
irritation, dry eye, and lacrimal pump failure. The
latter includes both primary and acquired pathology
of the lacrimal drainage system. steps. First, attention should be directed to identify-
ing any causes of ocular irritation, including trichiasis,
distichiasis, blepharitis, or meibomitis. In addition,
Examination the eyelids should be examined for any signs of prior
The examination of the tearing patient should begin trauma or scarring.
with the skin of the face and eyelids, looking for any Next, eyelid position and tone should be evaluated.
signs of dermatitis that may be a cause of ocular irri- Is there eyelid retraction present? If so a workup for
tation. Examination of the lids should proceed in two hyperthyroidism is indicated if no other cause is
CHEN18-263-288.I 3/22/01 2:27 PM Page 266
identified (e.g., prior surgery). Examine the upper and Testing

lower eyelids for entropion or ectropion. Intermittent Tests of Tear Function and Stability
entropion may be induced in the office by having Schirmer’s Testing There is much debate in the cur-
patients attempt to close their eyelids while you hold rent literature over the predictive value of Schirmer’s
the upper lid in place with your finger. The puncta testing. There is no doubt that there exists both a high
should be carefully evaluated. Are there signs of false-positive and false-negative rate for these tests.
inflammation? Is the puncta stenotic? Is a medial The Schirmer I test is performed without anesthesia,
ectropion present or is the puncta well positioned in and measures reflex and basic secretion. Less than
the tear lake? Eyelid tone should be assessed with the 10 mm of wetting after 5 minutes is a positive result.
snap-back and the distraction tests. In the snap-back The Scirmer II test is performed in the same man-
test, the lower eyelid is pulled down and then the ner, and the inside of the nose is irritated with a
examiner’s finger is gently removed. The patient is cotton-tipped applicator. In the basic secretion test,
asked not to blink. In a “normal” eyelid, the lid the eye is anesthetized with topical anesthetic drops,
should quickly and completely “snap-back” into posi- and the Schirmer test is performed. Wetting less than
tion against the globe. With eyelid laxity the lid 10 mm is again considered abnormal.
returns to position slowly, and may actually assume In our office, we have found that performing the
an ectropic configuration. For the distraction test, the basic secretion test for a 3-minute period yields
central lower eyelid is grasped between the exam- equally predictive if not better results. It is important
iner’s two fingers and pulled horizontally away from in all of the above tests to be sure the inferior fornix is
the globe. Greater than 7 mm of distraction is consid- dried well with a cotton-tipped applicator prior to
ered a positive result. inserting the filter paper.
Examination of the lacrimal system should include
both the lacrimal gland and the lacrimal sac. The
Tear Break-Up Time This test measures the stability
upper lid should be lifted as the patient looks infero-
of the tear film, and is an indicator of a deficient
nasally to best view the palpebral lobe of the lacrimal
mucin (or possibly lipid) layer. One drop of 2% fluo-
gland. Enlargement of the gland, inflammatory or
rescein is instilled into the eye. The cornea is inspected
cystic changes, or tenderness may indicate a hyper-
with a cobalt blue filter, and the patient is instructed
secretory cause for the patients tearing. The medial
not to blink. The time from a blink to the first visible
canthus should be examined for any signs of ery-
area of dryness (absence of fluorescein) is measured.
thema or swelling in the area of the lacrimal sac. The
Normal results are 15 to 35 seconds. Less than 10 sec-
lacrimal sac should be palpated for any masses or ten-
onds is considered abnormal.
derness, and then the sac should be massaged toward
the canaliculi to see if any pus or discharge is present.
The nose should be examined with a lighted nasal Tests of Lacrimal Patency
speculum. Turbinate hypertrophy and any septal Dye Disappearance Test The dye disappearance test
deviation should be noted. Inflammatory changes and is a physiologic test of lacrimal function that can be
allergic rhinitis may contribute to tearing. Finally, the performed in the office. One drop of 2% fluorescein is
nose should be examined for any masses or polyps. instilled into each eye. After 5 minutes, the two eyes
The conjunctiva and cornea should be examined are evaluated. A normal result is minimal or no dye
for any signs of ocular irritation. Any corneal staining remaining. Abnormal results show varying amounts
could indicate an etiology for the patient’s tearing of dye retention. Results are most useful when com-
(punctate keratopathy, corneal abrasion, corneal paring the two sides for significant asymmetry.
ulcer, recurrent corneal erosion, viral keratitis, etc.). Abnormal results indicate either blockage or stenosis
The upper lid should be everted and examined for of the lacrimal drainage system, or failure of the
signs of papillary conjunctivitis, and the fornices lacrimal pump.
should be examined for the possibility of a foreign
body being present. Conjunctivochalasis, in which Jones I and Jones II Tests Like the dye disappear-
excess folds of conjunctiva override the punctal open- ance test, the Jones I test is a test of physiologic
ings, is another cause of tearing. lacrimal outflow function. In the Jones I test, 2% fluo-
The anterior chamber should be examined for any rescein is placed in the eye. The nose is sprayed with
signs of iritis. A complete eye exam should be per- a topical decongestant. After 5 minutes, the area
formed to establish the patient’s baseline status prior under the inferior turbinate is examined with a blue
to beginning any medical or surgical therapy light for staining. If none is evident, the inferior turbi-
(Fig. 18–3). nate may be swept with a cotton-tipped applicator or
CHEN18-263-288.I 3/22/01 2:27 PM Page 267
Epiphora (adults)
No Lid laxity?
Yes Ocular irritation
Pump failure?
1. Lid/lash malposition
Distraction test, >8 mm,
(entropion, trichiasis,
or snap-back test
distichiasis)
2. Ocular surface disease
e.g., superficial punctate
keratopathy
Yes No
Yes No
Punctal
ectropion
Check Schirmer's
Corneal
basic lacrimal
irregularity
secretory test
Yes No
<10 mm >10 mm
Yes No
(at 5 min) (at 5 min)
Rx: medial
Punctal
Conjunctivitis spindle
stenosis?
Corneal ulcer, iritis procedure
Photophobia
Rx: artificial tears, Reevaluate Yes No

Rx: lubricants
Gel, Punctal plugs for other causes
1
Floppy eyelid
Rx: 3-snips syndrome?
punctoplasty Hx of sleep
apnea
Yes No
Sleep apnea workup Diagnostic

Rx: eye shield and probing
horizontal lid shortening and irrigation
1
Floppy eyelid syndrome: spontaneous eversion
of upper lids; tarsal thickening and sebaceous
hyperplasia; papillary conjunctivitis.
FIGURE 18–3 Clinical pathway for managing epiphora (adults).
a roll of cotton and examined for staining. Alterna- ance test, this may indicate either blockage or stenosis
tively, patients may be asked to blow their nose ant of the lacrimal drainage system, or failure of the
the tissue examined for staining. A negative result by lacrimal pump.
convention means that no dye is present (an interpre- In the Jones II test, the remaining dye in the fornix
tation that has led to never-ending confusion among is irrigated from the eye. The punctum is then
students and physicians alike—we prefer to indicate dilated and a 3 cc syringe of normal saline or sterile
if dye is present or not). As with the dye disappear- eye wash on an irrigating canula is inserted through
CHEN18-263-288.I 3/22/01 2:27 PM Page 268
the inferior puncta and canaliculus and irrigation is

performed. Reflux of fluid (and possibly dye)
through the lower puncta indicates an obstruction of
the lower canaliculus proximal to the common
canaliculus. Reflux through the upper punctum with
none entering the nose indicates obstruction at or
just below the lacrimal sac. Retrieval of fluorescein
with the nasal irrigant indicates a functional obstruc-
tion or stenosis. If the irrigant comes through clear,
this indicates that no dye reached the lacrimal sac.
This is due to a pump failure, punctal stenosis, or
possibly a proximal canalicular stenosis (bypassed
by the irrigating canula). As with the Schirmer’s test,
the Jones I and II tests must be interpreted with cau-
tion. Up to 22% of normal subjects may have an
abnormal result on Jones I testing.14
FIGURE 18–4 Lacrimal scintigraphy. Failure of the

Lacrimal Irrigation Test Without first placing dye, tracer to reach the lacrimal sac by 5 minutes indicates
the lacrimal canaliculi can be irrigated as described marked delay (as seen on right eye’s tracing).
above with the Jones II test. Sterile saline or eye wash
mixed with a few drops of gentamicin eye drops (to
produce a bitter taste) are used. Results are similarly most distal area of tracer activity is noted (Fig. 18–4).
interpreted, although a functional obstruction cannot As with the dye disappearance test and the Jones I
be identified. Attention should be paid to comparing test, this is a physiologic test of lacrimal outflow.
the resistance to irrigation on the two sides, as well as
any strictures in the canaliculi. Digitally Subtracted Dacryocystography Although
not a functional test, this is the most useful test for
defining the anatomy of the lacrimal drainage sys-
EARL... In our office, we routinely
P fashion simplified lacrimal canulas from 114-
inch 27-gauge needles. The needles are cut with
tem. It can identify areas of stenosis, dacryolithes,
masses, as well as certain bony abnormalities. It is
invaluable in communicating to patients the exact
nature of their symptoms.
utility scissors to between 1/2 and 3/4 inches. Any To perform the test, topical anesthetic drops are
burrs are filed down using the side of the scissors. placed in each eye. The inferior puncta are dilated,
This provides a disposable lacrimal irrigation can- and then a 20-French angiocatheter is passed through
ula that is narrower than most prefabricated the inferior puncta and into the canaliculus. The tub-
canulas, allowing easier irrigation without dila- ing is gently taped to the cheek and the other side is
positioned in a similar manner. Approximately 3 to
tion, and with less patient discomfort.
5 cc of radiopaque dye (with 350 to 370 mg/cc of
iodine) is injected simultaneously through both sys-
tems, and sequential images are recorded under fluo-
Probing Probing beyond the canalicular system is roscopy using a computerized digital subtraction
uncomfortable for the patient, and should be reserved program (Fig. 18–5).
for the operating room.
...
Radiographic Studies
Dacryoscintigraphy A drop of radioactive tracer
(sodium pertechnetate) is placed in each eye. Sequen-
P
1.
EARL A realistic workup for the
tearing patient includes the following:
Compete history and ocular exam
tial images are obtained over a 30-minute period with 2. Three-minute basic secretion test
a gamma camera. The tracer is followed from the ocu- (Schirmer’s with anesthesia)
lar surface, to the canaliculi, the lacrimal sac, the 3. Lacrimal irrigation
lacrimal duct, and the nose. Absence of tracer in 4. Scintigraphy and dacryocystography (if
the lacrimal sac by 5 minutes indicates marked delay. available) (Fig. 18–6)
The two sides are compared for asymmetry, and the
CHEN18-263-288.I 3/22/01 2:27 PM Page 269
A B
FIGURE 18–5 Digitally subtracted dacryocystography. Both sidea are injected simultaneously. (A) A patient with
a unilateral complete obstruction of the right eye. (B) A unilateral filling defect consistent with a dacryolith located
within the lacrimal sac of the left eye.
TREATMENT OF CONGENITAL temic antibiotics and warm compresses are recom-

NASOLACRIMAL DUCT OBSTRUCTION mended for dacryocystitis.
Evaluation Surgical Management

Congenital nasolacrimal duct obstruction is most Probing and Irrigation
often due to an imperforate membrane at the valve of Patients with persistent tearing after 9 months to 1
Hasner. Infants present with chronic tearing from one year of age are taken to the operating room for prob-
or both eyes, discharge, and occasionally recurrent ing and irrigation under general anesthesia. Studies
episodes of dacryocystitis. It should be noted that tear have shown success rates of 95% when probing is car-
production in infants increases with age, and there- ried out before the age of 13 months, versus 33% if
fore onset of symptoms may not occur until after the performed after the age of 2 years.16
first few months of life. Tear production is propor- The mucosa under the inferior turbinate is con-
tionately delayed in preterm infants.15 stricted with 2.5% phenylephrine—either sprayed or
Office examination is often limited, but should first preferably soaked on neurosurgical-cottonoids or
focus on other causes of tearing (trichiasis, ocular sur- cotton-tipped applicators. Both eyes are again exam-
face disease, nasal pathology). The medial canthus ined in the operating room using surgical loops to
should be inspected for any signs of dacryocystitis, identify any abnormalities of the eyelids, eyelashes,
and the area of the lacrimal gland should be palpated or the ocular surface. The puncta are then dilated, and
for any masses, tenderness, or discharge. Attempt a number 1 (or smaller—”0” or “00”) probe is inserted
should be made to identify an upper and lower punc- into the inferior or superior puncta. The probe is first
tum on each side. Nasal exam may be attempted, passed vertically for 2 mm, then medial and slightly
looking for signs of allergic rhinitis or turbinate superior while countertraction is held on the lower lid
hypertrophy. Except in rare cases, probing is best (Fig. 18–7). Once a “hard stop” on bone is reached, the
reserved for the operating room setting. probe is rotated inferiorly, slightly laterally, and
slightly posteriorly to enter the nasolacrimal duct.
Aligning the top of the probe with the supraorbital
Medical Management notch of foramen will often give the proper orienta-
Because 90% of cases will spontaneously resolve by tion. Although some tightness may be felt as the
the age of 1 year, initial treatment should be conserv- probe passes through the duct, significant force
ative. Parents should be instructed on the proper should never be used, as it may lead to creation of a
method of lacrimal massage. Massage should be per- false passage. The probe will meet increasing resis-
formed as frequently as feasible, or at least five repe- tance as it passes through the bony canal, with addi-
titions twice a day. Topical antibiotic drops are used tional resistance possible at the distal end of the duct
for cases with frequent mucopurulent discharge. Sys- as it passes through the obstructed valve of Hasner or
CHEN18-263-288.I 3/22/01 2:27 PM Page 270
Diagnostic probing and irrigation
Canalicular
Rule out stenosis
obstruction, 100% reflux through
No reflux
(100% reflux though opposite punctum
(Patient tastes irrigant)
same canaliculus)
Lacrimal SAC obstruction;

Reevaluate for Evaluate other
total nasolacrimal duct
nonlacrimal causes canaliculus
obstruction
No other cause Rx: Conjunctival

DCR, or
Canalicular DCR, or Rx: DCR
1 DCR with retrograde
Consider DSDCG
and scintigraphy intubation
Nasal exam Some reflux thru other

punctum, irrigates to throat
Lacrimal stenosis
Turbinate
hypertrophy or Nasal mass
mucosal edema
DSDCG1
ENT workup
Has stenosis No stenosis
Try Rx: inhaled or dilation nor dilation
steroids or systemic
antihistamine/decongestant
Scintigraphy
Lacricath
and S-tube Delay No delay
If no improvement,
evaluate for other causes,
ENT workup
Check lid laxity,
Reevaluate for
punctal stenosis
other causes
or ectropion
Yes No
Treat cause Functional nasolacrimal

duct obstruction
Rx: lacricath
and S-tube
Improved Still tearing
DCR
1
DSDCG, digital subtraction dacryocystography
FIGURE 18–6 Diagnostic probing and irrigation.
270
CHEN18-263-288.I 3/22/01 2:27 PM Page 271
A B
FIGURE 18–7 Nasolacrimal probing. Countertraction must be held on the lid. The probe must be oriented along
the path of the canaliculus.
rubs against the inferior turbinate. Remember: the dis- nose with a frazier suction tip to confirm patency of
tance from the lacrimal puncta to the floor of the nose the system.
is 20 to 25 mm in children (30 to 35 mm in adults).17
Next, the nose is examined with a nasal speculum.
A larger Bowman probe is directed laterally under the Inferior Turbinate Infracture
inferior turbinate until the two probes touch and Infracture of the inferior turbinate is indicated when
“metal-on-metal” is felt and heard. The inferior nasal exam reveals a “tight” opening between the infe-
turbinate is examined, and if it is felt to be tightly rior turbinate and the lateral nasal wall. To perform
opposed to the lateral nasal wall, it may be infrac- this procedure, the periosteal elevator is placed under
tured using a periosteal elevator. At the end of the the inferior turbinate (Fig. 18–8). The elevator is stabi-
procedure, fluorescein-tinted saline should be irri- lized with the surgeon’s second hand at the external
gated through the canaliculus and recovered from the opening to the nose laterally. With the second hand
CHEN18-263-288.I 3/22/01 2:27 PM Page 272
Crawford tubes are our first choice due to the con-

sistent results we have achieved with this apparatus.
Regardless of which specific system is chosen, we
emphasize that for congenital nasolacrimal duct
obstruction, a bicanalicular tube yields significantly
higher results than the monocanalicular systems cur-
rently in favor for certain canalicular lacerations.19
They are inserted following punctal dilation and ini-
tial probing with a Bowman probe. Retrieval may be
aided by bending the probe 15 degrees at the distal
third of the probe.20 The probe is inserted in the same
manner as previously described. Again, remember
that in an infant the probe needs to be inserted only 20
to 25 mm to be retrieved. A nasal speculum is used to
examine the nose (previously treated with topical
2.5% phenylephrine), and then the retrieval hook is
inserted laterally under the inferior turbinate. It is best
to insert the hook with the tip oriented vertically.
When “metal-on-metal” is heard and felt, the hook is
rotated one-quarter turn toward the probe to engage
the olive. The probe is slowly retracted until the hook
and olive are felt to engage, and then the hook is used
FIGURE 18–8 Infracture of the inferior turbinate. A
to pull the probe out the nose. The process is repeated
periosteal elevator is used to rotate the inferior turbinate
inward, until a “crack” is felt. The procedure is indicated in with the other punctum.
congenital cases where a narrow opening is noted between Once both canaliculi have been successfully intu-
the inferior turbinate and the lateral nasal wall. bated, the probes are removed from the ends of the
tube, and the tube is tied to itself within the nose
using three square knots. It is helpful to have an assis-
acting as a fulcrum, the head of the instrument is tant stabilize the first knot so that it is not tied too
rotated medially until the turbinate is felt to give (an deep within the nasal passage. The tube is then
audible “crack” may be heard and felt). Finally, fluo- anchored to the lateral mucocutaneous junction inside
rescein-tinted saline is irrigated through the lacrimal the nose with a blue 6-0 Prolene suture (the area may
sac and retrieved through the nose with a frazier suc- be injected with a small amount of 1% lidocaine with
tion tip, thus confirming the patency of the system. epinephrine at the start of the case for hemostasis).
Prior to tying the Prolene, the ocular side of the tube
Silicone Intubation should be tested to ensure adequate “give” between
Silicone intubation is used to provide a stent through the two puncta. Alternatively, if a threaded Crawford
the lacrimal apparatus. Its primary indication is in tube is used, the ends of the tubing may be carefully
any infant who requires repeat probing. It is also rou- stripped with two forceps. The threads can then be
tinely used in primary cases in older children (beyond tied to themselves and the tube either left unanchored
18 months), or when significant strictures or “tight- or anchored as above.
ness” is noted during primary probing. Postoperatively, the patient is placed on a topical
There are a number of silicone intubation systems antibiotic/steroid drop four times a day for one week,
now on the market (Fig. 18–9). The Crawford tubes then one drop a day as long as the tube is in place. Sil-
are fashioned with an olive-shaped tip on the end of icone tubes are routinely left in place for 6 weeks to
the probes. The tip is engaged by a retrieval hook and 3 months. In adults, we leave the tube in place until
pulled out through the nose. The Ritleng probe con- irrigation around the tube is possible in the office.
tains a Prolene thread between the probe and the sili- Depending on the patient’s age, tubes are removed
cone tube that is similarly engaged with a hook and either in the office or in the operating room.
pulled through the nose.18 Other systems (Gabour,
Quickert-Dryden, etc.) use a probe either attached to Balloon Dacryocystoplasty
or placed within the silicone tubing. These are Balloon dacryocystoplasty using the Lacricath system
removed from the nose either with the use of a groove is gaining popularity in treating congenital naso-
director or under direct visualization with a long, nar- lacrimal duct obstruction in the pediatric patient. Indi-
row hemostat. cations are similar to those described for silicone
CHEN18-263-288.I 3/22/01 2:27 PM Page 273
Silicone tube
Silicone tube
Quickert-Dryden probe
Crawford
probe
Crawford
retriever
Grooved director
A B
Ploypropylene
Ritleng probe
suture
Silicone tube
Ploypropylene
suture
Hook
Nasal endoscope
FIGURE 18–9 Silicon tubes. (A) Crawford. (B) Quickert-Dryden, Gabour. (C) Ritleng.
intubation. For primary cases, balloon dilation may be The procedure is performed in the operating room
performed when a focal area of stenosis or tightness is after probing and turbinate infracturing (if indicated).
noted on probing. Most recurrent cases may benefit The inflation chamber is filled as directed with sterile
from the procedure, unless there is clearly an absence water or saline, and all air bubbles are evacuated from
of resistance to a no. 2 Bowman probe or larger. the chamber. The appropriate-size lacrimal balloon
CHEN18-263-288.I 3/22/01 2:27 PM Page 274
catheter (pediatric, adult, or dacryocystorhinostomy caine with epinephrine 1:100,000 is injected transcon-
revision) is then attached to the inflation chamber. With junctivally near the punctum. The punctum is dilated
the lock engaged, the balloon is expanded to ensure with a punctal dilator (severe punctal stenosis may
proper function. The lock is then disengaged and the bal- require careful dilation with a sharp probe or needle).
loon completely deflated. Antibiotic ointment may be Gently grasping lateral to the punctum with a toothed
applied to the balloon to ease its passage. The superior forceps, one blade of a Wescott scissors is inserted
punctum is redilated (if needed), and then the balloon into the punctum as far vertically as allowed (approx-
is inserted through the punctum and into the lacrimal imately 2 mm). The scissors is rotated medially, and
duct in the manner previously described. The balloon is the punctum and conjunctiva are cut. The procedure
positioned so that the second marking (15 mm) on the is repeated with the scissors held laterally, and then
probe is at the punctum. It is inflated to 9 atmosphere the flap is excised horizontally at its base (three-snip
for 90 seconds, deflated, repositioned, and reinflated procedure). Alternatively, a Holtz sclerostomy punch
for an additional 60 seconds after which it is deflated. may be used to excise a similar amount of tissue.
The probe is pulled back until the lower mark is visible
(10 mm), and the cycle is repeated. The system should
then be reevaluated with a no. 2 or larger Bowman Punctal Ectropion: Medial Spindle
probe, and retreated if any stenotic areas remain. Punctal ectropion may be successfully treated with
this procedure. After topical anesthetic, lidocaine 2%
Dacryocystorhinostomy with epinephrine 1:100,000 in injected transconjuncti-
Dacryocystorhinostomy (DCR) procedures are rarely vally into the medial aspect of the lower lid below and
indicated in the pediatric population. The most com- lateral to the punctum. A small amount should be
mon indication is for congenital epiphora that has placed subcutaneously as well. With an assistant
failed all of the above surgical options. Trauma and retracting the lid outward, the conjunctival surface is
recurrent dacryocystitis are relative indications as dried and a diamond pattern is marked with the apex
well. Two studies have quoted success rates ranging 3 to 4 mm below the punctum, measuring 4 mm ver-
from 77%21 to 90%.22 tically by 6 to 8 mm horizontally (Fig. 18–10). A
The procedure is the same as for adult patients, lacrimal probe may be placed within the canaliculus
with the obvious addition of general anesthesia. for protection. Conjunctiva and deep tissue are
Reported complications include surgical failure, excised with a no. 15 blade and/or Wescott scissors.
wound infections, and complications related to sili- The defect created is closed with double-armed 5-0
cone or Jones tubes. chromic gut sutures. The first needle is passed
through conjunctiva and deep tissue above the spin-
dle, exiting within the wound. The needle is
SURGICAL TREATMENT IN ADULTS regrasped and passed through the center of the
wound and out through the skin. The other arm is
“Pump” Failure
passed in a similar two-step manner through the
Tearing due to pump failure or other eyelid abnor- lower edge of the wound. Two to four sutures are
malities (entropion, ectropion, eyelid retraction, etc.) passed in this way. The punctum should be observed
should be corrected. Often, pump failure may to turn in as the sutures are tied externally over small
respond to a horizontal tightening procedure (i.e., a cotton bolsters (made from the cotton ends of a cotton-
lateral tarsal strip), but the examiner should first treat tipped applicator).
any contributing ocular surface irritation (blepharitis,
trichiasis) prior to this procedure. If a tarsal strip is
anticipated, attention should be placed preoperatively Nasolacrimal Stenosis
on assessing the medial canthal tendon for laxity, and The following procedures are indicated in adults
assessing the position and patency of the punctum in with symptomatic epiphora, and patency on naso-
relation to the tear lake (punctal ectropion, punctal lacrimal irrigation. Eyelid and dry eye etiologies must
stenosis). Also, a complete evaluation of the lacrimal be ruled out. Lacrimal scintigraphy should show
system should be done even in cases of obvious pump delay, and dacryocystography will often show areas
failure, for multiple causes of tearing can often be of focal stenosis.
encountered in the same patient.
Punctal Stenosis: “Three-Snip” Procedure Probing and Irrigation

Isolated punctal stenosis may be treated in the office Although probing and irrigation has been reported as
setting. The punctum is anesthetized with topical 4% a primary treatment for epiphora in adults,23 we feel
lidocaine on a cotton-tipped applicator, and 2% lido- that the underlying chronicity of these diseases
CHEN18-263-288.I 3/22/01 2:27 PM Page 275
Lid margin
Punctum
Inferior margin
of tarsal plate
Retractors
Conjunctiva
Fornix
A B
C D
FIGURE 18–10 (A) Medial spindle marked on inner aspect of right lower eyelid. (B) A diamond excision
measuring 3 mm vertically and 6 mm horizontally is formed. (C) Double-armed 5-0 chromic gut sutures are passed
through the edges of the diamond, through the wound bed, and (D) externalized over cotton bolsters to invert the
puncta.
responds better to either of the procedures below for focal areas of stenosis on digitally subtracted dacry-
initial therapy. ocystography are particularly amenable to this proce-
dure. We routinely perform this procedure in the
Nasolacrimal Intubation operating room under intravenous sedation with local
anesthesia, although the manufacturer has distributed
Nasolacrimal intubation with silicone tubes is an
recommendations for the procedure to be performed
appropriate procedure for adults with epiphora sec-
in the office with oral valium and local anesthesia.
ondary to nasolacrimal stenosis, particularly when
In either setting, 2% lidocaine with epinephrine
limited to the upper system. Overall success rates of
1:100,000 is injected in the area of the medial canthus,
68.6% symptomatic improvement have been re-
first from the upper lid and then the lower lid. After
ported, with significantly higher rates in canalicular
punctal dilation, 4% viscous lidocaine on a lacrimal
stenosis (75.9%) versus nasolacrimal stenosis (25%).24
canula can be irrigated through the nasolacrimal sys-
The procedure is performed as described in the pre-
tem. Topical anesthetic should be placed in the eye.
vious sections.
The inflation device should be prepared as directed
by the manufacturer, and filled with saline or sterile
Balloon Dacryocystoplasty water as previously described. The adult-size balloon
Symptomatic tearing adult patients with incomplete should be attached and tested. Prior to inserting the
or intermittent obstruction of the nasolacrimal system balloon, the lacrimal system can be probed with a
may benefit from this procedure. Success rates of 87% no. 1 or no. 2 Bowman probe. The balloon may be
subjective improvement at 2 months and 73% at 6 lubricated with antibiotic ointment, and then it is
months have been reported.25 Patients found to have inserted through the superior punctum and into the
CHEN18-263-288.I 3/22/01 2:27 PM Page 276
lacrimal duct in the manner previously described. The unknown if this is a cause or a consequence of primary
balloon is positioned so that the second marking acquired nasolacrimal duct obstruction.27
(15 mm) on the probe is at the punctum. It is inflated The traditional external DCR has consistently
to 9 atmospheres for 90 seconds, deflated, reposi- demonstrated success rates of 91% and higher (usu-
tioned, and reinflated for an additional 60 seconds, ally greater than 95%28, 29), and is our procedure of
then deflated. The probe is pulled back until the lower choice (versus endonasal laser-assisted DCR, with
mark is visible (10 mm), and the cycle is repeated. The success rates closer to 63%30). Risks and complications
system should then be reevaluated with a no. 2 or with the external approach include a cutaneous scar,
larger Bowman probe, and retreated if any stenotic nasal bleeding, cerebrospinal fluid (CSF) leak, and
areas remain. persistent tearing. Meticulous attention to anatomy
We routinely follow balloon dacryocystoplasty in and surgical technique can minimize these risks.
an adult patient with silicone intubation using the The procedure is usually performed under local
Crawford tubes as described for the infant. It should anesthesia with intravenous sedation, although gen-
be recalled that in the adult, the total length from the eral anesthesia is occasionally required. An incision
punctum to the valve of Hasner is 30 to 35 mm. The line should be marked 8 to 10 mm nasal from the
nasal mucosa is decongested with topical 2.5% medial canthus, beginning just below the medial can-
phenylephrine placed on applicators below the infe- thal tendon and continuing inferiorly for 1.5 to 2.0 cm.
rior turbinate. Retrieval of the Crawford probe is Lidocaine 2% with epinephrine 1:100,000 is injected
aided by placing a 15-degree bend in the probe, as into the medial canthus from both the upper lid and
well as by visualizing the nasal passage with a specu- the lower lid. The area below the incision line in infil-
lum to ensure that the hook is being placed far enough trated subcutaneously. An anterior ethmoidal block
laterally and that it is beneath the inferior turbinate. is performed by carefully tracking the needle
Postoperatively, the patient is placed on a topical transconjunctivally along the medial orbital wall to a
antibiotic/steroid drop four times a day for 1 week, depth of 20 mm, then slowly injecting 1 cc of anes-
then one drop a day as long as the tube is in place. Sil- thetic. The anterior ethmoidal artery is 24 mm from
icone tubes are routinely left in place for 6 weeks. At the medial orbital rim (Fig. 18–11). The nose is
the 6-week visit, irrigation around the tube is attemp- sprayed with 2.5% phenylephrine, then packed with
ted. If irrigation is successful, the tube is removed. If 4% topical cocaine on 1- by 3-inch neurosurgical cot-
the system is not patent, the patient is reevaluated at tonoids. The neurosurgical cottonoids should be
4-week intervals. Repeat failures should prompt a placed medial to, and beneath, the middle turbinate.
nasal exam for signs of mucosal congestion, which A small amount of lidocaine can be injected at the
can then be treated aggressively with inhaled steroids internal nasal mucocutaneous junction where the sil-
and systemic antihistamines with or without a decon- icone tube will eventually be anchored. There is still
gestant. After 6 to 9 months, the tubes should be debate over the need for prophylactic antibiotics, with
removed and the patient followed. Persistent tearing some studies quoting infection rates as high as 8%31
may be treated with repeat balloon dilation or dacry- to 12%.32 In a prospective study, we found the rate of
ocystorhinostomy.
Lacrimal sac
Complete Nasolacrimal Duct Obstruction
Dacryocystorhinostomy
Dacryocystorhinostomy (DCR) is indicated for cases
of complete nasolacrimal duct obstruction at or distal
to the lacrimal sac, cases of partial obstruction that
have failed other treatments, and cases of recurrent
dacryocystitis. Anterior
The etiology of acquired nasolacrimal duct obstruc- ethmoidal
nerve
tion may be divided into primary and secondary
causes (Table 18–1). Linberg and McCormick26 were
the first to report on the histopathologic findings in pri- Anesthetized
area
mary acquired nasolacrimal duct obstruction as con-
sisting of early inflammatory changes and late fibrotic FIGURE 18–11 Anterior ethmoidal block. The needle is
changes. Additional studies have documented similar tracked along the medial orbital wall for 20 mm, then 1 cc of
pathologic changes in the nasal mucosa, although it is anesthetic is injected while slowly withdrawing the needle.
CHEN18-263-288.I 3/22/01 2:27 PM Page 277
postoperative infection to be as low as 3.4%,33 and

EARL ...
therefore reserve the use of intraoperative antibiotics
for cases of active dacryocystitis, associated medical
conditions (e.g., Wegener’s granulomatosis), or atyp-
P Disinserting the medial
canthal tendon is more commonly advo-
cated to improve exposure of the superior fun-
ical intraoperative findings (tumor, marked mucosal
thickening, etc.). dus of the lacrimal sac during reoperations for
failed DCRs. By incorporating this step into a
primary procedure, visibility is improved, and
EARL ... The fatal cocaine dose is
P approximately 1 g for an adult. 34 This
amount is contained in 10 mL of a 10% solution.
larger flaps can be fashioned.
Periosteum anterior to the anterior lacrimal crest is

Although topical doses do not correlate directly
next incised with a no. 15 blade. A periosteal elevator
with intravenous doses, the usual maximum is used to dissect beneath periosteum, over the ante-
dose used clinically is 200 mg (equivalent to 3 rior lacrimal crest, and into the lacrimal fossa
mg per kg for a 70-kg patient). The maximum (Fig. 18–12). The nasal packing is removed if it is still
adult dose of lidocaine with epinephrine is 7 present. The osteotomy is begun by breaking through
mgkg, or approximately 20 cc of a 2% solution the anterior floor of the lacrimal fossa with a curved
hemostat. Alternatively, bone may first be removed
for a 70-kg patient.
from the anterior lacrimal crest with a small Kerrison
rongeur (Fig. 18–13). Either way, great care must be
taken to avoid sacrificing nasal mucosa. As the open-
After allowing 15 minutes for the epinephrine to ing is enlarged, larger rongeurs are introduced. Bone
take effect, the skin is incised with a no. 15 blade should be removed cleanly, without any twisting
(Fig. 18–2). A straight Stevens scissors should be used motion, which would increase the risk of CSF leak-
to bluntly dissect through orbicularis down to perios- age. The final osteotomy should include the bulk of
teum. The orientation of the dissection should be par- the anterior lacrimal crest, and the lacrimal fossa to
allel to the orbicularis fibers, and therefore relatively the posterior lacrimal crest. Superiorly, bone removal
atraumatic. Attention should be paid to identification should stop 2 to 3 mm inferior to the frontoethmoidal
to the angular artery, which will be located in the soft suture to avoid damage to the cribriform plate.
tissue nasal to the incision. Between three and five 4-0 Anatomic studies have shown that the mean distance
silk traction sutures are then placed from deep in the from the internal common punctum to the cribriform
nasal aspect of the wound (the angular artery should
be in the tissue included in this bite). The needles are
removed and the tissue is retracted nasally and
anchored to the surgical drape above the contralateral
eye. Any bleeding vessels may be cauterized with
bovie cautery. Freer elevator
EARL... If the view is inadequate at

P this point, enlarge it as needed. Additional
traction sutures may help as well. A headlight
will improve visualization as the case proceeds.
Frontal process
of maxillary bone
Blunt dissection is continued superiorly until the

medial canthal tendon is identified. After cleaning off
any fibrous attachments, the tendon is disinserted
using a supersharp or a no. 11 blade. Using surgical
tape to form a blade guard with only 3 mm of the
blade exposed prevents damage to surrounding FIGURE 18–12 Periosteal elevator is used to dissect into
structures. the lacrimal sac fossa.
CHEN18-263-288.I 3/22/01 2:27 PM Page 278
Nasal
mucosa
Tear sac
Cut
bone
FIGURE 18–13 Bone removal with Kerrison rongeurs.
plate is 25.1 ; 2.95 mm.35 It seems more likely that Posterior stub
CSF leaks occur due to fracture propagation from
improper twisting rather than direct penetration. The Anterior flaps
final opening should be at least 10 mm in all diame-
ters, with 15 mm or larger being the norm.
FIGURE 18–14 Formation of lacrimal sac and nasal
mucosal flaps.
EARL ...
P Insufficient size of the
osteotomy is the most common cause of a
failed DCR. Even in successful procedures, the
surgical wound. Failure to identify tenting of the nasal
mucosa is a likely indication that the osteotomy has
soft tissue opening shrinks markedly in the imme- opened into an anterior ethmoidal air cell, a situation
noted to occur in up to 46% of DCR procedures.40 The
diately postoperative period.36–38 Alternatively,
nasal mucosa is incised in a similar manner to the
Linberg et al,39 examining the intranasal ostium, lacrimal sac. Bleeding should be minimal if the co-
found that there was not a strong correlation caine pledgets were correctly placed. The posterior
between size of the bony osteotomy and surgical flap of nasal mucosa is then anastomosed to the pos-
success. Despite the contrary evidence, we terior lacrimal sac flap using at least two interrupted
believe that a larger osteotomy improves the 5-0 Vicryl sutures on a small half-circle needle.
chance of surgical success.
EARL ...
Next a lacrimal probe is inserted through either
P Although some authors
argue against the need for posterior
flaps,41 we believe that the formation of anterior
canaliculus, and the lacrimal sac is tented into the
wound. A no. 15 blade is used to incise the sac verti- and posterior flaps increases the likelihood of
cally for it’s entire length (Fig. 18–14). The sac is maintaining postoperative patency.
opened, and any dacryoliths or pus is sent for cul-
ture and biopsy. Relaxing incisions are placed with
scissors at the superior and inferior edges of the ver- Although we do not routinely use mitomycin C
tical incision, forming a capital “I”. If indicated, a with our DCRs, the application may be of some use
biopsy specimen can be taken from the posterior flap in reoperations, particularly in those cases with an
at this time (we feel that an in tact anterior flap is associated systemic granulomatous or inflammatory
more predictive of surgical success). condition (Wegener’s granulomatosis, as an example,
A periosteal elevator is placed in the nose until it shows a higher rate of DCR failure,42 and may benefit
tents the nasal mucosa through the osteotomy into the from topical antimetabolites). After the posterior flaps
CHEN18-263-288.I 3/22/01 2:27 PM Page 279
are sutured, 1 cc of 0.2 mgcc mitomycin C may be there are intraoperative signs of dacryocystitis, the
soaked on a neurosurgical cottonoid and left in place patient should be given intraoperative intravenous
for up to 30 minutes as the procedure is completed.43 antibiotics, as well as a 7- to 10-day course of oral
The cottonoid may be removed transnasally later. antibiotics. The patient is seen for follow-up on post-
Care should be taken to avoid contact with the globe, operative day 7. The silicone tubes are left in place for
and copious irrigation should be initiated if any con- at least 6 weeks, and preferably 3 months. The tubes
cern exists. may be removed after irrigation around the tubes is
Silicone tubes are then passed through the upper successful.
and lower puncta and brought out through the
lacrimal sac incision, then through the osteotomy to Complications
exit the nose. Since the nasal passage is under direct The most frequent complication of DCR is persistent
visualization, any silicone tube system will be or recurrent tearing. The techniques explained here
retrieved with ease. should lead to a success rate of over 95%. We often
address DCR failure with an endoscopic laser
approach, described below.
EARL... Most cases of canalicular Bleeding is the next most common complication.
P stenosis diagnosed in the office will suc-
cumb to careful probing in the operating room.
Orbital hemorrhage is rare, but may occur if the ante-
rior ethmoidal artery is traumatized either during
injection of local anesthesia or during bone removal.
If one or both probes meet an impasse at the Orbital hemorrhage associated with proptosis, vision
common canaliculus, the lacrimal sac may be loss, or elevated intraocular pressure should be
approached internally and a cutdown of the treated with a lateral canthotomy. Intraoperative
“common punctum” carefully performed (see bleeding from the nasal mucosa may be a sign of ele-
vated blood pressure, and should be evaluated and
Canaliculodacryocystorhinostomy, below).
managed appropriately. Bleeding from the mucosal
tissue should decrease after the flaps are sutured
together. Persistent bleeding at the conclusion of the
The anterior flaps are next approximated with 5-0 case should prompt a thorough nasal examination
Vicryl. The medial canthal tendon is reattached to its with coagulation of any actively bleeding vessels. If
insertion above the posterior lacrimal crest, again with oozing persists, appropriate nasal packing with antibi-
the 5-0 Vicryl. The traction sutures are removed and otic ointment may be indicated for 24 to 48 hours.
the site is inspected for hemostasis. If a potential space Cerebrospinal fluid leaks may be encountered
exists in the orbicularis plane, it should be closed with during lacrimal surgery, as explained above. Small
5-0 chromic gut. Skin is closed with a running 6-0 plain leaks will usually seal on their own, but are best
gut suture. The probes from the silicone tubes are patched with muscle or fascia. Larger leaks require
removed, and the tube is tied to itself within the nose neurosurgical consultation (although consultation is
using three square knots. It is helpful to have an assis- advisable in all cases). Antibiotics should be pre-
tant stabilize the first knot so that it is not tied too deep scribed in all CSF leaks.
within the nasal passage. The tube is then anchored to
the lateral mucocutaneous junction inside the nose Endoscopic Laser-Assisted DCR
with a blue 4-0 Prolene suture (the area should be Although a recent prospective study has shown a sta-
injected with a small amount of 2% lidocaine with epi- tistically significant increase in success rate for tradi-
nephrine at the start of the case for hemostasis). Prior tional DCR versus the endoscopic laser-assisted
to tying the Prolene, the ocular side of the tube should approach,30 it is likely that patient-driven interest in
be tested to ensure adequate “give” between the two laser surgery and “no scar” surgery will continue to
puncta. The nose and oropharynx are carefully drive demand for this procedure. At present, the main
inspected for adequate hemostasis prior to concluding advantages include the absence of a surgical scar, and
the case. If there is a concern for bleeding from the decreased operating time (approximately 23 minutes
nasal or lacrimal flaps, a collagen44 or Gelfoam stent versus 78 minutes).30 Countless new surgical proce-
soaked in thrombin45 may be placed. dures are being described including transnasal
Postoperatively, the patient is instructed to use top- procedures30, 46–52 and transcanalicular approaches.53–58
ical antibiotic/steroid ointment three times a day for The basic procedure is performed under local anes-
1 week, and at bedtime for 1 week. Topical antibi- thesia with intravenous sedation. All laser safety pro-
otic/steroid drops are used on a similar schedule. If tocols must be observed, including laser safety glasses
CHEN18-263-288.I 3/22/01 2:27 PM Page 280
for all operating room personnel. Then 2% lidocaine dioxide (CO2), holmium:yttrium-aluminum-garnet
with epinephrine 1:100,000 is injected into the medial (Ho:YAG), neodymium:YAG (Nd:YAG), and com-
canthus in the region of the lacrimal sac through both bined CO 2-Nd:YAG. A combination suction tip/
the upper and the lower lids. An anterior ethmoid laser guide handle aids in smoke evacuation. The
block is given transconjunctivally along the medial bony opening should ultimately be enlarged to a
orbital wall, and the nasal passage is sprayed with minimum 10-mm diameter in all directions. Any
2.5% phenylephrine and packed in the region of the laser char must be removed with either the suction
middle turbinate with 4% topical cocaine soaked on or with intranasal forceps to avoid thermal damage.
neurosurgical cottonoids. The canalicular system should then be intubated
A 20-gauge fiberoptic retinal light pipe, lubri- with silicone tubes as previously described.
cated with antibiotic ointment, is passed through Postoperative medications include topical antibi-
the inferior or superior punctum and canaliculus to otic/steroid drops four times a day for 1 week, then
the lacrimal sac (Fig. 18–15). The cocaine sponges daily as long as the silicone tubes are in place. The
are removed, and the area is inspected using a rigid tubes are left in place for a minimum of 6 weeks, then
nasal endoscope. Using the area illuminated by the removed when irrigation around the tubes is success-
light-pipe as a guide, the overlying nasal mucosa ful in the office.
and then bone are removed using an approved
laser system (settings will vary based on the type
...
of laser used). Laser systems currently in use
include potassium titanyl phosphate (KTP), carbon P EARL The one situation where
we have found the endoscopic laser-
assisted DCR technique to offer a distinct advan-
tage is during reoperations for failed DCRs.58
The procedure is performed as described above,
Light pipe
although a retinal light pipe is optional—the sur-
gical site can usually be identified with a lacrimal
probe. We routinely use the KTP laser for this
procedure. Silicone tubes are placed at the end
of the procedure, and left in place for at least 3
months for reoperations.
Laser delivery
system
Canalicular Obstruction
Canaliculodacryocystorhinostomy (caDCR)
Aspiration
A caDCR is an adjuvant procedure to a DCR or to a
combined conjunctival DCR (cDCR)/DCR, in which an
obstructed common canaliculus or distal individual
Endoscope canaliculus is reconstructed. Success rates as high as
66% after prior DCR failures have been reported.59, 60
The procedure is performed using the operating
microscope. Preoperative dacryocystography is rec-
ommended to confirm the location of the obstruction
as being in the distal or common canalicular system.
A standard DCR incision is made and the anterior
crus of the medial canthal tendon is identified and
reflected medially. Bowman probes are inserted
through the canaliculi until the obstruction is identi-
fied. The scar tissue is excised, a standard DCR is per-
FIGURE 18–15 Laser-assisted endoscopic dacryocys- formed, and the system is intubated with a silicone
torhinostomy (DCR). The light pipe is used as a guide to tube. Lacrimal sac-to-canalicular flaps are fashioned
initiate the osteotomy. in addition to the usual nasal mucosa–lacrimal sac
CHEN18-263-288.I 3/22/01 2:27 PM Page 281
A B
FIGURE 18–16 Canaliculodacryocystorhinostomy. Scar tissue from the common canaliculus is excised, and the
common canaliculus is resutured to the lacrimal sac fundus. (A) Stitching (anastomosis) of the posterior flaps of
lacrimal sac and nasal mucosa. (B) Anastomosis of anterior flaps of lacrimal sac and nasal mucosa, and anastomosis
of common canaliculus to lacrimal sac fundus.
flaps, and are anastomosed with 6-0 absorbable suture tum, and marked with a hemostat (Fig. 18–18). If the
in a similar manner (Fig. 18–16). tube is felt to be abutting the middle turbinate, a par-
tial turbinectomy should be performed. A straight
Conjunctival Dacryocystorhinostomy (cDCR) Pyrex tube of appropriate size is then placed over the
In 1965, Lester Jones61 described the placement of a probe, positioned in the soft tissue tract, and the Bow-
Pyrex glass tube to bypass the lacrimal system. To man probe is withdrawn (Fig. 18–19). The tube is
date, these Pyrex tubes remain the only proven anchored to the lid tissue medially with a 6-0 Vicryl
material for the artificial elimination of tears—aided
by the capillary and hydrophilic forces inherent to the
medium. Surgical success rates as high as 96% have
been reported.62
Indications for a cDCR include punctal or canalicu-
5910 Beaver blade
lar obstruction refractory to dilation or probing,
canalicular scarring after a canalicular laceration, cica-
tricial eyelid or conjunctival changes resulting in fail-
ure of the lacrimal pump not amenable to corrective
eyelid procedures, and occasionally after a failed
DCR.
The procedure is performed as part of a standard
DCR, or it can be performed secondarily after a failed
DCR. Prior to closing the anterior flaps for a DCR, a
vertical incision is made through the body of the
caruncle with a no. 11 blade. A 15-gauge needle is then
passed slightly anteriorly and inferiorly through the
opening in the caruncle, through the lacrimal sac, and
into the nose (Fig. 18–17). With the needle in place, the FIGURE 18–17 Conjunctivorhinostomy. The procedure
tract is enlarged with the no. 11 blade. A no. 00 Bow- is begun after the posterior flaps of the DCR have been
man probe is then threaded through the lumen of the sutured. A 15-guage needle placed through the caruncle
needle. The needle is positioned with the tip halfway incision into the lacrimal sac. The needle track is then
between the lateral nasal mucosa and the nasal sep- enlarged with a no. 11 blade.
CHEN18-263-288.I 3/22/01 2:27 PM Page 282
Hemostat congestion of the nasal mucosa blocking the tube? The

first two may require resizing with a new tube, the
latter may benefit from oral antihistamine/deconges-
tants combined with intranasal inhaled steroids.
Bowman
probe
EARL ... It is imperative that any
Middle
turbinate Rhinostomy
site
P time a Jones tube is to be removed, a tem-
porary plug be placed. It can be in the form of a
gold dilator designed for this purpose, or a large
Nasolacrimal
Nasal lacrimal probe. The tissue around the tube has
duct
septum
been known to rapidly contract after removal,
sometimes necessitating reoperations.
FIGURE 18–18 No. 00 lacrimal probe is placed through

the lumen of the needle and used to measure the distance Migration of the tube is most often due to improper
halfway to the nasal septum. tube placement at the initial surgery. If possible, the
tube should be repositioned in the office, although
operative revision may be indicated.
In addition to the causes of bleeding discussed in
either through the hole in the tube collar (if present) the DCR section, an oversized Jones tube may rub
or completely encircling the tube just below the collar. against the nasal septum and cause recurrent bouts of
Postoperatively, the patient is placed on topical epistaxis. Resizing is indicated.
antibiotic/steroid drops four times a day for 1 week, Inflammation around the tube may respond to top-
then daily for 3 weeks. The patient is instructed to ical steroids. The tube should be removed as
aspirate a small amount of saline or eyewash through described above, and any buildup removed. Infection
the tube on a daily basis to remove debris. The patient of the conjunctiva or soft tissues may be treated topi-
is told to gently support the tube with a finger when cally or systemically, respectively. Severe complica-
sneezing or blowing the nose. tions including scleral erosion and subcutaneous
Variations on this surgical procedure have been migration with inflammation have been reported.68
reported. Henderson63 describes the use of a 1.5-mm
trephine to cut a soft tissue tract for the tube. Others
have recommended the use of mucous membrane ADDITIONAL CONDITIONS
grafts to line the fistula tract instead of the Pyrex
tube.64, 65 Canalicular Lacerations
Current opinion is that the tube should remain in Canalicular lacerations can occur as a result of trauma
place indefinitely unless difficulties arise.66 in a variety of settings, including motor vehicle acci-
dents, dog bites,69 sports injuries, and even seemingly
Complications minor trauma around the home. The presence of a
A successful cDCR outcome is dependent as much on canalicular laceration should be a red flag for other
postoperative management as on intraoperative potential ocular injuries, and before planning surgi-
complications. The procedure is open to all of cal correction, a complete eye exam and imaging stud-
the complications discussed in the DCR section. Other ies (when an orbital fracture or foreign body is
complications are due to the prolonged presence of suspected) are required.
the Pyrex tubing within the orbital tissues.67
Recurrent tearing in a patient with a Jones tube
requires a thorough exam. Is there soft tissue overrid- Repair with Bicanalicular Intubation
ing the opening (conjunctiva or caruncle)? If so, exci- Even a seemingly obvious canalicular laceration
sion is indicated. Irrigation should be performed. If it should be probed prior to repair in the operating
is negative, a nasal speculum exam should follow. Is room. Many presumed canalicular lacerations will be
the tube abutting the middle turbinate? Is it too long, found to be shallow eyelid lacerations that spare the
riding against the septum? Is there a large amount of lacrimal apparatus. If patients’ tetanus immune status
CHEN18-263-288.I 3/22/01 2:27 PM Page 283
Medial canthal
tendon
Jones’ tube
Middle turbinate
Nasal septum
Rhinostomy
site
Inferior turbinate Nasolacrimal
duct
A B
FIGURE 18–19 Proper placement of the pyrex tube.

C (A) Diagram. (B) Nasal view. (C) CAT scan.
is unknown, they should receive a tetanus booster lus more difficult. It is possible to perform the proce-
shot. Contaminated wounds are treated with intra- dure with regional nerve blocks (supraorbital/frontal,
venous antibiotics preoperatively or intraoperatively infraorbital, etc.). The nose is sprayed with phenyl-
(either Ancef, 1 g IV, or clindamycin, 600 mg IV if soil ephrine 2.5%, and packed beneath the inferior
contamination is suspected). If there is excessive tis- turbinate with 4% cocaine soaked on neurosurgical
sue edema, intravenous corticosteroids may be of cottonoids. It is important that the wound be well irri-
value. If the patient is not being operated on immedi- gated during the surgical prep. A drop of topical 10%
ately (canalicular lacerations should be operated on phenylephrine into the wound may help to decongest
within 48 hours, and preferably within 24 hours), the the surrounding soft tissue.
wound should be dressed with antibiotic ointment The wound is inspected and the medial cut end of
and sterile gauze. the canaliculus identified. The canaliculus is approx-
We prefer to repair canalicular lacerations in the imately 2 mm in external diameter, white, and
operating room under general anesthesia. Local anes- slightly shiny compared to the surrounding tissue.
thesia is to be avoided because it will distort the Except when the laceration is just medial to the
anatomy and make identification of the cut canalicu- puncta, the cut medial end will more likely be found
CHEN18-263-288.I 3/22/01 2:27 PM Page 284
in the deeper tissue closer to the medial wound edge

than anticipated.
EARL... Identifying the cut end of

P the canaliculus is the most important (and
often the most difficult) part of the operation.
Flooding the wound with sterile saline, and irri-
gating air through the intact canaliculus, may
help to identify the cut end by following any bub-
bles released into the wound. Alternatively, vis-
coelastic or fluorescein tinted saline may be
injected into the intact canaliculus after the
wound bed is dried.
Once the medial edge of the canaliculus is identi-

fied, a Crawford probe is inserted through the punc-
FIGURE 18–20 Repair of canalicular laceration. Peri-
tum, into the wound, and through the medial end of
canalicular tissue is reaproximated with 7-0 sutures.
the cut canaliculus. Tissue adjacent to the canaliculus
should be gently grasped with a toothed forceps dur-
ing this step. With the forceps providing countertrac- nephrine 1:100,000 should be injected into the lacera-
tion on the soft tissue, the probe is advanced until a tion and into the medial canthal region over the
bony stop is felt, then directed in the usual manner lacrimal sac. After allowing 15 minutes for hemosta-
through the nasolacrimal canal to exit into the nose. sis, a standard DCR dissection can be carried out.
The probe is retrieved with a Crawford hook and the With the lacrimal sac opened vertically, the common
process is repeated for the intact canaliculus. internal punctum can be enlarged and the lacrimal
Attention is then directed to repair of the lacera- probes guided through soft tissue and into the
tion. If there is minimal tension on the wound, the lacrimal sac. The sac is closed with 5-0 Vicryl. Skin is
pericanalicular tissue can be reapproximated with closed in the usual manner.
two interrupted 7-0 Vicryl sutures; one inferior and Postoperatively, the patient is instructed to use top-
one superior to the canaliculus (Fig. 18–20). If signifi- ical antibiotic/steroid ointment three times a day for 1
cant tension exists, deep tissue should first be closed week, and at bedtime for 1 week. Topical antibi-
with 5-0 Vicryl or chromic gut. otic/steroid drops are used on a similar schedule. If
Prior to completing closure of the deep tissue, the there are intraoperative signs of wound contamina-
medial canthal tendon needs to be evaluated. If the tion, the patient should be given intraoperative antibi-
tendon is involved in the laceration, it should be reap- otics, as well as a 7- to 10- day course of postoperative
proximated to the periosteum above the posterior antibiotics. The patient is seen for follow-up on post-
lacrimal crest using 5-0 Vicryl on a small half-circle operative day 7, and the skin suture is removed. The
needle. If both ends of the cut tendon are visible, it silicone tubes are left in place for at least 3 months.
can be reattached to itself. The tubes may be removed after irrigation around the
The Crawford probes are removed and the silicone tubes is successful.
tube is tied off and anchored to the lateral nasal wall
in the usual manner, taking care not to have too much Repair with a Monocanalicular Stent
tension between the silicone tubes and the lids. Tying Although we favor repair with bicanalicular intuba-
off the tube will usually bring any margin lacerations tion as described above, there is certainly a role for
into good apposition. If not, full-thickness eyelid lac- monocanalicular repair in the surgeon’s armamentar-
erations should be repaired in the usual fashion with ium. Indications would include repair of lacerations
6-0 silk margin sutures. Skin may be closed with 6-0 in the office or at the bedside, situations where
plain gut or with Prolene. entrance to the nasolacrimal duct is unobtainable with
If the medial end of the canaliculus is too dam- traditional methods, and particularly cases where the
aged to allow identification, or if a combined upper laceration is adjacent to the puncta.
and lower canalicular laceration is present that can- Surgery proceeds in the usual manner. The mono-
not be reanastomosed, local lidocaine 2% with epi- canalicular stent is cut to size, allowing the maximum
CHEN18-263-288.I 3/22/01 2:27 PM Page 285
amount of tubing to bypass the laceration site (i.e., Canaliculitis

when positioned, the tube should extend at least Primary infections of the canaliculi are uncommon.
10 mm beyond the laceration). Once the distal end The most common etiologic organism is Actinomyces
of the canaliculus is intubated, the plug is inserted israelii, although other bacteria and fungi have been
into the punctum with a plug inserter. Forceps must cultured. Patients most often present with pain and
be used to hold the laceration in close approxima- swelling in the medial canthal region, often associated
tion until deep and pericanalicular tissue is repaired with a thick discharge from the punctum. Lacrimal
as described above (the monocanalicular stent will sac swelling or distention should be absent. Examina-
not support the wound as does a bicanalicular stent). tion demonstrates focal swelling and erythema of the
The tube should remain in place for at least 3 punctum (more often inferior), and a thick, granular
months. discharge is often expressed from the punctum.
Dacryocystitis Management
Dacryocystitis is most commonly caused by bacterial Therapy should proceed in a stepwise manner. Topi-
infections, although cases of fungal dacryocystitis cal or systemic antibiotics alone are usually insuffi-
have been reported. Although seen in all age groups, cient, although they may be used in conjunction with
it is most prevalent in women between the third other treatments. Initial therapy should consist of
through fifth decades.70 There is a second peak in punctal dilation and a “three-snip” procedure, fol-
infants with congenital nasolacrimal duct obstruction. lowed by aggressive curettage with a 2-mm curette.75
In a retrospective study by Coden et al71 the most Curettage should continue until no further concre-
common organisms isolated from patients with tions can be removed. Irrigation of the canaliculus
dacryocystitis requiring lacrimal surgery were Staphy- with antibiotic solution may be performed as well.
lococcus epidermidis (27.3%), Staphylococcus aureus Recalcitrant cases should have the procedure
(22.1%), Pseudomonas aeruginosa (8.7%), Haemophilus repeated. Recurrences at this point are best treated
influenzae (5.8%), Proprionibacterium acnes (4.7%), and with more aggressive debridement of the canaliculus,
Proteus vulgaris (4.1%). Two cases with Candida albi- often requiring a “cut-down” procedure.
cans were isolated as well. Rarely, an underlying lym-
phoma of the lacrimal sac may present with acute or
chronic dacryocystitis.72, 73 ADDITIONAL SURGICAL TREATMENTS
Patients present with pain, swelling, and erythema
Dacryocystectomy
in the area of the lacrimal sac. A secondary preseptal
cellulitis may occur. Symptoms develop over 24 to 48 Dacryocystectomy involves the removal of the
hours. Discharge from the punctum may or may not lacrimal sac and duct. The primary indication for
be present. dacryocystectomy is a malignant lacrimal sac tumor.
Even with complete dacryocystectomy, 5-year sur-
vival rates for malignant epithelial tumors are 50 to
Management 85%.76 Occasionally, it is also indicated in cases of
Treatment consists of oral antibiotics and warm com- acute or chronic dacryocystitis without epiphora, par-
presses. We prefer a broad-spectrum antibiotic like ticularly in cases with associated vasculitic conditions
Augmentin 875 mg twice a day for 7 to 10 days. Alter- (e.g., Wegener’s granulomatosis).77
natives in penicillin allergic patients include clin- If the indication is dacryocystitis, a limited dacry-
damycin, a macrolide (e.g., azithromycin), or a ocystectomy (removal of the sac only) may be per-
fluroquinolone (e.g., ciprofloxacin). formed under local anesthesia with intravenous
Patients presenting initially with, or those who sedation. If the procedure is being performed for a
develop, a tense, swollen, lacrimal sac will often lacrimal sac tumor, the bony canal may be removed,
respond well to primary incision and drainage of the and general anesthesia is occasionally preferred.
sac.74 If the sac is truly distended, local anesthesia is The procedure is begun in the standard manner for
not needed. The incision should be made into the a DCR. After the periosteum has been elevated and
body of the swollen sac, either with a no. 11 Bard- the medial canthal tendon disinserted, any remaining
Parker blade or with an 18-gauge needle. Pus should fibrous adhesions to the lacrimal sac are dissected
be expressed from the incision, and sent for culture. free. This may include attachments to the medial
The incision can be irrigated with antibiotic solution orbicularis as well as to the periosteal origin of the
on a lacrimal canula, then packed with antibiotic oint- inferior oblique muscle. If a tumor is suspected, tis-
ment and gauze dressing. Systemic antibiotics are sue should be sent for frozen section biopsy. The
prescribed as above for 7 to 10 days. lacrimal sac is opened as in a standard DCR, and a
CHEN18-263-288.I 3/22/01 2:27 PM Page 286
window of tissue is sent for biopsy. If the presence of is excised with turbinate scissors to allow the Pyrex
a tumor is confirmed, the incision is closed, and scis- tube to have an unobstructed pathway once it enters
sors are used to excise the sac at the common the nasal cavity. Attention is then turned to the
canaliculus and at the opening to the lacrimal canal. medial canthal region where a vertical transcaruncu-
Surgery should proceed with the removal of the bony lar incision is made using the monopolar electro-
nasolacrimal canal and membranous nasolacrimal cautery device with a fine-needle tip. This incision is
duct. Complete removal may best be accomplished carried down to the periosteum overlying the lacrimal
via a Caldwell-Luc transantral approach, although it sac fossa, which is also incised. A large punctal dilator
can proceed from a standard DCR approach with is then positioned in the previously made incision site
stepwise removal of bony tissue. and directed downward at approximately 15 degrees
Deep tissue may be closed with 5-0 Vicryl, and skin to the horizontal and slightly anterior. Using a mal-
is closed in the usual manner. In the presence of let, the lacrimal dilator is gently advanced until the
tumor, most authors advocate deferring the placement end is visible in the nasal cavity. A Jones tube of
of a Jones tube for at least a year. If the procedure is the appropriate length and flange size (as described
being performed for a nonmalignant indication, the under cDCR, above) is then placed flush in the carun-
lacrimal incision and biopsy are omitted. cle bed over a Bowman probe and the intranasal posi-
tion is confirmed using a nasal speculum. After
Conjunctivorhinostomy flushing the tube and confirming that it is patent, the
flange is sutured in position using a 5-0 Vicryl suture.
In 1971, Raine78 described a technique referred to as This technique provides excellent functional and
“office conjunctivorhinosteotomy” in which a manual aesthetic results with minimal surgical morbidity and
orthopedic drill, fitted with a Steinmann pin was used no external facial incisions. Although we have initially
to access the nasal cavity from the caruncle without a performed this procedure in the operating room, it
dacryocystorhinostomy. We recently described a could just as easily be performed in a minor operating
modification of this technique using a fine-needle suite (as originally described). It requires a total
monopolar cautery unit, a punctal dilator, and mal- surgery time of less than 20 minutes and uses instru-
let.79 The indications for the procedure are essentially mentation that is readily available, making it a time-
the same as those for a cDCR, but the minimal efficient option for the management of epiphora
amount of time and surgery required lends itself to secondary to canalicular obstruction.
performance on patients unable to tolerate an
extended surgical procedure. A similar procedure has
been described by Murube-del-Castillo,80 in which the
CONCLUSION
passage is created entirely within the soft tissue The lacrimal surgeon is reminded to approach every
between the orbit and the nasal atrium. tearing in a systematic manner. A complete exam of
Following administration of intravenous sedation, the patient, the eye, and the lacrimal system is
two drops of topical tetracaine 0.5% are administered demanded even in cases where the source of the prob-
to the operative eye. Local anesthesia is accomplished lem seems obvious. Too often, a surgeon is led to
using 2% lidocaine with epinephrine 1:100,000 focus on the first anatomic abnormality observed,
injected in the medial canthal region, caruncle, and without considering a possible multifactorial etiology.
middle meatus of the nose. The nasal cavity on the By performing a complete workup prior to instituting
side to be treated is packed with neurosurgical cot- any treatment regimen, the surgeon guarantees him-
tonoids soaked in 4% cocaine solution. self the highest success rate, and a truly satisfied
Prior to beginning the procedure, the nose is exam- patient. Only in this manner can the subtleties of
ined, and if needed, a portion or the middle turbinate lacrimal surgery be appreciated and mastered.
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Ophthalmol 1982;100:306–309. of the lacrimal sac. Ophthalmic Surg 1977;8:85–90.
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Chapter 19
THYROID OPHTHALMOPATHY:
EYELID RETRACTION
J. Justin Older
Eyelid retraction may occur in the upper or lower eye- examination, laboratory studies such as thyroid func-
lid. It may be associated with thyroid eye disease, tions or thyroid antibody tests should be obtained. In
prior trauma due to surgery or accidents, and in some some cases, there is no evidence of thyroid malfunc-
cases the cause is unknown. Once the etiology is tion or of abnormal thyroid antibodies. Eyelid retrac-
understood, an approach to treatment can be under- tion in these patients is similar to retraction in patients
taken. Upper eyelid retraction associated with thyroid with thyroid eye disease and responds well to the
eye disease is easier to repair than lower eyelid retrac- same surgical treatment.
tion for two major reasons: gravity and proptosis.
Both work against the lower eyelid repair. Gravity Surgical Management
pulls and proptosis pushes the lower eyelid down-
ward. However, with proptosis the globe is further Timing of Surgical Intervention
from the lateral orbital rim and an attempt at tighten- The decision to operate should be made up of several
ing the lid to correct retraction would probably make elements. The first question to consider is the activity
the situation worse. Proptosis can also be a problem of the thyroid disease. Is the patient euthyroid and
for upper eyelid correction but not to the same extent how long has the lid retraction been stable? Ideally
as in the lower lid. If proptosis is significant, the the amount of retraction should not have changed for
upper lid must be stretched a long way to cover the the past year. However, some patients are very dis-
globe. This chapter discusses decision making, as well turbed by the symptoms of exposure, and 6 months of
as surgical technique in the repair of eyelid retraction stability may suffice before surgery is undertaken. In
related to thyroid eye disease. spite of waiting 6 months to 1 year before operating,
changes may still occur after surgery. Thyroid eye dis-
ease can flare up at any time, even long after the thy-
UPPER EYELID RETRACTION ASSOCIATED roid gland is rendered inactive.
WITH THYROID EYE DISEASE Along with activity of disease, the surgeon must
consider the degree of proptosis before performing
Diagnosis retraction surgery. Is proptosis just a cosmetic prob-
When a person presents with upper eyelid retraction, lem, or is there evidence of optic nerve damage? If
the first consideration in diagnosis is thyroid eye dis- nerve damage is suggested by loss of visual acuity,
ease. A history of prior or current thyroid problems decrease in visual field, decreased color acuity, or per-
is often easy to elicit. However, in some cases the haps even radiologic evidence of optic nerve pressure,
patient is unaware of any such history. A clinical orbital decompression should be considered. If the
examination might reveal other signs of Graves’ dis- nerve is healthy and not threatened, upper eyelid
ease, such as proptosis or extraocular muscle restric- retraction can be done to camouflage the proptosis as
tion. If the diagnosis is not obvious from the physical well as protect the cornea. However, if the proptosis is
289
CHEN19-289-296.I 3/22/01 2:28 PM Page 290
significant but not threatening to the nerve and the After orbital decompression, the proptosis had
patient is willing to undergo decompression surgery, decreased and the upper lids were lower. She now
this should be performed before eyelid retraction had clinically significant ptosis that could be consid-
repair. In most cases, decompression surgery will not ered an overcorrection of the retraction repair.
eliminate the need for retraction surgery, but it will A 40-year-old man required upper eyelid retraction
make it much easier to achieve a good result. If repair because of exposure symptoms. Fortuitously,
extraocular surgery is also needed, the order should his insurance company refused to authorize eyelid
be orbit first, muscles next, and then eyelid repair. surgery. During the several months the patient and I
Orbital decompression might make the lower eyelid tried to convince his insurance company that eyelid
retraction repair unnecessary, but upper eyelid retrac- surgery was medically necessary, the patient devel-
tion usually persists after orbital decompression. oped proptosis with optic nerve damage. In this case,
orbital decompression was performed followed
several months later by upper eyelid retraction repair
EARL ...
P If at all possible, from a
clinical point of view, wait for 6 months to
1 year of eyelid position stability before attempt-
with good results (Figs. 19–1 to 19–4).
ing surgical repair of upper eyelid retraction. Surgical Approaches

The goal of treatment for upper eyelid retraction is
the weakening of contractile forces of Müller’s and
To illustrate the problems with timing the opera- levator muscles and resetting of the resting position of
tions, here are two anecdotal accounts. A 50-year-old the upper eyelid to a lower level. People with thyroid
woman had eyelid retraction that was stable for more eye disease have varying degrees of increased con-
than 1 year. I performed bilateral eyelid retraction traction of the extraocular muscles. If there is eyelid
surgery. While she was recovering, she developed retraction, it is caused by increased contraction of
bilateral proptosis that threatened both optic nerves. Müller’s and levator muscles. The amount to which
Decompression surgery was done with good results each of these muscles contributes to the amount of
except that she was then overcorrected for the eyelid contraction cannot be determined clinically, but a
retraction. The original upper lid retraction repair was large amount of contraction usually indicates that
done to fit the small amount of proptosis that she had. both muscles are involved.
Eyelid retraction
Stable Unstable
Proptosis No Proptosis Proptosis No Proptosis
Nerve No nerve Eyelid Nerve No nerve Exposure No

damage damage surgery damage damage symptoms symptoms
Option of
Orbit No
cosmetic Decompression Exposure Wait
surgery first exposure
orbital surgery
Try lubrication Wait
Eyelid surgery Helps No help Try lubrication
Wait Lid surgery Helps No help
Wait Lid surgery
FIGURE 19–1 When to perform surgery in thyroid eye disease: flow chart.
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THYROID OPHTHALMOPATHY: EYELID RETRACTION • 291
FIGURE 19–2 A 38-year-old man with proptosis and left FIGURE 19–3 Patient in Fig. 19–2 2 months after left
upper eyelid retraction. orbital decompression.
Numerous surgical approaches have been advo- Surgical Technique

cated for the correction of upper eyelid retraction The patient is brought into the operating room and
associated with thyroid eye disease. Although the a line is drawn in the upper lid crease with the
approaches vary, the goal in all cases is to weaken patient awake. If the surgery is unilateral, the upper
the forces of the levator and Müller’s muscles. The dif- lid crease should match that of the nonoperative
ferent techniques can be divided into two main eye. For bilateral surgery, the creases should match
approaches: transconjunctival and transcutaneous. each other. If a blepharoplasty is to be done at the
Through either approach, the surgeon can recess same time, the lines for skin removal should be
Müller’s muscle, the levator aponeurosis, or both. drawn with the lower line at the intended lid
Spacers such as eye bank sclera, fascia lata, or synthetic crease.
material may or may not be employed with either type Once the lines are drawn, the patient is given intra-
of recession. Müller’s muscle may be excised rather venous sedation and the lids are cleaned and injected
than recessed. The levator may be weakened by with the local anesthetic. My preferred solution is
myotomy rather than recessed. Most of the surgeons
describing the various techniques report very good to
excellent results.1–16 Although I have tried transcuta-
neous and transconjunctival approaches, with and
without spacers, I have obtained my best results with
a Müller’s muscle and levator aponeurosis recession
without any spacers (Fig. 19–5).
Müller’s muscle
Levator
Conjunctiva aponeurosis
FIGURE 19–4 Patient in Fig. 19–2 4 months after left

orbital decompression and 11 days after left upper eyelid FIGURE 19–5 Points of incisions in recession of levator
retraction repair. aponeurosis and Müller’s muscle.
CHEN19-289-296.I 3/22/01 2:28 PM Page 292
lidocaine with epinephrine mixed 50 : 50 with bupiva-

caine with epinephrine. Wydase (hyaluronidase) is
then added, 1 mL for every 10 mL of the anesthetic. A
total of 2 to 3 mL is usually needed to fully infiltrate
each eyelid. The patient is then prepped and draped
for surgery while the surgeon scrubs. This method of
Septum
injecting before prepping allows the epinephrine to
take effect, thereby decreasing some of the bleeding. Levator
During this time the intravenous sedation is allowed aponeurosis
to wear off so that the patient will be alert enough to
open the eyes during the procedure. If there is no con-
traindication, I prefer to use Diprivan (propofol)
because it is short acting, and the patient can be alert
in 10 to 15 minutes.
Incisions are made in the previously drawn lines.
I prefer to use the Ellman unit set on “cutting” with
a power setting of 3 or 4. This seems to keep bleed-
ing down. Of course, any technique for skin inci-
sions is acceptable. If a blepharoplasty is to be done,
the skin is now removed. Any fat removal is also
done at this time.
Once the skin incision is completed, I cut through FIGURE 19–6 Disinsertion of levator aponeurosis from
the orbicularis muscle with the Ellman unit set on upper border of tarsus.
“hemo” using the broad needle electrode, which is
used primarily for fulguration. The needle used for
cutting is a thin wire gauge electrode. This incision With the muscle fibers taut, they can be severed using
goes to the epitarsal tissues that are then removed scissors or a cauterizing instrument (Fig. 19–7). I pre-
from the tarsus. This releases the attachment of the fer the Ellman unit using the broad needle and a set-
levator aponeurosis to the tarsus. The superior 3 to ting of “hemo/partially rectified.” The fibers of
5 mm of tarsus are now visible and free of any Müller’s muscle are adherent to the underlying con-
fibrous tissue. Levator aponeurosis is disinserted junctiva and care should be taken not to buttonhole
from the upper border of the tarsus. Just superior to the conjunctiva. Injecting anesthetic below Müller’s
the tarsus is a vascular plexus within Müller’s mus- muscle can help to separate it from the conjunctiva. If
cle and the conjunctiva. Dissection into this area the conjunctiva is cut, it should be repaired with a
will cause significant bleeding. 7-0 chromic suture with the knot internalized away
from the globe. The Müller’s muscle should be sepa-
rated from the tarsus across most of the eyelid. While
EARL ...
P Use of a cauterizing
instrument such as the Ellman or a dis-
posable hand cautery will help to decrease
performing this muscle weakening, I sit the patient
up numerous times so I can judge the amount of cor-
rection. I prefer to achieve small amounts of lid drop
between each situp so as not to overcorrect the lid
bleeding while recessing the very vascular
position. When much of the muscle is weakened but
Müller’s muscle. the lid is still too high, I pull downward on the tarsus
and push the slips of Müller’s muscle upward with a
If there is only a small amount of eyelid retraction, cotton-tipped applicator. When the eyelid is in the
the patient can sit up at this time so the surgeon can proper position, the cornea can easily be seen through
see if there has been any significant reduction in the the conjunctiva. There are still a few slips of muscle or
amount of eyelid retraction. Usually, just separating fascia connecting the tarsus with the main muscle
the levator aponeurosis from the tarsus will give very mass.
little correction (Fig. 19–6). The next step of weaken- In most cases, significant eyelid retraction is usu-
ing Müller’s muscle is usually necessary. The fibers of ally 2 to 3 mm. When this amount of retraction is
Müller’s muscle must now be carefully separated properly corrected, the combination of Müller’s mus-
from the upper border of the tarsus. Tension should cle and levator aponeurosis is recessed about 7 to
be achieved by having the assistant pull down on the 8 mm above the tarsus. Most of the cornea shows
tarsus while the surgeon pulls up on Müller’s muscle. through the conjunctiva with this amount of recession.
CHEN19-289-296.I 3/22/01 2:28 PM Page 293
Cut edge
levator aponeurosis
Müller’s muscle
Conjunctiva
Tarsus
Cut edge
levator aponeurosis
FIGURE 19–7 Separation of Müller’s

muscle from the superior tarsal border
using an Ellman unit.
If the lid seems too low after some dissection is done, Müller’s muscle to the upper border of tarsus or to
it can be lifted by reattaching a small amount of some epitarsal tissue. This is more difficult than
weakening the muscle; therefore, I prefer to slowly
recess the muscles and check the height frequently by
having the patient sit up numerous times.
This technique requires judgment in deciding the
correct end point. It is not a millimeter-for-millimeter
procedure. I like the final position of the upper eyelid
to be 1 or 2 mm below the upper limbus because I
expect a 1-mm rise after surgery. Of course, the post-
surgical lift may be more or less than 1 mm. There-
fore, the surgeon must set the lid so that more or less
than a 1-mm rise will still be acceptable. For instance,
an older person will accept a lower eyelid position
than a younger one because older people tend to have
Levator smaller palpebral fissures.
Müller’s muscle aponeurosis
The curve of the eyelid is also very important.
People with upper lid retraction due to thyroid eye
Intact disease tend to have lateral elevation more than
conjunctiva medial. To correct this, dissection must be carried to
an area above the lateral canthus. The problem is
that the palpebral portion of the lacrimal gland is in
this area. To avoid this lateral dissection, I often per-
form a lateral tarsorrhaphy that brings the lateral
upper eyelid down. It also has the advantage of
bringing the lower lid up, a benefit in most people
with thyroid eye disease. Once the desired height
and curve are satisfactory, I close the skin with a
running 6-0 Prolene (polypropylene) suture. No
deep sutures are used to keep Müller’s muscle or the
FIGURE 19–8 Recession of levator aponeurosis and levator aponeurosis in place. A reverse Frost suture
Müller’s muscle without placement of spacer. to keep the upper lid down during healing is not
CHEN19-289-296.I 3/22/01 2:28 PM Page 294
FIGURE 19–9 A 40-year-old woman with preoperative

upper eyelid retraction.
FIGURE 19–10 Patient in Fig. 19–9 1 month after left
upper eyelid retraction repair.
advisable because it might lead to an overcorrection LOWER EYELID RETRACTION

(Figs. 19–9 and 19–10).
Surgical Management
Repair of lower eyelid retraction is much more diffi-
cult than surgery for the upper eyelid, especially if
EARL... A small lateral tarsorrha-
P phy will help achieve a good upper lid
curve without having to dissect very far laterally.
there is any degree of proptosis. If proptosis is pre-
sent and the lower lid retraction is significant, seri-
ous consideration should be given to reducing the
This decreases the risk of injury to the lacrimal proptosis with orbital decompression, deep orbital
gland ductules. fat removal, or anterior advancement of the lateral
orbital rim.
If the patient has lower eyelid retraction of 2 mm
or less, a lateral tarsorrhaphy in combination with
The question is often asked as to why the lid
the upper eyelid repair might give enough lift to the
stays where it is put rather than retract upward to
lower lid. This may lead to a slightly elevated lateral
its original position. After all, the use of spacers
canthus, which is often cosmetically acceptable.
such as cadaver sclera was developed to prevent
If orbital decompression is desired, I perform a
this retraction. I believe that there is a degree of
transconjunctival inferior floor removal with a
retraction but this is figured in when choosing the
transnasal ethmoid bone removal by an otolaryngol-
final height at surgery. The epinephrine in the anes-
ogist. As part of this procedure, I release the lower lid
thetic causes Müller’s muscle to retract so that
retractors and perform a lateral tarsorrhaphy. This
before beginning surgery the lid is higher than its
combination is usually sufficient to correct the lower
normal resting position. The amount of retraction
lid retraction.
caused by the drug is probably 2 mm. Using this
reasoning, a 1-mm overcorrection is really 3 mm.
Therefore, with this technique I am dropping the lid
5 to 6 mm by recessing the muscles 6 to 8 mm. The
EARL ...
postoperative swelling retards some eyelid retrac-
tion also. Observation shows that most patients are
about 2 mm below the desired height for the first
P Releasing the lower lid
retractors in combination with a lateral
tarsal strip and/or a lateral tarsorrhaphy while
week. Within a month, the lid settles at the perma- performing an orbital floor decompression
nent height. I have performed more than 100 of
may be enough to correct lower lid retraction.
these procedures with only two overcorrections and
two undercorrections in patients who had no A separate procedure with a spacer may not
change in the activity of their thyroid eye disease be necessary.
during or after the retraction surgery.
CHEN19-289-296.I 3/22/01 2:28 PM Page 295
Surgical Technique surgery. Nevertheless, unavoidable hemorrhage or

If there is significant lower lid retraction, and none of lack of blood supply to an important structure could
the above approaches is appropriate, I will use ear have serious consequences to the globe. These com-
cartilage as a spacer and recess the lower lid retrac- plications would be treated using ophthalmological
tors. A transconjunctival incision is made from the lat- methods, but it is not within the scope of this text to
eral canthus to an area just below the punctum. The discuss these.
incision should be about 5 mm below the inferior bor-
der of the tarsus. The lower lid retractors and the Lower Eyelid Surgery
orbital septum are incised. Ear cartilage is taken by
The major complication of lower eyelid repair is
making an incision behind the ear and undermining
undercorrection. It is difficult to raise the lower eye-
skin. A full- or partial-thickness cartilage graft is
lid because the only place it can be lifted is the lateral
taken. The dimensions of the graft should be roughly
canthus or a small amount at the medial canthus. If
the size of the desired correction. For a 2-mm retrac-
the globe is proptotic, the task is even more chal-
tion, the graft should be 2 to 3 mm in height and the
lenging. Therefore, if there is any reasonable way to
width of the lower lid defect. The graft should have a
decrease the proptosis before attempting repair of
convex and concave side, if taken from the appropri-
significant lower eyelid retraction, it should be done.
ate part of the ear. Obviously, the concave side should
If proptosis is significant but there is no evidence of
face the globe. The superior part of the graft is sewn to
optic nerve involvement, significant lower eyelid
the inferior tarsus and the inferior border of the graft
retraction could be a medical reason to decrease the
is attached to the recessed lower lid retractors. The
proptosis before attempting lower eyelid retraction
conjunctiva is repaired with an absorbable suture
repair.
such as 7-0 chromic or 6-0 mild chromic. Knots are
Overcorrection is unlikely, but if the piece of carti-
away from the globe. One or more 6-0 silk sutures
lage used is too high, the lid could be above the infe-
are passed through the lower eyelid margin and
rior limbus. Repair of this problem would require
taped to the forehead to keep the lower lid on stretch
reoperating and trimming the cartilage. I would wait
for several days or longer, if tolerated. I prefer to keep
at least 6 months to even consider trimming the graft
the suture in place for 1 week.
because of the possibility of cartilage shrinkage. As
with the upper eyelid repair, many potential compli-
cations to the globe and vision are possible, but it is
COMPLICATIONS not the purpose of this text to discuss them.
Upper Eyelid Surgery
The major complications of upper eyelid retraction CONCLUSION
surgery are over- and undercorrection. In my experi-
ence, the total of both complications that required There are several reasons spacers are not necessary
repair was about 5%. Overcorrection is correctable by to keep the lid from retracting back to its original
ptosis repair. My approach is a levator aponeurosis position. Epinephrine causes a contraction of
advancement via a skin incision. If the original levator Müller’s muscle of about 2 mm. Therefore, by plac-
and Müller’s muscle recession was done in the man- ing the upper eyelid 1 mm below the desired end
ner described in this chapter, the levator aponeurosis point, the surgeon is actually overcorrecting the eye-
should be intact and relatively easy to find. The lid by 3 mm. Postoperative swelling causes the
aponeurosis is advanced to the anterior border of the tissues to stay separated for a few days and causes
tarsus. The patient is asked to sit up and the curve and the eyelid to drop about another millimeter. As the
height are checked. Once the lid is about 1 mm above swelling recedes and the epinephrine wears off,
the desired height and the curve is acceptable, the the eyelid retracts about 3 mm. This usually results
skin incision is repaired. in a successful correction.
Undercorrection is repaired by a repeat procedure. The treatment of upper eyelid retraction related
I usually wait 6 months before attempting another to thyroid eye disease is not controversial. The vast
surgery. This wait allows the eyelid to settle into its majority of surgeons agree that surgical correction
permanent position. The few undercorrections I is the best way to correct the problem. However,
have had were small and the repeat procedure was there are many ways to achieve the same goal. The
successful. procedure that is presented in this chapter has
Other complications, such as globe perforation or been successful for me, as well as for many other
diplopia, could most likely be prevented by careful ophthalmologists.
CHEN19-289-296.I 3/22/01 2:28 PM Page 296
REFERENCES
1. Anderson RL: Commentary. Ophthalmic Surg 1991;22: 10. Levine MR, Chu A: Surgical treatment of thyroid-
322–323. related lid retraction: a new variation. Ophthalmic Surg
2. Bartley GB: The differential diagnosis and classification 1991;22:90–94.
of eyelid retraction. Ophthalmology 1996;103(1):168–176. 11. Older JJ: Surgical treatment of eyelid retraction associ-
3. Chalfin J, Putterman AM: Müller’s muscle excision and ated with thyroid eye disease. Ophthalmic Surg 1991;
levator recession in retracted upper lid. Treatment of 22:318–322.
thyroid-related retraction. Arch Ophthalmol 1979; 12. Older JJ: Treatment of upper eyelid retraction: external
97:1487–1491. approach. In: Putterman AM, ed: Cosmetic Oculoplastic
4. Collin JR, O’Donnell BA: Adjustable sutures in eyelid Surgery: Eyelid, Forehead, and Facial Techniques, 3rd ed.
surgery for ptosis and lid retraction. Br J Ophthalmol Philadelphia: WB Saunders, 1999:151–157.
1994;78:167–174. 13. Oliver JM, Rose GE, Khaw PT, et al: Correction of lower
5. Flanagan JC: Retraction of the eyelids secondary to thy- eyelid retraction in thyroid eye disease: a randomised
roid ophthalmopathy—its surgical correction with controlled trial of retractor tenotomy with adjuvant
sclera and the fate of the graft. Perspect Ophthalmol antimetabolite versus scleral graft. Br J Ophthalmol 1998;
1981;5:195–202. 82(2):174–180.
6. Grove AS: Eyelid retraction treated by levator marginal 14. Putterman AM: Treatment of upper eyelid retraction:
myotomy. Ophthalmology 1980;87:1013–1018. internal approach. In: Putterman AM, ed: Cosmetic Ocu-
7. Harvey JT, Anderson RL: The aponeurotic approach to loplastic Surgery: Eyelid, Forehead, and Facial Techniques,
eyelid retraction. Ophthalmology 1981;88:513–524. 3rd ed. Philadelphia: WB Saunders, 1999:159–168.
8. Harvey JT, Corin S, Nixon D, et al: Modified levator 15. Small RG: Surgery for upper eyelid retraction, three
aponeurosis recession for upper eyelid retraction in techniques. Trans Am Ophthalmol Soc 1995;93:353–365;
Graves’ disease. Ophthalmic Surg 1991;22:313–317. discussion 365–369.
9. Lemke BN: Anatomic considerations in upper eyelid 16. Tucker SM, Collin R: Repair of upper eyelid retraction:
retraction. Ophthalmic Plast Reconstr Surg 1991;7(3): a comparison between adjustable and non-adjustable
158–166. sutures. Br J Ophthalmol 1995;79(7):658–660.
CHEN20-297-304.I 3/26/01 8:45 AM Page 297
Chapter 20
RESTRICTIVE MYOPATHY
Sherwin J. Isenberg
For the strabismus surgeon, thyroid ophthalmopathy ficult. Treatment, however, may be indicated for
is one of the more common problems encountered in vision-threatening problems such as optic nerve atro-
adults. These patients are among the most unhappy phy or exposure of the cornea.
when they first present to the office, but are also Initially, diplopia is usually appreciated in upgaze
among the most grateful when surgery is successful. only, although it may also be sensed on abduction of
They are initially unhappy because their double the affected eye or eyes. As the disease worsens, ver-
vision (diplopia) is often disabling, or if less severe, tical and, occasionally, horizontal diplopia will
can often only be neutralized with an embarrassing become more disturbing as it occurs closer to primary
chin-up or other head position. position (straight-ahead gaze). Finally, even in pri-
mary gaze patients see double, forcing them to adopt
an abnormal head position, usually chin up, to avoid
EVALUATION the diplopia.
History
Examination
Patients often relate that their first indication of this
Thyroid-related strabismus is caused by inflamma-
problem was a feeling of fullness in one or both orbits.
tion and restriction of all four rectus muscles. Clini-
The conjunctiva becomes congested and then
cally, the most common presentation is a restriction
inflamed, especially over the location of the four rec-
limited to the inferior rectus (IR) muscle, which pulls
tus muscles. The eyelids then become edematous and
the eye or eyes downward. The patient may com-
proptosis begins. This orbital inflammation will usu-
pensate by elevating the head to bring the eyes into
ally worsen and then improve over a period of 1 to
downgaze, which is the least affected position.
24 months. After the inflammation is gone, a number
Therefore, after assessing the head position, the stra-
of problems often remain.
bismus examination should be performed with the
In most cases, the patient’s appearance is quite typ-
head placed in the straight-ahead position (“forced
ical. Blinking is reduced. The eyelids appear edema-
primary position”).
tous and are retracted, making the patient appear to
be constantly staring, and do not fully follow the eye
EARL ...
in downgaze. The conjunctiva appears as described
above. This chapter focuses only on the myopathy.
Diplopia often begins during the inflammatory
P Perform the strabismus
measurements with the patient’s head
directed straight ahead. Do not allow the patient
phase. Most clinicians do not treat patients during this
phase only for the strabismus problems because the to assume his desired abnormal head position
ocular alignment will change as the inflammation during measurements.
waxes and wanes making precise correction very dif-
297
CHEN20-297-304.I 3/22/01 2:29 PM Page 298
The hypotropia should be quantified with a verti-

cal prism bar in primary position, then with the head
turned upward, downward, to the left, and to the
right. The largest hypotropia is measured on
attempted upgaze and the least on downgaze. The
hypotropia is worse on looking to the side of the
affected muscle than on looking to the other side. If
both IR muscles are involved, the examination will be
as described, except on side gaze which will be more
equal. Excyclotorsion is appreciated with the double
Maddox rod test, especially if both IRs are involved.
A small esotropia of 12 prism diopters or less may
result from tight IR muscle without involvement of
the medial rectus (MR) muscles because the IR is a
secondary adductor. FIGURE 20–1 To perform the forced duction test, the
The MR is the second most commonly affected conjunctiva is grasped with two forceps and the eye is
muscle, often in combination with the IR muscle. A moved into maximum elevation while gently directing the
clinical dilemma sometimes arises if the MR muscle eye outward. A constraint to elevation indicates a restric-
tion produced by the inferior rectus muscle.
is the only extraocular muscle clinically affected. The
clinician may mistake the restricted MR muscle, with it is restricted. If the eye can be moved, there is no
resultant deficient abduction, as the presence of a significant restriction and a diagnosis other than thy-
sixth cranial nerve paresis. A careful examination of roid myopathy should be considered.
the globe and eyelids will almost always reveal some It should be noted that a mild to moderated restric-
of the typical thyroid findings described above, which tion may be felt when moving the eye in any position
facilitates the diagnosis. A restricted MR muscle pre- because of the orbital congestion and frequent sub-
sents with esotropia that increases on abduction and clinical involvement of the other muscles.
decreases on adduction. If the IR is not involved
(although it usually is), the esotropia is about the
same on upgaze and downgaze. EARL... Perform the forced duction
The lateral and superior rectus muscles are very
rarely affected and thus are not considered in this
chapter, although the general principles described
P test while gently moving the eye outward.
An inward (enophthalmic) direction will
below are usually applicable to them. decrease the apparent restriction and may be
misleading.
Clinical and Laboratory Tests
Forced Duction Tests Induced Ocular Hypertension Test
In typical cases as described above, this very useful If the forced duction test is performed properly, there
test is not always needed. But if the case is marginal is no need to perform the induced hypertension test,
and the diagnosis is questionable, a forced duction because it is less specific.
test performed in the office reveals restriction of the The induced ocular hypertension test is performed
appropriate extraocular muscle. The test should be by measuring the intraocular pressure with the
performed in the operating room when the patient is patient looking in primary position and repeating the
under general anesthesia. The conjunctiva is first measurement with the eye looking as far as possible
anesthetized with an eye drop. The conjunctiva is into the restrictive position. If a significant restriction
grasped with one, or preferably two, forceps, at the exists, the intraocular pressure should increase at least
lateral and medial sides of the limbus to test the IR or 4 mm Hg. Conversely, this author has seen a few
at the upper and lower pole of the limbus to test patients with elevated intraocular pressure, increased
the MR muscle (Fig. 20–1). If the test is performed cupping of the optic nerve, and thyroid ophthal-
in the office, the patient is then asked to look as far mopathy normalize their intraocular pressure after
upward as possible to test the IR or toward the lateral strabismus surgery alone.
side of the eye with the allegedly affected MR mus-
cle. The clinician should then attempt to move the eye Other Tests
further in the same direction while gently pulling the The orbit can be imaged with ultrasonography. The
eye outward. If the eye cannot be moved any further, B-scan will demonstrate hypertrophied extraocular
CHEN20-297-304.I 3/22/01 2:29 PM Page 299
THYROID OPHTHALMOPATHY: RESTRICTIVE MYOPATHY • 299
muscles, whereas the A-scan will reveal high reflec- Surgical Planning
tivity of the muscles caused by edema. There can be as many as three steps for the overall
Radiographic imaging by magnetic resonance surgical treatment of Graves’ ophthalmopathy. Prior
imaging (MRI) or computed tomography (CT) will to strabismus surgery, it may be necessary to decom-
also show the enlarged extraocular muscles but press the orbit. Orbital decompression can often
will also reveal a specific pattern of edema fre- improve mild to moderate strabismus problems. Con-
quently associated with thyroid ophthalmopathy— versely, orbital decompression performed after stra-
the edema tapers before the tendonous insertions. bismus surgery can cause new, or a recurrence of,
This is different from some other orbitopathies. The strabismus problems. Thus, orbital decompression,
proptosis can be well documented with these tests. when indicated, should always precede strabismus
surgery. Eyelid surgery should be performed last
when indicated.
MEDICAL MANAGEMENT
Medical treatment is generally not initiated only for
the diplopia. These treatments, which include sys- PITFALL
temic corticosteroids, immunosuppresive therapy,
and radiation, are of value if vision is threatened or Do not perform strabismus surgery if an
reduced by damage to the optic nerve by the enlarged orbital decompression operation is contem-
extraocular muscles and congested orbit or the cornea plated. Strabismus correction should always
from exposure. Because the strabismus measure- follow decompression.
ments are usually changing until the inflammation
abates, these medical modalities have not been too
useful for elimination of diplopia, especially when
Patients should be informed of the surgical goals. If
their side effects are considered. Nonetheless, some
successful, the patient will regain single vision on dis-
authors have used systemic corticosteroids for early
tant gaze and in the reading position. Patients must
onset diplopia.1
be informed that diplopia may very likely continue in
Prisms can be useful in smaller deviations
some gaze positions away from primary gaze.
(6 12 p.d.). This modality does not always work even
The surgery for thyroid-induced strabismus consists
in smaller deviations because the hypotropia is often
only of recessions. The orbit is usually tight and con-
incomitant. Thus, a prism correction for the primary
gested. Resections or transpositions will only increase
position may still permit diplopia on sidegaze. Botu-
the tightness and further restrict ocular rotations that
linum has been advocated early in the disease, but is
are already compromised. Recessions will decrease
of little use once the fibrosis ensues.2
restrictions and improve ocular rotations. Recessions
may, however, worsen the proptosis and occasionally
aggravate corneal exposure. Patients should be warned
SURGICAL MANAGEMENT about the possibility of increased proptosis.
Timing
Operating too early may reactivate the orbital inflam- EARL... Strabismus surgery in dys-
mation and lead to renewed proptosis and muscle
enlargement. The use of prisms or an occluder can
lessen or alleviate the diplopia while waiting for the
P thyroid ophthalmopathy should consist of
recessions only.
situation to stabilize. Normally, it is wise to wait at
least 6 months after the inflammatory signs have
diminished and the proptosis is stable to perform stra- The recession can be performed with or without
bismus surgery. Coats and associates,3 however, the adjustable suture technique.5 If both IR and/or
recently reported that if the patient is particularly both MR muscles are to be recessed, only one muscle
handicapped by the diplopia or anomalous head posi- of each pair needs to be placed on an adjustable
tion, earlier surgery can be successful. Even after wait- suture to allow later correction of ocular alignment. If
ing an appropriate time, if there are signs of operating on one or more MR and IR muscles at the
continued inflammation such as conjunctival injection same surgery, it is easier to apply the adjustable tech-
or chemosis, surgery should still be deferred. Metz4 nique on the MR in one eye and the IR in the other
reported operating on such a case, which resulted in eye. After the surgery, one eye is then adjusted hori-
corneal opacification, thinning, and vascularization. zontally and the other vertically as explained below.
CHEN20-297-304.I 3/22/01 2:29 PM Page 300
The conjunctival approach is less controversial. For of the hook is incised. Tissue on top of the muscle and
strabismus surgery in general, one can incise the con- then to either side is cleaned with blunt and sharp
junctiva at the limbus, in a paralimbal area,6 or in the dissection.
fornix. In the case of thyroid ophthalmopathy, how- The surgeon should then decide whether to deal
ever, the tight restrictive orbit dictates that the con- specifically with the anterior Tenon’s capsule and fat
junctiva be recessed to further loosen the tightness. pad that overlies the muscle or to dissect it and allow
To achieve a conjunctival recession, a limbal it to retract (Fig. 20–3).
approach is necessary whether one utilizes an
adjustable suture or not.
EARL... In the case of surgery on
The choice of sutures is important. Most surgeons
use absorbable sutures for strabismus. For recessions
without the adjustable technique, one may prefer to
P the IR muscle, some authors have felt that
the posterior displacement of anterior Tenon’s
use Dexon, Vicryl, or Biosorb. For the adjustable tech-
nique, however, we have shown that it would be safer capsule enhances the drooping (ptosis) of the
to use Vicryl (usually 6-0, although 5-0 can be used lower eyelid.8
for a very restrictive muscle) because it is the least
slippery absorbable suture.7 This property prevents
further retraction of a tight muscle during the adjust- This ptosis almost invariably follows the large reces-
ment process. For nonrestrictive situations, Biosorb is sions of the IR muscles warranted to correct thyroid-
the most slippery suture, which facilitates the adjust- induced hypotropia. Sutures can be placed within the
ment process. The conjunctival incision may be anterior Tenon’s capsule and inserted onto the sclera
repaired with any absorbable suture, usually between on either side of the IR muscle. This may allow reces-
a 6-0 and 8-0 size, while recessing the conjunctiva as sion of the IR, even on adjustable suture, while mini-
described below. mizing retraction of Tenon’s and lower lid ptosis.8
A suture is then passed through the muscle and
Surgical Technique locked at either end.
Conjunctival Incision
The incision should be made down to the sclera with
EARL... If an adjustable recession is
blunt-tipped scissors at the limbus in front of the mus-
cle insertion to permit later recession of the conjunc-
tiva. The conjunctiva and Tenon’s capsule is
P desired the surgeon should use 6-0 Vicryl
(or 5-0 if the muscle is extremely tight) because
undermined toward and 45 degrees away from the it is the least slippery absorbable suture and will
muscle. Relaxing incisions are made through the con-
not tend to retract at the time of adjustment.
junctiva and Tenon’s capsule angled 45 and 135
degrees away from the plane of the initial incision.
Muscle Capture and Suturing If the recession is not of the adjustable variety,
Small and then large hooks are used to capture the another type of 6-0 or 5-0 absorbable suture may be
muscle (Fig. 20–2). The connective tissue over the tip
FIGURE 20–3 After the surface of the muscle is cleaned

FIGURE 20–2 The inferior rectus muscle is captured on of adhesions, the fat pad is visible, extending from the sur-
a muscle hook. face of the muscle to the eyelid.
CHEN20-297-304.I 3/22/01 2:29 PM Page 301
Repositioning the Muscle

The number of millimeters of recession can then be
determined by moving the eye into, or close to,
primary gaze and measuring the number of millime-
ters the anterior edge of the disinserted muscle pas-
sively falls from the limbus or original muscle
insertion. If a nonadjustable technique is used, the
two needles attached to the muscle suture should be
placed within the sclera at that point about 10 mm
apart. The sutures are then tied tightly with three
knots to secure the muscle to the new location. If no
adjustable suture is being used, it is better to avoid a
“hang-back” technique that suspends the muscle
from the insertion to prevent the possibility of later
FIGURE 20–4 The muscle was so tight that the sutures slippage of the usually tight muscle (see Complica-
were placed within the muscle lying on the hook instead of tions, below). It is common, if operating on both
anterior to the hook.
inferior or MR muscles, to perform an asymmetrical
amount of recession on each side depending on the
used. The muscle is then disinserted from the sclera magnitude of the restriction.
with blunt-tipped scissors.
The muscle may be so tight that it is difficult to fit
a hook under the muscle insertion. There may be no
EARL... If an adjustable technique
room anterior to the hook to insert the needle within
the tendonous insertion. If so, place the needle
within that portion of muscle overlying the hook
P is used, the needles attached to the
Vicryl suture are inserted within the sclera at
(Fig. 20–4). either end of the original insertion line and the
There are two patterns that the surgeon may muscle is allowed to retract to its natural posi-
observe upon disinsertion. The IR may be so tight as tion as the eye is placed in, or near to, primary
to immediately retract toward the orbital apex when
position.
disinserted. There have even been cases reported of
the muscle snapping in two due to the tightness. The
other commonly seen pattern is for the newly disin-
serted muscle to just fall right onto the sclera in the A double throw knot is then made followed by a
original location. This muscle is barely distensible, slipknot (Fig. 20–5). Excessive Vicryl is then excised.
thus producing a restriction only when the eye moves
opposite its field of action. This muscle may need a
lesser amount of recession.
A B
FIGURE 20–5 (A) The muscle is recessed behind the insertion. An adjustable suture approach is shown by the
presence of a slipknot. (B) Recession of the inferior rectus muscle with an adjustable suture.
CHEN20-297-304.I 3/22/01 2:29 PM Page 302
FIGURE 20–6 The conjunctiva is advanced prior to clo- FIGURE 20–7 The conjunctiva is sutured so as to recess
sure. it to the original insertion line of the muscle. It is important
that the Vicryl sutures attached to the muscle be accessible
to permit adjustment.
Conjunctival Closure
Absorbable sutures of either 7-0 or 8-0 are used to preparations may predispose the cornea to infection.
recess the conjunctiva (Fig. 20–6). Usually, the two Lubrication of the cornea, especially with ointment,
ends of the conjunctiva previously cut to create the may be necessary after surgery. As the surgically
relaxing incision are sutured together and then to induced edema and chemosis subside, the exposure
each corner of original muscle insertion line. This will keratopathy often improves. Surgical decompression
create a recession of the conjunctiva to the original of the orbit may occasionally become necessary,
insertion line of the muscle, which will improve the although it may have been better performed before
restrictive ocular rotations (Fig. 20–7). Any sizable the strabismus surgery.
opening in the conjunctiva posterior to the original
muscle insertion line can be closed with an inter-
rupted suture, although this is often unnecessary.
PITFALL
Adjustment
Either later the same day of surgery or on the next Carefully monitor the cornea after strabismus
day, the adjustment can be performed.6 For recession surgery because large recessions can cause
of the MR muscle(s), it would be advantageous to cre- increased corneal exposure.
ate a small overcorrection of about 5 p.d. of exotropia
at the time of adjustment. For recession of the IR mus-
cle(s), because of the phenomenon of late slippage Over- and Undercorrections
(see Complications, below), it would be wise to adjust
Unfortunately, strabismus is not an exact science and
the muscle to orthotropia at distance and, if possible,
the patient may have an over- or undercorrection after
at near. To be safe, I also test the alignment in the
surgery. Prisms are often very helpful to treat minor
reading position before being satisfied with the eye
over- or undercorrections because the residual devia-
position if operating on an IR muscle.
tion is more comitant than before surgery. Postopera-
tive prisms, when necessary, are more satisfactory to
COMPLICATIONS patients than the use of prisms before surgery.
For a sizable undercorrection, it may not be wise
Increased Proptosis in the Postoperative Period to reoperate on the same muscle if a large recession
Sometimes the restrictions imposed by tight extraoc- (7 6 to 7 mm) has been previously performed. The
ular muscles in dysthyroid ophthalmopathy serve to surgeon may then elect to perform the second surgery
pull the eye inward, countering the proptosis com- on the contralateral superior rectus for a residual
monly seen. Upon recession of one or more muscles in hypotropia in the affected eye or the contralateral MR
an eye, the proptosis can become more prominent. if an esotropia is still present.
The surgeon should carefully examine the cornea For a sizable overcorrection (or a slipped muscle as
after strabismus surgery for any epithelial erosions. discussed below), the previously recessed IR or MR
Routine postoperative use of topical corticosteroid can be advanced with or without the assistance of an
CHEN20-297-304.I 3/22/01 2:29 PM Page 303
adjustable suture. If a muscle slippage had occurred, guidelines presented above, the amount of recession
the surgeon may prefer a nonabsorbable suture (such will often exceed the usual “maximum” numbers of 5
as Dacron or merseline) for the reoperation on the to 6 mm. It is not unusual to recess a restrictive IR 9 to
same muscle. 11 mm for Graves’ ophthalmopathy. Connections
exist between the IR and the lower eyelid via the cap-
sulopalpebral head. Even when all obvious attach-
Late Slippage of the Muscle
ments on the orbital side of the IR have been incised
It has been recognized that a few days to weeks after as far back as possible, retraction of the lower eyelid
surgery on the IR has been concluded, often when the will often result.
patient has had a satisfactory result, a hypertropia This problem can be reduced by maintaining the
develops. 9 Versions reveal less infraduction than normal position of the Tenon’s capsule that normally
shortly after the surgery. Reoperation, when neces- invests the IR about 6 mm posterior to the IR inser-
sary, reveals the IR to have slipped further back than tion. Sutures of 6-0 silk can be placed through Tenon’s
placed at the time of surgery. This phenomenon has capsule on both sides of the IR and then attached to
been variously attributed to a weakness in adjustable the sclera at that position. A similar maneuver has
sutures (unlikely), a tongue of intermuscular septum described using an adjustable technique.8 Despite
or Tenon’s capsule insinuating itself between the heal- attempts at prevention, the retraction may still occur.
ing muscle and the sclera, unsuspected strong retrac- Some patients will elect to have the eyelid retraction
tion by the superior rectus muscle, and retraction repaired at a later date.
imposed by Lockwood’s ligament. To avoid this com-
plication, some surgeons have resorted to the use of
nonabsorbable sutures, whereas others are careful to Torsional Diplopia Before and After Surgery
dissect away any tissue above or below the muscle. Torsional diplopia, usually excyclotorsion, has been
Yet other ophthalmologists adjust the patient to reported in patients after strabismus surgery and after
orthotropia with the concern that any overcorrection orbital decompression surgery.10 The excyclotorsion
may predispose to this late slippage. may have been present before the initial surgery, but
was ignored because of the large vertical diplopia.
Exotropia in Downgaze Recession of one or both IR is usually curative.
Following decompression surgery, incyclotorsion
It is frequently necessary to perform large recessions
may present, especially if the orbital floor was operated.
of both IR muscles for bilateral restriction. Normally
The globe may, to some extent, “fall” inferiorly toward
the IR has adducting power in downgaze as a secon-
the maxillary sinus, putting the superior oblique ten-
day action. With large recessions, however, the
don on stretch due to its course through the trochlea
adducting power will be reduced in downgaze, pro-
that would engender incyclotorsion. The superior
ducing an exotropia engendered by the superior
oblique tendon(s) may subsequently need weakening.
oblique muscles. This problem may adversely affect
reading. To prevent this, the surgeon should shift the
insertion of each IR one-half to a full tendon width Difficulty Reading After Surgery
nasally when placing the sutures directly within the The amount of recession of a medial or IR muscle per-
sclera. If utilizing “hang-back” or adjustable tech- formed to restore orthotropia in primary distant posi-
niques, the needles should be shifted nasally relative tion may cause an exo- or hyperdeviation on
to the original IR insertion line when inserted within attempted reading. Should this persist, appropriate
the sclera. prisms should be incorporated into a separate pair of
reading spectacles.
PITFALL
CONCLUSION
Prevent postoperative reading problems
The correction of strabismus and restrictive myopa-
caused by exotropia in downgaze by shifting
thy related to thyroid ophthalmopathy requires an
IR muscles nasally when recessing them. in-depth understanding of the disease process, proper
timing, evaluation, measurements, and good clinical
skills in adapting to each patient’s individual needs.
Retraction of the Lower Eyelid This chapter covered some of the unique factors that a
Thyroid ophthalmopathy often causes severe restric- comprehensive ophthalmologist will find useful in
tion of the IR. When recessing the IR following the the management of these patients.
CHEN20-297-304.I 3/22/01 2:29 PM Page 304
REFERENCES
1. Sterk CC, Bierlaagh JJ, de Keizer RJ: Motility disorders for adjustable strabismus surgery. Ophthalmic Surg
in endocrine ophthalmopathy. Doc Ophthalmol 1985; 1998;9:151–156.
59:71–75. 7. Neumann D, Neumann R, Isenberg SJ: A comparison
2. Dunn WJ, Arnold, O’Connor PS: Botulinum toxin for of sutures for adjustable strabismus surgery. J Am Assoc
the treatment of dysthyroid ocular myopathy. Ophthal- Pediatr Ophthalmol Strabismus 1999;3:91–93.
mology 1986;93:470–475. 8. Pacheco EM, Guyton DL, Repka MX: Changes in eye-
3. Coats DK, Paysee EA, Plager DA, Wallace DK: Early lid position accompanying vertical rectus muscle
strabismus surgery for thyroid ophthalmopathy. Oph- surgery and prevention of lower lid retraction with
thalmology 1999;106:324–329. adjustable surgery. J Pediatr Ophthalmol Strabismus
4. Metz HS: Complications following surgery for thyroid 1992;29:265–272.
ophthalmopathy. J Pediatr Ophthalmol Strabismus 9. Hudson HL, Feldon SE: Late overcorrection of
1984:21:220. hypotropia in Graves’ ophthalmopathy. Ophthalmology
5. Lueder GT, Scott WE, Kutschke PJ, Keech RV: Long- 1992;99:356–360.
term results of adjustable suture surgery for strabismus 10. Garrity JA, Saggau DD, Gorman CA, et al: Torsional
secondary to thyroid ophthalmopathy. Ophthalmology diplopia after transanthal orbital decompression and
1992;99:993–997. extraocular muscle surgery associated with Graves’
6. Santiago AP, Isenberg SJ, Neumann D, Spierer A: The orbitopathy. Am J Ophthalmol 1992;113:363–373.
paralimbal approach with delayed conjunctival closure
CHEN21-305-314.I 3/26/01 8:46 AM Page 305
Chapter 21
COMPRESSIVE OPTIC NEUROPATHY
Clinton D. McCord
Infiltrative orbitopathy thyroid disease can be threat- cally, visual symptoms of compression of the optic
ening to a patient’s vision when swollen orbital tis- nerve are almost always preceded by other nonspe-
sue, primarily the extraocular muscles, may compress cific congestive symptoms of discomfort, fullness, and
the optic nerve. The prevalence of optic neuropathy irritation. Most observers have noted that DCON does
in patients with Graves’ disease is felt to be generally not necessarily correlate with the amount of exoph-
less than 5%, but when neuropathy occurs it should thalmos, and most series comment that many of the
be diagnosed and managed with some urgency.1 most severe cases of neuropathy can occur in eyes
with little protrusion.2, 4
CLINICAL SETTING
EARL ... The failure of the eye to
Dysthyroid compressive optic neuropathy (DCON) is
generally seen in older patients (average age 60). The
incidence of compressive neuropathy in the thyroid
P prolapse forward with increasing orbital
congestion would lead to loss of orbital compli-
patient clusters around the 6th and 7th decades.2–4 ance and more compression.8, 9 Many studies
The characteristic female predisposition seen in thy- observe that the most important clinical sign of
roid disease in general does not apply to compressive increased risk of neuropathy in these patients is
neuropathy, as males are almost equally affected.3 increasing restriction of motility, usually verti-
Many studies have shown that the more severe ocular
cal, on the basis of the enlarged and fibrotic
muscle problems in thyroid disease occur over the age
of 50, and there have been no cases of neuropathy extraocular muscles.2–4
reported in the younger age groups of children and
young adults affected with thyroid eye disease in any
Only one series has correlated DCON with the
series.5, 6
amount of exophthalmos.3
Visually, the patient with early compressive neu-
ETIOLOGY AND CLINICAL SIGNS ropathy may complain only of a graying or degrada-
tion of color sensation, usually to red, and then
It is felt that the underlying process causing DCON subsequently complain of reduced vision or blurring.
in Graves’ orbitopathy is infiltration, edema, and Visual field defects can usually be demonstrated as
swelling of the extraocular muscles particularly in the central and paracentral scotomas. Arcuate, altitudi-
apex of the orbit. Histopathology of the extraocular nal, and constrictive defects may also be noted. Affer-
muscles shows initial infiltration by lymphocytes and ent pupillary defects may be present but may not be
plasma cells followed by fibroblasts and the subse- seen if there is symmetrical neuropathy. The optic
quent production of mucopolysaccharides.7 Clini- nerve may appear normal in approximately half of
305
CHEN21-305-314.I 3/22/01 2:31 PM Page 306
the cases, with papilledema or optic atrophy in the cal nerve compression can be sight threatening. Three
rest.2–4, 11 Commonly there is asymmetry of orbital main modalities of treatment are available to combat
involvement.2, 3, 7 The process seems to be more com- this process and each modality can produce relief in
mon in diabetics and in smokers.3, 12 certain patients, but no single modality seems to pro-
duce relief in all patients. A combination of modali-
ties of treatment is commonly necessary, but care and
DIAGNOSIS judgment must be used with the treatments available
The presence of visual symptoms or reduced vision in because each treatment modality has potentially seri-
the Graves’ patient with congestive-appearing orbits ous side effects.
should suggest compressive optic neuropathy. Blurring
Systemic Steroids
and visual symptoms as the result of corneal exposure,
however, must always be taken into consideration. Whether or not treatment with systemic steroids is
successful is somewhat dependent on the criteria for
response that one uses for success. In the early series
EARL... Color desaturation is spe-
P cific for optic neuropathy.2–4
of Day and Caroll,14 at least two lines of improvement
on the Snellen chart was felt to be an adequate
response. Others have used the same criteria.2 Pred-
nisone doses of 80 to 120 mg per day were perscribed
Computed tomography (CT) or magnetic resonance for at least 30 days. It was felt that there is an
imaging (MRI) scans of the orbits characteristically immunosuppressive threshold in each patient that
show enlarged extraocular muscles with crowding in must be reached before a response occurs. If there was
the orbital apex, which is characteristic of the patient to be a response to oral steroids, signs of visual
with compressive neuropathy and confirms the diag- improvement were evident within 1 week. Using this
nosis of apical compression of the optic nerve with criteron, there was at least a 50% favorable response
direct pressure on the nerve and its blood supply.2–4, 7 to steroids, with some achieving lasting remission.2, 14
When diagnosing Graves’ orbitopathy on the basis
of muscle enlargement, one must be aware of all
EARL... In the author’s experience,
other clinical entities that can be associated with
enlargement of extraocular muscles: Inflammatory
myositis (orbital pseudotumor) will show enlarge-
P permanent remission of optic neuropathy
to steroids occurs less frequently, and some
ment of the muscles that extends to involve the ten-
cases that initially respond will relapse, or occa-
don and usually show some inflammatory signs in
the perioptic tissue. A single muscle is usually sionally will respond with an additional course of
involved in adults with inflammatory myositis. Vas- steroids, or commonly will need additional
cular congestion from a carotid-cavernous fistula or modalities of therapy for best response.15
arterial venous shunt can cause muscle enlargement
with a disproportionate engorgement of the superior
ophthalmic vein. Orbital congestion with Graves’ dis- Figure 21–1 shows a patient with compressive
ease, however, may also cause some superior oph- neuropathy who demonstrated a complete response
thalmic vein enlargement. Neoplastic disease can to systemic steroids. Intravenous pulse steroids
involve the extraocular muscles, causing enlarge- using 1 g of methyl prednisone per day for 3 days
ment, but usually takes the form of a focal nodularity has been beneficial in some series, but remissions
as seen in patients with metastatic carcinoma of the and the need for additional treatment was noted.16
breast.7, 13 Sergott et al 17 felt that the varying response of
patients with compressive optic neuropathy to sys-
temic steroids was the result of differences in the cir-
TREATMENT OF COMPRESSIVE culating subgroups of lymphocytes in Graves’
NEUROPATHY patients. Differences in extraocular muscle reflectiv-
ity to A-scan ultrasonography has also been reported
Graves’ disease is known to be a self-limiting process, to be helpful in predicting the outcome of immuno-
and ultimately the inflammatory infiltrative process suppressive treatment in thyroid eye disease. 18 It
will subside; however, permanent damage to the should be emphasized that if a reasonable visual
optic nerve and orbital fibrosis may occur if efforts are response is not forthcoming following an adequate
not made to control and reduce the severity of the dosage of steroids, their prolonged use should be
“hot” inflamed phase. Focal pressure from the infil- avoided because of the serious systemic side effects
trative disease of the extraocular muscles causing api- that can occur (Fig. 21–2).
CHEN21-305-314.I 3/22/01 2:31 PM Page 307
THYROID OPHTHALMOPATHY: COMPRESSIVE OPTIC NEUROPATHY • 307
A B
FIGURE 21–1 (A) A 66-year-old man, 4 weeks postradioactive iodine treatment, presenting with reduced color
vision and decreased central visual activity to 20/100 in the right eye and 20/80 in the left eye. Clinical congestive
symptoms were not severe. (B) Computed tomography (CT) scan of patient showing enlarged medial rectus muscles
causing crowding in the apex of the orbit and encroaching on the optic nerve. The patient was placed on oral pred-
nisone, 100 mg per day, and a return of vision to 20/30 was obtained in both eyes within 1 week and further improve-
ment in 2 weeks. He was tapered off the medication over a 2-week period.
Supervoltage Radiotherapy surrounding periorbital tissue is shown in Fig-

Modern external beam radiotherapy for the treatment ure 21–3. Erickson et al 24 have demonstrated the
of Graves’ disease was popularized at Stanford Uni- shrinking of the size of the extraocular muscles fol-
versity, where good results were reported in a series lowing radiotherapy through the use of orbital ultra-
of patients with the generalized infiltrative orbital sound. Hurbli et al,23 Kazim et al,25 Threlkeld et al,26
problems associated with Graves’ disease.19 Kriss,19 Olivotto et al,27 and Rootman and Nugent 3 have used
Brennan et al,21 Lloyd and Leone,22 and Hurbli et al23 high-voltage external beam radiotherapy to treat the
have used radiotherapy with success for the treatment
of generalized orbital inflammation and congestive
symptoms, in most cases using a dosage of 2000 cGy
with a 6-megavolt (MV) accelerator or equivalent. The
dosage of irradiation received by the optic nerve and
FIGURE 21–2 Patient with compressive optic neuropa-

thy who had been on high doses of systemic steroids for 6 FIGURE 21–3 Standard isodose curves with external
months. Prolonged steroids were being used because the beam supervoltage irradiation most commonly used for the
patient was “not responding.” Subsequent orbital decom- treatment of dysthyroid compressive optic neuropathy.
pression was performed with some improvement. (Modified from Miller et al.28)
CHEN21-305-314.I 3/22/01 2:31 PM Page 308
B
FIGURE 21–4 (A) A 72-year-old man, 12
months post–radioactive iodine treatment, with
congestive symptoms and progressive loss of color
sensation and reduced visual acuity to less than
20/80 in each eye. Systemic steroids produced
C
inadequate response. (B) Coronal CT scan of
patient showing enlargement of all extraocular muscles crowding the orbital apex. (C) Same
patient following 2000 cGy of external beam irradiation, 6 MV, with a linear accelerator with
return of vision to 20/30 in the right eye and 20/25 in the left. Additional systemic steroids were
used during radiotherapy to reduce edema.
more severe patients with compressive neuropathy, total dose of 3000 to 3500 cGy, although radiation
with a good to excellent response in 60 to 90% of pa- retinopathy following the standard technique and a
tients (Fig. 21–4). In all series, however, many patients standard dose of 2000 cGy has been reported.28, 29
required additional treatment with supplemental sys-
temic steroids or in some cases orbital decompression
for the best response (Fig. 21–5). PITFALL
It should be emphasized that radiotherapy should
be delivered by a radiotherapist experienced with the An important contraindication to radiother-
proper technique to avoid complications. Errors in apy is known diabetic or retinal vascular dis-
dosage calculation and treatment technique may cause
ease, which may lower the threshold for
the serious complication of radiation retinopathy or
even damage to the optic nerve. The threshold for reti-
radiation retinopathy.
nal damage induced by radiation is believed to be a
A B
FIGURE 21–5 (A) Patient with extreme con-

gestive dysthyroid orbitopathy and vision
reduced to less than 20/200 in each eye. Systemic
steroids produced little response. (B) Same patient
following supervoltage irradiation with return of
vision to 20/60 in the right eye and 20/40 in the
left. (C) Same patient after additional course of
systemic steroids was given for 3 weeks, with the
return of vision. Following irradiation the patient
C seemed to be more steroid responsive.
CHEN21-305-314.I 3/22/01 2:31 PM Page 309
A B
FIGURE 21–6 (A) A 46-year-old woman 6 months following treatment with radioactive iodine with onset of con-
gestive orbitopathy and reduced visual acuity bilaterally unresponsive to systemic steroids. (B) Visual field in left
eye showing central and paracentral scotomata.
Radiotherapy Technique less therapeutic effect and more side effects. The stan-
The patient is sufficiently immmobilized and posi- dard technique will produce the desired isodose
tioned so that the proper dosage of irradiation can be curves to the orbital tissue.
calculated for delivery to the retro-orbital tissues. Irra-
diation doses of 2000 cGy are given in 10 fractions Orbital Decompression
over 12 days. For well-collimated irradiation, a 4- or 6- Over the years relief from compression of the optic
MeV linear accelerator is used. Any delivery device nerve caused by the enlarged muscles has been
with lower voltage or less focus will run the risk of accomplished by removal of various portions of the
A B
FIGURE 21–7 (A) Same patient as in Fig. 21–6 3 months following bilateral orbital decompression and supple-
mental systemic steroids. (B) Posttreatment visual field and left eye showing resolution of scotomata.
CHEN21-305-314.I 3/22/01 2:31 PM Page 310
bony orbit. Practically every orbital wall, separately The translid approach would be more effective in
or in combination, has been resected to relieve exoph- alleviating the compressive changes in the posterior
thalmos and optic nerve compression in the apex of orbit.34 By necessity, a larger area of anterior bone is
the orbit. Surgical removal of the roof of the orbit from removed when orbital decompression is performed
the transcranial approach or removal of the lateral anteriorly through the translid approach to provide
wall of the orbit alone was utilized for a number of exposure of the posterior orbit for decompression.
years.30 Removal of the floor and ethmoids (antral- Many patients with DCON have profound orbital
ethmoidal) through a transantral approach was popu- edema, which will ultimately subside.
larized by Walsh and Ogura31 and others.31, 33 Removal
of the floor and ethmoids through a transeyelid
approach was popularized by McCord34 and others35
(Figs. 21–6 and 21–7). For extremely severe cases, a
PITFALL
three-wall decompression has been also described.36
In patients with DCON, the object of surgical In the presence of edema and minimal exoph-
decompression is to relieve pressure in the part of the thalmos, removal of large areas of bone, par-
orbit where compression is taking place. Because ticularly in the anterior orbital floor, is not
many patients do not have severe exophthalmos, the recommended because it can result late post-
surgical technique used should be one that can operatively in enophthalmos and the so-
achieve bone resection only in the apical portion of called setting-sun eye as seen in the patient in
the orbit. Figure 21–11.
...
P EARL It is the author’s opinion
that bone resection is best accomplished
with the transantral approach (Fig. 21–8), in
A step-by-step description of orbital decompres-
sion via the transeyelid and transantral approach is
covered in Chapter 22, “Thyroid Ophthalmopathy:
which bone resection can be performed more Orbital Decompression for Aesthetic Indications.”
specifically in the apex of the orbit alone because Because the techniques of orbital decompression
and indications for surgery vary somewhat between
it has been shown that more apical bone
series, comparisons may not be precise; however,
removal is possible while using the transantral from 60 to 80% of patients gained significant improve-
approach than it is using the translid approach ment in vision.33–35 All series incorporated the other
(Figs. 21–9 and 21–10). modalities of treatment (steroids and irradiation) in
each patient’s regimen.
A complication of orbital decompression is wors-
ening of double vision particularly if there is signifi-
cant preexisting motility disturbance.
...
P EARL The surgical technique that
produces maximum relief of pressure at
the apex of the orbit but minimal displacement
of the eye would reduce the amount of addi-
tional motility disturbance.
A common side effect of decompression, particu-

larly through the translid approach, is a worsening of
upper lid retraction because of a downward settling
of the eye.34, 37 Other more severe complications such
as cerebrospinal fluid (CSF) leakage or loss of vision
FIGURE 21–8 Technique of orbital bone removal using have occurred.
the transantral antral-ethmoidal decompression (Ogura pro- Contraindications to surgical (antral-ethmoidal)
cedure). (From McCord,15 with permission.) orbital decompression include preexisting sinus
CHEN21-305-314.I 3/22/01 2:31 PM Page 311
Optic nerve
Medial rectus
muscle
Area of bone Posterior wall

removed of antrum
Ethmoidal
air cells
Neurovascular
bundle FIGURE 21–9 Comparison of area of
bone removal in transfornix and
A transantral decompression techniques
under direct visualization during
Optic nerve surgery. (A) Usual bony defect in the
floor and ethmoids obtained through
Medial rectus the transfornix (translid) approach to
muscle antral-ethmoidal decompression. The
shaded area represents bone that is most
Posterior wall
often excised by the surgeon with rea-
Area of bone of antrum sonably good visualization. Additional
removed bone can be removed through this
approach without good visualization,
but visualized bone is the most likely to
be removed in any decompression pro-
cedure. (B) The usual bony defect
Ethmoidal
air cells
obtained via the transantral approach.
The shaded area is the bone most often
Neurovascular
removed by the surgeon with direct
bundle
visualization. (From McCord,15 with
B permission.)
FIGURE 21–10 (A) coronal CT

scan in patient with Graves’ disease
showing area of orbit where compres-
sion is the greatest. (B) coronal CT
scan in same patient following orbital
decompression through the
transantral approach with good
A B expansion of apical orbital contents.
CHEN21-305-314.I 3/22/01 2:31 PM Page 312
disease, medical problems such as uncontrolled

hypertension, and any bleeding disorder, pharmaco-
logically induced or otherwise.
SUMMARY
Almost every patient presenting with signs of com-
pressive neuropathy should be given a trial of sys-
temic steroids as the initial treatment (Fig. 21–12). In
the last few years the efficacy and safety of supervolt-
age irradiation has become apparent and for many,
including this author, it has become the treatment of
choice for patients who are unresponsive to steroids.
Even if the patient is felt to be a nonresponder to
FIGURE 21–11 Patient with secondary enophthalmos
steroids, systemic steroids should be used in conjunc-
and hypo-ophthalmos following orbital decompression for tion with radiotherapy, particularly to reduce initial
compressive neuropathy. The patient had aggressive bone orbital reaction to the irradiation itself. In the treat-
removal while the orbit was in a severely edematous state. ment of DCON, I prefer to reserve orbital decompres-
With resolution of the orbital edema, and overcorrection sion for patients who fail to achieve a permanent
with sinking of globe position occurred. remission with steroids and irradiation.
Graves' disease
5%
Dysthyroid compressive optic neuropathy (DCON)

(Decreased motility, failure of relief
of pressure at orbital apex)
Decreased supraduction, central acuity,

and color desaturation
Systemic steroid Supervoltage

Orbital decompression
(80 –120 mg Prednisone per day) radiotherapy
Degree of exophthalmos
2,000 cGy:
Recurrence of symptoms in 10 fractions,
over 2 weeks Minimal to mild Moderate/severe
Vision impaired
Additional trial
of steroids
Transantral Transeyelid
Decompression Decompression
(Bone resection in (Resection of bony
orbital apex) floor of orbit)
Possible complication: Possible complications:

loss of vision Increased upperlid
retraction CSF leakage
Loss of vision, worsening
of diplopia
FIGURE 21–12 Clinical pathway for management of dysthyroid compressive optic neuropathy.
CHEN21-305-314.I 3/22/01 2:31 PM Page 313
There have been reports of success using other The mainstay of the treatment of compressive
immunosuppressive agents such azathioprine, imu- neuropathy in Graves’ disease, at present, remains
ran, and cyclosporine, but they have been combined the triad of systemic steroids, supervoltage radio-
with steroids in most of the series, so their usefulness therapy, and orbital decompression singly or in
is not clear.38–42 Beneficial effects of plasmapheresis combination.
has also been reported.43, 44
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1981;99:120.
extraocular muscles in patients with endrocrine exoph-
36. Kennerdell JS, Maroon JC: An orbital decompression thalmos before and after treatment. Orbit 1987;6:53–57.
for severe dysthyroid exophthalmos. Ophthalmology 43. Dandona P, Marshall NI, Bidey SP, et al: Successful
1982;89:467–472. treatment of exophthalmos and pretibial myxoedema
37. Trokel SL, Cooper WC: Orbital decompression: effect with plasmapheresis. Br Med J 1979;10:374.
on motility and globe position. Ophthalmology 1979; 44. Schrooyen M, Winand R, et al: Plasma exchange therapy
86:2064. for severe Graves’ orbitopathy. Orbit 1986;5:105–110.
CHEN22-315-326.I 3/26/01 8:47 AM Page 315
Chapter 22
ORBITAL DECOMPRESSION FOR
AESTHETIC INDICATIONS
Mark A. Codner
Although the risk of impending visual loss is of para- which may also contribute to decreased visual acuity.
mount importance in the evaluation and management Careful examination of eyelid position and lagoph-
of patients with Graves’ orbitopathy, once the diag- thalmos is performed with documentation of the
nosis of compressive optic neuropathy has been degree of lid retraction in the upper and lower lids.
appropriately excluded or treated, the main emphasis Eye protective mechanisms including the presence of
of treatment becomes correction of the hallmark fea- a Bell’s phenomenon are documented. Examination
tures of Graves’ disease including exophthalmos and of eye motility is very important with attention to the
lid retraction. In addition to improving the aesthetic degree of range of motion, diplopia, or restrictive stra-
appearance, surgery for orbital decompression also bismus. Photography is helpful to document the
improves symptoms secondary to corneal exposure. degree of motility restriction in various fields of gaze.
Documentation of the amount of exophthalmos is
PREOPERATIVE EVALUATION important to ensure that changes have stabilized
before surgery as well as to monitor the progress of
Patients who present for surgical evaluation have retroplacement following decompression. A Hertel
generally had a number of diagnostic and therapeutic exophthalmometer is used with standard base mea-
modalities that should be documented. The time of surement to document the degree of exophthalmos.
onset of Graves’ disease and the onset of eye changes A specific part of the initial examination includes
should be documented. Medical or surgical ablation evaluation of orbital compliance. Patients with good
of the thyroid gland must precede elective orbital orbital compliance demonstrate full range of ocular
decompression with an adequate period of observa- motility without restrictive diplopia. Gentle pressure
tion for thyroid replacement to achieve a stable euthy- on the closed eyelid results in easy retroplacement of
roid state. The primary signs and symptoms the globe with signs of periorbital fullness from pro-
requiring documentation include measurement of the lapse of soft orbital fat (Fig. 22–1A). Patients with
degree of exophthalmos, eyelid retraction, symptoms these findings of good orbital compliance generally
of exposure, pain, headaches, double vision, and loss have good results following orbital decompression.
of visual acuity. To ensure that there is no residual On the other hand, signs of poor orbital compliance
active inflammation, a 6-month period of stabilization including fibrosis of the orbital tissues with poor
of eye changes should be documented by photogra- range of motion and diplopia generally are predictive
phy by a family member before orbital decompres- of poor aesthetic results following surgical decom-
sion is performed. pression with increased risk of worsening diplopia.
Examination of the patient includes careful visual Radiographic preoperative evaluation includes
acuity testing including color vision testing to evalu- computed tomography (CT) of the orbits with coro-
ate compressive optic neuropathy. Slit-lamp exam is nal and axial views to examine the degree of extraoc-
used to document evidence of exposure keratopathy, ular muscle enlargement (Fig. 22–1B). The orbital apex
315
CHEN22-315-326.I 3/22/01 2:32 PM Page 316
A B
FIGURE 22–1 (A) A patient with type I Graves’ orbitopathy. (B) Coronal computed tomography (CT) scan demon-
strating the enlargement of the extraocular muscles.
is evaluated for evidence of crowding or optic nerve orbital fat volume with mild enlargement of the
compression. The bony orbital configuration includ- extraocular muscles. Although the orbital changes are
ing the relationship to the ethmoid air cells and max- symmetrical, eyelid retraction is variable and may be
illary sinus is important for surgical planning. Patients asymmetric.
with unilateral exophthalmos should have a CT scan Patients with type II Graves’ orbitopathy have
to make sure there is no underlying orbital tumor. signs of orbital fibrosis including restrictive diplopia.
Patients are more equally distributed between female
and male with an average age in the 50- to 60-year age
Indications for Surgery group. In addition to diplopia, the incidence of com-
The indications for orbital decompression for aesthetic pressive optic neuropathy is significant. Although the
reasons primarily include significant exophthalmos average Hertel measurement is only 1 mm greater
with symptoms of corneal exposure, unilateral exoph- than in type I, examination of proptosis shows poor
thalmos, or asymmetry. Most patients have functional orbital compliance.3 CT scan reveals significant mus-
problems ranging from mild ocular irritation and cle enlargement, most commonly of the inferior and
tearing to more severe exposure symptoms. In addi- medial recti, with minimal increase in orbital fat vol-
tion to improving the appearance of the eyes, surgi- ume. Orbital changes are commonly asymmetric and
cal decompression improves these symptoms. require appropriate surgical planning.
Furthermore, most patients following orbital decom-
pression will require eyelid surgery including tar-
solevator recession and lateral canthoplasty with
EARL... Patients with type I Graves’
possible lower lid spacer to complete the rehabilita-
tive sequence. Decompression is an important step
in this process, making the final eyelid surgery more
P ophthalmopathy with mild proptosis are
candidates for the inferior forniceal approach
predictable. using conservative two-wall antroethmoidal
Clinically, patients with Graves’ orbitopathy have decompression.
been divided into two types based on the presence of
restrictive myopathy with diplopia.1, 2 Patients with
type I have orbital fat hyperplasia and tissue edema, The inferior fornix transconjunctival incision with
which cause exophthalmos. There is little orbital lateral canthotomy provides excellent exposure and
inflammation or fibrosis of the extraocular muscles has less risk of postoperative ocular motility distur-
and therefore no restrictive diplopia and good orbital bance. Overcorrection of the lateral canthoplasty can
compliance. Although proptosis may be significant, be used to correct lower lid retraction at the time of
there is generally normal orbital function, and the risk decompression. Patients with type I findings with
of compressive neuropathy is low. The patient popu- more significant exophthalmos can also undergo infe-
lation for type I consists most commonly of women rior forniceal antroethmoidal decompression. Modi-
in the 30- to 40-year age range. fications include more aggressive bony removal of
Proptosis can be mild or severe, with an average the posterior ethmoids, complete bony removal of the
Hertel measurement of 22 mm.3 There is little orbital inferior orbital neurovascular canal, and aggressive
asymmetry and CT scan demonstrates increased removal of anterior and posterior orbital fat.4, 5
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THYROID OPHTHALMOPATHY: ORBITAL DECOMPRESSION FOR AESTHETIC INDICATIONS • 317
frontoethmoid suture is the anatomic boundary

EARL... Patients with type II orbito-
P
between the medial wall and the orbital roof. This
important landmark represents the level of the floor
pathy generally require the transantral,
of the anterior cranial fossa. The cribriform plate lies
transoral approach for orbital decompression. medial to the ethmoid labyrinth and may extend 5 to
10 mm below the level of the frontoethmoid suture.
This anatomic relationship is important during dis-
ANATOMY section of the superior ethmoid air cells. The ethmoid
air cells are characterized by a thin, bony honeycomb
The adult bony orbit is pyramidal in shape with an within the ethmoid sinus lined by a thin layer of
average volume of 30 cm3.6 The orbital rims form a mucosa. The anterior and posterior ethmoidal foram-
rectangular shape and consist of the thickest bone. ina lie just above the frontoethmoidal suture and con-
The widest dimension of the orbit is 1 cm posterior to tain the anterior and posterior ethmoidal arteries and
the bony rim. The four walls of the orbit converge at branches of the nasociliary nerve. These anatomic
the orbital apex, which is approximately 40 mm pos- structures are important landmarks that approximate
terior to the inferior orbital rim. Because the dimen- the level of the anterior cranial fossa. In addition, the
sions of the orbit are variable, the surgeon should not optic nerve lies 5 to 10 mm behind the posterior eth-
rely on measurements to guide dissection of the pos- moidal foramen. The maxilloethmoid suture line sep-
terior orbit. Precise knowledge of the anatomy is arates the medial wall from the orbital floor.
required to safely perform orbital decompression and The orbital floor is made up of three bones: maxil-
avoid injury to the optic nerve and orbital contents lary, zygomatic, and palatine. The orbital floor is
(Fig. 22–2). roughly triangular shaped and extends along the infe-
The medial portion of the inferior orbital rim is rior orbital fissure toward the orbital apex. The poste-
made up of the maxillary bone and contains the infra- rior extent of dissection is determined by the posterior
orbital foramen 4 to 10 mm below the central portion wall of the maxillary sinus. The orbital floor ends at
of the rim. The lateral portion of the inferior orbital the pterygopalatine fossa and does not extend all the
rim consists of the frontal process of the zygomatic way to the apex. The palatine bone contributes to a
bone, which is the thickest part of the orbital rim. The small portion of the orbital floor located at the most
medial rim is made up of the frontal process of the posterior extent of the orbital apex. The orbital plate
maxillary bone and contains the lacrimal sac fossa. of the maxillary bone is the largest bony contributor to
The medial wall of the orbit is formed by four bones: the floor and also forms the roof of the maxillary
maxillary, lacrimal, ethmoid, and sphenoid. The lam- sinus. This is the thinnest part of the orbital floor and
ina papyracea is posterior to the lacrimal fossa; mea- marks the location for the initial ostetomy during
suring 0.2 mm in thickness, it is the thinnest portion of decompression. The infraorbital neurovascular bun-
the orbit. This fragile bony wall overlies the ethmoid dle passes from the infraorbital sulcus into the bony
air cells, which number three to eight. Superiorly, the canal and is identified as a bony ridge just lateral to
Lesser
sphenoid
Greater sphenoid wing Frontal bone
wing
Palatine bone
Ethmoid
bone
Zygomatic
bone
Lacrimal
bone
Inferior orbital
fissure Nasolacrimal
canal
Infraorbital Orbital
groove plate of
maxillary Maxilla FIGURE 22–2 Frontal view demonstrating
bone the bony anatomy of the orbit.
CHEN22-315-326.I 3/22/01 2:32 PM Page 318
the midline of the orbit. Neuropraxia of the infraor- rior orbit for compressive optic neuropathy to obtain
bital nerve is not uncommon during orbital decom- adequate decompression into the posterior ethmoid
pression resulting in temporary anesthesia of the sinus back to the ethmoid-sphenoid suture line.8, 9 The
cheek and upper lip. The inferior orbital fissure sepa- sphenopalatine artery, which is a terminal branch of
rates the floor from the lateral orbital wall and con- the internal maxillary artery, is located medial to the
tains branches of the inferior ophthalmic vein, posterior ethmoid recess. Aggressive dissection in this
maxillary division of the trigeminal nerve, and area should therefore be avoided. Significant bleed-
parasympathetic fibers from the pterygopalatine gan- ing from this artery through a transorbital approach
glion. Posterior to the infraorbital sulcus, the inferior may require a maxillary antrostomy for exposure and
fissure joins the superior orbital fissure at the level of ligation through the maxillary antrum. The remain-
the optic canal. der of the roof of the maxillary antrum extends along
Orbital decompression expands the confines of the the bony support for the inferior orbital fissure.
bony orbit by allowing the contents to be displaced The anterior wall of the maxillary antrum extends
into the maxillary and ethmoid sinuses. The maxillary from the inferior orbital rim to the alveolar process of
antrum is pyramidal in shape and is enveloped by the the maxilla. The infraorbital foramen is located on the
maxillary and zygomatic bones, with the roof of the anterior wall just below the orbital rim. Exposure of
antrum contiguous with the orbital floor. The medial the anterior wall for transantral decompression
wall of the maxillary antrum makes up the support should limit dissection at the infraorbital foramen
for the lateral wall of the nasal cavity and is formed by and the pyriform aperture. The canine and premolar
the palatine plate, ethmoidal and maxillary processes tooth roots extend 10 to 15 mm into the alveolar
of the inferior nasal concha, and the unciform process process, a few millimeters below the anterior wall of
of the ethmoid.7 The superior and middle turbinates the antrum, and should be avoided during antros-
are part of the ethmoid bone, whereas the inferior tomy. The medial wall of the maxillary antrum con-
turbinate concha is a separate bone. The floor of the tains the maxillary ostium, which opens at the
maxillary antrum lies just above the hard palate and approximate midpoint of the medial wall just poste-
alveolar process. The lateral wall of the antrum rior to the nasolacrimal duct, which may be visual-
extends within the frontal process of the zygoma. The ized as a thickened groove along the medial wall. The
posterior extent of the antrum is formed by the ptery- maxillary ostium opens on to the hiatus semilunaris,
goid processes. The apex of the antrum is an impor- which is bounded inferiorly by the unciform process
tant landmark for orbital decompression. A triangular of the ethmoid.
strut of bone separates the apex of the antrum from
the posterior ethmoid recess at the level of the maxil-
EARL... The maxillary ostium is a
loethmoid suture (Fig. 22–3). This strut must be
entirely resected during decompression of the poste- P highly efficient route of drainage for blood
following decompression, and because injury to
the ostium may impair drainage, the ostium
should be preserved when a nasoantral window
is created.
Accessory maxillary ostia are common and should

be identified and preserved.
The nasolacrimal duct passes through the lacrimal
sac fossa, which is formed by the junction of the max-
illary and lacrimal bones. Injury to the nasolacrimal
duct should be avoided during orbital decompression
when either the transorbital or transantral approach is
used. Decompression can extend up to the posterior
FIGURE 22–3 Close-up view of the skeletal anatomy of lacrimal crest with preservation of the bony canal to
the left orbit following removal of the medial wall and avoid injury to the lacrimal drainage system. The
inferior floor demonstrating the triangular strut of bone anterior cranial fossa may be as little as 1 mm above
separating the posterior ethmoid sinus and the apex of the the upper border of the medial canthal tendon at the
maxillary antrum. midlevel of the lacrimal sac.
CHEN22-315-326.I 3/22/01 2:32 PM Page 319
SURGICAL PROCEDURES nasal cavity is packed with cottonoids soaked with

cocaine 4%. The patient is placed in reverse Trende-
Preoperative Preparation lenburg position for increased venous drainage. Once
Once the decision to proceed with orbital decompres- the patient is sterilely prepared, corneal protectors are
sion has been made, the indications and goals of the used during the entire case. Moistened Gelfoam
surgery should be discussed in detail with the patient squares or Healon can be used to protect the cornea in
and family. The steps of the surgery should be clear cases of extreme proptosis.
and the patient should understand the potential risks, A lateral canthotomy is performed with a scalpel
including hematoma necessitating emergent evacua- followed by an inferior cantholysis with straight Iris
tion, prolonged edema, and the risks of diplopia or loss scissors. Retraction sutures are placed along the lid
of vision. The patient must be aware that additional margins for exposure of the inferior fornix (Fig. 22–4).
surgery will be likely for the correction of either motil- A needle-tip electrocautery is used to divide the
ity problems or eyelid retraction. Medical clearance conjunctiva and capsulopalpebral fascia 4 mm below
should be obtained prior to surgery, with particular the inferior arcade. Dissection proceeds anterior to the
emphasis on controlling hypertension, documen- orbital septum, which should be preserved to avoid
tation of normal clotting parameters, and cessation of fat prolapse into the surgical field. A malleable retrac-
anticoagulative products (including aspirin, ibuprofen, tor is used to expose the inferior orbital rim. The
and coumadin) for 2 weeks prior to surgery. Surgery periosteum is incised with the cautery along the rim,
should be delayed if active sinusitis is present. Periop- and a Joseph elevator is used to dissect the periorbita
erative steroids should be considered to reduce edema exposing the inferior and medial orbit. The lacrimal
following surgery, and stress steroids should be sac should not be injured, and medial dissection
administered if systemic steroids have been used extends up to the frontoethmoidal suture. Posterior
within 1 year of surgery. dissection proceeds to the inferior orbital fissure.
Following adequate subperiosteal exposure, a
Inferior Forniceal Antroethmoidal Orbital small osteotome is used to create an osteotomy in the
Decompression central portion of the orbital floor medial to the infra-
The transorbital approach to orbital decompression orbital neurovascular bundle. A Kerrison rongeur is
provides excellent exposure to the inferior and medial used to remove bone and maxillary sinus mucosa in a
orbital walls.8, 10 This technique is most commonly piecemeal fashion. Posterior resection should proceed
used for patients with type I Graves’ orbitopathy with to the posterior extent of the maxillary antrum.
good motility and excellent orbital compliance. Globe Hemostasis can be achieved with electrocautery, cold
retroplacement of 4 mm or more can be achieved with irrigation, and hemostatic packing with bonewax,
this technique. The procedure is performed under a Gelfoam, or Surgicel. The ethmoid sinus can be easily
general endotracheal anesthesia. The inferior and entered with a Freer elevator, exposing the ethmoid
medial orbital walls are infiltrated with lidocaine 2% air cells. A pituitary forceps is used to complete the
with 1 : 100,000 dilution epinephrine, and the superior ethmoidectomy. A Durden suction cautery can be
A B
FIGURE 22–4 Inferior forniceal antroethmoidal orbital decompression. (A) Area outlining the extent of bony resec-
tion of the orbital floor. (B) Preservation of the infraorbital neurovascular bundle.
CHEN22-315-326.I 3/22/01 2:32 PM Page 320
used for hemostasis in the ethmoid sinus. For patients also removed under direct visualization, with care
with mild exophthalmos and good orbital compli- taken to avoid injury to the extraocular muscles
ance, aggressive resection of the ethmoids including (Fig. 22–5).
the triangular strut of bone at the posterior maxillary
antrum is not required. Furthermore, the orbital floor
EARL ...
P
lateral to the infraorbital canal should be preserved to Orbital fat removal is a
reduce the risk of postoperative hypoglobus.
useful adjunct to bony decompression
Following bony resection, a U-shaped flap of peri-
orbita is outlined with the base of the U just inside the with additional retroplacement of 1 mm for
inferior orbital rim. The flap is divided with Westcott each cubic centimeter of fat removed.
scissors along the outline and the periorbita removed,
allowing the orbital fat to prolapse into the surgical
field. Gentle pressure on the globe forces the pro- Prior to closure, absolute hemostasis should be
lapsed fat into the osteotomy, allowing the eye posi- achieved. A nasoantral window is an optional tech-
tion to move posteriorly. Symmetrical dissection is the nique to increase drainage of the maxillary sinus. The
best method to gauge accurate retroplacement for nasal antrostomy is performed through the nasal cav-
bilateral cases. For unilateral cases, additional retro- ity following infracture or resection of the anterior por-
placement of the eye in surgery can be achieved by tion of the inferior turbinate. A right-angled pointed
increasing the size of the osteotomy or with additional rasp is used to create the nasoantral window below the
periorbita removal. For more severe cases of exoph- maxillary ostium into the inferior portion of the max-
thalmos in type I Graves’ orbitopathy, additional illary antrum under direct visualization to avoid injury
retroplacement is achieved by combining antroeth- to the maxillary ostium. The maxillary mucosa is
moidal decompression with aggressive fat removal.4, 11 resected with electrocautery over the bony antrostomy
Anterior fat pads are removed through the lower lid to improve drainage. Closure of the inferior fornix
incision and an upper blepharoplasty incision is made conjunctiva is performed with a continuous 6-0 plain
for the removal of preaponeurotic fat. Intraconal fat is catgut suture. The lateral canthus is repaired using a
A B
FIGURE 22–5 (A) Basal view prior to orbital decom-

pression. (B) Intraoperative view demonstrating the amount
of fat that was removed at the time of decompression.
(C) Basal view after decompression and selective fat
C removal of the left side.
CHEN22-315-326.I 3/22/01 2:32 PM Page 321
4-0 Prolene attaching the edge of the tarsal plate to the lar positioning as used for the transorbital approach.
periosteum inside the lateral orbital rim. In addition to injection of the medial and inferior
orbital walls with lidocaine 2% with epinephrine
1 : 100,000 dilution, the gingivobuccal sulcus is also
EARL ... Symmetrical supraplace-
P ment is performed to elevate the lower
lid position without tightening the lower lid to
injected followed by nasal packing with cocaine 4%.
A gingivobuccal sulcus incision is made above the
canine tooth and extended posteriorly for approxi-
avoid “clothes-lining” of the lid below the promi- mately 2 cm to the first molar above the level of the
nent globe. tooth roots with preservation of a cuff of mucosa for
adequate repair (Fig. 22–6). The periosteum is incised
with a needle-tip electrocautery and a Joseph eleva-
tor is used to dissect the periosteum off the anterior
A 6-0 nylon suture is placed to close the lateral can-
wall of the maxillary antrum. The infraorbital neu-
thotomy and avoid lateral commissure webbing.
rovascular bundle should be identified and preserved
with dissection remaining inferior to the foramen. Fol-
Transantral Antroethmoidal Decompression lowing bony exposure, a 10-mm osteotome is used to
The transantral approach offers additional exposure create a Caldwell-Luc maxillary antrostomy, which
to the posterior ethmoid sinus and orbital apex in should be superior to the canine tooth root. Kerrison
addition to direct access to the medial and inferior rongeurs are used to enlarge the bony window,
orbital walls.12 This increased posterior exposure remaining inferior to the infraorbital nerve. The max-
makes the transantral approach useful for decom- illary antral mucosa is removed from the anterior wall
pression of compressive optic neuropathy and for with cautery and the superior mucosa is removed
patients with type II Graves’ orbitopathy with poor with a curette to expose the bony orbital floor.
compliance. The disadvantage of this approach is the Removal of the ethmoid air cells is performed by
risk of diplopia with decreased ocular motility from entering the ethmoid sinus with a Freer elevator supe-
the underlying poor compliance. 13, 14 Globe retro- rior to the maxillary ostium halfway between the
placement can be 4 to 6 mm depending on the under- anterior and posterior walls of the maxillary sinus just
lying compliance of the orbital tissue. If transantral behind the nasolacrimal canal (Fig. 22–7). Ethmoidec-
decompression is indicated for compressive optic tomy is performed using a combination of curettage
neuropathy, a conservative approach performing one and direct excision with the suction electrocautery.
eye at a time should be considered. When decom- Dissection proceeds superiorly to the level of the fron-
pression is performed for aesthetic indications, bilat- toethmoid suture, preserving the anterior and poste-
eral decompression may be performed. General rior ethmoidal vessels. Care should be taken to avoid
endotracheal anesthesia is recommended with simi- overaggressive dissection within the ethmoid sinus to
A B
FIGURE 22–6 Transantral antroethmoidal orbital decompression. (A) Exposure of the anterior wall of the maxilla
through a gingivobuccal sulcus incision. (B) Resection of the medial and inferior orbital floor through the Caldwell-
Luc maxillary antrostomy.
CHEN22-315-326.I 3/22/01 2:32 PM Page 322
Area of Roof of
ethmoidectomy maxillary sinus
Area of
ethmoidectomy
Orbit
Bony Posterior wall

prominence of maxillary
of nasolacrimal sinus
Maxillary Maxillary duct
ostium bone Maxillary Medial wall
A ostium of maxillary sinus B
FIGURE 22–7 (A) Orbital decompression via transantral approach through maxillary sinus. The dotted line delin-
eates the area of ethmoidectomy. (B) Transantral view of maxillary sinus at junction of medial and posterior walls and
roof.
prevent injury to the cribriform plate. Hemostasis can then removed. The orbital fat prolapses into the bony
be achieved with a combination of electrocautery and decompression with gentle pressure on the globe. In
Surgicel hemostatic packing. Prior to beginning addition to wide removal of the periorbita to allow
decompression of the orbital floor, the bony strut in displacement of the orbital contents into the ethmoid
the posterior ethmoid recess separating the ethmoid sinus and maxillary antrum, removal of retroseptal
sinus and the posterior antral wall should be (postseptal and preaponeurotic) and intraconal fat is
removed. Removal of this bone is facilitated through performed as an adjunct to bony decompression with
the transantral approach and is required in cases of approximately 1 mm of retroplacement for each cubic
compressive optic neuropathy. centimeter of fat removed. Care should be taken to
Following completion of the ethmoidectomy, resec- avoid injury to the inferior rectus and inferior oblique
tion of the orbital floor is performed. The bone medial when performing fat resection. Just as for the inferior
to the infraorbital neurovascular bundle is removed
with rongeurs or pituitary forceps, taking precaution
to avoid penetration of the overlying periorbita. Bony Inferior
resection is performed connecting the ethmoidectomy rectus
window to the infraorbital groove laterally. Resection
proceeds anteriorly to the inferior orbital rim and pos-
teriorly to the apex of the maxillary antrum. For cases
Bony opening
of extreme exophthalmos, decompression may pro- in floor of orbit
ceed lateral to the infraorbital neurovascular bundle
with complete removal of the bony canal and orbital Periosteal
floor anterior to the inferior orbital fissure. Following flap
completion of the bony decompression, hemostasis is Lateral
obtained with electrocautery along the perimeter of rectus
the osteotomy.
To achieve maximal retroplacement of the globe, a Medial
combination of bony decompression, wide removal rectus
of periorbita, and orbital fat resection is performed.
The needle-tip electrocautery is used to make parallel
incisions in the periorbita medial and lateral to the FIGURE 22–8 Transantral view of roof of left maxillary
location of the inferior rectus muscle (Fig. 22–8). The sinus (or floor of left orbit). Bony opening is the surgical
posterior periorbita is divided, creating a three-sided defect created for orbital decompression. Dotted line delin-
flap of periorbita that is gently teased anteriorly and eates incision through inferior periorbita.
CHEN22-315-326.I 3/22/01 2:32 PM Page 323
A B
FIGURE 22–9 Clinical photographs demonstrating results of transantral orbital decompression before (A) and
after (B) surgery. (Courtesy of C. D. McCord.)
forniceal approach, a nasoantral window may be per- A neutral vector is represented by a line that is verti-
formed for drainage through the maxillary antros- cal, and a negative vector exists when the line angles
tomy below the maxillary ostium. A right-angle rasp posteriorly from the cornea to the rim. This relation-
is passed through the nasal cavity below the inferior ship can be altered by retroplacement of the globe
turbinate into the anterior maxillary antrum under through orbital decompression and by increasing the
direct visualization. The antrum should be entered on anterior projection of the orbital rim and maxilla
the inferior lateral wall to avoid injury to the naso- through onlay grafting (Fig. 22–10). Onlay grafting
lacrimal duct. Once absolute hemostasis has been has the advantage of increasing the anterior position
achieved, the gingivobuccal sulcus incision is closed of the orbital rim and midface without the morbidity
with a continuous 4-0 chromic suture. Transantral associated with more significant craniofacial
antroethmoidal decompression can often result in approaches that advance the orbital rim.16 Although
globe retroplacement of 4 to 6 mm (Fig. 22–9). bone grafts can be used, the preferred technique uti-
lizes a Porex orbital rim implant that is fixed to the
maxilla. A combined lateral canthotomy and fornix
Orbital Rim Augmentation incision or a transcutaneous lid margin incision can
Surgical decompression of the orbit is a reliable be used to expose the inferior orbital rim. A Joseph
method to achieve retroplacement of the globe for the elevator is used to dissect the periosteum, creating an
correction of the appearance of patients with Graves’ adequate pocket for the implant. Care should be
ophthalmopathy. The approach recommended
depends primarily on the degree of eye prominence
and compliance of the orbital tissue. Alhough decom-
pression is generally the initial procedure performed,
most patients will require additional eyelid surgery
to correct retraction of the upper and lower eyelids.
The aesthetic changes following orbital decompres-
sion should be allowed to stabilize for 3 months prior
to adjunctive soft tissue surgery. At the time of eyelid
surgery, augmentation of the inferior orbital rim and
anterior maxilla has been performed in select patients
with maxillary hypoplasia who have undergone
orbital decompression and have residual eye promi-
nence. The vector relationship of the anterior portion
of the globe to the inferior orbital rim has been FIGURE 22–10 Diagram demonstrating the vector rela-
described as a negative vector for patients with tionship between the globe and the inferior orbital rim.
exophthalmos.15 The vector relationship is defined by Patients with exophthalmos have a negative vector that can
a line drawn on lateral view of the orbit from the be altered by retroplacement of the globe and onlay grafting
anterior point of the cornea to the inferior orbital rim. of the infraorbital rim and maxilla.
CHEN22-315-326.I 3/22/01 2:32 PM Page 324
taken to avoid compression of the infraorbital neu- administered during surgery, followed by 1 week of
rovascular bundle. Once the implant is positioned, oral steroids. To avoid corneal exposure, liberal use
fixation is achieved with two titanium lag screws, of ophthalmic ointment is recommended for several
which can be used from a standard miniplate fixation weeks after surgery. Patients should remain in the
system of 1.3 mm in diameter by approximately hospital for at least one night for postoperative care,
16 mm in length placed directly through the implant. which is to include frequent visual examinations for
The soft tissue of the midface is released by incising any changes in visual acuity.
the periosteum at the base of the dissection. The
entire flap of midfacial soft tissue is then advanced COMPLICATIONS
superiorly. Fixation of the soft tissue of the midface is
accomplished by suturing the tissue directly to the The most severe potential complication that can occur
implant with a 4-0 Prolene. Following midfacial aug- following orbital decompression is decrease or loss of
mentation, the remainder of the eyelid surgery is vision. Patients and family members must have these
completed (e.g., recession of eyelid retractors, place- risks fully explained prior to surgery. Visual loss can
ment of lower lid spacer) (Fig. 22–11). be caused by direct injury to the optic nerve during
decompression of the orbital apex or secondary to
POSTOPERATIVE CARE central retinal artery occlusion from optic nerve com-
pression caused by edema or retrobulbar hematoma.
The emphasis on postoperative care is directed at Frequent postoperative examinations are performed
minimizing postoperative corneal dryness, bruising, to aid in early diagnosis of decreasing visual acuity.
and swelling. A temporary Frost suture may be useful Prompt management includes reoperation with lat-
in the immediate postoperative period to maintain eral canthotomy and evacuation of the hematoma.
traction of the lower lid and avoid lower lid retraction Delayed canthal repair may be performed once the
secondary to edema. Continuous use of ice packs is edema has improved and vision has stabilized.
recommended for 48 hours, with elevation of the Another complication that may affect vision is
patient’s head. Perioperative steroids are generally diplopia. Periorbital edema may cause swelling of
used to reduce swelling. Intravenous steroids are the extraocular muscles, particularly involving the
A B
FIGURE 22–11 (A) Patient with Graves’ disease follow-

ing maximal globe retroplacement with decompression,
showing residual eye prominence and deficient infraorbital
rim support. (B) Porex orbital implant is shown in approxi-
mate position prior to surgery. (C) Patient is shown after
bilateral lower lid surgery with placement of Porex orbital
C rim implants with improved appearance and lid position.
CHEN22-315-326.I 3/22/01 2:32 PM Page 325
A B
FIGURE 22–12 Patient with Graves’ disease before (A) and after (B) a comprehensive approach to the surgical
management including orbital decompression, strabismus surgery, and eyelid surgery. (Courtesy of C. D. McCord.)
inferior rectus, producing motility restriction in toma, wide antral drainage appears to reduce the
upward gaze. Conservative management with an incidence of sinusitis or discomfort associated with
extended course of oral prednisone for 3 months accumulation of fluid within the maxillary sinus.
should be practiced. Persistent diplopia may require
surgical correction of the extraocular muscles.
Surgery for postdecompression strabismus should be CONCLUSION
performed only after failure of conservative manage- Surgical decompression of the orbit is a fundamental
ment because this surgery may reduce the results part of managing the patient with Graves’ ophthal-
achieved with decompression. Hypoglobus may mopathy (Fig. 22–12). Once appropriate medical treat-
result following orbital decompression and is more ment has been completed and the patient is rendered
common following overresection of the orbital floor euthyroid on thyroid replacement, retroplacement of
in patients with compliant orbital contents. Although the globe can be performed using these reliable tech-
retroplacement of the globe will often improve the niques. Although orbital decompression is ideally
position of the retracted lower lid by reducing the performed in an elective situation, compressive optic
horizontal tension on the lid, hypoglobus may neuropathy represents an emergency situation that
worsen the appearance of the retracted upper lid due requires prompt diagnosis and immediate surgical
to inferior positioning of the globe. Other complica- decompression. Most patients will require additional
tions include prolonged numbness in the distribution staged surgery following orbital decompression to
of the infraorbital nerve, persistent facial edema, and complete and maintain the improvement in the
sinusitis. Although creation of a nasoantral window appearance and protective function of the eyelids
may not prevent formation of a significant hema- (Fig. 22–13).
Thyroid Eye Disease
Mild Moderate Severe
Orbital Compliance Orbital Compliance

Type I Type II
Orbital Fat Inferior Forniceal Transantral Antroethmoidal

Removal Only Orbital Decompression Orbital Decompression
FIGURE 22–13 Exophthalmos: thyroid eye disease

CHEN22-315-326.I 3/22/01 2:32 PM Page 326
REFERENCES
1. Nunery WR, Martin RT, Heinz GW, Gavin TJ: The 8. Anderson RL, Linberg JV: Transorbital approach to
association with cigarette smoking with subtypes of decompression in Graves’ disease. Arch Ophthalmol
ophthalmic Graves’ disease. Ophthalmic Plast Reconstr 1981;99:120–124.
Surg 1993;9(2):77–82. 9. Kennerdell JS, Maroon JC: An orbital decompression
2. Frueh BR, Musch DC, Grill R, et al: Orbital compli- for severe dysthyroid exophthalmos. Ophthalmology
ance in Graves’ eye disease. Ophthalmology 1985;92: 1982;89:467.
657–665. 10. McCord CD: Orbital decompression for Graves’ dis-
3. Tanenbaum M, McCord CD, Nunery WR: Graves’ oph- ease: exposure through lateral canthal and inferior
thalmopathy. In: McCord CD, Tanenbaum M, Nunery fornix incision. Ophthalmology 1981;88:533–541.
WR, eds. Oculoplastic Surgery, 3rd ed. New York: Raven 11. Hecht SD, Guibor P, Wolfley D, Wiggs EO: Orbital dis-
Press, 1995:379–416. section defatting technique for Graves’ disease. Ann
4. Tanenbaum M: Orbital decompression for Graves’ Ophthalmol 1984;16:314–315.
orbitopathy. In: Bosniak S, ed. Principles and Practice of 12. Walsh TE, Ogura JH: Transantral decompression for
Ophthalmic Plastic and Reconstructive Surgery. Philadel- malignant exophthalmos. Laryngoscope 1957;67:544–568.
phia: WB Saunders, 1996:967–982. 13. McCord CD: Current trends in orbital decompression.
5. Olivari N: Transpalpebral decompression of endocrine Ophthalmology 1985;92:21–33.
ophthalmopathy (Graves’ disease) by removal of intra- 14. Shorr N, Neuhaus RW, Baylis HI: Ocular motility prob-
orbital fat: experience with 147 operations over 5 years. lems after orbital decompression for dysthyroid oph-
Plast Reconstr Surg 1991;87:627–641. thalmopathy. Ophthalmology 1982;89:323–328.
6. Dutton JJ: Atlas of Clinical and Surgical Orbital Anatomy. 15. Jelks GW, Jelks EB: The influence of orbital and eyelid
Philadelphia: WB Saunders, 1994. anatomy on the palpebral aperture. Clin Plast Surg
7. McCarthy JG, Jelks GW, Valauri AJ, Wood-Smith D, 1991;18:183.
Smith B: The orbit and zygoma. In: McCarthy JG, ed. 16. Wolfe SA: Modified three-wall orbital expansion to cor-
Plastic Surgery. Philadelphia: WB Saunders, 1990: rect persistent exophthalmos or exorbitism. Plast Reconstr
1574–1670. Surg 1979;64:448–455.
CHEN23-327-346.I 3/26/01 8:52 AM Page 327
Chapter 23
ENUCLEATION
William P. Chen
Enucleation is the procedure by which the eyeball

(globe) is removed intact from the orbit. It is a psy-
chologically traumatic event for the patient. Tradi-
tionally the procedure is performed as a treatment for
intraocular malignancy, suspected intraocular tumor,
pain in an end-stage diseased eye (for example, glau-
coma), disfigured eye (for example, buophthalmos),
and unsightly phthisical eyes, and to improve on cos-
metic appearance when an eye is nonfunctional. The
globe and its intraocular content are removed intact
for pathologic examinations in cases of suspected
intraocular tumor. The removed segment of optic
nerve that is still attached to the globe is studied for
proximal tumor extension in cases of retinoblastoma,
choroidal melanoma, and other tumors.
Enucleation is often considered a simple operation
where the globe is separated from its six extraocular
muscles attachment and then severed from the optic
nerve, followed by replacement with some form of
orbital implant—spherical, Iowa, Allen, Universal,1
fully integrated Stone-Jordan implant (Figs. 23–1 and
23–2) dermis-fat graft, or hydroxyapatite implant and
variants of porous implant with motility coupling
mechanism. But successful enucleation requires an
appropriate degree of surgical skill, an understand- FIGURE 23–1 Stone-Jordan implants and variations.
ing of orbital anatomy and its influence by surgical
manipulation, and an understanding of the interac-
tion of socket dynamics with the ocular prosthesis. INDICATIONS FOR SURGERY
A greater understanding of the presence of orbital
fibroconnective tissue septa2 (see Chapter 1), aware- Indications for enucleation and evisceration must be
ness of rotatory displacement of orbital tissue follow- carefully assessed before deciding upon the most
ing an enucleation without implant placement,3 and appropriate procedure. Evisceration techniques are
improved surgical techniques have refined the surgi- discussed in Chapter 24, but it is useful to discuss
cal steps of enucleation as it is currently practical. and compare the indications for both procedures—
327
CHEN23-327-346.I 3/22/01 2:33 PM Page 328
PITFALL
Conventional wisdom states that there is a

greater probability of sympathetic oph-
thalmia with evisceration because micro-
scopic quantities of uveal pigments are
always left behind in the ciliary body attach-
ment, in the scleral channels where the vor-
tex veins exits the globe, and in the peripap-
illary areas.
There have been rare case reports of sympathetic

ophthalmia after enucleation even when there has
FIGURE 23–2 Stone-Jordan implant in a left orbit. Note not been any past history of corneoscleral rupture or
recession of conjunctival edges around the implant with perforation.
chronic infection.
enucleation and evisceration—as there is some over- PITFALL

lap in the decision-making process.
In the past, evisceration has often been mentioned Following ruptured globe injury with uveal
as the procedure of choice in end-stage endoph- prolapse, the patient who chooses eviscera-
thalmitis. The reasoning for this was derived from tion should be aware that the traumatic injury
the preantibiotics era, in which the risk of contiguous in itself may result in sympathetic oph-
spread of central nervous system infection following thalmia, and that evisceration may increase
transection of the overlying conjunctiva are greater that likelihood.
than that in evisceration.4 With the wide availability
of antibiotics and its routine use when indicated prior
to surgery, the data did not support the concept that
central nervous system infection or meningitis is A patient with a ruptured globe and uveal pro-
more likely to occur following enucleation than lapse who chooses enucleation still has a possibility
following evisceration.5 of developing sympathetic ophthalmia, though pre-
In terms of sympathetic ophthalmia, the medical sumably less than with evisceration.
literature cites an incidence of 1 in 20,000 to 1 in 25,000 There are some absolute contraindications for evis-
in those cases where there was corneal or scleral rup- ceration. Foremost is the suspicion of or presence of
ture with presence or history of uveal tissue entrap- intraocular malignancy. With intraocular malignancy
ment. It is felt that sympathetic ophthalmia is a not manageable by medical treatment, enucleation is
delayed hypersensitivity-type immune response; the procedure of choice because the globe and its
therefore, if a traumatized eye is beyond hope of intraocular contents will be removed completely.
recovery of any functional vision, it is believed that For patients with a blind painful eye whose fundus
early enucleation within 10 to 14 days following the can be examined to rule out an intraocular tumor,
initial corneoscleral rupture greatly reduces the chance evisceration offers a relatively atraumatic and cos-
for development of sympathetic ophthalmia.6–12 Duke- metically acceptable means of pain relief. When the
Elder13 reported that sympathetic ophthalmia had fundus cannot be visualized, preoperative ultrasound
occurred 50 years after an initial injury. and/or magnetic resonance scan should be per-
Surgeons are now aware of these concerns and formed to rule out any tumor if an evisceration is to
tend to meticulously remove as much of the clinically be performed. Otherwise, enucleation would be the
apparent uveal pigments in the eviscerated scleral procedure of choice.
shell, and therefore the incidence of sympathetic oph- In the patient who has had repeated ocular injury
thalmia following evisceration seems extremely rare, or surgeries, whose sclera may be either thickened or
further blurring the sympathetic ophthalmia issue shrunken, for example in a scleral buckling proce-
raised by proponents of enucleation.14, 15 dure, it is often difficult to perform an evisceration
CHEN23-327-346.I 3/22/01 2:33 PM Page 329
ENUCLEATION • 329
with removal of all uveal pigments, and to place a Preoperative Counseling

spherical implant. Enucleation may be preferred here. Perhaps one of the most important settings where the
In patients with buphthalmos, scleromalacia, or patient needs the physician’s reassurance, explana-
staphyloma, there may not be normal scleral tissue for tions, and psychological support is before an enucle-
closure following an evisceration and, again, enucleation. Patients need to be aware that the enucleation
ation may be preferred. involves complete removal of their diseased or
The main advantage of evisceration over enucle- deformed eye, that there will not be a globe inside the
ation in nonneoplastic ocular conditions is that the orbit after surgery, and that they will need to have an
procedure is simpler, with less orbital manipulation, ocular prosthesis fitted approximately 2 months fol-
hemorrhage, and associated trauma. It results in lowing the surgery (Figs. 23–3, 23–4, and 23–5). The
greater retention of the motility of the remaining scle- indication, whether it is pain, poor visual prognosis,
ral shell, which can be dynamically transmitted to the averting the risk of sympathetic ophthalmia, or
overlying ocular prosthesis. removing an intraocular tumor, needs to be clearly
Custer 16 presented his series of 58 enucleation explained. The patient and family must understand
patients and noted that prior trauma is the most com- the final, permanent nature of the enucleation proce-
mon cause of blind painful eyes. The ocular discom- dure and the permanent loss of that eye.
fort significantly interfered with the patient’s daily
life in 53% of the patients and caused disabling con-
tralateral photophobia in 17%; 93% of patients expe-
EARL ...
rienced complete resolution of preoperative pain
within 3 to 185 days (average, 22 days) after the
surgery. All cases of contralateral photophobia
P The orbital volume dis-
crepancy following removal of a globe
(average volume of 7 cc) as compared to the
resolved after enucleation. replacement with a 18- to 20-mm sphere (3.05
There will always be proponents for either enucle- versus 4.19 cc) plus an ocular prosthesis
ation or evisceration in nontumor cases. The pendu- (1.5–2.0 cc) should be explained to the patient.
lum seems to swing between the two procedures with
the progress of modern medical sciences, the use of
corticosteroids, the availability of different types of
Following enucleation, there usually will be a vol-
orbital implants, and the constant refinement in sur-
ume deficit or relative enophthalmos, although some
gical techniques.
ENUCLEATION
Materials and Techniques
There has been a tremendous expansion in the avail-
able materials and improved techniques for enucle-
ation over the last twenty years. These include the
introduction of porous implants (hydroxyapatite and
its synthetic variants from France and China), porous
polyethylene implant (Medpor, from Porex), Alu-
mina (aluminium oxide Al 2O 3 ), the availibility of
motility coupling peg systems and titanium pegs, the
use of various implant wrapping materials, includ-
ing autogenous and preserved human fascia lata, eye
bank sclera, preserved human and bovine peri-
cardium, Polyglactin 910 (Vicryl) mesh, polytetraflu-
orethylene PTFE (Gore-tex) mesh, and the use of
different-shaped implants including spherical, trun-
FIGURE 23–3 Prosthesis are made from taking an
cated, and conical. There is also variation in the depth
impression of the socket space using elastic impression
of insertion of the implant when implants are material (e.g., Lang’s LD-21 Alginoid powder). A cast is
wrapped versus unwrapped, and in evisceration then made of it and dental wax used to make a positive
where the implant may be placed either within the impression of the cast. The anterior chamber and iris may be
scleral cavity or behind in the retrobulbar space such added on later. A frontal cast is then made and together
that there are two layers of sclera folded in front of with the socket impression cast, the final prosthesis is man-
the implant. ufactured from methyl methacrylate.
CHEN23-327-346.I 3/22/01 2:33 PM Page 330
FIGURE 23–5 Patient wearing prosthetic eye in left side.
Surgical Anatomy
FIGURE 23–4 A finished custom prosthetic eye.
There has been continued evolution in our knowledge
of orbital anatomy. To perform optimal surgery, it is
patients’ facial contour, superior orbital rim, and important to remember the following anatomic points:
supratarsal sulcus tend to camouflage this discrepancy.
1. The medial rectus inserts 5.3 mm from the limbus.
The patient should be informed of the choices of enu-
The inferior rectus inserts 6.8 mm from the limbus.
cleation versus evisceration; the availability (depending
The lateral rectus inserts 6.9 mm from the limbus.
on geographic location and institution) of various
The superior rectus inserts 7.9 mm from the limbus.
synthetic orbital implants and hydroxyapatite and syn-
2. The average horizontal diameter of the cornea is
thetic porous implants; the advantages and disadvan-
11.75 mm.
tages of wrapping material, including autogenous
The average vertical diameter of the cornea is
tissue and preserved eye bank tissues, for example, fas-
10.6 mm.
cia lata bovine pericardium, synthetic wraps such as
3. The medial rectus insertion is separated from the
Vicryl (polyglactin) and Gore-tex (PTFE); and the risk
lateral rectus insertion by an arc distance of
of communicable diseases such as syphilis, hepatitis,
approximately 24 mm.
and human immunodeficiency virus (HIV). (The case
Similarly, the vertical recti muscles are 25 mm
report of a HIV-seronegative donor whose screened
apart.
bone, kidneys, and corneas infected seven patients with
4. The intraorbital segment of the optic nerve is
the HIV virus should be kept in mind.)
25 mm long.
5. The inferior oblique muscle inserts to a point of the
sclera overlying the macula, and is 8 mm inferior
PITFALL to the inferior border of the lateral rectus insertion
on the globe.
The recent discovery of prion disease is of 6. The inferior oblique and the inferior rectus are
concern if bovine sources are used, such as enclosed by fascial connective layers that are con-
tinuous with the inferior capsulopalpebral fascia
pericardium or bovine trabecular bone.
(CPF), and forms Lockwood’s ligament.
7. The capsulopalpebral fascia (rudimentary equivalent
to the levator aponeurosis and levator muscle) shares
The patient should be aware that motility coupling its origin with the inferior rectus via the inferior
is available to maximize the prosthesis motility fol- palpebral head, and splits into fascial insertions into
lowing a hydroxyapatite or synthetic porous implant. the apex of the inferior fornix, the lower margin of
It will require a second-stage procedure, that is, sec- the inferior tarsus, and subdermally over the lower
ondary drilling of a hole for placement of a titanium lid skin. Medially, the CPF connects with ligamen-
peg (using either the Bio-Eye hydroxyapatite system tous attachments of the medial canthal ligaments
with titanium motiity peg, or the MedPor Motility (anterior and posterior lacrimal crests), and laterally
Coupling Post, also made of titanium). the lateral canthal ligaments (lateral canthal tubercle).
CHEN23-327-346.I 3/22/01 2:33 PM Page 331
ENUCLEATION • 331
8. Traction on any of the extraocular muscles, levator following severe trauma, the correct eye is often exter-
muscle, or optic nerve can result in the oculocardiac nally deformed.
reflex, a sudden slowing of the heart rate. Clamping
of the optic nerve alone, without traction, has also
...
been reported to cause slowing of the pulse.17
Clinical Points
P EARL In cases where the exter-
nal appearance of both eyes is normal, the
surgeon must compulsively reexamine the fun-
The following physiologic and surgical principles are dus. Intraoperative, indirect ophthalmoscopy is
important for the orbital surgeon: advisable to confirm that the correct eye has
1. An excessive amount of orbital manipulation will been selected.
lead to swelling and disruption of the orbital fibro-
connective tissue septae.
The author stresses the finality of the enucleation
2. Meticulous control of hemorrhage will result in
procedure. No degree of thoroughness is excessive to
less deposition of blood and hemosiderin in the
prevent removal of the wrong eye.
orbit, and lessen the possibility for reactive fibro-
sis of the orbital tissue.
3. The volume of an average size globe is 7.0 mL. ENUCLEATION WITH
4. The volume of a 16-mm spherical implant is 2.15 mL. MYOCONJUNCTIVAL ATTACHMENTS
The volume of a 18-mm sphere is 3.05 mL.
The volume of a 20-mm sphere is 4.19 mL. Choice of Anesthesia
The volume of a 22-mm sphere is 5.58 mL. Although enucleation may be performed adequately
5. Extraocular muscles are viable in contractile func- with local and retrobulbar anesthesia, the author
tion and retain their length and width when they favors the use of general anesthesia as it lessens the
are placed in an optimal length, close to its physio- psychological and emotional impact of this procedure
logic length–tension relationship. on the patient.
6. Tenon’s layers in front of the implant should be In addition to general anesthesia, a retrobulbar
closed with nonabsorbable sutures or delayed injection of equal mixture of 2% Xylocaine with
absorbing sutures like 4-0 Vicryl (polyglactin), 1 : 100,000 epinephrine and 0.5% bupivacaine (Mar-
Dexon (polyglycolic acid), or PDS (polydiox- caine) plus hyaluronidase (Wydase) is given. The epi-
anone). The conjunctiva is usually closed with run- nephrine improves hemostasis, and the local anes-
ning 6-0 Vicryl. thetic blocks the oculocardiac effect from manipula-
tions of the extraocular muscles and optic nerve.
Presurgical Setup Bupivacaine provides pain relief for up to 24 hours.
Removal of the wrong eye is one of the greatest dis- For situations where regional anesthesia is pre-
asters that can occur to the ophthalmic surgeon and ferred instead of general anesthesia, for example, for a
patient. Every ophthalmologist and surgeon must be medically unstable patient, the surgeon may elect to
aware of this possibility, no matter how remote. apply a retrobulbar injection with 3 mL of local anes-
Preoperatively, the ophthalmic surgeon should thetic, supplemented by a frontal nerve block for the
mark the forehead or trim the lashes on the appropri- upper lid and a midinferior fornix block for the lower
ate side. These methods, however, are not fail-safe. In eyelid (branches of the infraorbital nerve).
the operating room, the surgeon must compulsively
review the chart, including the operative permit and Surgical Technique
examination notes. It is beneficial then that the sur- A self-retaining eyelid speculum is applied. The con-
geon prep and drape the patient. Traquair17 has sug- junctiva is dissected from the limbus in a 360-degree
gested the use of local anesthesia as a means of peritomy fashion using a pair of sharp Westcott scis-
preventing removal of the wrong eye since the patient sors. The underlying Tenon’s layer is undermined in
will likely be aware of any inadvertent error. It must all quadrants to the equator. Each of the four recti
never happen that a surgeon hurries into the operat- commencing with the medial rectus is hooked, iden-
ing room where the patient is already under general tified, secured on a double-armed 6-0 Dexon suture,
anesthesia and begins the operation without delay. and detached from the globe. During this maneuver,
Once a sterile operative field is set up, the surgeon care should be taken not to sever the intermuscular
must again verify that the correct eye is about to septum and the sheath along each rectus muscle, as
undergo enucleation. In situations of enucleation one normally would perform in strabismus repair. It
CHEN23-327-346.I 3/22/01 2:33 PM Page 332
Lateral rectus
muscle (severed)
FIGURE 23–6 Steps in enucleation

with myoconjunctival attachment. Each
of the four recti are isolated with 6-0 Medial rectus
Dexon sutures. The superior oblique muscle (severed)
tendon is transected. The inferior
oblique is sutured to the inferior border
of the lateral rectus; 4-0 silk traction
sutures are in place over the medial and
lateral rectus stump.
is, however, necessary to dissect in a plane between optic nerve is still encased with orbital tissue behind
the sclera and overlying orbital tissues in the oblique the posterior Tenon’s layer, the hemostat is ideally
quadrants between the four recti muscles to facilitate introduced closed and the tips used to strum the optic
the subsequent enucleation. The superior oblique ten- nerve. When the optic nerve is identified, the two
don is hooked and detached from the globe. It is ends of the clamp are opened and applied over the
allowed to retract, as the upper quadrant is not a fre- optic nerve. The posterior placement of the clamp will
quent site for postoperative implant migration. The influence the size of the opening in the posterior
inferior oblique muscle is hooked and isolated on a 6- Tenon’s layer following transection of the optic nerve.
0 Dexon suture, and saved for attachment to the infe- With the hemostat in place, a gently curved pair of
rior border of the lateral rectus near its insertional end slender Metzenbaum scissors is then used to transect
such that it may function as a hammock (Fig. 23–6). the optic nerve between the globe and the hemostat
The question of whether physical manipulations in again, approaching from a medial direction. Alter-
an enucleation actually accelerate the spreading of nately, one may elect to use a tonsil snare with an 18-
tumor cells in eyes containing malignant melanoma gauge wire loop, looping it around and behind the
has been raised.19, 20 A “no-touch” technique for enu- globe but in front of the clamp (Fig. 23–9). This may
cleation has been described.21 Conclusive evidence as be performed from any of the oblique quadrants,
to whether this really makes a difference is still although it is more practical from the lateral quadrant,
unavailable.
At this point, the four recti and the inferior oblique
muscles have been isolated with double-armed 6-0
Dexon, whereas the globe remains attached to the
orbital apex by the optic nerve. To facilitate access to
the optic nerve, 4-0 silk sutures are applied over the
muscle stumps of the medial and lateral recti for use
as traction sutures. With gentle traction on the two
sutures, the globe is pulled forward (Fig. 23–7), and
then the medial traction suture is pulled slightly more
to rotate the globe laterally. The optic nerve is made
more accessible from the medial quadrant; the
maneuver prolapses the globe in a forward position
and separates itself from the posterior half of the
extraocular muscle cone, thereby avoiding inadver-
tent transection of any of the five muscles that have FIGURE 23–7 The 4-0 silk sutures are applied over the
been tagged. From a medial direction, a gently curved muscle stumps of the medial and lateral recti for use as trac-
hemostat is used to clamp on the optic nerve, usually tion sutures. With gentle traction on the two sutures, the
3 to 5 mm behind the globe (Fig. 23–8). Because the globe is pulled forward.
CHEN23-327-346.I 3/22/01 2:33 PM Page 333
ENUCLEATION • 333
Enucleation
snare
Clamp
FIGURE 23–9 A tonsil snare with an 18-gauge wire is

looped around and behind the globe but in front of the
clamp, placing the loop of the snare around the optic nerve
medially.
FIGURE 23–8 The globe is rotated laterally while a

curved clamp is introduced from the medial direction. with an open gap in the posterior Tenon’s layer (Fig.
Either a curved scissors or an enucleation snare may be 23–11). The inferior oblique is attached to the inferior
used to transect the optic nerve. edge of the distal portion of the lateral rectus, putting
it close to its normal physiologic length, and allow-
placing the loop of the snare around the optic nerve ing it to help support the implant’s weight like a
medially. hammock.
The optic nerve with its posterior stump tissue is
severed and the globe removed. Before submission for
pathologic study, the surgeon should carefully exam-
EARL... Smit et al3 reported a rota-
ine the enucleated globe. Should there be any evidence
of extrascleral extension of tumor, or involvement of
the optic nerve with tumor, one should consider fur-
P tory displacement of the orbital contents
in enucleated orbit without implant placement.
ther excision of the adjacent orbital tissues or addi- They noted a superior to posterior rotation, and
tional optic nerve. The optic nerve segment that is still a posterior to inferior sagging of the orbital con-
in the clamp can be easily identified and further resec- tents when the globe is removed.
tion may be performed if indicated (Fig. 23–10).
Havre22 described the technique of obtaining a longer
section of the optic nerve with the enucleation speci- The superior muscle complex is retracted posteri-
men. Whether it is a snare or a scissor, it may be used orly; the orbital fat is distributed anteriorly and infe-
to walk along the optic nerve posteriorly to obtain up riorly. This tends to obliterate the inferior fornix and
to 10 mm of optic nerve. In patients with retinoblas- move the distal end of the inferior rectus upward.
toma, an intraoperative frozen section analysis of the When a spherical implant is placed, Smit et al3 noted
distal optic nerve can be used to verify clear margins restoration of a more normal orbital-extraocular-
of resection.23 fascial septal relationship.
For an average-sized adult orbit, the author favors
the use of a 18- or 20-mm spherical orbital implant,
EARL... The clamped optic nerve
P and its central retinal vessels are lightly
cauterized with a unipolar cautery, effectively
whether it is silicone rubber, acrylic, hollow sphere,
or porous implant. (Less often used implants, such as
the Universal-type implant, Allen implant, and Iowa
eliminating the major source of hemorrhage in implant, all require that the extraocular muscles be
enucleation. tied to the front surface or edge of the implant, effec-
tively pulling the implant back into a position where
the length–tension relationship of the extraocular
The clamp is removed. At this point the entire muscles is nonphysiologic.) With the spherical
socket may be examined and should appear clean, implant inserted (Fig. 23–12), the four recti muscles,
CHEN23-327-346.I 3/22/01 2:33 PM Page 334
Inferior
oblique rectus
FIGURE 23–10 The optic nerve seg-
muscle Optic nerved (severed)
ment that is still in the clamp can be eas- sutured to with central retinal
ily identified, and further resection may lateral rectus arteriole
be performed if indicated. The central muscle
retinal vessels are cauterized before the
clamp is released. The orbit is examined
for hemostasis.
with the inferior oblique attached to the lateral rectus,

EARL... The four recti are hooked
P
are gently pulled forward by the double-armed 6-0
Dexon sutures (Fig. 23–13). The Tenon’s layer and
to the subconjunctival plane of each fornix,
subjacent orbital tissues at the level of the anterior
one-third of the implant are closed from opposite approximating the normal physiologic position.
oblique quadrants (superotemporal to inferonasal,
superonasal to inferotemporal) using interrupted By now the conjunctiva should be free of wound
sutures of 4-0 Polydek (Fig. 23–14). As the tissues are tension and may be easily closed with a continuous
brought together, adjacent quadrants are similarly 6-0 Vicryl suture.
closed with interrupted sutures. Each of the four recti Coston24 was the first to describe suturing extra-
muscles’ suture is then passed through the overlying ocular muscle to the fornix. Chen and McCord25 out-
conjunctiva (Fig. 23–15). The superior and inferior lined the interrelationship of forniceal movement
recti are each attached to the fornix 10 to 12 mm from
the horizontal edges of the conjunctival wound, in
their respective fornix, keeping them 20 to 25 mm
across from each other. The medial and lateral recti
are attached myoconjunctivally to the medial and lat-
eral fornices about an inch (25 mm) apart.
Spherical
implant
FIGURE 23–11 The orbital space may be examined and FIGURE 23–12 A spherical implant is placed in the
should appear clean, with an open gap in the posterior orbit, without any attempt at closure of the posterior
Tenon’s layer. Tenon’s layers.
CHEN23-327-346.I 3/22/01 2:33 PM Page 335
ENUCLEATION • 335
Anterior
Tenon’s capsule
FIGURE 23–13 The four recti muscles, with the inferior

oblique attached to the lateral rectus, are gently pulled for-
ward by the double-armed 6-0 Dexon sutures.
and prosthetic motility, and described the technique

of enucleation with myoconjunctival attachment FIGURE 23–14 The Tenon’s layer and subjacent orbital
(Fig. 23–16). Nunery and Hetzler26 presented their tissues at the level of the anterior one-third of the implant
enucleation technique utilizing the foregoing princi- are closed from opposite oblique quadrants (superotempo-
ple, with the addition of an ear cartilage graft placed ral to inferonasal, superonasal to inferotemporal) using
anteriorly between the conjunctiva and the Tenon’s interrupted sutures of 4-0 Polydek.
layers.
Topical antibiotic ointment (bacitracin or bacitracin-
EARL... A soft silicone conformer
polymixin) is applied to the fornices.
P with holes is fashioned to the proper size
and placed to maintain the fornices. This is pre-
ferred over a rigid conformer to avoid adding
tension to the wound edge.
The lid margins should appose each other. A light

pressure bandage consisting of a piece of Telfa dress-
ing and two eye patches is applied. There is seldom
any need to apply a very heavy bandage as one sel-
dom gets orbital hemorrhage with this technique. A
tight bandage will only lead to pain, discomfort, and
Myoconjunctival patient complaints. A gram of cefalosporin antibiotic
attachment
suture is given intraoperatively for prophylaxis. The patient
is not routinely discharged on any oral antibiotic.
Postoperative Care
The patient is seen after 5 days and the dressing
removed. The lids should retain the conformer well.
FIGURE 23–15 Each of the four recti muscles’ suture is
The patient is gently introduced to the new appear-
then passed through. The superior and inferior recti are
ance of the socket, which has either a clear or white
each attached to the fornix 10 to 12 mm from the horizontal
edges of the conjunctival wound, in their respective fornix, silicone conformer in place, and is instructed on daily
keeping them 20 to 25 mm across from each other. The cleaning and the instillation of topical antibiotic oint-
medial and lateral recti are attached myoconjunctivally to ment to the socket mucosa by way of the holes on the
the medial and lateral fornices about 25 mm apart. The con- conformer. Patching is discouraged and patients are
junctiva is then closed horizontally with a 6-0 polyglactin encouraged to allow the wound to ventilate. They
(Vicryl) suture. may wear a shield for social occasions.
CHEN23-327-346.I 3/22/01 2:33 PM Page 336
Horizontal
orbital septa
Lateral
Vertical rectus
orbital septa
Medial
rectus
A
FIGURE 23–16 (A) A cross-sectional

view of the right orbit containing a
spherical implant, with myoconjuncti-
val attachment. (B) Forniceal movement
as a result of contractions of the medial B C
rectus and (C) lateral rectus are trans-
mitted to the prosthetic eye.
Although there is great variation in the time inter- significant improvement in vertical eye movements
vals before prosthetic fitting, it is generally necessary but did show improved motility of 14 to 20% in hori-
to wait at least 6 to 8 weeks for the wound to heal zontal movements.
before any fitting be attempted. Early photographs
taken by the author in 1980 show socket motility fol- VARIATIONS ON THE BASIC
lowing enucleation with myoconjunctival attachment
of the four recti (Fig. 23–17). Note the relatively good
ENUCLEATION TECHNIQUE
movement of the fornices in horizontal gazes, rela-
tively limited movement on upgaze, and fair move- Autogenous Dermis-Fat Graft
ment on downgaze. These findings compare This procedure has been used either as a suitable
favorably with recent infrared oculographic studies space-occupying implant following primary enucle-
of prosthetic motility by Kikkawa (to be published) ation, or as a secondary procedure to replace a
showing that in wrapped porous orbital implants that exposed or migrated implant.27–32
are unpegged (with motility coupling device), the
horizontal excursions are in the range of 64% of a nor- Autogenous Fascia Lata
mal eye, whereas the horizontal saccades and pursuit The overall incidence of spherical implant extrusion is
movements are in the 45% range. Pegging of currently less than 1%. Therefore, in most cases it is seldom nec-
available porous implants did not show statistically essary to wrap an implant.
CHEN23-327-346.I 3/22/01 2:33 PM Page 337
ENUCLEATION • 337
A B
C D
FIGURE 23–17 Photographs of socket motility follow-

ing enucleation with myoconjunctival attachment of the
four recti. (A) Straight-ahead view. (B, C) Note relatively
good movement of the fornices in horizontal gazes, (D) fair
movement on downgaze, and (E) relatively limited move-
E ment on upgaze.
Autogenous Ear Cartilage

PITFALL Nunery and Hetzler26 described a variation of the
myoconjunctival enucleation technique in which a
Implants may extrude if the wound closure piece of ear cartilage, with the recti attached to it, is
is not meticulous, or if the tissues are com- implanted between Tenon’s fascia and the conjunc-
tiva. The cartilage serves as a template for transmis-
promised from poor blood supply (for exam-
sion of extraocular motility and as a barrier against
ple, diabetes), wound infection, immunosup- extrusion.
pression, poor wound healing, alkali burn,
trauma, previous ocular surgeries, or past
exposure to radiation therapy. Synthetic Wraps
Synthetic wraps like polyglactin (Vicryl) and PTFE
(Gore-tex) are available for both primary enucleation
as well as for secondary placement of implant in
anophthalmic socket.
In these cases, for primary implant or secondary
implant placement following enucleation, the Eye-Bank Sclera
implant may be further secured by wrapping it in Eye-bank sclera has been used for wrapping sec-
autogenous fascia lata. Autogenous fascia lata has ondary alloplastic implants.33 There may be a sub-
the advantages of being easy to harvest, free of stantial cost involved. In Los Angeles, it costs up to
exogenous contamination, and resistant to shrinkage $1,000 per specimen. There is also increasing aware-
or rejection (unlike donor tissue). A sheet of fascia ness that the current screening for HIV is not fail-safe.
approximately 2 inches square is quite adequate to However, freeze-dried banked tissues (human dura
completely cover a 20-mm sphere. The fascia lata is or sclera) that have been hyperirradiated with gamma
sutured like a wrapper around the sphere, using a rays (available commercially from Germany) may
nonabsorbable suture. It is then placed such that have less risk than glycerin-preserved sclera.
uninterrupted fascia is facing forward. The four recti Prion’s disease is a group of infectious pathogens
are then sutured to the fascia lata over the anterior that cause fatal neurodegenerative disease in human
one-third of the spherical implant. and animals. These pathogens can induce spongiform
CHEN23-327-346.I 3/22/01 2:33 PM Page 338
encephalitis and Creutzfeldt-Jakob disease. Unlike since 1989. It is currently marketed under the name
usual contagion, this class of agents does not contain of Bio-eye and comes with the availability of a tita-
DNA or RNA. Prions are proteins that reside on neu- nium motility peg system (Fig. 23–18). The following
ronal surface and can undergo conformational modi- chemical formula illustrates the components in it its
fication. Infectious prions can cause adjacent healthy manufacturing:
cellular prions (alpha helix form) to change to an
“infectious” prion (beta helix form). It therefore can
10[Ca2CO3 ]+6(NH4 )2HPO4+2H2O
multiply without the use of DNA or RNA, as all other Coral
living agents require. The infection may spread by
sporadic mutation, host-to-host transmission (via ¡ Hydrothermal ¡ Ca10(PO4 )6(OH)2
graft material and eye-bank material), or through Reaction Hydroxyapatite
inheritance of genes. It can transfer across species
lines between human and bovine lifestocks through The porous coralline structure of hydroxyapatite
brain, muscle (meat), and milk. contains 500-m-diameter pores that are similar to the
haversian systems of human cancellous bone. It has
Tutoplast been used in oral surgery, orthopedic surgery, and
skull repair with good results. The placement of a
Tutoplast (human pericardium, sclera, and fascia lata)
wrapped, windowed hydroxyapatite implant instead
is available commercially. PeriGuard (bovine peri-
of an inert solid sphere allows fibrovascular ingrowth
cardium) is also available, although the issue of
into the implant. This buried, vascularized hydroxya-
prion’s disease is unsettling.
patite implant can then be secondarily drilled and fit-
ted with a peg. The drill hole becomes lined with host
fibrovascular tissue and the inserted peg can be
MODIFICATION IN ENUCLEATION FOR directly coupled to the ocular prosthesis.
CHILDREN WITH RETINOBLASTOMA A porous orbital implant offers the potential to
enhance prosthetic motility including the rapid dart-
Because the tumor may be present in the supra-
ing prosthetic movement (“conversational eye
choroidal space of the optic nerve head, the objective
movement”). (The comparative excursion studies of
is to perform the enucleation with minimal manipu-
Kikkawa et al are discussed below.)
lation and to obtain a long section of optic nerve. To
Hydroxyapatite implant has been used as
facilitate this, the surgery is performed under general
anesthesia. A lateral canthotomy may be performed 1. a primary implant after enucleation,
to facilitate the enucleation and placement of the 2. a delayed secondary implant following enucleation,
implant. Hemostat clamps or snares are avoided as 3. a secondary implant following extrusion,
they may cause compression artifacts on the optic 4. a replacement secondary implant, and
nerve specimen. After the globe is removed, the sec- 5. a primary implant following evisceration (see
tion of optic nerve is measured and then submitted Chapter 24).
separately. The distal cut edge of the optic nerve
should be examined with intraoperative frozen sec-
tions to determine if tumor is present and/or if fur-
ther surgical resection should be performed.23 Shields
and Shields34 advocate the use of an 8-mm trephine
to create a scleral window adjacent to the main lesion
on the enucleated specimen, and curette out fresh tis-
sues for DNA analysis in specialized laboratories
while the remainder of the globe is preserved in for-
malin for axial sectioning and permanent pathologic
examination. The majority of these pediatric patients
receive an 18-mm spherical implant.
PLACEMENT OF MOTILITY-ENHANCING
IMPLANT: HYDROXYAPATITE IMPLANT FIGURE 23–18 Bio-eye hydroxyapatite orbital implant
with titanium peg. (Courtesy of Integrated Orbital Implants,
The original coralline hydroxyapatite implant has 12526 High Bluff Drive, Suite 300, San Diego, California
been used as an implant material after enucleation 92130-2067.)
CHEN23-327-346.I 3/22/01 2:33 PM Page 339
ENUCLEATION • 339
Technique whereas the conjunctiva may be closed with 6-0 Vicryl

At the time of surgery, the enucleated socket is pre- in a continuous fashion.
sized with sterile trial spheres. A sterile 18- or 20-mm Ferrone and Dutton,35, 36 using technetium 99 bone
hydroxyapatite implant is presoaked in dilute gen- scans, have shown that vascularization can occur as
tamicin solution. Dutton (oral communication) early as 10 weeks. Shields et al37–39 reported magnetic
described using a large syringe with the plunger resonance imaging evidence of vascular ingrowth as
removed, and filling it with 20 mL of dilute gentam- early as 4 weeks. Currently, a minimal period of 6
icin solution. The implant is placed into the syringe months is recommended for complete fibrovascular
and the plunger reapplied. Air in the syringe is then ingrowth. During this period, a preliminary fitting of
forced out through the tip of the syringe. The tip is ocular prosthesis is performed.
then capped with the fingertip and the plunger then
pulled back so that residual air in the porous implant
is drawn out by the vacumn. The implant is now per- COUPLING TO IMPLANT BY PLACEMENT
meated with liquid, which seemed to help promote
OF TITANIUM MOTILITY PEG
vascular ingrowth. It is wrapped with a donor eye-
bank sclera or other synthetic wrap. It is oriented with After an adequate time period, a second-stage proce-
the hexagonal rosettes of the coralline exoskeleton dure can be performed. For the Bio-eye (natural
aligned axially to the anteroposterior direction of the hydroxyapatite) system, a drill hole 9 mm deep by
orbit. 3 mm in diameter is made through the conjunctiva
and the scleral shell, and into the anterior portion of
the vascularized hydroxyapatite implant. A flat head
...
P EARL If donor sclera is used, the peg is inserted. Further time elapse is allowed, usu-
ally 4 to 6 weeks for the conjunctival tissues to epithe-
area of the optic nerve of the banked
lialize and line the trough of this 3-mm-diameter pit.
sclera should be placed anteriorly in the orbit. When this is complete, a plastic peg with a round
The wrap effectively adds 1 to 1.5 mm to the hemispheric head is then placed in the hole in place of
overall diameter of the implant. the flat head peg or sleeve. A final prosthesis is made
with a posterior concavity in its center to fit over the
round head peg sitting over the implant. The maker of
Four rectangular windows are made through the Bio-eye, Integrated Orbital Implants of San Diego,
sclera, measuring 2*6 mm each, preferably 6 to California, has recently made available a titanium
7 mm from the center of the anteriorly oriented optic motility peg system. (If an hydroxyapatite implant is
nerve ending. used for evisceration and subsequently the patient is
satisfied with the prosthetic motility, drilling may not
be necessary.)
The porous polyethylene implant (MEDPOR
EARL ... The implanted sphere is
P placed further posterior in the orbit and
therefore the four recti need to be attached
orbital implant, from Porex Surgical of College Park,
Georgia)40, 41 may be inserted without a wrap, and a
titanium motility coupling post (MCP) is available
more anteriorly to be effective. The posteriorly that does not require as deep drilling through the
oriented corneal window serves as the fifth and implant (Fig. 23–19). It has a 5-mm screw length. It is
about two-thirds the cost of hydroxyapatite, lighter,
largest window for vascular ingrowth from the
stronger, and environmentally friendly. However,
back of the orbit. wrapping of this implant is still recommended if recti
muscles are to be attached to the implant.
When hydroxyapatite implant is planned as a sec-
At each of the five windows, a 1-mm vascular ondary implant, the socket should exhibit at least 4 to
access hole is drilled to the core center to further pro- 5 mm of lateral movement, although sometimes one is
mote early fibrovascular ingrowth from the anterior able to locate the extraocular muscles even in a non-
ciliary artery of each of the recti. These drill holes can moving socket. In secondary implantation, the hydroxy-
be made with a hand-held 20-gauge needle. The apatite implant should be wrapped. If suitable
sclera-wrapped implant is inserted into the orbit. Each wrapping material is not available, the anterior part of
of the four recti is sutured to the anterior scleral lip of the hydroxyapatite is flattened and the conformer
the corresponding rectangular window. The anterior should be vaulted on its back surface to reduce the pos-
Tenon’s layer is closed with interrupted 5-0 Vicryl, sibility of conjunctival irritation, thinning, and erosion.
CHEN23-327-346.I 3/22/01 2:33 PM Page 340
yapatite Implant, Perry 44 presented the following

complications:
1. First stage (from surgery to hole-drilling):
Abnormal postoperative pain (especially after
evisceration)
Conjunctival prolapse from inflammation
Infection
Early exposure (for repair of erosion defects
greater than 3 mm, Perry advocates the use of
dermis graft; donor scleral patch grafting and
small hard palate graft have also been used to
repair these defects)
Poor socket movement, especially if unwrapped
Too large implant size.
2. Postdrilling stage:
Late exposure
Drilling too early before vascularization
Infection
Excessive movement, “gapping”
Insufficient movement
Extrusion of peg
Clicking sounds from peg and conformer
FIGURE 23–19 MEDPOR MCP system with titanium Pyogenic granuloma around peg.
motility coupling post. (Reproduced with permission from
Porex Surgical, 4715 Roosevelt Highway, College Park, There have been more recent reports of significant
Georgia 30349-2417.) complication rates associated with drilling of hydrox-
yapatite implants.45, 46
At present, a hydroxyapatite implant has the fol-
Contraindications lowing disadvantages:
Contrindications to the use of hydroxyapatite 1. Increased pain during the postoperative period
implants include scarred muscles that are difficult to 2. Increased incidence of erosion of overlying Tenon’s
locate, orbital malignancy with potential for recur- layers and conjunctiva compared to an inert spher-
rence that may be masked by the radiologic images of ical implant
the hydroxyapatite implant, and orbital infection. 3. Costs—of hydroxyapatite, $650 to $850 each, as
well as wrap for the implant; the costs of motility
coupling, if chosen, include surgeon, operating
EARL... In general, sockets with a
P compromised vascular supply or known
impaired healing should not have hydroxy-
room, and anesthesia
4. A variable waiting period for vascular ingrowth,
up to 6 to 12 months
5. Need for preliminary fitting of ocular shell before
apatite implants. final prosthetic fitting.
Prevention and Management of Implant Exposure

These implants may also fail to vascularize well in
very elderly patients. The more commonly mentioned complications47 of
hydroxyapatite implant include the following:
Complications
1. Implant migration
Overall, the advantage of a hydroxyapatite implant is 2. Infection48
that it closely approximates a physiologic “inte- 3. Exposure
grated” implant if the healing is uneventful. Pros- 4. Socket contraction.
thetic motility is improved.
Buettner and Bartley42 reported on eight cases of To help prevent these complications, Dutton has
hydroxyapatite implant erosion. Goldberg et al 43 advocated flattening or truncating the anterior face of
reported on six cases of similar problems. At the the spherical implant to improve prosthetic motility
1993 First International Symposium on Hydrox- as well as reduce pressure and friction across the
CHEN23-327-346.I 3/22/01 2:33 PM Page 341
ENUCLEATION • 341
conjunctival wound and the front of the implant. may be placed either within the scleral cavity or
Using a 20- to 22-mm sphere, the front surface is flat- behind in the retrobulbar space such that there are
tened to about 14 mm with a scalpel or a burr. A wrap two layers of sclera folded in front of the implant.
is used. The prosthesis must be vaulted on its poste- In addition, there are technique variations in the
rior side to prevent direct central pressure on the attachment of the four recti muscles:
hydroxy-apatite implant.
1. Myoconjunctival attachment where the recti are
attached to the fornices (Chen and McCord)
2. Attachment to the porous implant directly with no
EARL ...
P In most cases, the flat-
tened hydroxyapatite surface gives ade-
quate prosthetic motility as it improves it to a
wrapping material
3. Attachment to the wrapped implant over the four
quadrants of the recti muscles
degree halfway between the pegged and the 4. Attachment to the wrapped implant as well as to
the respective fornices (Shore).
round, unpegged implants.
The current availability of different implant wraps
may be bewildering, but some studies, such as that of
Using truncation and preinfiltration of the implant Jordan et al,52, 53 help clarify the differences between
with saline, Ferrone and Dutton36 observed complete wraps. Jordan et al reported comparitive vasculariza-
vascularization in as little as 3 months. tion results on seven types of wraps, including
banked sclera, polyglactin 910 (Vicryl), PTFE (Gore-
tex), bovine pericardium (Periguard), processed
human pericardium (Tutoplast), processed human
PITFALL
fascia lata (Tutoplast), and processed human sclera
(Tutoplast). Vicryl mesh,52, 53 Gore-tex mesh, and
Custer49 has reported postoperative rotation of
processed human sclera vascularized within 4 weeks,
flattened hydroxyapatite enucleation implant whereas the rest required more than 8 to 12 weeks.
in 5 out of 16 patients. Three were clinically All of the wraps studied except Vicryl mesh required
significant, and two of them had strabismus the cutting of windows for vascular ingrowth. They
preoperatively (one esotropia, one exotropia). are also more difficult to wrap around the implant as
compared to Vicryl mesh. The Vicryl mesh-wrapped
implant appeared to vascularize sooner than the
tissue-wrapped implants. It eliminates the need for
Hornblass et al50 and Shields and Shields51 have
donor tissue or a second incision.
reported a low rate of complications using hydroxy-
apatite when meticulous preparation and techniques
are utilized.
...
FURTHER TECHNIQUE VARIATIONS
P EARL The polyglactin mesh
allows 360-degree entry of fibrovascular
tissue as opposed to entry through scleral win-
As already discussed, there are variations in materi- dows, and it is absorbable.
als and techniques in enucleation. There are several
other porous implants available, such as synthetic
variants from France (FCI France), China, and Brazil; The polyglactin mesh is readily available, easy to use,
bovine trabecular bone; a porous polyethylene and very inexpensive (Fig. 23–20). To achieve a high
implant (MEDPOR, from Porex); and Alumina (alu- success rate, Jordan et al recommend that the
minium oxide Al2O3 ). There are also variations in the polyglactin mesh- wrapped hydroxyapatite implant
availability of motility coupling peg systems and tita- must be moistened and seated properly in the orbital
nium pegs, in the use of various implant wrapping space to avoid exposure, which is inherently possible
materials, including autogenous and preserved in all types of porous orbital implant. Jordan et al also
human fascia lata, eye-bank sclera, preserved human reported on a synthetic hydroxyapatite implant (FCI
and bovine pericardium, polyglactin 910 (Vicryl) France)54, 55 and will be reporting the results on the
mesh, PTFE (Gore-tex) mesh, and in the use of differ- Chinese implant56 as well as two new forms of hydrox-
ent-shaped implants, including spherical, truncated, yapatite—the M-sphere and the Brazilian implant.
and conical. Other variations are in the depth of inser- Another useful report is that of Dresner,57 who
tion of the implant when implants are wrapped versus reported on 13 cases of exposed polyethylene
unwrapped, and in evisceration where the implant implants, with 12 of the exposure cases identified
CHEN23-327-346.I 3/22/01 2:33 PM Page 342
TABLE 23–1 EXCURSION, SMOOTH

PURSUIT, AND SACCADES
Pegged Unpegged p
implant implant value
Horizontal
excursion 84.4% 63.9% .024
Horizontal smooth
pursuit 57.9% 43.8% .033
Horizontal
saccades 63.8% 46.8% .007
Vertical excursions, No statistical differences
pursuits, and
saccades
FIGURE 23–20 Vicryl (Ethicon polyglactin 910) knitted

mesh wrapped around a hydroxyapatite implant. The pre-
and smooth pursuit and saccades in the horizontal as
cut sheet of mesh measures 2.5*3 inches. First, wrap the well as vertical planes. Percent motility was deter-
mesh around the implant and tie with 4-0 polyglactin mined by taking the ratio of the movement of the arti-
suture. Trim off excess mesh. Drill holes may be applied ficial prosthetic eye (whether pegged or unpegged) to
using a 20-guage needle, and then the wrapped implant the movement of the natural eye of the same
may be inserted into the anophthalmic orbit. The extraocu- patient.The results are summarized in Table 23–1.
lar muscles can the be attached to the Vicryl-mesh-wrapped Nine of the ten patients reported subjectively that the
hydroxyapatite implant. Next, close the Tenon’s layers and implant motility improved after pegging. This study
conjunctiva in separate layers. (Courtesy of David R. Jordan by Kikkawa et al will be very helpful for physicians
MD, Ottawa, Canada). involved in counseling patients on whether to
undergo the pegging procedure.
early on, within 6 weeks from surgery. One patient
developed exposure after placement of a motility peg.
Dresner used autogenous thin dermis fat graft or auto-
EARL... One can conclude that peg-
genous temporalis fascia graft for repair in all cases,
and concluded that overall exposure of porous poly-
ethylene implant is uncommon.
P ging does improve prosthetic motility by
10 to 20% of the horizontal eye movements.
Custer et al58 reported on the comparative motil- Smooth pursuit in the horizontal plane
ity of hydroxyapatite versus alloplastic enucleation improved the least (14%). There is no improve-
implants. In their studies, all implants were wrap- ment at all in the vertical fields.
ped with donor eye-bank sclera, and the six extraoc-
ular muscles were attached to the scleral-wrapped
implant. However, some studies have shown that fewer
than 10 to 25% of patients undergo the secondary pro-
cedure of pegging, implying that at least some of this
EARL... Custer et al’s findings sug-
P gest that there is no motility benefit of
nonpegged hydroxyapatite over spherical allo-
group are quite satisfied without pegging.
EARL... Despite commercial mar-

plastic implants.
P keting efforts, patients should be informed
that even with perfect pegging and coupling of
Kikkawa et al, 59 at the 1999 ASOPRS meeting,
the prosthesis and a lack of complications, the
reported their results of prosthetic motility compar-
ing pegged to unpegged porous orbital implant in 10 perfectly coupled implant gives only 58 to 84% of
patients—six patients had hydroxyapatite implants, the natural human eye’s movement, not 100%
and four had porous polyethylene implant (Medpor). as some patients may expect.
Infrared oculography was used to track excursions,
CHEN23-327-346.I 3/22/01 2:33 PM Page 343
ENUCLEATION • 343
Globe with disease or

trauma requiring removal
Finding of
intraocular tumor, shrunken sclera No tumor
buphthalmos, scleromalacia
Enucleation Evisceration
(Higher theoretical probability

for sympathetic ophthalmia)
Advantage: simpler, less traumatic,
better motility
With traditional † spherical implant $* Porous polyethylene (Medpor) $$ Hydroxyapatite implant:
†
myoconjunctival attachment implant (— wrap): Nonpegged (requires wrap) $$$
†
†
Nonpegged Pegged, plastic or titanium peg Nonpegged vs spherical implants:
no difference in motility,
Pegged, titanium peg achieved 44–64% horizontal
Wrap: Autogenous fascia lata, (motility coupling post) movement of normal eye59
$ Polyglactin (Vicryl) mesh,
Pegged: achieved 58–84% horizontal
$ P.T.F.E. (Gore-Tex) mesh,
movement of normal eye59
$$$$ Eye bank sclera,
(Human Tutoplast, No statistical difference in
Bovine Periguard) vertical excursions, pursuits+saccades,
between pegged+nonpegged implant.59
* $ symbols represent the relative values
of implants, where $$$ is most expensive.
FIGURE 23–21 Clinical pathway for enucleation.
CONCLUSION remains a very viable and practical one-step option,

as it provides a degree of motility that is close to that
Enucleation with placement of a traditional orbital
of an unpegged porous implant, at a much lower cost
implant coupled with myoconjunctival attachment, 24
and lower rate of surgical complications (Fig. 23–21).
as well as evisceration plus implant without pegging,
REFERENCES
1. Jordan DR, Anderson RL, Nerad JA, Allen L: A pre- 8. Green WR, Maumenee AE, Sanders TE, Smith ME:
liminary report on the universal implant. Arch Ophthal- Sympathetic uvietis following evisceration. Trans Am
mol 1987;105:1726–1731. Ophthalmol Otolaryngol 1972;76:625–644.
2. Koornneef L: Orbital septa: anatomy and function. 9. Croxatto JO, Galentine P, Cupples HP, et al: Sympa-
Ophthalmology 1979;86:876–880. thetic ophthalmia after pars plana vitrectomy-lensec-
3. Smit TJ, Koornneef L, Zonneveld FW, Groet E, Otto AJ: tomy for endogenous bacterial endophthalmitis. Am J
Primary and secondary implants in the anophthalmic Ophthalmol 1984;91:342–346.
orbit. Ophthalmology 1991;98(1):106–110. 10. Green WR, Maumenee AE, Saunders TE, Smith ME:
4. Afran SI, Budenz DL, Albert DM: Does enucleation in Sympathetic uvietis following evisceration. Trans Am
the presence of endophthalmitis increase the risk of Acad Ophthalmol Otolaryngol 1972;76:194–197.
postoperative meningitis? Ophthalmology 1987;94(3): 11. Stafford WR. Sympathetic ophthalmia: report of a case
235–237. occurring ten and one-half days after injury. Arch Oph-
5. Walter WL: Update on enucleation and evisceration. thalmol 1965;74:521–524.
Ophthalmic Plast Reconstr Surg 1985;1:243–252. 12. Liddy L, Stuart J. Sympathetic ophthalmia in Canada.
6. Marak GE: Recent advances in sympathetic oph- Can J Ophthalmol 1972;7:157–159.
thalmia. Surv Ophthalmol 1979;24:141–146. 13. Duke-Elder S: System of Ophthalmology, vol 9, Diseases of
7. Rubin JR, Albert DM, Weinstein M: Sixty five years of the Uveal Tract. St. Louis: CV Mosby, 1966:558–593.
sympathetic ophthalmia. A clinicopathologic review of 14. Rao NA, Robin J, Hartmann D, et al: The role of the
105 cases (1913–1978). Ophthalmology 1980;87:109–121. penetrating wound in the development of sympathetic
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ophthalmia: experimental observations. Arch Ophthal- following dermis-fat grafting for anophthalmic socket
mol 1983;101:102–104. reconstruction. Ophthalmology 1985,92:1342.
15. Levine MR, Pou CR, Lash RH: Evisceration: Is sympa- 33. Frueh BR, Felker GV: Baseball implant: a method of
thetic ophthalmia a concern in the new millennium? secondary insertion of an intraocular implant. Arch
Ophthalmic Plast Reconstr Surg 1999;15(1):4–8. Ophthalmol 1976;94:429–430.
16. Custer PL: Enucleation of blind painful eyes. Paper 34. Shields JA, Shields CL: Intraocular Tumors. A Text and
presented at: 30th Annual Scientific Symposium of Atlas. Philadelphia: WB Saunders, 1992.
the American Society of Ophthalmic, Plastic, and 35. Ferrone PJ, Dutton JJ: Rate of vascularization of
Reconstructive Surgery (ASOPRS); October 23, 1999; coralline hydroxyapatite ocular implants. Ophthalmol-
Orlando, FL. ogy 1992;99(3):376–379.
17. Munden PM, Carter KD, Nerad JA: The Oculocardiac 36. Dutton JJ: Coralline hydroxyapatite as an ocular
reflex during enucleation. Am J Ophthalmol 1991;111(3): implant. Ophthalmology 1991;98(3):370–377.
378–379. 37. De Potter P, Shields CL, Shields JA, Flanders AE, Rao
18. Traquair HM: Local anesthesia in enucleation of the VJ: Role of magnetic resonance imaging in the evalua-
eyeball. Ophthalmic Rev 1916;35:75–89. tion of the hydroxyapatite orbital implant. Ophthalmol-
19. Zimmerman LD, McClean IW, Foster WD: Does enu- ogy 1992;99(5):824–830.
cleation of the eye containing a malignant melanoma 38. Shields CL, Shields JA, Eagle RC, De Potter P:
prevent or accelerate the dissemination of tumor cells? Histopathologic evidence of fibrovascular ingrowth
Br J Ophthalmol 1978;62:420–425. four weeks after placement of the hydroxyapatite
20. Zimmerman LD, McClean IW: An evaluation of enu- orbital implant. Am J Ophthalmol 1991;111:363–366.
cleation in the management of uveal melanoma. Am J 39. Shields CL, Shields JA, De Potter P: Hydroxyapatite
Ophthalmol 1979;87:741. orbital implant after enucleation. Arch Ophthalmol
21. Fraunfelder FT, Boozman FW, Wilson RS, Thomas AH: 1992;110:333–338.
No-touch technique for intraocular malignant 40. Karesh JW, Dresner SC: High density porous polyeth-
melanoma. Arch Ophthalmol 1977;95:1616–1620. ylene (Medpor) as a successful anophthalmic socket
22. Havre DC: Obtaining long sections of optic nerve at implant. Ophthalmology 1994;101:1688–1696.
enucleation. A new surgical technique based on the 41. Remulla HD, Rubin PAD, Shore JW, et al: Complica-
anatomy of the posterior fascia bulbi. Am J Ophthalmol tions of Porous Spherical Orbital Implants. Ophthalmol-
1965;60:272–277. ogy 1995;102:586–593.
23. Karcioglu ZA, Halk BG, Gordon RA: Frozen section of 42. Buettner H, Bartley GB: Tissue breakdown and expo-
the optic nerve in retinoblastoma surgery. Ophthalmol- sure associated with orbital hydroxyapatite implants.
ogy 1988;95:674–676. Am J Ophthalmol 1992;113:669–673.
24. Coston TO: The spherical implant. Trans Am Acad Oph- 43. Goldberg RA, Holds BH, Ebrahimpour J: Exposed
thalmol Otolaryngol 1970;74:1284–1286. hydroxyapatite orbital implants, reports of six cases.
25. Chen WP: Thesis for Fellowship Candidacy to the Ophthalmology 1992;99(5):831–836.
American Society of Ophthalmic Plastic and Recon- 44. Perry A: Used of hydroxy apatite implant after enucle-
strustive Surgery, 1981. ation. Presented at the First International Symposium
26. Nunery WR, Hetzler KJ: Improved prosthetic motility on Hydroxyapatite Implant, La Jolla, CA, January 1993.
following enucleation. Ophthalmology 1983;90(9): 45. Jordan DR, Chan S, Mawn L, et al: Complications asso-
1110–1115. ciated with pegging hydroxyapatite implants. Ophthal-
27. Smith B, Petrelli R: Dermis-fat graft as a movable mology 1999;106:505–512.
implant within the muscle cone. Am J Ophthalmol 1978; 46. Edelstein C, Shields CL, DePotter P, et al: Complica-
85:62–66. tions of motility peg placement for the hydroxyap-
28. Smith B, Bosniak SL, Lisman RD: An autogenous atite orbital implant. Ophthalmology 1997;104(10):
kinetic dermis-fat orbital implant. Ophthalmology 1982; 1616–1621.
89(9):1067–1071. 47. Christmas NJ, Gordon CD, Murray TG, Tse D, et al:
29. Smith B, Bosniak S, Nesi F, Lisman R: Dermis-fat orbital Intraorbital implants after enucleation and their com-
implantation: 118 cases. Ophthalmic Surg 1983;14(11): plications: a 10-year review. Arch Ophthalmol 1998;
941–943. 116: 1199.
30. Migliori ME, Putterman AM: The doomed dermis-fat 48. Jordan DR, Brownstein S, Jolly SS: Abscessed hydroxy-
graft orbital implant. Ophthalmic Plast Reconstr Surg apatite orbital implants. Ophthalmology 1996;103:1784.
1991;7(1):23–30. 49. Custer PL: Postoperative rotation of hydroxyapatite
31. Nunery WR, Hetzler JT: Dermal-fat graft as a primary enucleation implants. Arch Ophthalmol 1999;117:
enucleation technique. Ophthalmology 1985;92:1256. 1521–1523.
32. Shore JW, McCord CD Jr, Bergin DJ, Dittmer SJ, 50. Hornblass A, Biesman BS, Eviatar JA: Current tech-
Maiorca JP, Burks WR: Management of complications niques of enucleation: a survey of 5,439 intraorbital
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ENUCLEATION • 345
implants and a review of the literature. Ophthalmic Plast so-called counterfeit implant. Ophthalmic Plast Reconstr
Reconstr Surg 1995;11:77–86. Surg 1998;14(4):244–249.
51. Shields CL, Shields JA: Hydroxyapatite orbital implant 56. Jordan DR, Pelletier C, Gilberg S, Brownstein S,
after enucleation. Experience with initial 100 cases. Arch Grahovac S: The Chinese implant. In press.
Ophthalmol 1992;110:333–338. 57. Dresner SC: Management of exposed porous polyeth-
52. Jordan DR, Allen L, Ells A, et al: The use of Vicryl mesh ylene implants. Paper presented at 30th Annual Scien-
to implant hydroxyapatite orbital implants. Ophthalmic tific Symposium of the ASOPRS; October 23, 1999;
Plast Reconstr Surg 1995;11(2):95–99. Orlando, FL.
53. Jordan DR, Ells A, Brownstein S, et al: The use of Vicryl 58. Custer PL, Trinkaus KM, Fornoff J: Comparative motil-
mesh to implant hydroxyapatite orbital implants—an ity of hydroxyapatite and alloplastic enucleation
animal model. Can J Ophthalmol 1995;30(5):241–246. implants. Ophthalmology 1999;106:513–516.
54. Jordan DR, Gilberg S, Mawn L, Brownstein S: The syn- 59. Kikkawa DO, Vasani SN, Guillinta P, Mannor GE,
thetic hydroxyapatite implant: a report on 65 patients. Heinz GW: Prosthetic motility in pegged versus
Ophthalmic Plast Reconstr Surg 1998; 14(4):250–255. unpegged integrated porous orbital implants. Paper
55. Jordan DR, Munro S, Brownstein S, Gilberg S, presented at: 30th Annual Scientific Symposium of the
Grahovac S: A synthetic hydroxyapatite implant: the ASOPRS; October 23, 1999; Orlando, FL.
CHEN23-327-346.I 3/22/01 2:33 PM Page 346
CHEN24-347-354.I 3/26/01 8:53 AM Page 347
Chapter 24
EVISCERATION
William P. Chen
Evisceration is the surgical procedure by which the and Levine and Lash2 describe the relationship
intraocular contents of an eye is removed through a between sympathetic ophthalmia and evisceration,
paralimbal incision. The removed contents include all and other authors point out the rarity of sympathetic
accessible uveal tissues (iris, ciliary processes and cil- ophthalmia following evisceration.3–5
iary bodies, choroid), retina, vitreous, and lens. The There are numerous factors that affect the choice
scleral shell is left attached to the extraocular muscles, between enucleation and evisceration. For a more
the optic nerve, and the anterior and posterior ciliary thorough discussion of the decision-making process,
arteries. The cornea may or may not be removed. The see Chapter 23.
scleral shell is usually filled with a spherical implant
and closed. It may also be left empty and will heal by
secondary intention. EVISCERATION
Preoperative Counseling
INDICATIONS FOR SURGERY
Patients are informed of the possibility, albeit extre-
The main advantage of evisceration over enucleation mely small, of sympathetic ophthalmia. They are told
in nonneoplastic ocular conditions is that the proce- that the external coat of their eye, the sclera and optic
dure is simpler, with less orbital manipulation, hem- nerve, are not removed. They can expect a relatively
orrhage, and reduced postoperative swelling, pain, quick recovery and little postoperative pain, and can
and associated trauma. It results in greater retention look forward to the fitting of an ocular prosthesis in 6
of the motility of the remaining scleral shell, which to 8 weeks. They can expect relatively good move-
can be transmitted to movement of the overlying ocu- ment of the prosthesis, although never as good as the
lar prosthesis. Evisceration is especially useful in sit- normal remaining eye.
uations where there is a shortage of conjunctiva
because enucleation does cause further shortening of Presurgical Setup
the fornix.
The same degree of diligence, as described in Chapter
Relative contraindications to evisceration are
23, must be exercised by the surgeon to make sure
panophthalmitis or infectious scleritis, such as
that the correct diseased eye is being operated on.
Pseudomonas, and severe orbital infection with
involvement of the sclera (for example, some cases of
orbital mucormycosis may need exenteration). Choice of Anesthesia
Patients with past history of corneal scleral disruption Evisceration involves less manipulation than enucle-
and uveal prolapse (as in ruptured globe, or retinal ation and can be performed under regional anesthe-
detachment surgery with drainage of subretinal fluid) sia; 3 mL of 2% Xylocaine with 1 : 100,000 dilution
also pose contraindications to evisceration. Rao et al1 epinephrine and Wydase (mixed 10 mL of Xylocaine
347
CHEN24-347-354.I 3/22/01 2:34 PM Page 348
A B
FIGURE 24–1 (A) Frontal view of right eye. Following a 360-degree conjunctival peritomy, a limbal incision is
carried out and extended over 300 degrees or more. The corneal button may be used as a handle and then stitched back
in place after evisceration and implant placement, or excised in total. Dotted bars denote the axis of relaxing scleral cuts
superotemporally and inferonasally. (B) Frontal view. Left eye has been eviscerated and corneal pedicle is hinged
over inferior sector of limbus.
with 150 units of hyaluronidase) is given in a retro- 24–2). Besides the spoon, the sharp edge of a Freer
bulbar injection into the muscle cone. The upper and elevator with a suction instrument can be used to
lower lids are anesthetized with a frontal nerve block remove all uveal tissues.
as well as infiltration over the infraorbital nerve below
the inferior orbital rim.
Surgical Technique: Steps in Evisceration

The cornea may be left in place or excised.
Sparing the Cornea: Limbal Incision, with

Relaxing Scleral Cuts
For a well-vascularized cornea, a 360-degree con-
junctival peritomy is initiated, and undermining is
carried out in the sub-Tenon’s fascia plane to the
equator. An incision through the limbus is started
using a sharp blade followed by extension to each
side with corneoscleral scissors (Fig. 24–1). The
wound is extended to over 300 degrees leaving the
cornea attached at the inferior sector, and the corneal
pedicle can be grasped to facilitate handling during
evisceration. With one forceps grasping the cornea, a
cyclodialysis spatula is introduced to completely sep-
arate the iris root and ciliary body from the sclera. A FIGURE 24–2 An evisceration spatula is used to remove
small or medium-size evisceration spoon can be used intraocular content. The sharp edge of the instrument or a
to scoop the intraocular contents from the sclera (Fig. no. 15 blade may be used to scrape off all uveal tissues.
CHEN24-347-354.I 3/22/01 2:34 PM Page 349
EVISCERATION • 349
24–4). The scleral shell is then rinsed thoroughly with

EARL ...
P Frequently in a severely saline solution. A frequent source of vascular bleeding
is the four exit sites of emissary veins and the optic
shrunken and phthisical globe, it is possi-
nerve head. They should be very gently cauterized to
ble to lyse and excise the fibrous bands and control the oozing of blood.
membranes that are holding the collapsed inte- An 18- to 20-mm sphere can then be placed in the
rior scleral surfaces together, and the intraocular scleral shell (Fig. 24–5). The limbal corneal wound is
space can then be reexpanded to an adequate closed using interrupted transparent 6-0 nylon
volume for implant insertion (Fig. 24–3). sutures. The corneal epithelium is meticulously
scraped off. The anterior Tenon’s layer is then pulled
over the cornea and closed using 5-0 polyglactin
Cotton-tip applicators moistened with absolute (Vicryl) sutures in an interrupted fashion, followed by
alcohol (100% ethanol) may be used to denature any conjunctival closure with a running 6-0 polyglactin. A
residue of uveal pigment. conformer and light bandage are applied.
Sparing the Cornea: Paralimbal Incision, with

EARL... It is often difficult to place
P a sphere of greater than 18 mm unless
expansion sclerotomies are performed in a
Relaxing Scleral Cuts
In situations in which the cornea is opacified or vas-
cularized, an inferior paralimbal conjunctival incision
radial fashion through the internal surface of the is made, and the conjunctiva and Tenon’s fascia are
scleral shell.6 undermined. The paralimbal scleral incision is made
about 4 to 5 mm posterior to the limbus in a curved
fashion, covering 180 degrees. The pars plana region
The scleral incision can be performed using a nee- is entered and evisceration performed as described in
dle-tipped cautery on cutting mode, making one to the previous paragraph. A relaxing scleral cut may be
two slits per each of the four scleral quadrants (Fig. made in the midsection of this paralimbal incision.
Again, in a severely shrunken and phthisical globe, it
is possible to lyse and excise the fibrous bands and
membranes that are holding the collapsed interior
scleral surfaces together, and the intraocular space is
then reexpanded to an adequate volume for implant
insertion. Usually an 18-mm sphere is inserted. The
paralimbal posterior scleral incision is closed with
interrupted 6-0 nylon sutures. The Tenon’s layer is
closed using interrupted 5-0 Vicryl sutures. The con-
junctiva is closed with running 6-0 Vicryl. The im-
plant may be visible through the opacified or
vascularized cornea. A conformer and light bandage
is applied. The paralimbal incision technique seems
to result in fewer problems with wound dehiscence,
compared to evisceration techniques with incisions at
the corneal limbus (Wesley, personal communication,
1993).
Hydroxyapatite The use of a hydroxyapatite im-

plant at the time of evisceration requires that the pos-
terior part of the sclera be excised to provide a large
window for fibrovascular ingrowth. An 18-mm
hydroxyapatite implant that has been predrilled with
FIGURE 24–3 A Westcott scissors is used to lyse and 10 to 20 holes using an 18-gauge needle is inserted
excise fibrous membranes on the inside surface of the sclera. into the scleral pocket. (An excessively large implant
CHEN24-347-354.I 3/22/01 2:34 PM Page 350
A Frontal view: posterior portion of globe Side view
B C
FIGURE 24–4 (A) Expansion radial sclerotomies are carried out through the sclera in between the horizontal and
vertical recti muscles, in an anteroposterior direction. The cuts may start as far anterior as the equator or insertion of
recti and as far posterior as the optic nerve. (B) Surgeon’s view of the relaxing sclerotomy over the inferonasal quad-
rant. (C) Inferonasal sclerotomy on another patient showing full-thickness cut through sclera.
will result in a higher incidence of exposure and ero- After a 360-degree conjunctival peritomy and
sion.) The use of a hydroxyapatite implant with evis- undermining of the sub-Tenon’s fascial plane to the
ceration seems to be associated with a greater degree equator, the steps may proceed as in the first method
of postoperative pain. It often requires the use of more cited above (Fig. 24–1). Oblique relaxing scleral cuts
potent postoperative analgesics. Slow infusion of are made at the superotemporal and inferonasal
Marcaine drip via a 20-gauge epidural catheter quadrants, extending up to 10 mm in length.
inserted into the orbit has been described by Wesley
(personal communication, 1993).
...
Excision of Cornea: Relaxing Scleral Cuts
Evisceration with removal of the cornea is indicated
P EARL It is helpful to grasp with a
forceps the corneal button, which is still
attached to the limbus by a stalk, while eviscer-
for those patients who may still have corneal sensa- ating the intraocular contents (Fig. 24–2).
tion or corneal pain, when there is a chance of corneal
thinning, or in patients who have scleromalacia, as is
seen in connective tissue disorders or rheumatoid Again, in a severely shrunken and phthisical globe,
arthritis. The removal of the cornea allows the scle- it is possible to lyse and excise the fibrous bands and
ral edges to be united, which provides a secure membranes that are holding the collapsed interior
wound closure. scleral surfaces together, and the intraocular space is
CHEN24-347-354.I 3/22/01 2:34 PM Page 351
Spherical
implant
FIGURE 24–5 (A) Orbital implant inserted into scleral

cavity, or it may be inserted intraconally into the posterior
orbital space (retrobulbar space) if the surgeon chooses to
make a large posterior scleral incision to allow the implant
to be placed behind the posterior scleral flap. (B) Silicone
rubber implant in an introducer ready for insertion.
(C) Spherical implant is seated inside scleral cavity. C
then reexpanded to an adequate volume for implant allowing an 18-mm hydroxyapatite implant to be used
insertion (Fig. 24–3). The corneal button is then and the scleral edges to be closed without tension.
excised. With excision of the cornea, it is often difficult
to place any sphere lorger than 16 mm in size and still
EARL... Rather than discarding the
close the scleral edge. Here expansion radial sclero-
tomies are helpful6 to allow for placement of a larger
sphere, for example, 18 mm (Figs. 24–4 and 24–5). The
P posterior scleral button, one may thin it
and place it between the implant and the ante-
oblique scleral edges are overlapped and secured
rior overlapping scleral edges, giving it a double
with multiple double-armed 4-0 Polydek sutures in a
mattress fashion from superotemporally to infer- scleral barrier in front7 (Wesley, personal com-
onasally. Trimming at each side of the scleral wound munication, 1993).
is usually necessary to avoid redundant dog-ears. The
remaining free edge of the sclera is then secured to
the underlying sclera with a separate row of inter- An implant greater than 18 mm actually results in
rupted 4-0 Polydek sutures, forming a secure closure. a less effective range of angular rotation, as we reach a
Following this oblique closure, the Tenon’s layer is limit on the length–tension relationship of viable
closed horizontally with interrupted 5-0 Vicryl extraocular muscle. An oversized implant requires
sutures, and the conjunctiva is closed with a horizon- more conjunctival coverage and tends to foreshorten
tal running 6-0 Vicryl suture (Figs. 24–6 and 24–7). A the fornix, making it more difficult for prosthetic fitting.
conformer and light bandage is applied.
Excision of Cornea: 360-Degree Posterior
Hydroxyapatite When the cornea is excised and Equatorial Sclerotomy
hydroxyapatite is used, the posterior part of the sclera J. McCann (oral communication) described a para-
and the optic nerve head are excised to allow for vas- equatorial scleral cut following evisceration, essen-
cular ingrowth. The optic nerve vessels are cauterized tially allowing the posterior segment to hang back and
if possible. This effectively creates a posterior window, placing the implant in the scleral cavity. This allows
CHEN24-347-354.I 3/22/01 2:34 PM Page 352
Conjunctiva
Sclera closed
over implant
A B
FIGURE 24–6 (A) The anterior scleral edges have been overlapped and closed using mattress sutures. It is ori-
ented obliquely. The anterior Tenon’s layer is closed with 5-0 polyglactin (Vicryl), and the conjunctiva with 6-0
polyglactin. (B) Closure of scleral wound following evisceration with removal of cornea. The upper scleral wound
overlaps and is stitched to the lower scleral edge using multiple mattress sutures of 4-0 Polydek. The free edge of the
sclera is separately secured with a row of interrupted sutures.
the anterior scleral edges to be overlapped and closed bining with the two anterior scleral flaps to provide
without much tension. secure closure over the posteriorly placed implant. To
decrease infection from exposure of the implant to bac-
Excision of Cornea: Posterior Placement in the terial flora in the eyelashes during insertion, Rose uses
Intraconal Space, Eversion of Posterior Scleral the cut-off tip of the thumb of a sterile glove to insert
Flaps, Double-Flap Coverage of Implant the implant (Fig. 24–8).
Soll 7 described the posterior placement of an implant J. Long8 reported at the 1999 ASOPRS meeting a
following evisceration. G. Rose (oral communication) series of 49 patients who underwent evisceration with
in the United Kingdom (1998) preferred making an transocular placement of an unwrapped hydroxy-
oblique 1-inch posterior sclerotomy across the macular apatite implant into the intraconal space. He stated
area of the sclera. With two scleral cuts around it, the that posterior placement of an unwrapped implant
optic nerve area is then allowed to hang back like an allows for early vascularization, and permits a larger
island, thereby freeing the posterior scleral flaps. These implant to be placed; in his series there was no anterior
two edges are then everted and brought forward, com- erosion or extrusion over a 7-month to 4-year period.
Postoperative Care
Patients are seen on the fifth postoperative day and
the dressing removed. The lids should retain the con-
former well. Patients are gently introduced to the new
appearance of their “eye,” which may either be a
clean socket lined with conjunctiva, or, in cornea-
sparing evisceration, look similar to how it looked
before surgery with the opacified or vascularized
cornea in place. Patients are instructed on daily care of
the wound with instillation of topical antibiotic oint-
ment, and to allow the wound to ventilate. The author
usually prescribes a prophylactic course of antibiotics
starting intraoperatively because the implant is placed
in the sclera, a less vascularized area of the orbit as
FIGURE 24–7 Conjunctival closure completed with a compared to orbital tissues. Prosthetic fitting may be
running 6-0 polyglactin suture. arranged 1 12 to 2 months following the procedure.
CHEN24-347-354.I 3/22/01 2:34 PM Page 353
Evisceration
Sparing cornea Excision of cornea

coupled with expansion
radial sclerotomies, or
360° posterior equatorial
sclerotomy
Limbal incision Paralimbal incision ± anterior eversion of
± expansion ± relaxing scleral cuts posterior scleral flap
radial sclerotomies (posterior placement of implant)
FIGURE 24–8 Clinical pathway for evisceration.
If the implant should partially extrude due to poor CONCLUSION

tissue healing, it is best to reinforce the wound clo-
sure as soon as possible. Extrusion due to persistent Evisceration with placement of an alloplastic implant
infection should be managed by removing the in a nonneoplastic condition provides a simple solu-
implant and allowing the wound to drain, and with tion to ocular pain relief with retention of ocular pros-
appropriate systemic antibiotic therapy. The scleral thetic motility. There is less postoperative orbital
shell will collapse and the socket will heal by sec- swelling, and the procedure may be performed in
ondary intention. Other authors have reported much less time.
delayed primary wound closure to prevent implant
extrusion following evisceration for endophthalmitis.9
REFERENCES
1. Rao NA, Robin J, Hartmann D: The role of the pene- 6. Stephenson CM: Evisceration of the eye with expansion
trating wound in the development of sympathetic oph- sclerotomies. Ophthalmic Plast Reconstr Surg 1987;3(4):
thalmia: experimental observations. Arch Ophthalmol 249–251.
1983;101:102–104. 7. Soll DB: Evisceration with eversion of the sclera: shell
2. Levine MR, Lash RH: Evisceration: Is sympathetic oph- and muscle cone positioning of the implant. Am J Oph-
thalmia a concern in the new millennium? Ophthalmic thalmol 1987;104:265.
Plast Reconstr Surg 1999;1:4–8. 8. Long J: Evisceration: Improved orbital volume aug-
3. Green WR, Maumenee AE, Saunders TE, Smith ME: mentation trans-ocular implant placement. Paper pre-
Sympathetic uvietis following evisceration. Trans Am sented at: 30th Annual Scientific Symposium of the
Acad Ophthalmol Otolaryngol 1972;76:194–197. American Society of Ophthalmic, Plastic, and Recon-
4. Stafford WR: Sympathetic ophthalmia: report of a case structive Surgery; October 23, 1999; Orlando, FL.
occurring ten and one-half days after injury. Arch Oph- 9. Shore JW, Dieckert JP, Levine MR: Delayed primary
thalmol 1965;74:521–524. wound closure: use to prevent implant extrusion fol-
5. Liddy L, Stuart J: Sympathetic ophthalmia in Canada. lowing evisceration for endophthalmitis. Arch Ophthal-
Can J Ophthalmol 1972;7:157–159. mol 1988;106:1303.
CHEN24-347-354.I 3/22/01 2:34 PM Page 354
CHEN25-355-368.I 3/26/01 8:53 AM Page 355
Chapter 25
EXENTERATION
William P. Chen
Exenteration is the surgical procedure by which the

bulk of the contents within the orbital space is removed.
A total exenteration involves removal of the globe and
all the orbital tissues that are enclosed by the inner peri-
orbita. Most often, the exenterated orbit is either
allowed to heal primarily or overlaid with a split-
thickness skin graft. There are various modifications of
exenteration including those that spare the eyelid skin,
and expanded enucleation techniques with socket abla-
tion.1 A variety of reconstructive techniques exist,
including the use of dermis-fat grafts,2 temporalis mus-
cle transposition,3 the use of cranioplastic (methyl
methacrylate),4 methyl methacrylate with temporalis
transfer, osseointegration techniques using metallic ele-
ments,5 and a latissimus dorsi myocutaneous free flap.6
FIGURE 25–1 Basal cell carcinoma of long standing with
erosion down to the inferior orbital rim and zygoma.
INDICATIONS FOR SURGERY
There are numerous indications for exenteration, and bulky fornix involvement, invasive orbital menin-
although by far the most common is epithelial malig- gioma, aggressive orbital mycoses, sinus carcinoma
nancy with invasion of the orbit (Fig. 25–1). This with orbital extension, and metastatic orbital tumor
includes basal cell carcinoma, squamous cell carci- causing pain, severe exophthalmos, or unsightly
noma, and sebaceous cell carcinoma of the eyelid with appearance.
orbital involvement (Table 25–1). Malignant epithelial Other less defined indications include severe orbital
tumors of the lacrimal gland, for example, malignant fibrosis,8 orbital trauma, deformities such as neurofi-
mixed cell tumor, recurrent benign mixed tumor with bromatosis, and end-stage orbital inflammatory
malignant transformation, adenocystic carcinoma, processes with blindness. Bartley et al9 reported that
squamous cell carcinoma, and mucoepidermoid car- 70% of their series of 102 patients had squamous cell
cinoma, often require exenteration as a lifesaving carcinoma, basal cell carcinoma, or melanoma, with
measure. Sarcomas other than rhabdomyosarcoma7 squamous cell carcinoma being the single most com-
and lymphosarcoma also require exenteration. A list mon neoplasm that required exenteration. Three-
of other indications include conjunctival melanoma quarters of their patients had tumors that extended
with invasion of the orbit, squamous cell carcinoma into the orbit. Rini et al10 reported on the controversial
of the conjunctiva with orbital extension or diffuse role of exenteration in the management of uveal
355
CHEN25-355-368.I 3/22/01 2:36 PM Page 356
TABLE 25–1 OUTLINE OF ORBITAL PATHOLOGIES THAT MAY WARRANT EXENTERATION
Total Exenteration Subtotal Exenteration Enucleation with

(Lid-Sparing) Socket Ablation (Yeatts*)
Large BCC, in orbit Invasive conjunctival SCC, SCC of conjunctiva

with orbital extension Conjunctival malignant
or fornix involvement melanoma
SCC Cicatricial ocular pemphigoid
Sebaceous cell CA, with Alkali burn
orbit involvement Ciliary body, and choroidal
Primary malignant tumors melanoma with extrascleral
Invasive epithelial extension to bulbar
tumors of lacrimal gland: conjunctiva
malignant mixed cell,
adenocystic,
mucoepidermoid, SCC of
lacrimal gland
Sarcomas (excluding
rhabdomyosarcoma
and lymphosarcoma)
Conjunctival melanoma,
deep orbital involvement
Orbital extension of uveal
melanoma, without metastasis
Invasive orbital meningioma
Sinus CA, with orbital extension
Metastatic orbital tumor
with pain and disfigurement
Aggressive orbital mycosis
BCC, basal cell carcinoma; CA, carcinoma; SCC, squamous cell carcinoma.
* (A modification of Naquin’s procedure.)
melanoma with orbital extension. They present data wound to granulate in, or heal by, secondary inten-
that suggest that surgical intervention may hasten the tion will take time but allow the surgeon a better
patient’s demise. Other authors advocate exenteration chance of detecting possible tumor recurrence. The
for such cases.11 Levin and Dutton12 reported on advantage of this method also includes ultimately a
99 cases for exenteration over a 20-year period. The more filled-in orbit with good color match, and less
surgery was performed in 89% of cases for eradication sensitivity to cold temperature.
of presumed life-threatening malignancies, 6% for
eradication of presumed life-threatening infection, and
...
5% for alleviation of intractable pain or deformities.
The treatment of choice for all orbital tumors is
changing rapidly enough to warrant a thorough
P EARL Patients should be told
that they may experience hypoesthesia or
anesthesia in the forehead and maxillary regions
review of the subject each time the problem arises. due to surgery around the first and second
branches of the trigeminal nerve.
Preoperative Counseling
The surgeon should be thorough and comprehensive
in making sure that the diagnosis is accurate and war- Alternatives for wound coverage, including split-
rants such surgery. The indication for undergoing the thickness skin grafts or temporalis muscle transposi-
surgery as a lifesaving measure, to eradicate pre- tion (which results in transient pain on chewing and
sumed life-threatening malignancy, is explained to leaves a slight hollow deformity over the temporalis
the patient. The patient should be told clearly what fossa), can be discussed with the patient.
portion of the orbital contents is to be removed, An emotionally laden description of this procedure
whether it is complete (total), partial (subtotal, with as being “mutilating” is intentionally avoided as
sparing of eyelid skin), or enucleation with socket patients should be focused on dealing with the life-
ablation. The patient should be told that allowing the threatening nature of their disease and the lifesaving
CHEN25-355-368.I 3/22/01 2:36 PM Page 357
EXENTERATION • 357
nature of the surgery. In the relatively infrequent Presurgical Setup

case of exenteration for pain control or correction of The patient’s chart, surgical consent, and radiographic
socket deformities, patients will obtain improvement studies are reviewed. The orbit is reexamined to
in the quality of their lives, and they should not be determine that the correct side is to be exenterated.
viewed as suffering a setback when undergoing this The patient must be medically stable to undergo the
procedure. surgery, with normal platelets and coagulation pro-
For the recovery phase, the need for daily wound file as the surgery has the potential for significant
care and ultimate fitting of orbital prosthesis is pre- blood loss. In debilitated patients who must have the
sented. The patient should be aware that despite procedure, it is prudent to have typed and crossed
surgery, depending on the pathology of the lesion, blood or plasma fluids in reserve.
there is a chance that the tumor may recur.
Applied Anatomy Choice of Anesthesia

The following clinical and anatomic points must be Due to the psychological impact of this procedure,
recognized when approaching exenteration: general anesthesia is preferred for all variations of
As one dissects in the subperiosteal plane in a total exenteration.
or subtotal exenteration, the sites of increased resis-
tance are the superior oblique trochlea, the inferior Surgical Techniques
oblique origin posterior to the lacrimal sac fossa, the There are basically three variations of exenteration:
attachment of the medial and lateral canthi, and pos- total, subtotal (eyelid-sparing), and extended enucle-
teriorly the superior and inferior orbital fissures13 ation with resection of the conjunctival fornices (enu-
(Fig. 25–2). cleation with socket ablation1).
Cerebrospinal fluid leak may occur following the
use of monopolar cautery applied near the orbital roof
Total Exenteration
(at a low-power, high-frequency setting that is often
used by ophthalmic surgeon), usually over preexist- Under general anesthesia, the superficial periorbital
ing foramina. Wulc et al14 reported that in 50 cadaver tissue is infiltrated with 2% Xylocaine with 1:100,000
orbits, 16% had atrophic bony defects in the roof, epinephrine and hyaluronidase (Wydase).
especially posteromedially. It is postulated that the
thermal energy may transmit through the bony
...
defect, resulting in damage to the overlying dura.
These authors recommended bipolar cautery when
working in the deep orbit. They also noted that
P EARL The injection needle tip
should not penetrate any area suspicious
for tumor or any area behind the orbital rim.
monopolar cautery can penetrate the superior orbital
fissure with minimal pressure.
The roof and medial wall of the orbit are very thin.
Dissection should proceed with care so as to avoid The incision line is marked along the superior
penetration of the orbital walls with the potential for- orbital rim to include the tarsus and eyelid skin, over
mation of chronic sino-orbital fistulas. the lateral orbital rim to include the lateral canthal
Superior
orbital fissure
Trochlea of
superior oblique
muscle
Latheral Medial canthal

canthal tendon attachment
tendon
attachment
Origin of inferior
oblique muscle near FIGURE 25–2 Sites of increased
Inferior orbital lacrimal sac fossa resistance to dissection in orbital exen-
fissure teration. (Modified from Small.13)
CHEN25-355-368.I 3/22/01 2:36 PM Page 358
Frontal bone Over the medial wall, the angular vessels are
Periosteum
encountered and cauterized. The superficial limb of
the medial canthal ligament is elevated, followed by
the lacrimal sac and deep limb of the medial canthal
ligament. The anterior and posterior ethmoidal ves-
sels invariably bleed and need to be controlled with
Periosteal bipolar cautery and application of bone wax to the
elevator foramina. The lacrimal sac is divided from the mem-
branous portion of the nasolacrimal duct in the naso-
lacrimal canal. Superonasally, the trochlea is detached
or cut. Subperiosteal dissection along the superior wall
proceeds until the lacrimal gland is encountered; it is
elevated from the lacrimal gland fossa. The lateral wall
frequently has zygomaticotemporal vessels, which
should be cauterized. The lateral canthal raphe is
FIGURE 25–3 After periosteal incision, a Freer elevator detached. Dissection is continued inferiorly. The sur-
is used to elevate the orbital content from its underlying geon should take care not to cause any bleeding from
orbital walls. the infraorbital artery, which at times may course
very superficially within the orbital floor. The infero-
nasal dissection requires dissection of inferior oblique
raphe, over the inferior orbital rim to include the muscle origin from the posterior lacrimal crest region.
lower lid skin and tarsus, and medially to include The periorbita is progressively separated until the api-
the medial canthal raphe (medial canthal ligament, cal orbital tissues are mobilized posterior to the depth
lacrimal sac, canaliculi). If the surgery is performed of the orbital tumor involvement.
due to orbital invasion from an eyelid neoplasm, for A curved enucleation clamp is then applied to the
example, basal cell carcinoma, wide cutaneous mar- apical stump (Fig. 25–4), while a curved pair of Met-
gins should be marked, typically 10 to 15 mm beyond zenbaum scissors is used to cut the orbital tissues,
the clinically obvious lesion. A no. 15 blade is used to anterior to the clamp. An enucleation snare may also
make the initial skin incision in a circumferential be used for this purpose.15 Cautery is carefully
manner. This is followed by application of the cutting applied to the apical stump tissues. Ties consisting of
mode of the monopolar electrocoagulation unit, tra- sutures or vascular clips13 may also be used. During
versing the periorbital portion of the orbicularis oculi this maneuver, gentle compression using a gauze
muscle down to the orbital rim. Vascular oozing is sponge and the use of a suction tip helps in isolating
controlled with bipolar cautery. A circumferential the source of the bleeding, allowing methodical con-
periosteal incision is then made with the cutting bovie trol of the hemorrhage. Further cleaning of residual
around the orbital rim. A Freer elevator supple- orbital tissue is carried out. (In accessing the orbital
mented by malleable retractors is then applied sub- apex, should there be bulky tumor posteriorly, the
periosteally to elevate the orbital contents from the globe may need to be enucleated first to facilitate
orbital walls (Fig. 25–3). the complete removal of tumors at the apex.)
FIGURE 25–4 A curved clamp is

applied to the apical stump, while a
curved pair of scissors is used to cut the
orbital tissue anterior to the clamp. An
enucleation snare may also be used for
this purpose.
CHEN25-355-368.I 3/22/01 2:36 PM Page 359
FIGURE 25–6 Hand-held Simon dermatome (Davol)

used for harvesting of a split-thickness skin graft.
for egress of fluid during postoperative healing. The

FIGURE 25–5 Total exenteration removed the eyelids graft is laid inside the orbital walls and sutured ante-
and all intraorbital content except for the apical stump in
riorly to the remaining skin edges (Fig. 25–7). It is crit-
this right orbit. The orbital walls are allowed to granulate.
ically important to maintain proper orientation of the
split-thickness skin graft, with the “raw” side facing
If the exenterated orbit is allowed to heal via sec- the orbital walls. The graft is tamponaded with a Telfa
ondary intention16 (Fig. 25–5), that is, granulation, a dressing and Xeroform gauze moistened with antibi-
layered bandage dressing is applied. First, a small otic ointment (Fig. 25–8). Silastic foam17 and a 30-mL
piece of Surgicel (cellulose) is cut into a small coin size Foley catheter balloon18 have also been used as a tam-
and applied to the apical stump for hemostasis. A ponade on the skin graft.
Telfa dressing is then cut into triangular sheets and
laid on each of the four walls, extending anteriorly Subtotal Exenteration (Eyelid Sparing)
beyond the anterior orbital rim. The cavity is then In orbital conditions where there is no significant
packed with xeroform gauze (or Vaseline gauze) involvement of the eyelid skin, such as in orbital
moistened with antibiotic ointment. A semipressure extension of malignancies originating in the conjunc-
eye bandage is applied. tiva, intraocular tumors, tumors extending from the
If the orbit is to be lined with a split-thickness skin sinuses and nasal cavities, or primary orbital malig-
graft, the graft should be harvested immediately fol- nancies, the eyelid myocutaneous layers may be
lowing the exenteration (Fig. 25–6). Before placement spared from excision and used to fold in and around
in the exenterated orbit, the split-thickness graft is the superior and inferior orbital rims.
typically expanded using a mesher with grid plates The myocutaneous incision line is placed 2 to 3 mm
of either 1:1.25 or 1:1.5. The meshing process allows from the upper and lower lid margins and the medial
and lateral canthi. Following the elevation of intact
upper and lower lid myocutaneous flaps, the dissection
FIGURE 25–7 A split-thickness skin graft has been

applied onto the medial and inferior walls of this exenter-
ated right orbit. The four walls are lined together with FIGURE 25–8 The orbit is lined with Telfa dressing,
the apex. The anterior edges of the grafts are sutured to the packed with Xeroform gauze moistened with bacitracin
periorbital skin. ointment, and covered with two cotton eye pads.
CHEN25-355-368.I 3/22/01 2:36 PM Page 360
A B
FIGURE 25–9 (A) Clinical photograph showing exenterated orbit with preservation of the upper lid tarsus and
skin. The overhanging ridge of soft tissue has a “bow-string” appearance and actually makes it hard for the patient to
clean the roof of his orbit. (B) An exposed area developed over the superior wall and required gentle debridement and
coverage using a split-thickness skin graft.
is carried down to the orbital rim, after which the If necessary, the ophthalmic surgeon can enlist the
exenteration proceeds as mentioned in the previous help of an ear, nose, and throat colleague when
section. The spared skin and orbicularis muscle is working with sino-orbital diseases. Likewise, if the
draped over the anterior half of the orbital walls while orbital roof is involved, a combined ophthalmologic-
the posterior half may be allowed to granulate in, or neurosurgical team approach is beneficial because
covered with, a split-thickness skin graft. In patients dura of the anterior cranial fossa may be encoun-
with significant dermatochalasis, the upper and lower tered. The decision as to whether a defect in the
lid myocutaneous tissue may be sufficient to line orbital wall should be covered is influenced by fac-
the entire exenterated orbit. Attempts to preserve the tors such as the probability of tumor recurrence in
tarsus and eyelid margin usually leave a static-look- the area, the formation of sino-orbital fistulas, the
ing lid that is unnatural in appearance as healing possibility of osteomyelitis, and difficulty with eat-
takes place (Fig. 25–9). These attempts interfere with ing, chewing, or speech.
the subsequent fitting of a prosthesis and hinder the
examination of the orbital roof. Enucleation with Conjunctival Fornix Resection
Yeatts et al1 described an “enucleation with socket
Wound Coverage The eyelid skin is folded inward ablation” or “limited” subtotal exenteration, which is
and the orbital space dressed as in total exentera- modified from Naquin’s procedure (360-degree con-
tion, using Telfa dressing, Xeroform gauze, and eye junctival peritomy with enucleation, plus direct exci-
pads. Alternately, a Jackson-Pratt drain or Penrose sion of the lid margins, tarsi, and conjunctiva). In
drain is placed in the orbit. The upper and lower lid Yeatts et al’s procedure (Fig. 25–10), the skin incision
skin are sutured together with 5-0 silk sutures. The is made 2 mm from the upper and lower lid margins.
drain is removed after 1 to 2 days. The sutures are The superior plane of dissection remains suborbicu-
removed at 1 week. The eyelid skin gradually laris, traversing through the orbital septum until the
retracts into the orbit and lines its walls. Using this levator aponeurosis is reached. The levator is tran-
latter method, the orbit is lined in 3 to 4 weeks and sected to reach the intraconal space. The dissection is
a prosthesis may be fitted. continued posteriorly without penetrating the supe-
rior conjunctival fornix. The superior rectus is
detached from the globe and saved. The same is car-
EARL... In either the total or subto-
P
ried out for the lower lid, saving the inferior, medial,
and lateral recti. The two oblique muscles are cut. An
tal exenteration, if orbital tumors are
enucleation is performed (Fig. 25–11). Essentially, it
seen to affect the medial wall or floor of the is an en-bloc resection of the lid margins, tarsi, and
orbit, the adjacent sinuses must be opened to conjunctiva, with simultaneous enucleation. The con-
remove all tumor. junctival layer (both palpebral and bulbar positions) is
removed in its entirety as an intact layer. A spherical
CHEN25-355-368.I 3/22/01 2:36 PM Page 361
Total
exenteration
Subtotal
exenteration
Enucleation
with socket
ablation FIGURE 25–10 Comparative surgi-
cal dissection planes in total orbital
exenteration, subtotal orbital exentera-
tion, and enucleation with socket abla-
tion. (Modified from Yeatts et al.1)
orbital implant is placed and the muscles are imbri- antibiotic ointment over the next 3 to 4 months. Usu-
cated over the implant, followed by skin closure ante- ally the end result is an orbit that is half filled with
rior to it. The main indications for this procedure are orbital tissue (Fig. 25–12).
intraocular and conjunctival surface malignant neo-
plasms, for example, squamous cell carcinoma or
EARL ...
malignant melanoma of the conjunctiva, and
choroidal or ciliary body melanoma with extrascleral
extension to the bulbar conjunctiva.
P Although a granulating
orbit may still hide recurrence of tumor, it
is less likely to do so compared with techniques
using overlay of temporalis muscle, methyl
Postoperative Care for Total and Subtotal
methacrylate, or a dermis-fat graft.
Exenteration
The wound is not disturbed for at least 5 to 7 days,
after which the Xeroform gauze and Telfa dressing In orbits lined with split-thickness skin graft
are carefully removed. In orbits with a skin graft, the (Fig. 25–13), the graft may show a healthy pink hue
walls and orbital apex are kept moist with topical with some building up of keratinous debris. Hydrogen
Exenteration
Conjunctival and intraocular

Cutaneous tumor Orbital tumors without
malignancy with extrascleral
with orbital extension skin involvement
extension to bulbar conjunctiva
Total Subtotal “Limited”

exenteration (eyelid-sparing) subtotal exenteration
Subperiosteal dissection Subperiosteal dissection (Enucleation with socket ablation)

Remove lid margins,
tarsus-conjunctival
Anterior coverage with
fornices and globe
Granulation Coverage with eyelid skin and
orbicularis muscle Extraocular muscles spared
split-thickness
skin graft
Posterior half Coverage with
of orbit skin closure over
enucleation spherical
implant
Granulation Split-thickness
skin graft
FIGURE 25–11 Clinical pathway for three variations of exenteration.

CHEN25-355-368.I 3/22/01 2:36 PM Page 362
FIGURE 25–13 An elderly man with meibomian gland

FIGURE 25–12 A 17-year-old girl with adenocystic car-
carcinoma and intraepithelial spread to conjunctiva, after
cinoma of the lacrimal gland, who underwent exenteration
exenteration coupled with a split-thickness skin graft. The
and supplemental radiation therapy to the orbital walls
orbit is pink and lined with healthy skin.
postoperatively. The orbit had granulated well after
4 months, filling in half way. Note drop-out of her eyebrow
related to radiation therapy. COMPLICATIONS
Intraoperatively, the patient may have brisk hemor-
peroxide solution is useful for gently cleansing the rhage from the ophthalmic artery, and from the ante-
orbit. The graft eventually will be replaced by a healthy rior and posterior ethmoidal arteries.
underlying coat of epidermal elements, covering the
raw surface of the orbit. Family members are encour-
aged to take part in the daily cleaning, dressing, and PITFALL
antibiotic application. They are taught to use clean
cotton-tip applicators to clean out any mucous scabs Inadvertent penetration into the medial wall
(Fig. 25–14). The orbit is exposed to the air as much as may lead to sino-orbital or naso-orbital fistu-
possible to expedite healing (Fig. 25–15). The author las (Fig. 25–17).
prefers to assist and follow the patient frequently for
the first 2 months, after which monthly examinations
are adequate (Fig. 25–16). The usual healing process Fistulas are difficult to ablate, despite attempts at
takes 3 to 4 months, although occasionally 6 to direct closure or coverage with adjacent pedicle flap
9 months may be required in elderly patients with (Fig. 25–18). The fistulas result in a moist orbit and
slower wound healing. The patient should be closely may hinder the successful use of an orbital prosthesis.
followed at appropriate intervals for tumor recurrence.
FIGURE 25–15 A 19-year-old man with adenocystic car-

cinoma of the lacrimal gland, after exenteration. Surround-
FIGURE 25–14 An elderly man who had poor hygiene ing pigmentary skin migrates inward from the orbital rim in
and wound care following exenteration for orbital malig- a circumferential fashion. The posterior half of the orbit is
nancy (2 months postoperatively). granulating well with healthy pink tissues.
CHEN25-355-368.I 3/22/01 2:36 PM Page 363
FIGURE 25–16 Same 17-year-old girl as in Fig. 25–12, FIGURE 25–17 An elderly man with left orbital menin-
2 months after exenteration and only 1 month after comple- gioma had undergone exenteration with a split-thickness
tion of radiation treatment to the orbital surface. Note the skin graft. The medial orbital wall was noted to be
radiation-induced erythema and burn. extremely thin and the skin graft failed to take, eventually
causing necrosis and secondary infection, leading to sino-
orbital and naso-orbital fistulas.
As mentioned before, the inadvertent penetration
into the dura while using unipolar cautery along the
roof of the orbit has been known to cause cere- Savar 20 reported two cases of graft failure: one
brospinal fluid leakage. This requires that the bony patient received 15,780 rad over 16 years, and the sec-
defect be covered with autogenous fat, or transposi- ond patient received 14,000 rad during a 2-year
tion of temporalis muscle flap through the lateral wall period prior to exenteration and skin grafting.
of the orbit.19 Alternately, the bony defect is enlarged
so that the torn dura may be closed with 5-0 or 6-0 silk,
followed by coverage with split-thickness skin graft.14
PITFALL
PITFALL Meningitis may occur from undetected cere-
brospinal fluid leak. In areas of exposed bone,
Postoperatively, the graft or flap may fail, sec- a chronic low-grade osteomyelitis may occur.
ondary to bleeding, infection, or poor vascu-
lar supply in the bone of the orbital walls as a
result of previous high-dose radiation.
A 50-year-old man presented with a large lacrimal
gland tumor. It was removed via left lateral orbito-
tomy with bone flap. The bone flap was wired back
in place. Histopathology of the tumor mass revealed
poorly differentiated carcinoma, type unknown. Sys-
temic workup revealed no known primary. Exentera-
tion was performed within 10 days without disturb-
ing the bone flap. Postoperatively the orbit received
prophylactic radiation treatment. An exposed non-
healing area developed over the inner portion of the
lateral wall (bone flap). On exploration, avascular
bone with low-grade osteomyelitis was discovered.
The avascular bone flap was excised, and debride-
ment carried our until healthy bleeding bony wall
was encountered. A rotational flap was performed to
cover this area (Fig. 25–19). Another area of tissue
FIGURE 25–18 An elderly woman who had undergone breakdown occurred over the roof, measuring
total exenteration with maxillectomy, demonstrating open 5*7 mm; however, with diligent wound care, even-
communications between the orbit, sinuses, and nasopharynx. tually it spontaneously re-epithelialized. The patient
CHEN25-355-368.I 3/22/01 2:36 PM Page 364
FIGURE 25–19 A 50-year-old man who developed low- FIGURE 25–20 Benign epithelial breakdown in the
grade osteomyelitis of the lateral orbital bone flap following superior portion of exenterated orbit, in an elder woman
lateral orbitotomy and exenteration. The avascular bone was who underwent exenteration for basal cell carcinoma with
excised. A secondary breakdown in orbital lining of the roof orbital extension. Note radiation-induced telangiectasia
healed spontaneously with daily and diligent wound care. over the brow skin area in this fair-skinned woman.
is clear of tumor locally and systemically for 3 12 years. author has used CO2 laser to treat recurrent basal cell
In this case, the consecutive nature of two surgeries, carcinoma in the orbital walls (Fig. 25–21). Although
the radiation treatment, and the osteotomies for the the tumor ablation has had good results, subsequent
lateral orbital bone flaps contributed to the lack of split-thickness skin grafts tend to take poorly. This
perfusion in the flap and the subsequent development may be due to the high-energy destruction of bone
of necrosis and secondary infection. vascularity. In this situation, a regional flap may be
Periodically a lined orbit may have focal areas of used to cover the bare bone when it is certain that the
benign epithelial breakdown, forming an area cov- tumor has been completely eradicated.
ered with scab (Fig. 25–20). In general, all suspicious
lesions or enlarging areas of breakdown should
undergo biopsy. If the lesion proves to be benign, the
REHABILITATION
area should be debrided until healthy vascularized After the orbit is lined and partially filled with healthy
bone is encountered. It can then be covered with a granulation tissue, the patient may be scheduled for
split-thickness skin graft or a regional flap. If the prosthetic fitting by a trained ocularist or a dental
lesion is malignant, the entire tumor needs to be com- prosthesis specialist. The current form is usually made
pletely resected before any repair is performed. The of soft silicone rubber or a combination of methyl
methacrylate for the eye portion with surrounding
rubber edges for optimal camouflage for the facial con-
tour. Even though the prosthetic eyelids are static,
with the use of skin adhesive or spectacle frame it pro-
vides an option for the patient besides leaving it
exposed or wearing an occluder. Most men prefer to
wear a black patch over the exenterated socket.
A report on the use of osseointegrated implant in
exenterated orbit offers another alternative. Nerad et
al5 reported that titanium fixtures were anchored sub-
cutaneously to the orbital rim. During the secondary
procedure, the skin over the fixture is opened and the
titanium abutment is connected to the osseointegrated
titanium fixture on the orbital rim. The silicone
orbital/facial prosthesis is anchored by magnets to
FIGURE 25–21 Diagnostic excision of suspicious lesions the titanium fixtures and abutment. The magnets
in a healing exenterated orbit, using CO2 laser. Note the pre- ensure that the prosthesis is well aligned and prevent
cise, thin laser beam as oulined by the red aiming beam over accidental dislodgment. Tissue adhesive or tape are
the superior rim of the orbit. not necessary.
CHEN25-355-368.I 3/22/01 2:36 PM Page 365
RECONSTRUCTIVE TECHNIQUES a flap, then the dermatome is applied from the oppo-
site direction to harvest a deeper, free split-thickness
In situations where cosmetic appearance is very dermal graft. The donor site is then covered with the
important to the patient, and the tumor pathology flap of the attached split-thickness epidermal flap.
and location are such that recurrence is unlikely
(either intrinsically or during the life span of the Dermis-Fat Graft
patient), one may consider the following reconstruc- Following Smith et al’s23–25 reports of the use of the
tive techniques (Fig. 25–22). dermis-fat graft in enucleated sockets as a primary or
secondary orbital implant, Shore et al2 reported on
Temporalis Muscle Flap the use of the dermis-fat graft to reconstruct orbits
This technique was first reported by Naquin.3 The after subtotal exenteration. The intraperiosteal content
anterior one-third or one-half of the temporalis mus- of the orbit is removed, sparing eyelid skin when
cle is split coronally from its origin and rotated there is no evidence of tumor. An autogenous der-
through the lateral wall of the orbit, under the lateral mis-fat graft that is 20% oversized is implanted in the
orbital rim to cover the orbital space. It may also be orbit. The eyelid myocutaneous tissues are then
split sagittally and rotated over the lateral orbital secured overlying the dermis-fat graft. If the extraoc-
rim.21 The use of this muscle flap will leave a residual ular muscles were spared, they may be attached to
defect in the contour of the temporal fossa, and tran- the dermis portion of the graft for increased forniceal
sient pain on chewing can occur. The temporalis motility.
muscle may be covered with a split-thickness skin
graft if desired. Myocutaneous Flaps
Methyl Methacrylate In select cases, it is advantageous to use “distant”
myocutaneous pedicle flaps and free myocutaneous
Gass4 reported the use of methyl methacrylate as an
flaps. The former include a pectoralis major myocu-
implant immediately following exenteration. It was
taneous pedicle flap; the latter include a free latis-
used primarily for primary malignant orbital tumors
simus dorsi myocutaneous flap6 and rectus abdominis
that were confined to the retroseptal orbital space and
flap.26 These flaps have the advantage of being able to
without bony wall involvement. The eyelid skin is
fill in large surgical defects of the orbit, adjacent nasal
preserved and closed over the methyl methacrylate.
cavity, sinuses, and cranial cavity. Distant tissue flaps
Methyl methacrylate, however, is thermogenic and
require techniques of microvascular reanastomosis.
may lead to severe pain, chronically draining fistulas,
and recurrent formation of pyogenic granulomas.
Split-Thickness Dermal Graft

CONCLUSION
Mauriello et al22 described the use of a split-thickness Exenteration remains a necessary procedure in the
dermal graft to cover the exenterated orbit. From the treatment of primary orbital neoplasm as well as
donor site, the superficial epidermis is elevated first as intraorbital spread of dermatologic malignancies.
REFERENCES
1. Yeatts RP, Marion JR, Weaver RG, Orkubi GA: 6. Donahue PJ, Liston SL, Falconer DP, Manlove JC:
Removal of the eye with socket ablation. Arch Ophthal- Reconstruction of orbital exenteration cavities—the use
mol 1991;109:1306–1309. of the latissimus dorsi myocutaneous free flap. Arch
2. Shore JW, Burks R, Leone CR Jr, McCord CD Jr: Der- Ophthalmol 1989;107:1681–1686.
mis-fat graft for orbital reconstruction after subtotal 7. Abramson DH, Ellsworth RM, Tretter P, et al: The treat-
exenteration. Am J Ophthalmol 1986;102:228–236. ment of orbital rhabdomyosarcoma with irradiation
3. Naquin HA: Orbital reconstruction utilizing temporalis and chemotherapy. Ophthalmology 1979;86: 1330– 1335.
muscle. Am J Ophthalmol 1956;41:519–521. 8. Small RG, Lafuente H: Exenteration of the orbit in
4. Gass JDM: Technique of orbital exenteration utilizing selected cases of severe orbital contracture. Ophthal-
methyl methacrylate implant. Arch Ophthalmol 1969; mology 1983;90(3):236–238.
82:789–791. 9. Bartley GB, Garrity JA, Waller RR, Henderson JW,
5. Nerad JA, Carter KD, LaVelle WE, Fyler A, Brane- Ilstrup DM: Orbital exenteration at the Mayo Clinic.
mark P: The osseointegration technique for the reha- Ophthalmology 1989;96(4):468–473.
bilitation of the exenterated orbit. Arch Ophthalmol 10. Rini FJ, Jakobiec FA, Hornblass A, Beckerman BL,
1991;109: 1032–1038. Anderson RL: The treatment of advanced choroidal
CHEN25-355-368.I
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2:36 PM
Rehabilitation of exenterated orbit
Page 366
Lined and Coverage of
healed orbit raw orbit
Bare Wears eye Orbital prosthesis Osseointegrated Temporalis Methyl Free Following intraperiosteal “Distant” myocutaneous
orbit patch With soft silicone rubber titanium fixtures muscle flap methacrylate split-thickness sub-total exenteration pedicle flap1 and
Methacrylate conformer on orbital rim (Nerad) ± STSG implant dermal graft free myocutaneous flap2
and silicone rubber mold (Naquin) (Gass) (Mauriello)
(± skin adhesive and
± spectacle frame)
Silicone orbital/facial Autogenous dermis-fat
prosthesis anchored graft and closure with
by magnets eyelid's myocutaneous
tissues (Shore)
1 Pectoralis major
2 Free
latissimus dorsi, rectus abdominis
STSG, split-thickness skin graft.
FIGURE 25–22 Clinical pathway of rehabilitation of orbit following exenteration.

CHEN25-355-368.I 3/22/01 2:36 PM Page 367
melanoma with massive orbital extension. Am J Oph- 19. de Conciliis C, Bonavolonta G: Incidence and treatment
thalmol 1987;104:634. of dural exposure and CSF leak during orbital exenter-
11. Shields JA, Shields CL, Suvarnamani C: Orbital exen- ation. Ophthalmic Plast Reconstr Surg 1987;3(2):61–64.
teration with eyelid sparing: indications, technique, 20. Savar DE: High dose radiation to the orbit. Arch Oph-
and results. Ophthalmic Surg 1991;22(5):292–297. thalmol 1982;100:1755–1757.
12. Levin PS, Dutton JJ: A 20-year series of orbital exenter- 21. Holmes AD, Marshall KA: Uses of the temporalis mus-
ation. Am J Ophthalmol 1991;112:496–501. cle flap in blanking out orbits. Plast Reconstr Surg 1979;
13. Small RG: Exenteration of the orbit: Indications and 63(3):336–343.
Techniques. In: Smith BC, Della Rocca RC, Nesi FA, 22. Mauriello JA Jr, Han KH, Wolfe R: Use of autogenous
Lisman RD, eds. Ophthalmic Plastic and Reconstructive split-thickness dermal graft for reconstruction of the
Surgery. St. Louis, MO: CV Mosby; 1987:1151–1164. lining of the exenterated orbit. Am J Ophthalmol 1985;
14. Wulc AE, Adams JL, Dryden RM: Cerebrospinal fluid 100:465–467.
leakage complicating orbital exenteration. Arch Oph- 23. Smith B, Petrelli R: Dermis-fat graft as a movable
thalmol 1989;107:827–830. implant within the muscle cone. Am J Ophthalmol
15. Buus DR, Tse DT: The use of the enucleation snare for 1978;85:62–66.
orbital exenteration (correspondence). Arch Ophthalmol 24. Smith B, Bosniak SL, Lisman RD: An autogenous
1990;108:636–637. kinetic dermis-fat orbital implant. Ophthalmology 1982;
16. Putterman AM: Orbital exenteration with spontaneous 89(9):1067–1071.
granulation. Arch Ophthalmol 1986;104:139. 25. Smith B, Bosniak S, Nesi F, Lisman R: Dermis-fat
17. Benson MT, Gilmour H, Nelson ME, Rennie IG: Silastic orbital implantation: 118 cases. Ophthalmic Surg 1983;14
foam dressing for healing exenteration cavities. Oph- (11):941–943.
thalmic Surg 1990;21(12):849–851. 26. Levin PS, Ellis DS, Stewart WB, Bryant AT: Orbital
18. Mangus DJ, Davisson WF: A method for orbital lining exenteration—the reconstructive ladder. Ophthalmic
after exenteration. Plast Reconstr Surg 1967;40(3):228–229. Plast Reconstr Surg 1991;7(2):84–92.
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Chapter 26
ANOPHTHALMIC SOCKET
Richard A. Burgett and William R. Nunery
Evaluation of patients who have required removal of thalmic socket. It also requires understanding to cope
an eye for a pathologic process is unfortunately com- with issues such as postoperative pain, frequent office
mon. The orbit after removal of an eye by evisceration visits, and larger issues such as alteration of one’s
or enucleation is commonly referred to as the anoph- physical appearance.
thalmic socket. Anophthalmia by its very nature is an
unnatural state. When an eye is removed, more than
...
vision is lost. Removal of the globe opens the potential
for multiple complications caused by abnormal
mechanical interactions between the orbital tissues,
P EARL The ultimate goal in
anophthalmic socket surgery is perfect
static and dynamic symmetry.
eyelids, and prosthetic. A major goal of enucleation
or evisceration surgery is to minimize these mechan-
ical complications with the initial surgery to achieve a The hallmark of successful results in anophthalmic
satisfactory functional and cosmetic result. The goal surgery is symmetry with the normal contralateral
of anophthalmic socket evaluation is to recognize side. The ultimate result would be perfect symmetry
which mechanical complications are causing a less in both the static and dynamic state. Evaluating sym-
than desirable functional or cosmetic result. The goal metry should include assessment of upper eyelid
of treatment is to correct those mechanical complica- position, upper eyelid contour, fullness of the upper
tions without causing additional anophthalmic socket eyelid, eyelash position, lower eyelid height, and
complications.1 lower eyelid fullness. Achieving symmetry of the
Achieving excellent results in the anophthalmic prosthesis involves more than matching iris color
socket requires a multidisciplinary approach.2 The with the normal contralateral eye. Matching the size
traditional caregivers in this approach are the surgeon of the pupil and cornea as well as the color and vas-
and the ocularist. When the ultimate goal is to pro- cularity of the sclera are important. The shape of the
vide the best prosthetic result, the ocularist is charged prosthesis will determine the position of the prosthe-
with creating the best possible prosthesis and the sur- sis in the anophthalmic socket. Assessment of verti-
geon is charged with creating the best possible orbit to cal prosthetic position, anteroposterior prosthetic
hold that prosthesis. As removal of an eye is a psy- position, and position of prosthetic “visual axis” in
chologically charged event for any person, all office primary position are important. Dynamic symmetry
personnel for the surgeon and ocularist need to includes symmetric excursions of the eyelids, normal
approach the patient with sensitivity and sincerity. eyelid closure, and normal ocular movement. Perfect
The final component of the treatment team is ulti- static and dynamic symmetry is rarely if ever
mately the patient. Achieving superior results for the achieved; however, it should still remain the goal for
patient requires the patient to be able to communicate every surgeon and ocularist because it is the goal of
his or her specific concerns regarding the anoph- most patients.
369
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ANOPHTHALMIC SOCKET: prosthetic result. Furthermore, it places the underly-

COMPLICATIONS AND MANAGEMENT ing tissues back to their most anatomic configuration
for long-term anophthalmic socket stability.
Inadequate Orbital Volume—Without Implant Anophthalmic sockets, especially those without
Enucleation or evisceration without an ocular implants, demonstrate progressive contraction with
implant invariably leads to suboptimal anophthalmic apparent loss of orbital volume (Fig. 26–3). Although
socket result. An anophthalmic socket without an initially postulated that a disturbance in vasculature or
implant will have inadequate soft tissue volume. This orbital fat was the cause, anatomic studies have demon-
volume loss will be only partially restored with the strated normal vasculature and orbital fat in anoph-
prosthesis even when the prosthetic is oversized. thalmic sockets.5,6 Anatomic studies have demonstrated
This yields a socket with the appearance of enoph- the presence of the myofibroblast in anophthalmic
thalmos. Additionally, the orbital volume loss causes sockets.7 The myofibroblast, probably a modified
the upper eyelid to appear hollow or sunken. This fibroblast, is a cell type responsible for wound healing
deformity is commonly referred to as superior sulcus and contraction found throughout the body. As the
deformity. The excess weight from the oversized myofibroblast is felt to be responsible for wound con-
prosthesis causes laxity of the lower eyelid, shallow- traction, its presence in the anophthalmic socket may
ing of the inferior conjunctival fornix, downward be responsible for progressive conjunctival shrinkage
descent of the prosthesis, and worsening of the supe- and enophthalmos seen in some anophthalmic sockets.
rior sulcus deformity over time (Fig. 26–1).
The mechanical complications caused by lack of an Management: Secondary Ocular Implant
implant can only be corrected by placing an ocular
Implants and Materials
implant. Preoperative and postoperative computed
tomography (CT) studies by Smit et al3 demonstrate A wide variety of ocular implants are available.
that anophthalmia induces a rotary displacement of Selecting an implant requires selecting the size as well
the orbital contents where the superior rectus and lev- as the material. Most commonly used implants are
ator superioris palpebrae shorten, the inferior rectus spherical in shape and available in a variety of sizes.
elongates, and the prosthesis tilts up into the superior The spheres are sized by their diameter. However, the
fornix (Fig. 26–2). This abnormal rotary displacement spherical diameter is not linearly related to volume.
is consistent with the clinical findings of shallow infe- Table 26–1 demonstrates the diameter-to-volume rela-
rior fornix, deep superior fornix, superior sulcus tionship of various implant sizes.
deformity, and tilting of the prosthesis. CT demon-
strated that placement of an ocular implant helped TABLE 26–1 RELATIONSHIP BETWEEN
circumvent these anatomic changes, but implants IMPLANT DIAMETER AND IMPLANT VOLUME
placed at the time of enucleation prevented the rotary
displacement better than implants placed secondar- Diameter (mm) Volume (mL)
ily.4 Additionally, ocular implants placed at the initial
16 2.15
surgery have been demonstrated to require fewer
18 3.05
surgeries to attain a reasonable reconstruction.4 20 4.19
Although the best time to place an implant is gen- 22 5.58
erally at the time of enucleation, some patients may
present with an anophthalmic socket without an The surgeon’s goal is to replace 100% volume of
implant. Placement of a secondary implant helps the lost eye with the combined volumes of the
restore volume back to the orbit for an improved implant and prosthesis. The average volume of an
eye is 7.0 mL.
EARL ... Conventional thinking is

P that a 20-mm sphere wrapped in fascia
plus the volume of an average-sized prosthesis
replaces the volume of an average-sized eye.
However, a recent study by Kaltreider et al8 that
evaluated A-scan ultrasonography as a tool for
FIGURE 26–1 Clinical appearance of the superior sul-
cus syndrome hallmarked by a deep superior sulcus, predicting the ideal implant size suggests that
enophthalmos, and shallow inferior fornix. This appearance larger implants may be indicated.
is a consequence of inadequate orbital volume.
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ANOPHTHALMIC SOCKET • 371
FIGURE 26–2 Schematic demon-

strating the vertical rotational defor-
mity in the anophthalmic socket that
causes inadequate inferior fornix, tilt-
ing of the prosthetic, deepening of the
superior fornix, and superior sulcus
A deformity. (A) Blocked lines demon-
strate anophthalmic anatomy with an
implant superimposed on a lined
drawing of a normal orbit containing a
normal sized eye. a) Change in anterior
position of eye versus prosthesis;
b) Change in position of levator palpe-
brae superioris; c) Eyelid margin posi-
tions; d) Change in position of supra-
tarsal sulcus; e) Levator palpebrae
superioris—natural state; e1) Levator
palpebrae superioris—anophthalmic
state; f) Inferior rectus—natural state;
f1) Inferior rectus— anophthalmic state;
h) Change in vertical height of center of
eye versus implant; i) Change in axial
position of eye versus implant. (B) Enu-
cleation without implant induces more
rotational deformity and more tilting of
the prosthesis. (From Smit et al 3 with
B permission)
Kaltreider et al8 recommend using A-scan ultra-

EARL ...
sonography to select an implant that will replace 70
to 80% of the lost volume of the eye. In that study,
63% of 59 patients could have received an implant of
P Silicone spheres are the
gold standard based on a wide clinical
experience with a low rate of complications such
22 mm or more to replace 80% of the volume lost at
enucleation. as infection, exposure, or extrusion.
A B
FIGURE 26–3 Clinical appearance of a severely contracted anophthalmic socket. Contraction is noticeable with eye-
lids open (A) but more pronounced on attempted eyelid closure (B).
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Although silicone spheres give good static symme- Newer porous materials were devised for better
try with a low incidence of complication, diminished motility and carry the reputation of better ocular motil-
prosthetic motility prompted alternative designs in an ity. However, reports have indicated that motility of
attempt to improve motility. Iowa and Allen ring anophthalmic sockets with silicone versus porous
implants are acrylic implants with projections on the materials are no different when the implants are not
anterior surface designed to articulate with corre- coupled to the prosthetic with a peg device.17 To date,
sponding depressions on the posterior surface of the no formal study has quantitatively assessed motility in
prosthetic. Although these modifications improved a pegged anophthalmic socket. Coupling the implant
motility, the intervening conjunctiva often did not tol- to the prosthetic (“pegging”) usually improves motility
erate the repeated trauma. Implant exposure and but may be associated with aberrant ocular motility.
migration required many such implants to be ulti- Finally, pegging carries its own unique set of compli-
mately removed. Tantalum mesh was placed on the cations such as pyogenic granuloma formation, socket
front of acrylic implants to create better anopthalmic infection, implant infection, peg extrusion, and abnor-
socket and prosthetic motility. The conjunctiva toler- mal “clicking” noises with ocular motility.18
ated the mesh poorly, with frequent conjunctival In addition to consideration of implant type the sur-
breakdown and implant exposure. Removal of these geon must also choose a technique for fixating the
implants is commonly difficult from the dense cica- implant into position. The described technique of
tricial tissue that becomes intertwined into the mesh. imbrication of extraocular muscle over the front of the
To improve the motility of the anophthalmic socket, implant predisposes the implant to migration. Obser-
newer materials such as hydroxyapatite9 (e.g., Bio-Eye) vations that nonporous materials migrate over time are
and porous polyethylene10 (Medpor) were devised probably more indicative of a problem with extraocu-
and have gained popularity. They have been studied lar muscle suturing technique than the implant itself14
in primary enucleation as well as in secondary ocular (Fig. 26–5). Rigid fixation of the extraocular muscles to
implant procedures.10, 11 These materials are reported the implant regardless of the implant type is the pre-
to have vascular ingrowth into the implant, which will ferred method. To aid in this fixation, some implants
allow biointegration and subsequent coupling of the are covered with an additional material for fixation of
implant to the prosthetic with a peg device. Some extraocular muscles. Hydroxyapatite implants
authors feel that the fibrovascular ingrowth and bioin- require a wrapping material for extraocular muscle
tegration cause the implant to be less likely to migrate fixation; however, it is recommended to contain large
over time.12 However, these materials have higher fenestrations to allow vascular ingrowth. Porous
reported rates of conjunctival inflammation, implant polyethylene may also be wrapped with a material;
exposure, infection, and extrusion13–15 (Fig. 26–4) in however, the characteristics of porous polyethylene
some series. Other series report lower rates of compli- allows direct fixation of extraocular muscle to the
cations.16 These higher rates of complication may be implant without difficulty. Sutures may be passed
technique related12 or alternatively a testament to poor directly into silicone; however, fixation is aided sig-
tolerance of the conjunctiva to the mechanical trauma nificantly if the silicone material is wrapped with
induced by the porous implant. another material.
FIGURE 26–5 Implant migration of silicone spheres is

FIGURE 26–4 Hydroxyapatite implant exposure in a usually a result of inadequate implant fixation within the
nonpegged anophthalmic socket. extraocular muscle cone.
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The ideal material used to wrap the anophthalmic the muscle cone. Inferior and superior fornices are
implant may be autogenous sclera whenever possi- freed with sharp dissection. Each rectus muscle
ble. Autogenous sclera is an excellent material that group is identified with digital palpation. A double-
may be used in primary enucleations for trauma or armed 5-0 Vicryl suture is passed through each rec-
phthisis bulbi. Harvesting autogenous sclera in enu- tus muscle. A second pass is often made to assure
cleations for intraocular tumors is contraindicated good purchase of the rectus muscle group. Verifica-
because of concerns about residual tumor elements tion of good suture placement can be achieved by
within the sclera. Although autogenous sclera is often palpating the muscle group while exerting traction
available for primary enucleations, it is generally not on the suture.
available for secondary ocular implant procedures. The size of the chosen type of implant sphere is
Here, the traditional material for wrapping the selected. The standard size for good orbital volume
implant is donor sclera. Donor sclera demonstrates restoration is 20 mm, if the anopthalmic socket is not
superior handling characteristics, low antigenicity, too contracted. The sphere may be wrapped in the
good biocompatibility, and low complication rate, but surgeon’s choice of material (e.g., donor sclera, other
some risk of transmissible disease is present even preserved connective tissue, autogenous connective
with the best available screening techniques. Polyte- tissue, anophthalmic implant capsule, or Gore-tex
trafluoroethylene (Gore-tex) sheeting is a good alter- sheeting) to ease fixation of the implant into the mus-
native to donor sclera as this alloplastic implant is cle cone. The implant is introduced into the extraocu-
readily available and affordable.19 Beaver et al20 lar muscle cone. The double-armed Vicryl sutures are
demonstrated that multiple autogenous sources for passed into the wrapped implant sphere in their
acceptable connective tissue are available. Autoge- respective anatomic locations and tied. The sutures
nous fascia lata, temporalis fascia, and split dermis are then brought out through the fornices and tied
are well recognized; however, capsular tissue from a (Fig. 26–6). This maneuver removes tension from the
migrated implant and orbital rim periosteum are also conjunctival closure and creates improved conjuncti-
good alternatives. val fornices. The Tenon’s capsule is closed with 5-0
The ideal implant material for anophthalmic socket Vicryl in a buried interrupted fashion. The conjunc-
reconstruction remains a source of debate. A survey tiva is closed with a simple running suture (5-0
of surgeons who commonly perform enucleations Vicryl). A conformer and simple tarsorrhaphy suture
revealed that over 50% of enucleations performed in are placed. The tarsorrhaphy stitch is removed after
1992 used hydroxyapatite compared to 1% in 1989.21 one postoperative week. The conformer is left in posi-
In that series, over half of all enucleations were per- tion until fitting of a new prosthesis at approximately
formed with donor sclera.21 How the evolution of 8 weeks after surgery.
published reports and personal observation will affect
the longterm utilization of the large variety of avail-
able biologic and alloplastic materials is unknown.
Surgical Technique
After a preferred implant size and material are
selected with informed consent of the patient
regarding the risks and benefits of the different
options available, surgery can be planned. Place-
ment of a secondary ocular implant is generally per-
formed with a general anesthetic; however, local
anesthesia may be appropriate in the proper setting.
The socket is injected with an anesthetic mixture of
1% lidocaine, 0.25% bupivacaine, and 1:100,000 epi-
nephrine. This aids in intraoperative hemostasis and
postoperative pain. Traction sutures are placed in
the upper eyelid and lower eyelid for improved
exposure. A conjunctival incision is made in a hori-
zontal fashion across the anophthalmic socket with FIGURE 26–6 Passing the suture ends of the rectus mus-
a no. 15 Bard-Parker or no. 64 Beaver blade. Sharp cle to the wrapped implant and then out through the con-
dissection is taken into the center of the extraocular junctival fornices facilitates stable fornices and supports the
muscle cone. Blunt dissection may aid in opening conjunctival closure.
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Inadequate Orbital Volume—With Implant (e.g., Senn retactors) and reflected inferiorly. The con-
The presence of an ocular implant does not exclude tents of the anophthalmic socket are retracted superi-
an orbital volume deficit. Inadequate orbital volume orly with a large malleable retractor. This maneuver
despite an ocular implant presents in the same fash- exposes the edge of the inferior orbital rim. This soft
ion as without an implant. It may present with appar- tissue over the infraorbital rim is incised down
ent enophthalmos, excessively large prosthetic, deep through periosteum with a scalpel or cautery. The
superior fornix, superior sulcus deformity, or periosteum of the inferior orbital rim and orbital floor
pseudoptosis. If orbital volume is inadequate, the is elevated with a periosteal elevator (e.g., Freer ele-
position of the implant should be assessed. vator, Tenzel elevator).
Once the entire orbital floor is exposed, an appropriate-
Management: Subperiosteal Volume sized wedge may be placed in the subperiosteal space
Augmentation (Fig. 26–8). We generally use silicone wedges that are
If an ocular implant is present and appears to be well premanufactured for use on the orbital floor in a vari-
centered, the orbital volume can be augmented with ety of sizes. The size may be modified at the time of
the placement of an alloplastic implant in a subpe- surgery. Implants of other materials such as porous
riosteal location along the orbital floor 22–24 (Fig. 26–7). polyethylene (Medpor) are available. The implant
should be placed onto the orbital floor with its great-
Surgical Technique est height positioned slightly posterior to the equator
After general anesthesia, the lower eyelid, conjuncti- of the ocular implant. The implant should rest behind
val fornix, and lateral canthus are infiltrated with an the inferior orbital rim without requiring posteriorly
anesthetic mixture containing epinephrine. The pros- directed pressure to keep it in position. A tendency of
thesis may be removed or left in position. A cantho- the implant to prolapse anteriorly at the time of sur-
tomy is performed with a no. 15 Bard-Parker blade. gery indicates excessive anteroposterior dimension of
Cantholysis of the inferior crus of the lateral canthal the implant for the exposed floor. The area of floor
tendon is achieved with straight scissors. The lid is exposure should be enlarged to accommodate the
retracted inferiorly to reveal the conjunctival fornix. implant or the implant should be trimmed. Simi-
The conjunctiva and retractor layer is incised from the larly, horizontal buckling of the implant indicates
lateral canthus to the caruncle with Westcott scissors. excessive implant size for the amount of exposed
The lower eyelid is grasped with larger retractors orbital floor. Buckling of the implant should prompt
greater subperiosteal exposure or decreased width
of the implant. The implant should not be placed too
FIGURE 26–7 Subperiosteal placement of a volume

implant along the orbital floor can augment orbital volume FIGURE 26–8 Schematic demonstrating proper posi-
as demonstrated by this cadaver skull model. tioning of an orbital floor volume implant (“sled”).
CHEN26-369-386.I 3/22/01 2:37 PM Page 375
excessively anterior as this may shorten the inferior Surgical Technique

fornix. The procedure is started as described above. After the
horizontal conjunctival incision is made, the prior
implant is encountered. The implant is removed with
a combination of sharp and blunt dissection. Once
EARL... Inferior orbital rim perios-
P teum may be closed to help prevent
implant migration and extrusion; however, it
explanted, sharp and blunt dissection opens the
extraocular muscle cone. A capsule around the prior
implant is frequently encountered. It should be
may also cause eyelid retraction and shortening removed and may be used as a covering for the new
of the conjuctival fornix. implant if removed intact. The fornices are freed with
sharp dissection. The rectus muscle groups are iden-
tified, tagged with Vicryl suture, and sewn to a new
For this reason, we generally prefer not to close the implant sphere as described above. A conformer and
orbital rim periosteum. Usually, meticulous attention tarsorrhaphy suture are placed. The tarsorrrhaphy is
in implant placement without tension is all that is removed 1 week after surgery followed by prosthesis
required to prevent extrusion. The conjunctival inci- fitting 8 weeks after surgery.
sion is closed with absorbable suture (e.g., 6-0 mild
chromic) in either a running or simple interrupted Implant Exposure
fashion. The lateral canthal tendon is resuspended to Exposure of the anophthalmic implant may occur in
the internal periosteum of the lateral orbital rim with the immediate postoperative period or in a well-
a 4-0 Vicryl or 5-0 Prolene suture. Horizontal lid tight- healed anophthalmic socket. The primary cause of
ening procedures may be performed at this time if most implant exposures is probably mechanical.
indicated. One skin suture is usually required to close Implant exposures in the immediate postoperative
the small canthotomy incision. A conformer is placed period may be caused by excessive implant size, poor
to fill the conjunctival fornices without exerting ten- conjunctival wound closure, poor conjunctival tissue
sion on the eyelids or conjunctival wound. A simple quality, excessive conformer size, or excessive post-
tarsorrhaphy suture aids in holding the conformer in operative edema. Delayed implant exposures may
good position for the first postoperative week. The result from an abnormal mechanical interaction
prosthesis may be modified or fabricated 8 weeks between the implant and the prosthesis. Examples of
after surgery. such abnormal interactions would be an irregularity
of the implant wrapping material, abrasive surface of
a porous ocular implant, poor prosthetic fit, or unrec-
Implant Migration
ognized trauma to the socket during implant inser-
Implants may migrate to any position within the orbit tion/removal. Bacterial infection usually complicates
over time. The lack of rigid fixation of extraocular implant exposure and probably plays a significant
muscle to the implant with suture material at the time role in the pathogenesis. A vicious cycle of wound
of enucleation predisposes to implant migration. dehiscence, implant exposure, and implant infection
Implant migration can cause shallowing of conjuncti- ensues. If this vicious cycle progresses, implant extru-
val fornices or secondary eyelid malpositions. These sion is the likely end result. However, in some
abnormalities may cause difficulty keeping the pros- patients the process proceeds in a more indolent fash-
thesis well positioned in the anophthalmic socket. ion. For these patients, an attempt at salvaging the
This poor positioning may cause frequent involuntary ocular implant can be worthwhile.
extrusion of the prosthesis, giant papillary conjunc-
tivitis, or unacceptable cosmetic results (Fig. 26–5).
Implant migration may additionally complicate inad- Management: Patch Grafting
equate orbital volume. Initial management of an implant exposure includes
removal of the conformer or prosthetic and initiation
of antibacterial therapy. The conformer or prosthetic
Management: Secondary Ocular Implant is removed because it may be a source of mechanical
If an ocular implant is poorly positioned in the orbit, stress on the wound. Additionally, if left in place it
removal of the ocular implant with implantation of can trap purulent mucus over the dehiscence and act
another implant within the extraocular muscle cone detrimentally toward clearing infection. Cultures are
is indicated. If the orbital volume is inadequate, an appropriate diagnostic test as long as the tissue is
replacement of the implant with a sphere of larger not traumatized. Intense topical antibiotics are indi-
diameter is indicated. cated and oral systemic antibiotics may be helpful.
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Medical therapy alone may allow some implant expo- the clinician knows that extrusion is imminent. Occa-
sures to heal. However, many will not heal and will sionally complete extrusion will occur prior to the
require surgical management. patient consulting the physician for a problem.
The intuitive surgical procedure to repair an Late extrusions can also occur. These are often
implant exposure would be simple closure of the con- more indolent and present with discharge and
junctiva over the defect. However, this is not usually implant exposure that slowly progresses. Delayed
possible. The conjunctiva adjacent to the area of implant exposures and extrusions may be more com-
exposed implant is generally extremely friable. The mon with porous ocular implants13, 15 (Fig. 26–4).
tissue is often not healthy enough to support direct
closure. A surgical option is to sew a patch graft of Management Option 1: Secondary Ocular
into the area. An attempt to place a patch graft is war- Implant
ranted when the size of the defect tempts the surgeon Some surgeons prefer to allow the implant to
to free the conjunctival edges and close the defect pri- extrude spontaneously or remove the implant and
marily. If the conjunctival defect is large enough that allow the socket to heal. We generally proceed
the surgeon intuitively senses that direct closure even directly with a secondary ocular implant or dermis-
with freeing conjunctival edges is not possible, a more fat graft to the orbit.
significant socket revision (e.g., secondary ocular If the implant is removed and the socket is allowed
implant, dermis-fat graft) is probably indicated. Patch to heal, the result will be an extremely contracted
grafting should only be considered when the exposed socket. Placement of a secondary implant after such
implant has not migrated anteriorly. contracture can be technically difficult as the muscle
cone is often extremely scarred and contracted. With
Surgical Technique poor muscle cone anatomy, the patient remains at risk
for repeat implant extrusion or migration. For these
After local anesthesia, the operative area is prepped
reasons we proceed with socket reconstruction prior
with 5% povidone iodine solution. A lid speculum or
to extrusion if possible. If extrusion has occurred, we
eyelid retraction sutures are placed. The conjunctival
proceed as soon as possible.
edges are freed from the implant to create adequate
If most of the conjunctiva is present, a secondary
pockets to hold the patch graft. Autogenous fascia or
ocular implant may be placed. Placement of a sec-
donor sclera is used to fashion a patch for the defect.
ondary ocular implant in the face of an extruding
Biologic tissues are preferred to alloplastic materials
implant will have an increased risk of extrusion when
for use as a patch graft. The patch is sewn onto the
compared to secondary ocular implants in nonin-
implant with absorbable suture. The patch should lie
fected sockets. Patients should be advised that
flat without areas of irregularity. The patch should
implant infection and extrusion may occur after the
cover any mechanical irregularities of the implant
secondary implant procedure. Despite this risk, most
without causing any additional mechanical irregu-
secondary ocular implant procedures in this setting
larities. The conjunctiva is draped over the patch and
do not progress to repeat extrusion.
sewn into position with absorbable suture. Ideally,
the patch provides a more favorable scaffolding,
Surgical Technique
allowing conjunctiva to ultimately cover the defect.
Although scleral patch grafting may be successful, it The technique for placement of the secondary ocular
is plagued by a significant failure rate. Persistent implant is essentially the same as described above.
implant exposure may necessitate a secondary ocu- After general anesthesia, the explanted sphere is
lar implant procedure or dermis-fat grafting to the removed and discarded. The soft tissues are infil-
orbit. trated with an anesthetic mixture containing epi-
nephrine. The anophthalmic socket is vigorously
cleansed with 5% povidone iodine solution. Eyelid
Implant Extrusion traction sutures are placed. Surgical gauze is used to
All ocular implants carry some risk of extrusion. debride the socket. The socket is copiously irrigated
Extrusion most often occurs in the immediate postop- with an antibiotic solution such as cefazolin or clin-
erative period but may also occur after some period of damycin. A smaller implant sphere is selected (1 to
time. When extrusion occurs in the immediate post- 2 mm smaller in diameter). The new implant sphere is
operative period it usually presents with copious wrapped with either autogenous fascia or donor
purulent discharge associated with implant exposure. sclera. (Before donor sclera is selected, the potential
Occasionally the implant exposure is hard to detect risks of donated biologic tissue should be discussed
because it is obscured by the discharge. However, the with the patient.) The new orbital implant is soaked
implant becomes progressively exposed such that in antibiotic irrigation. The socket is inspected for
CHEN26-369-386.I 3/22/01 2:37 PM Page 377
contracture of the muscle cone. If muscle cone con-

EARL... Removal of epidermis with
P
tracture has started posterior in the orbit, the muscle
cone should be opened with a combination of blunt
the drill is much easier if performed prior
and sharp dissection. Each rectus muscle group is iso-
lated with a double-armed 5-0 Vicryl suture. Each rec- to the full-thickness skin incision.
tus muscle group is then sewn to the implant sphere
in its respective anatomic fashion. The Vicryl sutures The epidermis is removed until the skin is glisten-
are passed through the fornices to relieve tension ing white and the vascularity of the rete pegs can be
from the wound closure. Tenon’s capsule and con- visualized. The skin incision is then completed. Met-
junctiva are closed in separate layers with interrupted zenbaum scissors are used to deliver the skin with a
sutures if possible. A conformer is placed. The tars- large amount of attached fat. The donor site is closed
orrhaphy suture should bring the eyelids together with interrupted absorbable sutures to bring the
without tension. wound edge together. Skin is closed with a 5-0 non-
absorbable running subcuticular suture.
Management Option 2: Dermis-Fat Graft The dermis-fat graft is delivered to the anoph-
Placement of a secondary ocular implant is a viable thalmic socket. The double-armed Vicryl sutures
option for treating an extruding ocular implant.25, 26 placed in the recti muscles serve as cardinal sutures.
However, placement of a dermis-fat graft into the One end of the suture is passed through the conjunc-
anophthalmic socket holds several advantages. First, tival wound edge, and the other end is placed
secondary implant placement requires adequate con- through the graft. As the cardinal sutures are passed
junctiva for closure. In cases where conjunctiva is and tied, cotton-tipped applicators are helpful for
deficient, placement of the dermis fat graft adds suit- repositioning the fat component of the graft back into
able lining skin to the anophthalmic socket. Dermis in the orbit. After the cardinal sutures are placed, the
the anophthalmic socket adds a strong lining tissue at conjunctival-dermis interface is closed with inter-
the expense of some additional socket discharge rupted 5-0 Vicryl suture. The tissue added by the der-
caused by the dermis. Second, the rate of infection or mis usually permits placement of a large conformer
overt graft failure is extremely low even in infected without difficulty. A simple tarsorrhaphy suture is
sockets. Although overt graft failure is uncommon, placed. Postoperative care consists of removing the
significant graft shrinkage (fat atrophy) may occur tarsorrhaphy after 1 week. If the socket is suitable, a
over time and may indicate subacute graft failure new prosthesis may be fashioned after 8 weeks.
(Fig. 26–9).
PITFALL
Surgical Technique
After anesthesia, the anophthalmic socket is pre- Fat atrophy is a common occurrence after
pared in a similar fashion to that described above.
placement of an orbital dermis-fat graft.
Local anesthetic with epinephrine is injected. The
implant sphere is removed and discarded. The socket
is vigorously cleansed with povidone-iodine and
antibiotic irrigation. Any socket contracture is If loss of orbital volume is significant, a secondary
released and the conjunctival fornices are freed with ocular implant may be placed behind the dermis-fat
sharp dissection. Each rectus muscle group is iso- graft. Although fat atrophy is common, dermis-
lated with a 5-0 Vicryl suture. fat grafts placed in young children may demonstrate
The left lower quadrant of the abdomen is prepared progressive growth.27 The progressive growth may
for tissue harvesting. The right lower quadrant is even require secondary surgical debulking to treat
avoided to prevent future confusion regarding appen- proptosis. Significant growth has been seen only in
dectomy incisions at McBurney’s point. (Alternative younger children. Some patients develop difficulties
sites for harvesting include the upper outer quadrant with wound healing and epithelialization of the der-
of the buttocks and the lateral thigh.) Local anesthetic mal portion of the graft.28
with epinephrine is injected. An ellipse is marked par-
allel to and above the inguinal line. A no. 15 Bard- Shallow Inferior Conjunctival Fornix
Parker blade scores the skin at the resection margins Shallowing of the inferior conjunctival fornix is com-
at a partial skin thickness depth. The epidermis is mon in anophthalmic sockets. Sometimes the shal-
removed with a high-speed drill and a large diamond lowness will remain stable over time. However, the
burr. fornix may become progressively shallow in some
CHEN26-369-386.I 3/22/01 2:37 PM Page 378
A B
C D
FIGURE 26–9 Dermis-fat grafting to the anophthalmic socket. Each rectus muscle group is tagged with double-
armed suture (A). Each of the rectus muscle sutures is sutured to the dermis-fat graft as cardinal sutures (B). Anterior-
posterior view (C) and cross-sectional view (D) after placement of a dermis-fat graft to the orbit. The fornix suture in
(D) is optional and used only when redirection of the fornix is indicated. (From Nunery and Hetzler.26)
patients. The lack of an anophthalmic implant or patients find a prosthesis that “pops out” without
implant migration may precipitate progressive loss of warning unacceptable for most social interactions.
the inferior fornix. Chronic conjunctival inflammation
may also cause progressive loss of the fornix. Deep- Management: Inferior Conjunctival Fornix
ening of the superior fornix is often present. Reconstruction
Shallowing of the inferior conjunctival fornix com- If the inferior fornix is shallow but has sufficient con-
bined with lower eyelid laxity may cause significant junctiva, full-thickness horizontal mattress eyelid
difficulty in wearing a prosthesis. The most common sutures may reform the inferior fornix. One end of
difficulty encountered is the prosthesis coming out of a double-armed suture is passed into the conjunctiva
the socket with relatively minor changes in head posi- at the desired position for the maximum depth of
tion, eyelid rubbing, or Valsalva maneuvers. Most the fornix. The needle is directed inferiorly to engage
CHEN26-369-386.I 3/22/01 2:37 PM Page 379
the periosteum at the inferior orbital rim. The needle from the lower lip for ease of harvesting and postop-
is then brought out through the skin. The second arm erative course.
of the suture is passed in an identical fashion. Three or
four horizontal mattress sutures may be passed to
...
redirect the inferior fornix. Passing all sutures prior
to tying can simplify the procedure. Sutures may be
tied over a cotton bolster. A similar technique with-
P EARL If prior grafts have been
harvested from the lower lip, buccal
mucous membrane anterior to Stensen’s duct is
out passage of sutures through the eyelid skin has also readily available.
been reported by Neuhaus and Hawes29 (Fig. 26–10).
Free Mucous Membrane Graft Surgical Technique

Although the inferior fornix with adequate conjunc- A local anesthetic is injected into the lower conjuncti-
tiva may be successfully redirected with the above val fornix and lower lip. The oral cavity can be pre-
technique, conjunctival shortening is frequently prepared with oral chlorhexidine soulution (Peridex),
sent. A shallow contracted inferior conjunctival fornix oral antiseptic rinse (e.g., Cepacol), or Betadine swab
can be reformed by combining the above techniques of the lower lip. The anophthalmic socket is prepared
with placement of an interpositional full-thickness in the usual fashion with 5% povidone-iodone solu-
mucous membrane graft graft.30 Before proceeding tion. A lateral canthotomy with cantholysis of the
with mucous membrane grafting to the conjunctival inferior crus of the lateral canthal tendon affords
fornix, the socket volume and implant position should good exposure to the conjunctival fornix. A conjunc-
be assessed. If inadequate volume or implant migra- tival incision is made with a no. 15 Bard-Parker blade
tion is detected, then a secondary ocular implant in the point of maximum depth of the contracted
should be considered. Often revision of the socket will fornix. Care should be taken not to incise directly
deepen the inferior fornix. Re-creation of a deep over an anophthalmic implant. If necessary, the inci-
fornix can be facilitated by passing the sutures as sion can be made at the inferior edge of the tarsus.
described above. Dissection is taken through the retractor layer. Dis-
If the volume and implant position are deemed section is carried inferiorly to create a deep pocket
adequate, placing an interpositional graft with posterior to orbicularis and anterior to orbital tissues.
mucous membrane is an excellent reconstructive The size of the pocket is estimated visually or mea-
option. Options for an interpositional graft include sured with a caliper.
hard palate mucous membrane, donor sclera, and The lower lip is everted digitially or with retrac-
Gore-tex. We prefer mucous membrane harvested tors. The size of the desired mucous membrane graft
A B
FIGURE 26–10 One technique of reformation of the inferior conjunctival fornix. The shallow inferior fornix (A) is
reformed by creating a surgical adhesion to the inferior orbital rim periosteum (B). (From Neuhaus and Hawes.29)
CHEN26-369-386.I 3/22/01 2:37 PM Page 380
is marked with methylene blue. After an incision with maneuvers that improve orbital volume. Ptosis may
a no. 15 Bard-Parker blade, the graft is harvested with also arise from levator dehiscence or attenuation.
sharp dissection using Westcott scissors. The full-thick- Some pathologic disorders that precede enucleation
ness graft is harvested as thinly as possible and should such as trauma or multiple surgical procedures can
not contain glandular tissue. Gelfoam and gauze are cause ptosis. Additionally, the repeated trauma of
packed over the donor site and the lip is allowed to removing and reinserting a prosthesis can change the
relax back to its regular position. The graft is placed levator complex and cause true ptosis. Excessive
mucosal side down on a wet gauze and thinned fur- shortening of the superior fornix during enucleation
ther with Westcott scissors. The graft is placed into the closure may induce ptosis.
pocket and sewn into position with 6-0 Vicryl suture. If Measurement of ptosis can be performed in stan-
horizontal lower eyelid tightening is necessary, a dard fashions; however, the results require careful
lateral wedge of full-thickness eyelid may be excised. interpretation. Levator function is commonly reduced
A large conformer is placed. Ideally, the conformer in anophthalmic sockets. However, they respond to
should rest in the center of the graft tamponading the shortening of the levator complex as if the levator func-
graft inferiorly to create a deep fornix without rubbing tion were normal. Lash ptosis is common in anoph-
on the conjunctival closure. Full-thickness eyelid mat- thalmic ptosis and should be evaluated prior to repair.
tress sutures may be utilized as an adjunct to direct the
conjunctival fornix inferiorly if necessary. Retinal Management: Ptosis Surgery
sponge material placed in the conjuunctival fornix may Because orbital volume affects eyelid height, orbital
also be used as a temporary splint for the mucous volume should be assessed and reasonably treated
membrane graft in the first postoperative week. The prior to considering ptosis surgery. The easiest
lateral canthal tendon is resuspended with absorbable maneuver is to modify the prosthesis. Enlarging the
or permanent suture depending on the surgeon’s pref- superior portion of the prosthetic often improves the
erence. A simple tarsorrhaphy suture may be placed. A eyelid height (Fig. 26–11). If the prosthetic cannot be
Frost-type suture taped to the forehead may give the enlarged further and the orbital volume deficit
lower lid greater height. remains significant, a secondary ocular implant
Pain from the mouth is generally greater than pain should be considered.
from the anophthalmic socket. Standard analgesics If orbital volume is adequate, so that a secondary
may be used but topical oral anesthetics that can be ocular implant is unnecessary, and if prosthesis
purchased without a prescription are very helpful. manipulation has not adequately managed the ptosis,
Bleeding from the donor site is usually controlled ptosis surgery is reasonable.
with ice and compresssion. A wet tea bag held to a
bleeding oral site may help with hemostasis. After
1 week, the Frost suture or tarsorrhaphy is removed. Surgical Technique
The conformer is left in place for 8 weeks until a new After injection of a local anesthetic mixture contain-
prosthesis can be fabricated. ing epinephrine, the position for the desired eyelid
crease is marked. If excess skin is present on the
Ptosis upper lid, it is marked for excision. The skin is
Ptosis is very common in the anophthalmic socket. excised. The orbicularis is incised and a suborbicual-
Ptosis may arise from inadequate orbital volume. This ris plane is carried inferiorly until the tarsus is iden-
may be considered pseudoptosis as it responds to tified. The orbital septum is opened widely and the
FIGURE 26–11 Modifications to the

prosthetic may improve some cases of
ptosis.
CHEN26-369-386.I 3/22/01 2:37 PM Page 381
levator aponeurosis is identified. If orbital fat is ment of a tissue patch graft. Large exposures or large
encountered the surgeon should resist the temptation conjunctival cysts may require more significant socket
to trim preaponeurotic fat pads, as resection of fat revision such as placement of a secondary ocular
will only worsen orbital volume deficits and superior implant or dermis-fat graft.
sulcus deformity.
The upper edge of the tarsus is marked with meth- Giant Papillary Conjunctivitis
ylene blue. The eyelid measurements are used to esti- Giant papillary conjunctivitis (GPC) is an inflamma-
mate the desired amount of levator shortening. An tory condition of the conjunctiva that presents with
area of levator resection corresponding to the amount complaints of mucoid discharge, socket irritation, and
of ptosis plus 2 mm is marked with methylene blue. itching. GPC is diagnosed by demonstrating giant
This marking is incised. The marked area of levator papillae on the conjunctival surface of the upper eye-
aponeurosis and Müller’s muscle are excised. This lid. By definition, giant papillae are 1 mm or greater
excision may be carried out with a no. 15 Bard-Parker in diameter. They frequently abut the next papillae to
blade, a Beaver blade, sharp-tipped Westcott scissors, creat the classic “cobblestone” appearance. Thick
or a hand-held cautery device. The cut edge of the mucoid discharge is often present between these
levator is fixated to the tarsus with 6-0 or 7-0 silk giant papillae.
suture. The eyelid is inspected for height, contour, Although GPC most frequently is considered a
and symmetry. complication of soft contact lens wear, it may compli-
The eyelid height may be adjusted if necessary. It is cate prosthetic wear. The pathogenesis of GPC is from
wise to have communicated with the ocularist regard- both mechanical and immunologic factors. Abnormal
ing plans for prosthetic modification. If the ocularist mechanical interaction between the prosthetic and the
has increased the prosthetic size to improve ptosis, eyelids causes conjunctival inflammation. Immuno-
some overcorrection is indicated so that the ocularist logic response to surface deposits on the prosthesis
can decrease the size of the prosthetic postopera- plays a significant role.
tively. If the ocularist has fabricated the prosthetic
Management of Giant Papillary Conjunctivitis
with a different visual axis (e.g., hypotropia) to help
mask the ptosis, then eyelid height adjustment is Giant papillary conjunctivitis differs from most other
dependent on the ocularist’s plans regarding the complications of anophthalmia in that the treatment is
visual axis in the new or modified prosthetic. Because medical and not surgical. Removal of the prosthesis
the ocularist can still adjust eyelid height in the post- will improve GPC. Although this option is helpful in
operative period, the contour of the eyelid is probably very symptomatic cases, removal of the prosthetic
the most important feature that should be adjusted in over a significant period of time is usually unaccept-
the operating room. able to the patient. The physician should inquire
After the levator has been repaired, the eyelid regarding the frequency of prosthetic cleaning. If the
crease is reformed by suturing the orbicularis or skin patient has not already initiated frequent cleanings,
margin to the levator complex with 6-0 mild chromic. more frequent cleanings should be recommended. A
This maneuver can rotate the eyelashes with proper common cleaning frequency for a patient with GPC
placement of the suture. Skin is closed with 6-0 mild is every other day, but daily cleaning may be indi-
chromic or 6-0 prolene. The eyelid repair is allowed 6 cated in severe cases. If discharge persists, the ocular-
weeks to heal prior to prosthetic manipulation. ist can polish the prosthesis to remove immunologic
deposits and surface irregularities. Some old prosthe-
Conjunctival Cysts ses may require replacement altogether.
Conjunctival cysts may occur in the anophthalmic Pharmacologic therapies may significantly im-
socket. They usually occur anteriorly in the midpor- prove GPC and allow for continued prosthetic wear.
tion of the socket and cause problems with prosthetic Topical ophthalmic antibiotics often help discharge
fit or comfort. Occasionally, they may grow in the by treating bacterial suprainfection. A short course of
orbital tissue and behave as an orbital mass.31 topical antibiotics (1 to 2 weeks) is often helpful. Pro-
longed therapy usually offers little benefit if discharge
Management: Conjunctival Cyst Excision is still significant while on antibiotics. The inflamma-
Conjunctival cysts can usually be removed with sim- tory response can be diminished with topical oph-
ple elliptical excision under local anesthesia. The bed thalmic steroids. Fluoromethalone (FML) 0.1% is often
of the wound can be allowed to granulate in most cir- successful acutely and chronically at suppressing con-
cumstances. As the conjunctival cyst usually arises junctival inflammation. Prednisolone acetate 1% may
just anterior to the implant, cyst excision may precip- be used for severe cases. Inhibition of the inflamma-
itate implant exposure. Should an implant exposure tory response with mast cell stabilizers such as cro-
occur, it may be managed by mobilizing the conjunc- molyn sodium is an excellent long-term therapy to
tival wound edges followed by direct closure or place- improve GPC.
CHEN26-369-386.I 3/22/01 2:37 PM Page 382
CONGENITAL ANOPHTHALMIA grafting is finite. Because the tissues are actively

growing, insertion of gradually enlarging conformers
Congenital anophthalmia is a very rare birth defect. or prostheses stimulates soft tissue growth and soft
In most cases of clinical congenital anophthalmia, tissue expansion.36 Soft tissue expansion is generally
some residual ocular tissue can be identified. Severe the first phase of reconstruction and often lasts 3 to 6
microphthalmia may be congenital or acquired (e.g., months. Once initial expansion is complete, orbital
end-stage retinopathy of prematurity) and should be volume deficiency is addressed. Additional soft tis-
managed with similar considerations as true congen- sue expansion is often required after management of
ital anophthalmia. orbital volume by placing an ocular implant.
Anophthalmia in young children causes a unique
series of complications when compared to that in Bony Orbit Expansion
adults. The lack of adequate globe volume causes Animal and clinical evidence demonstrates that
inadequate growth of orbital bone and soft tissues.32 placement of an ocular implant within the congeni-
The presentation of congenital anophthalmia includes tally anophthalmic orbit stimulates bony orbital
blepharophimosis, ptosis, conjunctival contracture, growth.32–35 Implant selection must be individual-
inadequate conjunctival fornices, deficient orbital soft ized; however, we generally place the largest sili-
tissue volume, and deficient bony orbital volume. The cone sphere possible. In infants, a 16-mm sphere can
natural course of untreated congenital anophthalmia usually be placed. Larger spheres are placed later
is apparent gradual worsening of soft tissue inade- after the bony orbit has a chance to develop in
quacies and bony orbital hypoplasia. The natural response to the implanted volume. Usually it is rea-
course is usually not a true worsening of soft tissue sonable to attempt placing an adult-sized implant,
and bony orbit deficiencies but an increase in apparent such as a 20-mm sphere, by age 5 years.
deformity as the remainder of the face and sometimes Silicone is the preferred implant material for mul-
the normal contralateral orbit grow and develop. tiple reasons. First, implanting the largest allowable
sphere is necessary for orbital expansion but tempts
extrusion. The lower exposure and extrusion rate of
MANAGEMENT OF CONGENITAL silicone spheres when compared to porous implant
ANOPHTHALMIA materials make it a preferable choice. Second, repeat
surgery to place larger spheres is common as the child
Treatment of anophthalmia or severe microphthalmia grows. Silicone heals with less scar formation in the
in a small child should begin as soon as possible. Ani- orbit, making secondary surgery technically easier for
mal model studies demonstrate that enucleation early the surgeon and more easily tolerated by the patient.
in development causes inadequate orbital develop-
ment.33 The complications of congenital anophthalmia
Surgical Technique: Anterior Approach
should be addressed as early as possible to optimize
the restoration of orbital bony growth and soft tissue Ocular implants may be placed by either of two sur-
development.33–35 gical approaches.
EARL... The anterior approach is

P EARL ... Treatment of congenital
anophthalmia consists of soft tissue P well suited when significant residual ocular
tissue requires its removal and the amount of
expansion and bony orbital expansion. Soft tis-
sue expansion is achieved by placement of grad- conjunctival deficiency is mild or moderate.
ually enlarging conformers by an ocularist. Bony
orbital growth relies on surgical placement of
The anterior approach is essentially a traditional
ocular implants of increasing size. enucleation with minor modifications.
After general anesthesia, the retrobulbar space and
conjunctival surface is injected with an anesthetic mix-
Soft Tissue Expansion ture of 1% lidocaine, 0.25% bupivacaine, and 1:100,000
Although increasing soft tissue volume in adults gen- epinephrine. The local anesthetic aids in hemostasis
erally involves grafting tissue to the deficient tissue and postoperative pain control. It may be modified as
bed, this is a less feasible option in small children. needed for anesthetic safety for young patients or
Direct grafting of tissue is less feasible as the need for additional medical conditions. A 360-degree conjunc-
tissue volume is large and the available tissue for tival peritomy is performed with Westcott scissors
CHEN26-369-386.I 3/22/01 2:37 PM Page 383
and toothed forceps. Dissection is carried down to incision should not exceed 2 to 4 mm. Sharp soft tis-
bare sclera in all quadrants. If extraocular muscles can sue dissection is taken down to the lateral orbital rim.
be identified, they should be isolated using a muscle After the lateral rim is identified, blunt dissection
hook and tagged with 6-0 Vicryl sutures. If identifi- anterior to the rim creates an opening for the implant
able, the extraocular muscles may be disinserted from sphere within the soft tissue of the orbit. The largest
the globe with Westcott scissors. The remnants of the silicone sphere possible is inserted into the orbit. A
globe can be removed with sharp dissection or a lateral orbital bone window is generally not necessary
snare. The largest possible silicone sphere is placed but may be used as an adjunct. The conjunctiva may
into the muscle cone or centrally in the orbit through be closed with Vicryl suture if necessary. The canthal
the conjunctival peritomy. If the extraocular muscles tendons are reattached to the internal periosteum of
were identified and tagged with suture, then they may the lateral orbit with 5-0 Vicryl or Prolene. A standard
be sewn to the implant sphere. The implant sphere is or custom-made conformer is placed. A simple tar-
used unwrapped if there may be a need to replace the sorrhaphy suture generally holds the conformer in
implant with a larger implant at a later time. If good position.
extraocular muscles are not identifiable, then the
implant can be placed in the center of the orbit as pos-
terior as possible. Tenon’s capsule is closed with 5-0 CONCLUSION
or 6-0 Vicryl in a buried interrupted fashion. The con-
junctival edges may be closed with similar suture in Surgeons have much to offer patients who have
either a simple running or simple interrupted fashion. required removal of an eye for a variety of problems
An acrylic conformer is in the anophthalmic socket. A such as phthisis bulbi, irreparable trauma, and
simple tarsorrhaphy stitch using Vicryl or mild intraocular tumors. The best approach to achieving
chromic should close the eyelids without tension. satisfactory functional and cosmetic results is
proper enucleation technique. However, even with
optimal enucleation surgery complications of
Surgical Technique: Lateral Approach anophthalmia may occur.
The lateral approach is well suited for anophthalmic Many different goals exist in evaluating and treat-
sockets with severe conjunctival deficiency and with- ing the anophthalmic socket. Proper evaluation of the
out a need to remove remnants of ocular tissue. The anophthalmic socket relies on a systematic approach
lateral approach has a greater chance of implant mal- to delineate which mechanical complications of
position but much less chance of implant extrusion, anophthalmia are present (Fig. 26–12). Once all
even with large implants. mechanical complications are understood, a surgical
After general anesthesia, the anesthetic mixture plan may be created and executed to improve these
containing epinephrine is injected into the retrobul- mechanical problems. A laudible goal is that the
bar space and lateral canthus. A 5- to 10-mm lateral patient is pleased with the surgical and prosthetic
canthotomy is made with a no. 15 Bard-Parker blade. result. However, the ultimate goal is that patients are
Cantholysis of inferior and superior crura of the lat- pleased with themselves as a person. To that end both
eral canthal tendon is achieved with straight sharp the surgeon and the ocularist play a significant role in
scissors. The conjunctiva may be opened as an exten- fostering patients’ self-esteem against the short- and
sion of the lateral canthotomy, but the conjunctival long-term stress of having an eye removed.
REFERENCES
1. Bosniak SL: Reconstruction of the anophthalmic 4. Smit TJ, Koornneef L, Mourits MP, Groet E, Otto AJ:
socket: state of the art. Adv Ophthalmic Plast Reconstr Primary versus secondary intraorbital implants. Oph-
Surg 1987; 7:313–348. thalmic Plast Reconstr Surg 1990;6:115–118.
2. Custer P, Cook B: The team approach to the anoph- 5. Kronish JW, Gonnering RS, Dortzbach RK, Rankin JH,
thalmic patient. Adv Ophthalmic Plast Reconstr Surg Reid DL, Phernetton TM: The pathophysiology of the
1990;8:55–57. anophthalmic socket. Part I. Analysis of orbital blood
3. Smit TJ, Koornneef L, Zonneveld FW, Groet E, Otto flow. Ophthalmic Plast Reconstr Surg 1990;6:77–87.
AJ: Primary and secondary implants in the anoph- 6. Kronish JW, Gonnering RS, Dortzbach RK, et al: The
thalmic orbit: preoperative and postoperative com- pathophysiology of the anophthalmic socket. Part II.
puted tomographic appearance. Ophthalmology 1991; Analysis of orbital fat. Ophthalmic Plast Reconstr Surg
98:106–110. 1990;6:88–95.
CHEN26-369-386.I 3/22/01 2:37 PM Page 384
No Implant Secondary
Ocular
Socket Implant
Deficient Small Implant
Volume
Subperiosteal
Adequate Implant Volume
OK Augmentation
Migrated Secondary
Implant Ocular
Poor
Position Good Conjunctiva Implant
Extruded
Dermis-Fat
Poor Conjunctiva
Graft
OK
Small Patch Graft
Implant
Exposed Medium Secondary
Coverage
Ocular
Implant
Covered Dermis-Fat
Large
Graft
Secondary
Poor Volume
Ocular
Prosthetic Implant
Poor
Retention
Good Volume
Good
Cul-de-sac
Reconstruction
Retraction
Lower
Eyelid
Position Horizontal
Laxity Eyelid
Tightening
Good
May modify
Normal Prosthetic
Upper Prosthesis
Eyelid Ptosis
Position Ptosis
Large Prosthetic
Repair
FIGURE 26–12 Summary for evaluation and treatment of the anophthalmic socket. Although the complexities of
the anophthalmic socket prevent strict adherence to any set protocol of treatment, this schema is one rational approach
to approaching the identification and the management of the mechanical complications of anophthalmia.
7. Kaltreider SA, Wallow IH, Gonnering RS, Dortzbach 11. Massry GG, Holds JB: Coralline hydroxyapatite
RK: The anatomy and histology of the anophthalmic spheres as secondary orbital implants in anophthal-
socket—is the myofibroblast present? Ophthalmic Plast mos. Ophthalmology 1995;102:161–166.
Reconstr Surg 1987;3:207–230. 12. Kaltreider SA, Newman SA: Prevention and manage-
8. Kaltreider SA, Jacobs JL, Hughes MO: Predicting the ment of complications associated with the hydroxyap-
ideal implant size prior to enucleation. Ophthalmic Plast atite implant. Ophthalmic Plast Reconstr Surg 1996;
Reconstr Surg 1999;15:37–43. 12:18–31.
9. Ashworth JL, Rhatigan M, Sampath R, Brammar R, 13. Buettner H, Bartley GB: Tissue breakdown and expo-
Sunderland, Leatherbarrow B: The hydroxyapatite sure associated with orbital hydroxyapatite implants.
orbital implant: a prospective study. Eye 1996;10: Am J Ophthalmol 1992;113:669–673.
29–37. 14. Nunery WR, Cepela MA, Heinz GW, Zale D, Martin
10. Karesh JW, Dresner SC: High density porous polyeth- RT: Extrusion rate of silicone spherical anophthalmic
ylene (Medpor) as a successful anophthalmic socket socket implants. Ophthalmic Plast Reconstr Surg 1993;
implant. Ophthalmology 1994;101:1688–1696. 9:90–95.
CHEN26-369-386.I 3/22/01 2:37 PM Page 385
15. Nunery WR, Heinz GW, Bonnin JM, Martin RT, Cepela 26. Nunery WR, Hetzler KJ: Dermal-fat graft as a primary
MA: Exposure rate of hydroxyapatite spheres in the enucleation technique. Ophthalmology 1985;92:1256–1261.
anophthalmic socket: histopathologic correlation and 27. Heher KL, Katowitz JA, Low JE: Unilateral dermis-fat
comparison with silicone sphere implants. Ophthalmic graft in the pediatric orbit. Ophthalmic Plast Reconstr
Plast Reconstr Surg 1993;9:96–104. Surg 1998;14:81–88.
16. Christmas NJ, Gordon CD, Murray TG, et al: Intraor- 28. Shore JW, McCord CD Jr, Bergin DJ, Dittmar SJ,
bital implants after enucleation and their complica- Maiorca JP, Burks WR: Management of complications
tions: a ten-year review. Arch Ophthalmol 1998;116: following dermis-fat grafting for anophthalmic socket
1199–1203. reconstruction. Ophthalmology 1985;92:1342–1350.
17. Custer PL,Trinkaus KM, Fornoff J: Comparative motil- 29. Neuhaus RW, Hawes MJ: Inadequate inferior cul-
ity of hydroxyapatite and alloplastic enucleation desac in the anophthalmic socket. Ophthalmology 1992;
implants. Ophthalmology 1999;106:513–516. 99:153–157.
18. Jordan DR, Chan S, Mawn L, et al: Complications asso- 30. Weiss RA, McCord CD Jr, Ellsworth RM: Reconstruc-
ciated with pegging hydroxyapatite orbital implants. tion of the anophthalmic socket: lower eyelid malposi-
Ophthalmology 1999;106:505–512. tion and canthal tendon laxity. Adv Ophthalmic Plast
19. Karesh JW: Polytetrafluoroethylene as a graft material Reconstr Surg 1990;8:209–213.
in ophthalmic plastic and reconstructive surgery. An 31. Smit TJ, Koornneef L, Zonneveld FW. Conjunctival cysts
experimental and clinical study. Ophthalmic Plast Recon- in anophthalmic orbits. Br J Ophthalmol 1991;75: 342–343.
str Surg 1987;3:179–185. 32. Fountain TR, Goldberger S, Murphree AL: Orbital
20. Beaver HA, Patrinely JR, Holds JB, Soper MP: Periocu- development after enucleation in earky childhood.
lar autografts in socket reconstruction. Ophthalmology Ophthalmic Plast Reconstr Surg 1999;15:32–36.
1996;103:1498–1502. 33. Heinz GW, Nunery WR, Cepela MA: The effect of mat-
21. Hornblass A, Biesman BS, Eviatar JA: Current tech- uration on the ability to stimulate orbital growth using
niques of enucleation: a survey of 5439 intraorbital tissue expanders in the anophthalmic cat orbit. Oph-
implants and a review of the literature. Ophthalmic Plast thalmic Plast Reconstr Surg 1997;13:115–128.
Reconstr Surg 1995;11:77–88. 34. Tucker SM, Sapp N, Collin R: Orbital expansion in the
22. Conn H, Tenzel D, Schou K: Subperiosteal volume aug- congenitally anophthalmic socket. Br J Ophthalmol 1995;
mentation of the anophthalmic socket with RTV silas- 79:667–671.
tic. Adv Ophthalmic Plast Reconstr Surg 1990;8:220–228. 35. Cepela MA, Nunery WR, Martin RT: Stimulation of
23. Rose GE, Sigurdsson H, Collin R: The volume deficient orbital growth by use of expandable implants in the
orbit: clinical characteristics, surgical management, and anophthalmic cat orbit. Ophthalmic Plast Reconstr Surg
results after extraperiorbital implantation of Silastic 1992;8:157–169.
block. Br J Ophthalmol 1990;74:545–550. 36. Dootz GL: The ocularists’ management of congenital
24. Sergott TJ, Vistnes LM: Correction of enophthalmos micophthalmos and anophthalmos. Adv Ophthalmic
and superior sulcus depression in the anophthalmic Plast Reconst. Surg 1992;9:41–56.
orbit: a long-term follow-up. Plast Reconstr Surg 1987;
79:331–338.
25. Migliori ME, Putterman AM: The domed dermis-fat
graft orbital implant. Ophthalmic Plast Reconstr Surg
1991;7:23–30.
CHEN26-369-386.I 3/22/01 2:37 PM Page 386
CHEN27-387-418.I 3/26/01 8:55 AM Page 387
Chapter 27
ORBITAL DISEASES
Joseph A. Mauriello Jr.
Evaluation of orbital disease requires determination

...
P
of (1) the anatomic site and pattern of involvement, EARL Tumors, especially if they
whether diffuse or localized, and whether or not
are rapidly growing, may undergo hemor-
accompanied by a sinus and/or bone component;
and (2) whether the disease is a result of inflamma- rhage or necrosis, incite inflammation, and
tion or tumor.1–6 thereby mimic an inflammatory condition
The site of the disease may be inferred from the (Figs. 27–1 and 27–2).
history and clinical examination but is best defined
by axial and coronal orbital computed tomography
(CT). Anatomic sites may be divided into intra- At other times, scleral perforation may causes hem-
conal, within the extraocular muscles; extraconal, orrhage and mimic an inflammatory condition.7
within the bony wall of the orbit; and lacrimal A detailed history, examination, and orbital CT is
gland. In addition to the anatomic site, it is impor- essential to establish the site of the disease process as
tant to determine whether the process is diffuse or well as the appropriate differential diagnosis. The deter-
focal. The former process tends to favor an inflam- mination of whether orbital disease is present may
matory process or lymphoma whereas the latter sometimes partially be dependent on Hertel exophthal-
favors a tumor. mometry, a measure of the degree of proptosis relative
Axial proptosis suggests an intraconal process. The to the lateral orbital rim.8 It is useful to note that studies
direction of the nonaxial proptosis will determine the show proptosis varying by race. White male Hertel
site of pathology outside the muscle cone. Inferonasal exophthalmometry measurements range from 16.5 to
displacement of the globe, for example, is typical of a 21.7 mm, and white female from 15.4 to 20.1 mm. For
lacrimal gland mass located superotemporally along black males and females, these measurements are
the orbital rim. Limited elevation of the involved approximately 2 mm greater for the low normal, and
globe suggests a superior orbital mass or a tight infe- 3 mm greater for the upper limit of normal.8
rior rectus muscle inflamed and thickened by thyroid In the pediatric age group, the most common causes
orbitopathy (see Chapter 20). of tumors that have a rapid growth rate, and thereby
Bone or sinus involvement may accompany certain mimic an inflammatory process, include: rhabdo-
inflammatory processes such as Wegener’s granulo- myosarcoma, metastatic neuroblastoma, leukemia,
matosis but is extremely rare in disorders such as teratoma, granulocytic sarcoma, lymphangioma with
orbital inflammatory pseudotumor. Similarly, tumors hemorrhage.4 The most common causes in adults are
may primarily arise in bone such as osteoblastoma or large cell lymphoma or Burkitt’s lymphoma, and orbital
invade bone secondarily such as metastatic breast hemorrhage. Ruptured dermoid cysts may appear in
cancer. both age graps, but most commonly in children.4
387
CHEN27-387-418.I 3/22/01 2:39 PM Page 388
A B
FIGURE 27–1 (A) A 73-year-old man with a 3-day his-
tory of acute pain and swelling of left orbit. Vision had grad-
ually decreased to no light perception over a 4-year period.
Note inferotemporal displacement of proptotic globe with
marked hemorrhagic chemosis of conjunctiva and opacified
cornea. (B) Axial computed tomograph (CT) shows episcle-
ral extension of tumor causing apparent globe perforation.
(C) The tumor cells have basophilic nuclei with prominent
nuclei and abundant cytoplasm. Mitotic figures are present.
Low power shows tumor arising from the nonpigmented cil-
iary epithelium with periodic acid-Schiff (PAS)-positive
basement membrane surrounding individual cells. Despite
enucleation, the patient later died during reconstructive
surgery due to cardiac complications. Slides were reviewed
C at the ophthalmic branch of the Armed Forces Institute of
Pathology. (Adapted with permission from Mauriello et al.7)
Intraorbital or subconjunctival hemorrhage may
accompany any orbital tumor especially vascular orbital hemorrhage include: bleeding with an orbital
tumors and malignant tumors with rapid growth pat- tumor, especially hemangioma; less commonly, cav-
terns. Orbital hemorrhage may result in an inflam- ernous hemangioma, and hemangiopericytoma;
matory presentation.8 Specific orbital diseases may rarely a leukemic infiltrate or a metastatic neuroblas-
have the clinical signs and symptoms of pain, bilat- toma, which may be bilateral; or bleeding from an
erality, and enophthalmos. 8 Common causes of arteriovenous malformation, venous malformation,
varix lymphangioma, or a ruptured opthalmic artery
aneurysm (Fig. 27–3).6
Other causes of orbital hemorrhage include uncon-
trolled hypertension and blood dyscrasias, including
von Willibrand’s disease, hemophilia, and platelet
dysfunction due to severe kidney disease or a phar-
macologic agent.6
Rare causes of orbital hemorrhage include anemia,
scurvy, sickle cell anemia, hematic cysts, and malaria.6
Another clue to orbital processes is the presence of
orbital pain. Orbital pain may arise from inflamma-
tory processes and tumors. These include, most com-
monly, orbital cellulitis; idiopathic inflammatory
sundrome, including Tolosa-Hunt syndrome, involv-
ing superior orbital fissure, bacterial sinusitis, and
FIGURE 27–2 Patient after orbital biopsy of rhab- mucopyocele; cluster headache and migraine; sinoor-
domyosarcoma with acute massive proptosis due to appar- bital fungal infection. Orbital tumors that cause pain
ent tumor necrosis. Coronal orbital CT showed diffuse are, most commonly, adenoid cystic carcinoma;
orbital tumor prior to biopsy. (Adapted with permission nasopharyngeal, sinus carcinoma; metastatic carci-
from Mauriello.3) noma; schwannoma.4
CHEN27-387-418.I 3/22/01 2:39 PM Page 389
ORBITAL DISEASES • 389
A B
C D
FIGURE 27–3 (A) Elderly woman with superotemporally displaced and markedly proptotic right globe with grad-
ual onset over months. (B) Coronal CT scan shows peripheral inferior orbital mass. Intraoperatively the tumor invaded
the inferior oblique and inferior rectus muscles. (C) Biopsy by inferior orbitotomy shows spindle cells and ovoid-
shaped cells with prominent capillary network. The tumor does not show any malignant features. Typical storiform
pattern of tumor cells seen in this tumor is not prominent. (D) Photograph taken 5 years after presentation shows
improved position of globe, and there has been no recurrence on yearly CT for 10 years.
Rare causes of orbital pain include a tumor com- Orbital and intraocular calcifications are demon-
pressing a sensory nerve, especially at the foramen, strated on CT but are not visible on magnetic reso-
or an intracranial aneurysm.4 nance imaging (MRI).9 Causes of orbital and intra-
Causes of bilateral proptosis due to inflammation ocular calcifications are multiple and somewhat age
include thyroid orbitopathy, idiopathic orbital inflam- dependent. Calcifications may be extremely helpful
matory syndrome, Wegener’s granulomatosis, and in establishing a working differential diagnosis.
cavernous sinus thrombosis, most commonly result- Vascular lesions, such as venous angioma, Moncke-
ing from orbital cellulitis. The most common tumor berg’s sclerosis, and lymphangioma, may result in
that causes bilateral proptosis is lymphoma. Other orbital calcifications. Phleboliths may occur within a
more rare causes are metastatic neuroblastoma, vascular lesion or isolated, and may also result in
leukemia, and Langerhans’ granulomatosis. The lat- orbital calcifications.
ter includes the spectrum of Langerhans’ granulo- Tumorous causes of orbital calcifications include:
matosis or Histiocytosis X: eosinophilic granuloma,
fibro-osseous tumors
Hand-Schüller-Christian disease, and Letterer-Siwe
osteoma
disease. In extremely rare cases, malformations that
result in bilateral proptosis include congenital orbital ossifying fibroma
facial malformations, and ectropic brain.8a osteosarcoma
The most common causes of enophthalmos are dermoid cyst
due to an old blowout fracture, surgical trauma to dermolipoma
the orbit, silent sinus syndrome, and metastatic scir- plasmacytoma
rhous carcinoma. malignant epithelial lacrimal gland tumor
CHEN27-387-418.I 3/22/01 2:39 PM Page 390
mengingioma extremely rare. Cavernous hemangioma, schwan-

schwannoma noma, and isolated neurofibroma that originates from
optic nerve glioma a sensory nerve may be multiple (Fig. 27–4). Cav-
cavernous hemangioma ernous hemangiomas may grow during pregnancy.
hemangiopericytoma. Well-localized apparently encapsulated intraconal
tumors generally show evidence of gradual enlarge-
Intraocular calcifications that occur at an early age
ment over months and because of their intraconal
include the differential diagnosis of leukocoria:
location result in axial proptosis. With continued
retinoblastoma growth of the tumor, ultimately retinal striae and
Coats’ disease hyperopia develop.
persistent hyperplastic primary vitreous As indicated above, pain is more common with
Toxocara canis schwannoma and unusual in neurofibromas. It may
micropthalmos with cyst occur in about 20% of hemangiopericytomas.6 As
Intraocular calcifications at a later age that are most stated above, any intraconal tumor that causes hem-
common result from: orrhage may result in pain and sudden proptosis. The
author has observed such sudden hemorrhage with
phthisis bulbi hemangiopericytoma and cavernous hemangioma
optic nerve head drusen (Fig. 27–5). Patients with lymphangioma may also
senile hyaline plaque present with hemorrhage.
Rare causes include:
retinal dysplasia PITFALL
retinal astrocytoma
retinopathy of prematurity
Localized multiple tumors suggestive of cav-
choroidal osteoma
ernous hemangioma may also rarely be seen
The broad working classification of orbital tumors in patients with lymphangioma.
based on their anatomic presentation and pattern of
involvement on orbital CT presented below establishes
a differential diagnosis and management of tumors. On MRI, schwannomas and cavernous heman-
giomas are hypointense on T1-weighted images and
bright on T2-weighted images. Localized neurofibro-
INTRACONAL TUMORS mas occur in the third to fifth decade of life and are
Intraconal tumors are divided into those that origi- most often in the superior orbit.
nate from the optic nerve and its sheath and tumors
extrinsic to the optic nerve. Management
Intraconal (nonoptic nerve) tumors are better
observed unless there is significant proptosis, chori-
EARL... MRI, in selected cases, may
P help differentiate optic nerve tumors from
extrinsic tumors. Extrinsic tumors may appear
oretinal striae, progressive optic nerve disfunction
including loss of peripheral visual field, color vision,
and optic disk edema, or significant extraocular mus-
cle imbalance. It is difficult to justify removal of a
to obliterate the optic nerve on traditional CT.
well-circumscribed intraconal tumor in a patient who
has 20/20 vision and full ocular motility.
Coronal views are sometimes helpful to determine Cavernous hemangiomas are benign but heman-
exact location and position of optic nerve. In general, giopericytomas metastasize in 15% of cases and may
extrinsic tumors do not affect vision unless apical recur in 30% of patients. 12, 13 Any of these tumors
compression occurs. may be located anywhere in the lid or orbit. Bone
involvement in extraconal hemangiopericytomas is
Nonoptic Nerve Tumors rare in the author’s experience. Both fibrous histiocy-
The differential diagnosis of a well-circumscribed toma and hemangiopericytoma may also be localized
intraconal tumor that spares the optic nerve includes purely within the muscle cone. Solitary fibrous tumor
cavernous hemangioma, hemangiopericytoma, schwan- is a histologic variant of hemangiopericytoma. Histo-
noma, fibrous histiocytoma, isolated neurofibroma, logically, the spindle cell tumor has a storiform or cart-
benign intravascular papillary endothelial hyperpla- wheel-like pattern with intervening bands of dense
sia, and leiomyoma.10, 11 The two latter tumors are sclerotic collagen. Immunohistochemically distinctive,
CHEN27-387-418.I 3/22/01 2:39 PM Page 391
A B
FIGURE 27–4 (A) On axial magnetic resonance imaging (MRI) T1-weighted image, the tumor (cavernous heman-
gioma) is less intense than orbital fat, does not involve optic nerve, and displaces nerve laterally. (B) On T2-weighted
axial image, the lesion is hyperintense and enhances with contrast on fat suppression coronal MRI.
the tumor cells are CD-34 positive and S-100 negative, nerve compression, optic nerve sheath meningiomas
and are consistent with solitary fibrous tumor, a prob- within the optic canal result in early visual loss.
able histologic variant of fibrous histiocytoma. Meningiomas of the optic nerves are more aggressive
In both fibrous histiocytoma and hemangiopericy- than optic nerve gliomas especially when they occur
toma, metastases may occur most commonly to the in children14 (Fig. 27–6).
liver, bone, and lungs. Recurrence, metastases, and Optic nerve glioma occurs in childhood. Approxi-
death may occur after a long disease-free interval in mately 75% of optic nerve gliomas appear in the first
some patients 35 years after the original diagnosis. decade of life, and 90% appear in the first two decades.
Long-term follow-up is necessary.12, 13
EARL ...
P
Optic Nerve Tumors Approximately 30% of
The optic nerve tumors discussed here are known as patients with optic nerve gliomas have
optic nerve gliomas (pilocytic astrocytomas) and optic
neurofibromatosis and 15% of patients with neu-
nerve meningiomas. Optic nerve gliomas involve the
substance of the nerve and, therefore, cause earlier rofibromatosis have optic nerve gliomas.
loss of vision than optic nerve meningiomas and min-
imal associated proptosis. Again, as in apical intra-
conal orbital tumors that are subject to early optic Optic nerve gliomas have a limited growth pattern
and do not extend beyond the dura. They may cause
“kinky” distortions in the nerve and undergo muci-
nous or hemorrhagic degeneration.15
In patients with glioma or meningioma, optic
disk edema and optic disk pallor occur with almost
equal frequency.
...
P EARL Compression of the central
retinal vein may cause optic disk edema,
whereas compression of the optic nerve distal to
the central retinal vessel course within the nerve
substance causes optic disk pallor.16
Meningiomas arise within the meningothelial cells

FIGURE 27–5 Typical histopathologic pattern of benign that surround the optic nerve or ectopically and extra-
cavernous hemangioma with endothelial lines and cav- murally in the orbital soft tissues from embryonic rests
ernous spaces as compared to capillary-sized spaces in cap- of arachnida cells of ciliary nerves or within the orbital
illary hemangioma (not shown). bones. Most commonly they arise intracranially where
CHEN27-387-418.I 3/22/01 2:39 PM Page 392
A B
FIGURE 27–6 Right optic nerve meningioma with

centrally compressed lucent optic nerve (A) as compared
to fusiform thickening of optic nerve substance in patient
with optic nerve glioma with markedly decreased vision
shown on axial CT (B). On T1-weighted contrast MRI
(C), note enhanced glioma with nonenhanced arach-
noidal surround. C
the dura fuse to bone especially at the apex of the retrobulbar neuritis with few if any radiographic
orbit at the annulus of Zinn. Invasion of bone results signs of tumor. Progressive visual loss occurs with
in both bone erosion and hyperostosis.17, 18 tumor.
Again, patients with meningiomas and gliomas Gliomas cause fusiform thickening of the nerve
should be suspected of having systemic neurofibro- with the same density as the optic nerve. A character-
matosis. istic vertical kinking of the enlarged nerve just behind
the globe may be demonstrated on parasagittal MRI.
The edges of the tumor are smooth and bone erosion
SPECIAL CONSIDERATION
or hyperostosis and calcifications are rare. Enlarge-
ment of the optic foramen is most commonly due to
Bilateral gliomas usually suggest multifocal- expansion of the orbital segment of the optic nerve
ity and are almost universally associated due to optic glioma but may also result from an
with systemic neurofibromatosis because a enlarging chiasmal or intracranial optic glioma. With
single glioma is rarely sufficiently aggres- contrast, the glioma remains the same or shows dif-
sive to grow from one nerve to the other. In fuse uniform enhancement that involves the tumor
contrast, bilateral meningiomas may repre- that diffusely infiltrates the optic nerve (Figs. 27–6 and
27–7).19
sent spread of a single meningioma from one
MRI is superior to CT in delineating the posterior
optic nerve via the optic chiasm to the other
extent of a presumed glioma which is paramount in
optic nerve. surgical planning. Meningiomas tend to cause nar-
row thickening with a greater density than that of the
Approximately 15% of patients with neurofibro- optic nerve with railroad tracking. A lucent central
matosis have optic nerve gliomas. Optic nerve tumors compressed atrophic optic nerve is surrounded by a
in the canal cause early visual loss and may mimic a radiopaque tumor, the “tramtrack sign.”
CHEN27-387-418.I 3/22/01 2:39 PM Page 393
A B
FIGURE 27–7 (A) Whorls of meningothelial cells in meningioma. (B) Calcified psammoma body (whorls of
degenerated meningothelial cells) arising from proliferating arachnoid cells accompanying optic nerve glioma.
bital optic nerve are probably best left alone. Biopsy

EARL... The optic nerve sheath of
P
may be recommended if there is gross proptosis, loss
of vision to less than 20/200, or possible extension to
a meningioma has a cylindrical or irregu-
the chiasm.
lar growth pattern that enhances with contrast.
This pattern of growth and contrast enhance-
ment is not observed in a glioma. PITFALL
Coronal CT scans show a “bull’s-eye” appear- Marked arachnoidal hyperplasia associated

ance of the optic nerve with possible concomitant with gliomas may be confused pathologically
enlargement of the optic canal. The irregular edge of with meningioma. Arachnoidal hyperplasia
extraneural spread may cause bone erosion and associated with a glioma rarely extends
hyperostosis. Calcifications may be seen on CT but beyond the dura.
not on MRI. Meningiomas are highly vascular and
greatly enhance with contrast, unlike gliomas, which
may not enhance or only moderately enhance after
The main risk of observation is misdiagnosis,
contrast injection.20
which is unlikely, and spread to the chiasm, which
may make the tumor impossible to resect24–28
Management of Optic Nerve Tumors (Fig. 27–7).
As with any orbital tumor, the clinical course of optic Fine-needle aspiration biopsy is not recommended
nerve tumors may be followed by Ishihara color because of the risk of injuring the optic nerve. Fur-
plates, visual field every 3 to 6 months, exophthal- thermore, diagnosis is often made on clinicoradiologic
mometry, and CT scans when other clinical data sug- presentation.27–32
gest change. A frontal neurosurgical approach is recommended
Both malignant optic nerve gliomas and menin- if there is evidence of progressive tumor growth or
giomas are rare, with the latter being extremely significant loss of vision, especially if the tumor does
unusual. The latter may actually originate subclini- not appear to extend to the chiasm on radiologic
cally in the chiasm. Malignant optic nerve glioma examination. Initially, the chiasm is examined and if
occurs primarily in older men and has an extremely no tumor is found, the optic canal is unroofed and the
poor prognosis. Such patients present with pain and nerve excised. Radiation should be considered in
visual loss in one eye followed by visual loss in the the management of optic nerve glioma in patients
other eye, complete blindness within 4 months, and with 20/70 vision or better.
death usually within 9 months.21–23 Optic nerve gliomas may extend into the chiasm
and intracranially. A chiasmal tumor may cause
Management of Optic Nerve Glioma hydrocephalus by tumor blockage of the ventricular
Most optic nerve gliomas grow slowly or stop grow- foramina necessitating shunting, diencephalic syn-
ing in adulthood.16 Optic gliomas within the intraor- drome, mental retardation, ataxia, precocious puberty,
CHEN27-387-418.I 3/22/01 2:39 PM Page 394
and diabetes insipidus and rarely Foster-Kennedy FINE-NEEDLE ASPIRATION BIOPSY

syndrome. For these reasons, surgical indications are
not clear cut and are dependent to a large extent on As an adjunct tool, fine-needle aspiration biopsy
the location of the tumor. (FNAB) is of particular value in the diagnosis of pre-
Optic gliomas involving the optic chiasm are sumed metastatic lesions.39 The technique requires a
treated neurosurgically and may not be resectable. seasoned cytopathologist who ideally should be pre-
Such tumors may produce endocrine abnormalities sent at the time of the procedure. The risk of orbital
due to hypothalamic spread of tumor. Biopsy may be hemorrhage limits this technique for patients who
necessary to distinguish a chiasmal glioma from a were administered anticoagulants or platelet
craniopharyngioma, ependymoma, ganglioma, gran- inhibitors and who did not stop such medications for
ular cell myoblastoma, lymphoma, suprasellar germi- an adequate period prior to biopsy. The technique
noma, meningioma, Langerhans granulomatosis, may not allow for definitive diagnosis especially in
pituitary adenoma, or other tumor. Radiation of lymphoid tumors and in tumors where a sampling of
gliomas in the chiasmal area should be considered. In the tissue obtained may not be representative of the
addition, the risks and benefits of neurosurgical pathologic process.
biopsy of presumed chiasmal gliomas must be evalu-
ated in each individual case.31–35 DIFFUSE ORBITAL TUMORS AND
INFLAMMATORY PROCESSES
Management of Optic Nerve Meningioma
Like optic nerve gliomas, optic nerve meningiomas Diffuse orbital tumors are most often lymphoid in
are difficult to manage, but because of their more adults. The process is diffuse in that it involves more
aggressive growth pattern, surgical indications may than one surgical space within the orbit. The orbit
be less stringent. A presumed optic nerve menin- may be divided into surgical spaces consisting of the
gioma in a patient with vision of 20/50 or better intraconal, extraconal, and peripheral spaces. The lat-
should be observed. If the vision is 20/100 or less, a ter space is under the periorbita and is a potential
transcranial neurosurgical approach is warranted. space.
Patients with no light perception should undergo sur- Orbital lymphoid tumors are extremely rare in
gical extirpation of the entire optic nerve. Fortunately, children. On CT, lymphoid tumors present as a homo-
intracranial involvement is rare. Growth occurs dur- geneous mass that molds around the globe and gener-
ing pregnancy with involution after birth. Because ally does not cause bone or sinus invasion.
progesterone and estrogen receptors found in some
tumors may affect growth, pharmacologic antiprog-
EARL... Extremely advanced lym-
esterone agents may help reduce the size of tumors,
which may not be resected.36–38
Because of the delicate pial blood supply to the
P phoid tumors of the lacrimal sac may
indent the globe like an epithelial tumor because
meninges, excision of an optic nerve meningioma there is little space between the lacrimal sac and
without affecting this blood supply and optic nerve the medial aspect of the globe.
function is extremely difficult. The extramural com-
partment may be surgically stripped to relieve optic
nerve compression but microsurgical excision is nec- In such cases, a biopsy is necessary (see Lacrimal
essary and may result in blindness. Sac Tumors, below).
Fibroma, leiomyoma, lipoma, chondroma, and the The differential diagnosis of diffuse orbital tumors
extremely rare myxoma are all extremely unusual in adults include orbital hemorrhage, amyloid depo-
and their malignant counterparts are also rare. Lipo- sition, leukemia, sinus histiocytosis that may be bilat-
mas and liposarcomas have a low fat density similar eral, and a variety of spindle cell tumors.6 Diffuse
to that of the content of dermoid cysts on radiologic orbital tumors most commonly result from lymphoid
imaging. Chondrosarcomas show foci of calcification tumors and orbital inflammatory syndrome (pseudo-
on orbital CT. Erdheim-Chester disease is a systemic tumor of the sclerosing type).6
lipid granulomatosis that involves the orbit, bones, Any of the locally aggressive spindle cell tumors
lung, heart, and retroperitoneum. Ophthalmic com- such as hemangiopericytomas and frankly malignant
plications include optic neuropathy and lid lesions spindle cell tumors may present as diffuse orbital
that are more indurated than the common xanthe- tumors. Fibrous histiocytoma has a typical storiform
lasma. The histiocytes show intracytoplasmic cho- pattern on low power (Fig. 27–8). Reticulin stain out-
lesterol. lines the capillary basement membrane network. In
CHEN27-387-418.I 3/22/01 2:39 PM Page 395
A B
FIGURE 27–8 (A) Coronal orbital CT orbit shows shows a well-circumscribed tumor that almost entirely fills the
right orbit but whose epicenter of growth is the inferotemporal orbit and adjacent to optic nerve. This 61-year-old
Surinamese man developed marked painless, slowly progressive proptosis of 11 mm of the right eye over several
years. The encapsulated tumor was completely resected by lateral canthotomy and cantholysis via a transconjunctival
and transcaruncular approach. It measured approximately 6 cm in greatest diameter. (B) Histologically, the spindle cell
tumor had a fascicular pattern with foci of a storiform or cartwheel-like arrangement of cells with intervening bands
of dense sclerotic collagen confirmed on Masson trichrome staining. Immunohistochemically distinctive, the tumor
cells are CD-34 positive and S-100 negative, consistent with solitary fibrous tumor, a probable histologic variant of
fibrous histiocytoma. Vision improved from 20/200 to 20/25 in the right eye with significantly improved ductions in
all fields of gaze. (Presented at the fall 1997 meeting of the Orbital Society, San Francisco California by J.A. Mauriello.)
addition, a characteristic reticulin network is present ulocytic sarcoma, metastatic neuroblastoma, capillary
between the proliferating tumor cells. Malignant fibrous hemangioma that often involves the eyelid skin, lym-
histiocytoma may require extirpative surgery. Malig- phangioma, and alveolar soft part sarcoma which has
nant schwannoma is an extremely rare spindle cell a predilection for extraocular muscles and tends to be
tumor (Fig. 27–9). The malignant spindle cell tumors localized (Fig. 27–10).53
such as chondrosarcoma may be associated with bone Diffuse orbital involvement due to depositions in
erosion. Liposarcomas, another spindle cell tumor, tend the orbit are also unusual. Amyloid deposition may
to have a slowly progressive course over years. occur in the extraocular muscles, levator muscle, sub-
Diffuse tumors that occur mostly in children may conjunctival space, and within the orbit. Diffuse
involve bone; they include rhabdomyosarcoma, gran- deposits in the orbit may be calcified. The conjunctival
A B
FIGURE 27–9 (A) Patient with marked proptosis right eye due to biopsed malignant schwannoma. (Courtesy of
Armed Forces Institute of Pathology (AFIP), Ophthalmic Division Acc #1286961.) (B) Axial CT scan from another
patient with known renal cell caricinoma showed tumor involving lateral orbital wall with intracranial extension.
Workup for metastatic disease showed known renal cell carcinoma. Patient had minimal inflammatory signs. No
biopsy was necessary. Patient was referred for radiation therapy.
CHEN27-387-418.I 3/22/01 2:39 PM Page 396
FIGURE 27–11 Echinococcus cyst biopsied from orbit.

(Courtesy of AFIP, Ophthalmic Division Acc #1288047.)
FIGURE 27–10 Child with known neuroblastoma who cell myocarditis, streptococci, Borrelia burgdorferi, and
presented with bilateral subcutaneous hemorrhage. Axial Sjögren’s syndrome.
orbital CT scan shows multiple metastases involving soft Cysticercosis is an infectious cause of myositis.40
tissue and bone most evident in lateral orbit. (The pork tapeworm, Taenium solium, is acquired by
form of amyloidosis is not usually associated with consumption of undercooked pork. Cysticercus
systemic disease, whereas the eyelid form tends to be cellulose is the larval stage of Taenium solium. The
associated with systemic disease. bladderworms hatch in the intestine, and the systemic
infestation is called cysticercosis.) The spherical to
oval cysts of approximately 1 cm may be seen on CT
Orbital Inflammatory Disease and have a predilection for extraocular muscles. Sys-
Presentations and Management temic chemotherapy is the treatment of choice. Such
Orbital inflammatory disease often appears diffuse on lesions may also occur on the eyelids and conjunctiva.
CT. The causes of orbital inflammation include bacte- Figure 27–11 shows an echinococcus cyst obtained
rial orbital cellulitis and idiopathic orbital inflamma- from the orbit.
tory syndrome. Acute pseudotumor (idiopathic orbital In the treatment of idiopathic orbital inflammatory
inflammatory syndrome) has an abrupt, painful onset, syndrome, a trial of systemic corticosteroids is recom-
and if the optic nerve is involved, there may be visual mended. The initial dose is approximately 60 to 80 mg
loss. There are various patterns of idiopathic inflam- of oral prednisone for 2 to 3 weeks. Prednisone is
mation that are based on the anatomic structures tapered gradually by 10 mg per week. Intraocular
involved: sclerotenonitis, myositis, dacryoadenitis, tumors such as choroidal melanomas and retinoblas-
and optic nerve. The age of presentation is from teens toma may incite an inflammatory response without
to early 40s. In general, all forms of idiopathic orbital extraocular extension. In contrast, rare tumors such as
inflammatory tumors spare bones and sinuses. Orbital carcinomas of the ciliary body epithelium with extraoc-
CT is helpful in distinguishing the various anatomic ular extension may present with orbital cellulitis due to
forms. The sclerotenonitis form mimics acute bacter- hemorrhage and necrosis within the tumor and
ial orbital cellulitis and may require a trial of broad- resultant inflammation.2 An intraocular tumor may be
spectrum oral antibiotics or intravenous antibiotics. evident on CT (Fig. 27–1). Biopsy of pseudotumor gen-
The lack of any sinus involvement, history of retained erally shows scattered, mostly chronic inflammatory
foreign body, or history of dental infection is helpful in cells with varying degrees of fibrosis. Chronic scleros-
ruling out bacterial orbital cellulitis. ing pseudotumor may present without pain and
On orbital CT, the myositis pattern has irregular involve fibrosis of the orbital structures and ultimately
margins with enlarged muscle and may be unilateral lead to frozen globe. On CT scan, one sees bands of
or bilateral. This pattern may be associated with sys- fibrosis. The infiltrate does not mold about the globe
temic immune-mediated diseases due to Crohn’s dis- and has irregular margins. These lesions often require
ease, systemic lupus erythematosus (SLE), relapsing biopsy to rule out fungal infection or tumor.
polychondritis, Adie’s syndrome, rheumatoid arthri- Patients with orbital fungal infections present with
tis, allergic asthma, Wegener’s granulomatosis, pol- ptosis, ophthalmoplegia, proptosis, and severe peri-
yarteritis nodosa, viral upper respiratory tract infec- orbita pain. Clinically, a lack of inflammatory signs is
tion, streptococcal pharyngitis, Lyme’s disease, giant characteristic. Sinus involvement is characteristic but
CHEN27-387-418.I 3/22/01 2:39 PM Page 397
not always present. CT scan often shows an expansile with an infectious disease specialist as well as multi-
lesion infiltrating orbit from the adjacent ethmoid ple debridement with amphotericin B lavage. Diag-
sinus. Both the areas of active fungal disease in the nosis depends on culture, but on histopathologic
orbit and sinuses as well as secondary bacterial sinusi- examination Aspergillus shows a characteristic 2- to
tis enhance with contrast on CT and MRI. However, 4-m diameter, septated hyphae, and 45-degree
on MRI, the secondary bacterial sinusitis appears branching, whereas mucormycosis characteristically
hyperintense on T2-weighted image, whereas the fun- has a 10- to 20-m diameter, nonseptated hyphae, and
gal component is usually hypointense on T1- and T2- right-angle branching. On histopathologic examina-
weighted images (Fig. 27–12). Calcifications are tion, hyphae are demonstrated by periodic acid-Schiff
observed on orbital CT but not on MRI. Treatment (PAS) stain and other special stains for fungus, includ-
involves intravenous amphotericin B in consultation ing the Gridley and Giemsa stains.
A B
C D
FIGURE 27–12 (A) Elderly woman with

minimal inflammatory signs on clinical
examination except proptosis, blepharopto-
sis, and marked periorbital pain. (B) On T1-
weighted MRI, there is hypointensity of the
entire ethmoid sinus region and the right
orbital apex. (C) Fungal portion at orbital
apex and posterior ethmoid sinus is not
hyperintense on T2-weighted image, whereas
anterior ethmoid sinusitis is hyperintense.
(D) PAS-stain demonstrates hyphal elements
that are also seen on Gridley stain (E) (Modi-
E fied from Mauriello et al.101)
CHEN27-387-418.I 3/22/01 2:39 PM Page 398
Biopsy shows chronic inflammatory cell infiltrate In addition, serum ANCA tiers are dependent on
with varying degrees of fibrosis. Intraoperative cul- the extent and activity of the disease in patients with
tures and pathologic specials stains are useful to rule Wegener’s granulomatosis. Approximately 50% of
out fungal infection, especially if there is sinus involve- cytoplasmic-ANCA (c-ANCA) titers are positive in
ment or immunocompromised patient, and cocaine patients in the initial phase of the limited form of the
abuse with accompanying nasal, sinus, and orbital disease. The percentage approaches 100% in patients
chronic nongranulomatous involvement with irre- with active generalized disease.43
versible toxic optic neuropathy (Fig. 27–13).41 Recurrent disease may be treated with oral corti-
Lupus erythematosus, sarcoidosis, Wegener’s costeroids and low-dose radiation. In such cases, sur-
granulomatosis, periarteritis nodosa, and tuberculo- gical debulking has been advocated for recalcitrant
sis may present with chronic inflammation and mimic cases of diffuse sclerosing orbital pseudotumor.
a sclerosing or acute pseudotumor. Treatment of
Wegener’s granulomatosis involves immunosuppres-
sive agents, oral corticosteroids, and oral Bactrim.
LYMPHOID TUMORS
Consultation with an immunologist is advisable. In Presentation
Wegener’s granulomatosis, CT may also show in- Lymphoproliferative lesions should be differentiated
volvement of the paranasal sinuses and result in bone from idiopathic orbital inflammatory syndrome
destruction. (orbital pseudotumor). Lymphoid tumors generally
Recurrent orbital pseudotumor may require have a slow onset. However, aggressive lymphomas
biopsy. Recurrent myositis or any variant or orbital such as large cell lymphomas may have a more rapid
inflammatory syndrome requires a definitive workup onset. Involvement of the retrobulbar tissues causes
that may include biopsy of the extraocular muscle and proptosis and diplopia, whereas upper lid involve-
complete workup for a systemic vasculitis. The dif- ment often results in mechanical blepharoptosis.
ferential diagnosis includes Crohn’s disease, SLE, Unlike pseudotumor, orbital lymphomas are
rheumatoid disease, relapsing polychondritis, extremely rare in patients under age 30. The age of
rheumatoid arthritis, allergic asthma, Wegener’s gran- onset is older than orbital pseudotumor and ranges
ulomatosis, polyarteritis nodosa, viral upper respira- from 40 to 70 years. Lymphoid tumors of the con-
tory tract infection, pharyngitis and Lyme’s disease. junctiva are usually firm and nontender and only 10
Serum antinuclear antibody (ANA), sedimentation to 15% have associated systemic disease, whereas
rate, antineutrophilic cytoplasmic antibody (ANCA), one-third of orbital lymphoid tumors present with
rheumatoid factor, angiotensin-converting enzyme systemic disease and approximately two-thirds of
(ACE), serum lysozyme associated with systemic sar- eyelid lymphomas have concomitant systemic disease
coidosis, and single-stranded DNA due to Sjögren’s (Fig. 27–14).44 “Follicles” are suggestive but not diag-
syndrome are all helpful. Cardiac symptoms require a nostic of benign reactive hyperplasia.
chest x-ray and Holter monitoring as well as an elec-
trocardiogram to rule out giant cell myocarditis.42
A B
FIGURE 27–13 (A) Coronal orbital CT of patient with prolonged use of cocaine, who had decreased vision to
20/200 in right eye, shows right orbital and maxillary sinus infiltrate, which on biopsy demonstrated chronic inflam-
matory cells. (B) Biopsy from another patient with sclerosing orbital pseudotumor demonstrates marked orbital fibro-
sis and multiple lymphoid follicles. (Courtesy of AFIP, Ophthalmic Division Acc #280758.)
CHEN27-387-418.I 3/22/01 2:39 PM Page 399
A B
FIGURE 27–14 (A) Infiltrating tumor of the eyelid that on biopsy showed
malignant lymphoma. Patient had known systemic lymphoma at the time of
presentation and despite local radiation later died of systemic complications
of lymphoma. (B) Conjunctiva lymphoma in patient who later received local
radiation with no evidence of systemic lymphoma after workup by oncolo-
gist. (C) Elderly man with lymphoma involving parotid gland and inferior
orbit. (Presented in part by J. A. Mauriello and P. Langer at the combined meet-
ing of the American Society of Ophthalmic Plastic and Reconstructive Surgery
and the American Academy of Ophthalmology—Oculoplastic Surgery in Sys-
temic Disease, “Periocular Manifestations of Lymphoproliferative Disorders,”
C Chicago, December 4, 1996.)
Lymphoid tumors rarely affect vision unless there T1- and T2-weighted imaging and enhance to vary-
is apical orbital compression. Lymphoid tumors have ing degrees after gadolinium contrast injection.
a less explosive onset of week to months and are often Pathologic classifications of lymphoid tumors,
anterior and superior in location, nontender, palpable including the Working Formulation (National Cancer
rubbery orbital masses. Subconjunctival salmon- Institute) and Revised European-American Lym-
colored lymphomas often have an accompanying phoma (REAL) Classification 1994, are based on his-
boggy chemosis of the conjunctiva. The tumor may tologic, immunophenotypic, and genetic features. The
rarely involve the uvea diffusely. latter classification includes mucosa-associated lym-
Lymphomas are distinctly rare in children. When phoid tissue (MALT) that is an extraconal low-grade
such a diagnosis is made histologically, granulocytic lymphoma. MALT lymphomas often are associated
sarcoma, which may be part of systemic leukemia, with chronic inflammatory or autoimmune disorder
should be suspected.45 Management by a pediatric such as Sjögren’s disease or Hashimoto’s thyroiditis.47
oncologist is recommended.46 The prognosis of the lymphoma is related to its
Orbital CT of lymphoid tumors generally shows a cytologic features and additional characterization of
somewhat homogeneous, mildly contrast-enhancing infiltrate by immunoperoxidase and molecular
infiltrate that displaces but does not indent the globe hybrid studies. Lymphomas are almost exclusively B-
(Fig. 27–15). The latter pattern is generally seen in cell lymphomas. Monoclonality is associated with
solid tumors. Except for large cell, rapidly growing malignancy and tendency for systemic disease
tumors that tend to be associated with AIDS, lym- beyond the orbit.
phoid tumors rarely erode bone. The mass has an epi-
center of growth that spills into the surrounding Management
tissues. The tumor cells follow orbital fibroseptal After biopsy, a systemic workup for lymphoma,
planes, extend anterior to orbital rim, and may be leukemia, multiple myeloma, and Waldenström’s
sharply demarcated with abrupt, acute perpendicular macroglobulinemia includes physical examination
angulations. The tumors, as stated above, tend to be with palpation of lymph nodes, complete blood
diffuse and anterior, but may be posterior and local- count, serum protein electrophoresis to rule out
ized. On MRI, the lesion tends to be hypointense on Waldenström’s macroglobulinemia and multiple
CHEN27-387-418.I 3/22/01 2:39 PM Page 400
A B
FIGURE 27–15 (A) Axial coronal CT of orbit in 68-year-old woman with gradual onset of proptosis and ble-
pharoptosis over 2 months. Scan shows diffuse orbital mass typical of lymphoid tumor infiltrating the left lacrimal
gland and lateral orbit. Adjacent bone is not involved. (B) Biopsy shows monomorphous, well-differentiated lym-
phocytic infiltrate with individual cells displaying no cytoplasm and occasional nucleoli (left field). Monomorphous
infiltrate is adjacent to pale lymphoid follicle composed of polymorphous cells with more abundant cytoplasm and
occasional macrophage (right side of field). The findings are indicative of lymphoma.
myeloma, bone marrow biopsy to rule out leukemia, dosis, sarcoidosis, and cavernous sinus thrombosis
CT of abdomen and chest, and liver function tests. (Figs. 27–16 and 27–17). Other rare causes include col-
Low-dose radiotherapy is indicated for lymphoid lagen vascular disease such as trichinosis and Cys-
lesions of the orbit and ocular adnexa.48 In the series by ticercosis. At times, a biopsy may be necessary to
Kennerdell et al,48 a dose of 24 Gy with a 4- to 6-MV make the definitive diagnosis.
linear accelerator was employed. The lacrimal gland
and lens were carefully shielded from radiation. Acute
side effects included mild exophthalmos and chemosis
in 50% of patients and chronic exophthalmos in 33% of
patients. Bone involvement, central nervous system
extension, and bilaterally of the lymphoid lesions does
not preclude a favorable prognosis. Low-dose radia-
tion should be avoided in patients with diabetes and in
patients younger than 20 years of age because of pos-
sible retinal damage. No cataracts, corneal ulceration
or retinal injury occurred in this series. Chemosis
occurred in patients with conjunctival disease.
Localized orbital lymphoid disease is generally
treated with radiation; the dose is dependent on
whether the tumor is characterized immunohistolog-
ically as benign, atypical, or malignant. Systemic dis-
FIGURE 27–16 A 26-year-old woman with multiple
ease is treated with chemotherapy, which may also
episodes of myositis involving right medial rectus muscle
successfully irradicate the orbital component without initially. On T1-weighted MRI right medial rectus involve-
local orbital radiation.49–51 Plasmacytoma is the initial ment is hypointense but characteristically hyperintense on
presentation in 75% of patients with orbital involve- T2-weighted image. Patient had multiple recurrences after
ment in multiple myeloma.50, 51 oral corticosteroids and biopsy of muscle showed only
chronic inflammation within the muscle. Patient later
required radiation and immunosuppressive therapy when
ORBITAL DISEASE ACCOMPANIED BY she developed multiple muscle involvement. Ultimately,
EXTRAOCULAR MUSCLE ENLARGEMENT she was controlled by long-term corticosteroids. Patient has
been followed for 8 years. (Presented in part by J. A. Mau-
Extraocular muscle enlargement is commonly found riello and J. C. Flanagan at the annual fall meeting of the
in thyroid ophthalmopathy, myositis, lymphoma, American Society of Ophthalmic Plastic and Reconstructive
carotid cavernous or slow flow dural fistula, amyloi- Surgery; 1987; Dallas, TX)
CHEN27-387-418.I 3/22/01 2:39 PM Page 401
A B
FIGURE 27–17 (A) In a 62-year-old man with proptosis and diplopia and negative workup for thyroid disease,
orbital CT shows markedly enlarged right inferior rectus muscle. Other extraocular muscles are not enlarged. T1-
weighted MR showed hypointense inferior rectus muscle that on T2-weighted image (B) is hyperintense and markedly
enhances with contrast. Biopsy (not shown) of inferior rectus muscle showed chronic nongranulatomous inflamma-
tion. Patient had a fairly good response to systemic corticosteroids with improved proptosis and improved elevation
of the involved right eye.
Presentation fibrous dysplasia, ossifying fibroma, aneurysmal bone

The author has observed three patients with essentially cyst, reparative granuloma, and osteogenic sarcoma.6
the same clinical presentation. In a middle-aged man Distinctly rare tumors of bone that affect children and
with markedly limited elevation of the involved eye, young adults are giant cell tumors (benign osteoclas-
both CT and MRI showed only enlargement of the toma), infantile cortical hyperostosis (Caffey’s syn-
inferior rectus muscle that was consistent with either drome), intradiploic meningioma of the orbital roof,
lymphoma or thyroid orbitopathy. The MRI showed a and osteoblastoma.6 Adult onset orbital tumors of
markedly enlarged inferior rectus muscle that was bones include Brown tumor, intradiploic meningioma
hypointense on both T1- and T2-weighted images as of the orbital roof, benign hemangioma of the skull,
characteristically seen in thyroid orbitopathy. The Paget’s disease, and osteoma. Lipoma of the frontal
patient had no lid retraction or other clinical or sys- bone is an extremely rare adult orbital tumor.6 Of the
temic evidence of thyroid disease. Orbital biopsy, above, Brown tumor, intradiploic meningioma of the
which was done to rule out lymphoma, showed mini- orbital roof, and benign hemangioma of the skull
mal chronic inflammatory cell infiltrate. The patient rarely affect vision.6 By contrast, Paget’s disease may
subsequently developed thyroid orbitopathy and sero- result in visual loss due to lack of perfusion of the
logic chemical evidence of thyroid disease. optic nerve as blood is shunted from the optic nerve to
the tumor, and also due to bony compression of the
optic nerve.
EXTRACONAL ORBITAL DISEASE Tumors that originate from bones of the orbit and
Diffuse tumors that invade the intraconal and extra- sinus include aneurymal bone cysts, cavernous
conal space are listed above. Many such spindle cell hemangioma of the bone, fibrous dysplasia, metasta-
tumors that may be diffuse may also be strictly tic neuroblastoma, meningioma of the orbital roof,
extraconal and are not discussed again in this sec- ossifying fibroma, osteoma, and Paget’s disease.
tion. 52 Other such tumors that occupy a purely Brown tumors, chordoma, giant cell tumors (osoteo-
extraconal location without significant bone in- clastoma), infantile cortical hyperostosis (Caffey’s
volvement, also called peripheral orbital tumors, are Syndrome), lipoma of the frontal bone, melanomas,
vascular anomalies (arteriovenous malformation, osteogenic sarcoma, and reparative granuloma are
venous malformation, and vascular malformation), extremely rare tumors of the sinus or bone.6
orbital or subperiosteal hemorrhage, hematic cyst,
and cholesteatoma.6 Presentation
Ossifying fibroma and fibrous dysplasia occur in the
Tumors of Sinus and Bone pediatric age group. Ossifying fibroma might not be
The following group of tumors of bone that affect chil- diagnosed until adulthood. Because fibrous dyspla-
dren and young adults are relatively uncommon: sia is an arrest in the maturation of bone, this entity
CHEN27-387-418.I 3/22/01 2:39 PM Page 402
occurs principally in the first decade of life. Fibrous Nonosseous Tumors Originating in Paranasal
dysplasia causes bone sclerosis in a diffuse pattern, Sinus, Nose, and Oropharynx
whereas ossifying fibroma is a well-defined localized Nonosseous tumors that originate in the paranasal
lesion. Ossifying fibromas tend to be more aggressive sinus, nose, and oropharynx and secondarily invade
and are more likely to recur after surgical excision the orbit are, most commonly: epithelial tumors,
than fibrous dysplasia. Both processes are more com- including squamous cell carcinoma, sarcomatoid car-
mon in males. Patients most often present with prop- cinoma, inverted papilloma, mucoepidermoid carci-
tosis, but decreased vision, ptosis, headaches, and noma, adenocarcinoma, adenocystic carcinoma, and
nasal obstruction may occur with either process. malignant mixed tumors.6 Maxillary sinus tumors
Fibrous dysplasia also presents with facial asymme- most commonly invade the orbit secondarily. Less
try due to its diffuse nature. The association of frequently, nasal tumors and frontal sinus tumors
polyostotic fibrous dysplasia, with cutaneous pig- extend inferonasally into the nose. Ethmoid tumors
mentation, and precocious puberty is found in may extend into the orbit but more often invade the
Albright’s syndrome. nose. Basilar skull invasion may also occur.
Radiographically, ossifying fibroma often arises Among the less common nonosseous tumors that
from either the orbital plate of the frontal bone or the originate in the sinus, nose, and oropharynx is lym-
ethmoid sinus. In the final form, the tumor expands phoepithelioma (Schmincke tumor). This is an
the bone as if it were a balloon. A large mottled radio- extremely aggressive tumor of the oropharynx. A
dense pattern is present. Clinically, radiolucent areas small primary tumor may metastasize to the local
correspond to pathologic foci of cystic degeneration lymph nodes in approximately 70% of patients. The
or to psammomatoid ossicles. Ossifying fibroma is a tumor is composed of poorly differentiated squamous
true neoplasm. Fibrous dysplasia is a diffuse sclerotic cells with large vesicular nuclei. The squamous tumor
process with poorly defined borders. cells are nonkeratinizing and occur in a lymphoid
Ossifying fibroma is composed of a fibrous stroma. The two histologic variants, both with simi-
stroma with many fibroblasts and has variable larly poor prognoses, are the Regaud type, in which
amounts of woven and lamellar trabeculae that the cells are arranged in nests, cords, and islands, and
appear connected and resemble psammomatoid the Schminke type, which shows isolated cells scat-
bodies, hence the term psammomatoid ossifying tered diffusely throughout the lymphoid stroma.6
fibroma. The term juvenile ossifying fibroma has been
abandoned because the tumor occurs in adulthood. Secondary Tumors of the Orbit
In ossifying fibroma, osteoblasts rim the trabeculae There are myriad secondary tumors of the orbit. Tumors
and this tumor may be histopathologically mistaken may originate in the sinus, eye, eyelid, conjunctiva, or
for mengingioma (Fig. 27–18A). Histologically, lacrimal sac. Intraocular tumors that may have extrascle-
fibrous dysplasia, as an arrest in maturation of ral extension include malignant melanoma of the uvea,
bone, is composed of immature woven bone with- retinoblastoma, medulloepithelioma, carcinoma of the
out lamellar bone or osteloblasts (Fig. 27–18B). nonpigmented ciliary epithelium, granuloctyic sarcoma,
A B
FIGURE 27–18 (A) Ossifying fibroma with trabeculae rimmed by osteoblasts. Trabeculae resemble psammatoid
bodies seen on meningioma. (B) Fibrous dysplasia of frontal bone with immature woven bone. No osteoblasts are
present.
CHEN27-387-418.I 3/22/01 2:39 PM Page 403
leukemia, and lymphoma.6 Eyelid tumors with orbital

extension include basal cell carcinoma, squamous cell
carcinoma, sebaceous carcinoma, other adnexal carci-
noma, and melanoma.6 Conjunctival tumors include
squamous cell carcinoma, mucoepidermoid carci-
noma, and melanoma.6 Lacrimal sac tumors consist of
papilloma, squamous cell carcinoma, lymphoma,
melanoma.6 Intracranial tumors include sphenoid
ridge meningioma and chordoma.6 Sebaceous gland
carcinoma may originate from the Zeis or meibomian
glands of the eyelid or the sebaceous glands of the
caruncle (Fig. 27–19).
PEDIATRIC TUMORS FIGURE 27–19 Advanced sebaceous gland carcinoma

invading medial orbital wall. Note exposed globe.
Optic nerve glioma and meningioma as well as fibrous
dysplasia and ossifying fibroma were previously con-
sidered. A number of relatively common pediatric
tumors are cystic. These most commonly include der- ing as long as the entire cyst is palpable. Lesions are
moid cysts and lymphangioma, but microphthalmos prone to trauma and secondary chronic granuloma-
with cyst, congenital cystic eyeball, and teratoma tous inflammation when the keratin-containing,
should also be considered in the differential diagnosis.6 epidermal-lined cyst spills into the surrounding tis-
sues. Lesions may also originate within the nasal orbit
Presentation and require imaging (Fig. 27–20).
Dermoid cysts most often present in the superotem- In microphthalmos with cyst, 30% are bilateral.54
poral quadrant and do not require radiologic imag- This condition presents clinically most often as a
A B
FIGURE 27–20 (A) A 23-year-old man with

2-year history of gradual proptosis and mass in
nasal orbit on coronal T1-weighted MRI (not
shown) has characteristics of fat and indenta-
tion of medial globe. (B) Lesion was excised by
a lateral canthotomy with cantholysis and
swinging eyelid transconjunctival approach
that extended between the caruncle and plica
semilunaris into the superior conjunctival
fornix for excellent exposure. The cyst was
meticulously dissected from orbital structures
and was incised and decompressed, and the
entire remaining cyst was removed. (C) Biopsy
revealed chronic granulomatous inflammation
C and pilosebaceous units in epidermal lined wall
of cyst. Patient had uneventful recovery.
CHEN27-387-418.I 3/22/01 2:39 PM Page 404
A B
FIGURE 27–21 (A) A 2-year-old child who presented with ptosis and superior orbital mass. (B) Orbital CT scan
shows defect in orbital roof on left side. The patient ultimately required combined neurosurgical and orbital
approaches to excise glial hamartomatous tissue and repair bone defects.
lower eyelid mass and is unlike congenital cystic eye- Pulsating as well as positional exophthalmos, that
ball, in which the upper eyelid is more commonly is, dynamic proptosis, may result from a large bone
involved. Intraocular calcifications occur and an defect in the sphenoid bone in conditions such as a
enlarged orbit may be visualized on orbital CT. The massive frontal sinus mucocele, neurofibromatosis,
latter two features are seen with microphthalmos with meningocele, and encephalocele, and from vascular
cyst and not with congenital cystic eyeball. anomalies such as carotid cavernous fistula, venous
Encephaloceles and meningoceles result from her- angioma, arteriovenous (AV) malformation, and
niation of cerebral tissues through congenital dehis- metastatic renal cell carcinoma. The differential diag-
cences of bone (Fig. 27–21). The encephalocele nosis of a capillary hemangioma, lymphangioma, and
includes brain tissue with its meningeal sac, whereas varix should be considered. Dynamic proptosis may
the meningocele consists of only of meninges with no occur with a varix or capillary hemangioma but is not
brain tissue.55 The most common clinical presentation present with a lymphangioma. Typically, lymphan-
is in the superonasal orbit between the maxillary, eth- giomas grow with the face until puberty. Capillary
moid, and frontal bones. Coloboma, congenital glau- hemangiomas grow during the first 6 months of life
coma, and anophthalmos are sometimes found. and then regress upon reaching age 5 or 6. Clinically,
Ectopic brain may be confused with an encephalo- regression may be accompanied by bands of fibrosis
cele. Brain heterotopia is the occurrence of normal that appear white. Intravascular papillary endothelial
neural tissue outside the cranial cavity or spinal cord hypertophy may arise from the lumen of a variety of
without continuity with the brain or meninges. Brain vascular lesions in the eyelid and orbit including
heterotopia is most commonly reported in the nasal varix, cavernous hemangioma, and lymphangioma.
midline region. Bone may be absent between the brain Small intraluminal foci of intravascular papillary
and orbit, and dura is found in an encephalocele but endothelial hyperplasia (IPEH) are not uncommon
not in an ectopic brain. and this fact explains the reactive nature of IPEH.
...
P EARL... Encephlocele and meningo-
cele are usually in the superior nasal quad-
rant, whereas the dermoid cyst is in the super-
P EARL A lesion that has a sudden
change in size may be due to hemorrhage
within the tumor, but also may result from
otemporal quadrant. When a dermoid cyst is inflammation associated with an acute thombo-
superonasal, it may be confused with an sis rather than growth of a tumor or even malig-
encephalocele or meningocele. Coronal CT scan nant transformation of a preexisting tumor.
should always be obtained in a nasal dermoid
cyst to rule out a meningocele or encephalocele. Orbital vascular lesions such as lymphangioma
and IPEH may also have intracranial components.56
CHEN27-387-418.I 3/22/01 2:39 PM Page 405
A subcutaneous capillary hemangioma may mimic cavernous fistula will show a single dilated superior
a rhabdomyosarcoma especially if there is no skin ophthalmic vein that is usually not seen in a varix
component. Both tumors often present in the super- unless the other associated veins are dilated. In
onasal orbit. Capillary hemangioma is soft and carotid-cavernous fistula, proptosis does not increase
increases in size with crying. Rarely, biopsy may be with Valsalva’s maneuver or with dependent posi-
necessary to distinguish between the two entities tioning. A varix may be demonstrated with the
(Fig. 27–22). involved patient’s head in a dependent position.
Lymphangioma may present in adults with acute Orbital CT shows enlarged extraocular muscles on
hemorrhage. Typically, MRI is diagnostic in that it the involved side with clinically apparent arterializa-
shows hyperintense cystic lesions on T1- and T2- tion of the vessels to the limbus and a “swishing” sound
weighted images (Figs. 27–23 and 27–24).56–62 in the head that is synchronous with the pulse. An arte-
A palpable thrill or audible bruit suggests an arterial component necessitates neuroradiologic evaluation
rial component or arterial venous fistula, which dis- prior to any surgical intervention. Wright et al57
tinguishes itself clinically from a varix. A carotid reported 158 patients with orbital venous anomalies.
A B
C D
FIGURE 27–22 (A) Infant with lymphangioma that did not increase in size with crying. (B) Another infant with
obvious capillary hemangioma. Note superficial component. Such tumors require observation unless there is evidence
of amblyopia. At that time, consideration may be given to local steroidal injection. (C) Newborn with marked propto-
sis and biopsied undifferentiated malignant neoplasm. (D) A 4-year-old boy with development of firm right superonasal
mass over 2 months and mechanical ptosis. T1-weighted image (not shown) showed mild enhancement. Biopsy was
consistent with rhabdomyosarcoma. Patient responded to chemotherapy upon referral to pediatric oncologist.
CHEN27-387-418.I 3/22/01 2:39 PM Page 406
A B
FIGURE 27–23 (A) A 36-year-old man who presented with acute severe pain in the left periorbital area and an acute
rise in the intraocular pressure. This patient had two prior episodes several years earlier that were not as fulminant. All
ductions in the left eye were significantly limited and he had significant pain, nausea, and dizziness. Coronal T1-weighted
MRI shows evidence of fresh blood in multiple cystic spaces. T2-weighted image (B) shows hyperintense focus as deoxy-
hemoglobin is converted to methemoglobin 24 hours after acute hemorrhage. Due to severe incapacitating pain despite
several days of intravenous steroids, the patient underwent decompression of cysts by conjunctival approach under left
medial rectus muscle. Anterior orbital cysts were incised with copious venous thick, viscous blood obtained. Patient
had uneventful recovery with gradual improvement in motility and rapid decrease in intraocular pressure.
Most patients were infants or children with a dark blue optic nerve compression, severe proptosis due
swelling in the superomedial orbit. The most common to hemorrhage with or without pain, pain alone,
presenting complaint was orbital hemorrhage or prop- and cosmetic deformity especially with well-
tosis. Fifty percent of lesions enlarged with Valsalva circumscribed lesions (Fig. 27–25). An orbital hemor-
and 31% of these contained phleboliths. rhage that does not resorb may result in a hematic
A lymphangioma is thin walled with lymph-like cyst. This condition is more common in adults than
fluid, has loose septal stroma, and may contain lym- children. On MRI scan, similar to a lymphangioma,
phoid aggregates; it enlarges with upper respiratory the hematic cyst is hyperintense on T1- and T2-
infection. Orbital venous anomalies have smooth weighted images.62 Orbital varix may cause fat
muscle in their wall, overlapping endothelial cells, atrophy and secondary enophthalmos.63
and continuous basal lamina with mural pericytes. The differential diagnosis may include pediatric
Indications for surgery include loss of vision due to orbital diseases, tumors that present at birth, tumors
A B
FIGURE 27–24 (A) A 5-year-old girl with spontaneous hemorrhage, resulting in mechanical ptosis. CT scan
showed cystic that extended into superior orbit. On T1- and T2-weighted MRI, part of the cyst was hyperintense.
Because the process did not resolve, cysts within lymphangioma were decompressed via eyelid crease incision.
(B) Histopathology shows large spaces lines by endothelium with foci of dark blue lymphocytic aggregates consistent
with lympangioma. Patient had resolution of process for the past 3 years.
CHEN27-387-418.I 3/22/01 2:39 PM Page 407
A B
FIGURE 27–25 (A) A 59-year-old

woman with tearing and a mass bulging
through the lower eyelid medially that was
palpable and showed no change with the
Valsalva maneuver. Orbital coronal CT
scan on multiple views showed two
masses: an inferomedial extraconal mass,
separate from the lacrimal sac, and a left
intraconal mass. Excisional biopsy of the
left extraconal well-circumscribed mass on
pathologic examination showed a cav-
ernous hemangioma with lymphoid folli-
cles. Nine months later, the patient had an
abrupt onset of increased cheek swelling C
with mild pain on motion of the left eye
and 6 mm of proptosis of the left eye. (B) Coronal orbital CT scan showed enlargement of the intraconal
mass. A large well-circumscribed encapsulated lesion was excised by lateral orbitotomy. Marked adhe-
sions to surrounding structures were meticulously cauterized with the bipolar cautery and lysed. (C) On
biopsy, a capsule was seen around the tumor with lymphoid follicles with a pale germinal center and
endothelial-lined channels, as shown, containing lymph fluid consistent with a lymphangioma.
that present with massive unilateral proptosis at birth, Ewing’s sarcoma, and Burkitt’s lymphoma. Metastatic
and proptosis in the pediatric age group as a whole. neuroblastoma has a characteristic presentation with
The more common tumors and pediatric orbital dis- periorbital hemorrhage.53
eases that may present at birth include capillary
hemangioma, dermoid cysts, orbital cellulitis due to
ethmoiditis, orbital hemorrhage, idiopathic orbital CONGENITAL ORBITAL TUMORS
inflammatory syndrome (orbital pseudotumor), cran- AND CONGENITAL ANOMALIES
iostenosis, thyroid orbitopathy, rhadbomyosarcoma,
lymphangioma, unifocal or multifocal eosinophilic Teratoma
granuloma, xanthogranuloma, meningocele, and A teratoma is a congenital tumor composed of tissues
encephalocele.53 from more than one of the three germinal layers: ecto-
The more common presentations with massive uni- derm, entoderm, and mesoderm. Most teratomas con-
lateral proptosis at birth are rhabdomyosarcoma, lym- sist of only ectodermal and mesodermal tissue,
phangioma, ruptured dermoid cysts, and orbital whereas a minority are composed of mesodermal and
hemorrhage. Rare causes include undifferentiated sar- endodermal tissues.
coma, metastatic neuroblastoma, teratoma, and con-
genital cystic eyeball.53 Retinal Anlage Tumor (Melanotic
Causes of massive proptosis in children are most Neuroectodermal Tumor of Infancy, Pigmented
commonly orbital cellulitis, leukemia, granulocytic Retinal Choristoma)
sarcoma, histiocytosis X, rhabdomyosarcoma, and Melanotic neuroectodermal tumor in infancy usually
retinoblastoma with extraocular extension. Other rare occurs in infants younger than 1 year of age. The
causes include endodermal sinus tumor, metastatic tumor is probably of neural crest origin. Primary
CHEN27-387-418.I 3/22/01 2:39 PM Page 408
orbital involvement is rare, but the orbit usually LACRIMAL GLAND TUMORS
results from secondary invasion from a tumor of the
zygoma. Fewer than 10% are malignant. The tumor is Similar to any orbital lesion, lacrimal gland processes
unencapsulated and composes of two cells types in a may be due to tumor or inflammation. Lacrimal gland
moderately cellular vascular stroma: cells with hyper- inflammations include:
chromatic round or oval nuclei and scanty cytoplasm idiopathic inflammatory syndrome
arranged in nest or cords, and cells with abundant sarcoidosis
cytoplasm containing melanin pigment granules that Sjögren’s syndrome
resemble those of the retinal pigment epithelium. benign lymphoepithelial lesions
Wegener’s granulomatosis
Metastatic Neuroblastoma cholesterol granuloma
Neuroblastoma arises wherever embyonic neuroblas- eosinophilic granuloma
tic tissue is found: in the adrenal medulla (50%), thyroid orbitopathy9
retroperitoneal paraysympathertic and sympathetic
tisssue (25%), and mediastinal (10%) and cervical Lacrimal gland tumors may be divided into epithe-
sympathetic ganglion (2–5%). The tumor often lial tumors and lymphoid tumors:
invades the orbital bones. The tumor is composed of Epithelial tumors:
sheets of uniform small, round, undifferentiated cells pleomorphic adenoma (benign mixed tumor),
with massive areas of necrosis. Neurofibrillary tan- malignant mixed tumor, adenoid cystic carcinoma,
gles known as Homer-Wright rosettes are rarely pre- mucoepidermoid carcinoma,
sent. A pediatric oncologist should be consulted. squamous cell carcinoma, undifferentiated carcinoma
lymphoid tumor, leukemia (extremely rare)9
Metastatic Ewing’s Sarcoma Other tumors of the lacrimal gland are benign
This intramedullary tumor of bone occurs in patients cysts: dermoid cyst and lacrimal gland duct cyst. Soft
between ages 10 to 25. Both metastatic Ewing’s and tissue tumors of the lacrimal gland include heman-
metastatic neuroblastoma spare the globe. The bone giopericytoma, cavernous hemangioma, neurofi-
is usually involved but unlike in neuroblastoma, bilat- broma, schwannoma, and oncocytoma.9
eral metastases are rare. The tumor is composed of a As in the orbit, duration of enlargement (less than
uniform population of cells two to three times the size 6 months) and presence of pain suggest an inflamma-
of lymphoma arranged in dense sheets or cords. The tion such as idiopathic orbital inflammatory syn-
scanty cytoplasm may contain PAS-positive diastase- drome. Adenoid cystic carcinomas cause pain by their
sensitive glycogen. Because the tumor is usually pri- propensity to invade nerves. However, their duration
marily in the limb, treatment involves pediatric is usually more than 6 months. An orbital apex syn-
oncologic evaluation. drome may develop from superior orbital fissure
invasion with third, fourth, fifth, and sixth cranial
Alveolar Soft-Part Sarcoma nerve deficits, ocular sympathetic paresis, proptosis,
This tumor is a painless pink vascular growth that and even conjunctival chemosis.9
often appears well circumscribed on CT and tends to
invade extraocular muscles. The median age on pre- Presentation
sentation is 18 years and the tumor has a definite Bacterial dacryoadenitis (Fig. 27–26) may be indistin-
predilection for females. Lung and/or bone metas- guishable from pseudotumor of the lacrimal gland,
tases may occur 14 to 21 years after orbital biopsy, much as bacterial orbital cellulitis may mimic a tenons
excision, and local radiation. This tumor usually scleritis. In both cases, a trial of oral or even intra-
involves the deep soft tissues of the extremities, venous antibiotics is necessary prior to initiation of
thighs, and buttocks. The origin of the tumor is oral corticosteroids.
unknown. Sheets of uniform cells coalesce in a Painless masses of the lacrimal gland include lym-
pseudoalveolar organoid pattern that forms nests phoid tumors, pleomorphic adenomas, chronic scle-
of cells separated by thin fibrovascular septa. The rosing pseudotumors, or sarcoidosis (Fig. 27–27).
tumor cells are large and round to polyhedral in Lymphoid tumors occur in patients in their 50s and
shape. The cytoplasm of the cells contain finely gran- 60s. Dermoid cysts occur in infants but may become
ular eosinophilic cytoplasm with distinct cell bound- evident in middle age in some cases due to trauma.
aries. These PAS-positive diastase-resistant crystals Pleomorphic adenoma occurs in the fourth and fifth
are rectangular, rhomboid, or needle-shaped. On elec- decades of life, whereas adenoid cystic carcinoma
tron microscopy, which is diagnostic, the crystals appears in patients with a range of 12 to 74 years with
have a periodicity of 8 to 10 nm. a mean age of 39.4. Females predominate (59%).
CHEN27-387-418.I 3/22/01 2:39 PM Page 409
A B
FIGURE 27–26 (A) A 16-year-old girl with a 2-week history of left lacrimal gland tenderness. Despite trial of oral
cephalosporin for 5 days, pain persisted. Oral corticosteroids were started with marked improvement over 24 hours.
(B) CT scan of patient with acute bacterial dacryoadenitis.
On histopathologic examination, benign mixed

EARL... Bilateral disease suggests a
P
tumor (pleomorphic adenoma) is composed of epithe-
lial and connective tissue elements (Fig. 27–28). Ductal
systemic inflammatory, infectious, or lym-
elements are lined by a two layers of epithelium. The
phomatous process and is never associated with inner secretes mucus, whereas the outer layer of
an epithelial tumor. Moreover, the architecture epithelial cells may undergo metaplasia to form myx-
of the lacrimal gland tends to be more preserved oid, fibroid, and cartilaginous stromal elements.
in inflammatory conditions and, therefore, the Infectious mononucleosis may be associated with
lacrimal gland lobules may be palpated. lacrimal gland enlargement. Dacryops or lacrimal gland
duct cyst often occurs after a bout of inflammation or
A B
FIGURE 27–27 (A) A middle-aged woman with history

of ptosis and markedly limited elevation of right eye.
(B) Coronal orbital CT scan shows enlarged right lacrimal
gland and irregular infiltration of superior orbit and levator
complex. (C) Orbital biopsy on low power shows diffuse
pale infiltrate obliterating orbital fat that on high power is
composed of epithelioid cells and giants histiocytic. Sys-
temic workup was consistent with sarcoidosis, which was
resistant to oral corticosteroids. Intralesional injection may
prove beneficial, but risk of embolization into retinal and
choroidal circulation is possible when injecting any orbital
C lesion such as capillary hemangioma in children.
CHEN27-387-418.I 3/22/01 2:39 PM Page 410
A B
FIGURE 27–28 (A) An 18-year-old man

with a 6-month history of left lacrimal gland
mass. Orbital CT showed lack of bone erosion.
T1-weighted MRI (not shown) demonstrated
benign mixed tumor or pleomorphic adenoma
involving left lacrimal gland. Lesion is isoin-
tense with brain. (B) T2-weighted image shows
similar globular mass that is also isointense
with brain. (C) On high power, proliferating
epithelial elements within myxoid stroma are
consistent with diagnosis of benign mixed
C tumor of lacrimal gland.
trauma and pain may occur. Weeping or exposure to

cold tends to result in increased size. Decompression SPECIAL CONSIDERATION
of the cyst may occur with a rapid gush of tears.
Cysts are most often associated with the palpebral Like sebaceous gland carcinoma, malignant
rather than the orbital lobe of the lacrimal gland. mixed tumor of the lacrimal gland and ade-
An epithelial or mesenchymal tumor of sufficient noid cystic carcinoma of the lacrimal gland
size indents or flattens the globe in the quadrant of may present with a rapid growth and tumor
the eye that has pressure against it. Figure 27–28
nodules within the orbit. All such tumors
shows pleomorphic adenoma of the lacrimal gland.
may spread to the regional lymph nodes.
An inflammatory lesion such as sarcoidosis causes
an oblong contoured diffuse enlargement of the
lacrimal gland (Fig. 27–27B). A lymphoid tumor Patients with suspected local metastases should be
produces a pattern that may be oblong, but if suffi- referred to an otolaryngologist.
ciently advanced, lymphoma may be more diffuse The differential diagnosis includes idiopathic
and spill over beyond the lacrimal gland and inflammatory dacryoadenitis, lymphoid tumors, and
displace but not indent the globe (Fig. 27–29). Asso- epithelial tumors. Causes of bilateral lacrimal gland
ciated bone changes are typical with erosion seen in enlargement usually relate to systemic disease. They
epithelial tumors and dermoid cysts. Dermoid cysts include: sarcoidosis, idiopathic inflammatory syn-
cause smooth fossa formation of the adjacent bone, drome (pseudotumor), thyroid disease, Sjögren’s
whereas epithelial malignancies tend to cause a syndrome (may be associated with lymphoid tumors
moth-eaten erosion. Focal punched out lesions of of the lacrimal gland), benign lympoepithelial lesion,
bone occur in eosinophilic granuloma and choles- and Wegener’s granulomatosis.9 Systemic lupus ery-
terol granulomas of the superolateral orbital rim. A thematosus, tuberculosis, syphilis, and leukemia are
ruptured dermoid cyst may cause irregular erosion less common causes of bilateral lacrimal gland
of bone. enlargement.9
CHEN27-387-418.I 3/22/01 2:39 PM Page 411
parotid glands.64 Other causes include tuberculosis,

gout, syphilis, sarcoidosis, lymphoma, and leukemia,
which are known as Mikulicz’s syndrome.
Management
In patients with presumed pleomorphic adenoma,
excision of the tumor with the adjacent periosteum of
the bone is recommended to avoid multinodular recur-
rence of the tumor or even malignant transformation.
Biopsy of pleomorphic adenoma shows a mixture of
epithelial and connective tissue elements. Tubular
structures are arranged as an irregular anastomosing
pattern in a predominantly myxoid stroma. The duc-
tule elements are bounded by a double-layered wall of
epithelium. The inner layer secretes mucus or under-
goes squamous metaplasia. The outer layer may
FIGURE 27–29 Orbital CT scan of a 58-year-old with undergo metaplasia to form a myxoid, fibrous, or car-
bilateral lacrimal gland enlargement and biopsied well-
tilaginous stroma. Incisional biopsy may result in
differentiated lymphoma. Patient ultimately succumbed to
systemic disease.
multinodular recurrence and should be avoided.
In suspected cases of malignant adenoid cystic car-
cinoma (Fig. 27–31) or malignant mixed tumor of the
In benign lymphoepithelial lesion, intraductal prolif-
lacrimal gland, incisional biopsy is recommended.
erative changes cause luminal narrowing and ulti-
Adenoid cystic carcinoma is composed of aggregates
mately solid cellular aggregates termed epimyoep-
of small, tightly packed cells with hyperchromatic
ithelial islands (Fig. 27–30). In addition, proliferating
nuclei and minimal cytoplasm. A hyalinized stroma is
basement membrane material is present. Cystic dila-
present between the aggregates of cells. This pattern is
tion of the larger interlobular ducts may also occur.
typical of the basaloid form. A “Swiss chess” pattern
The surrounding glandular parenchyma shows a
with cellular nests of tumor cells is present. Definitive
prominent lymphoplasmacytic infiltrate with or with-
surgical excision includes radical surgery of exentera-
out associated follicles with extensive atrophy of the
tion with removal of orbital bone adjacent to the
acini. This benign lymphoepithelial lesion may be
tumor. Overall, in the case of adenoid cystic carci-
associated with Sjögren’s syndrome and may involve
noma, the 10-year survival is approximately 20%.
the salivary and lacrimal glands and is a lymphopro-
liferative disorder.
Malignant lymphoma of the ocular adnexa may be
associated with benign lymphoepithelial lesion of the
FIGURE 27–31 High-power view shows “Swiss cheese”

pattern of nests of tumor cells from adenoid cystic carci-
noma (left) arising in benign mixed tumor (right).
FIGURE 27–30 Proliferating intraductal epimyoepithe- Basophilic tightly packed small tumor cells, which contain
lial islands surrounded by sea of benign lymphocytes and scanty cytoplasm and hyperchromatic nuclei of adenoid
plama cells typical of benign lymphoepithelial lesion. cystic carcinoma, are surrounded by hyalinized stroma.
CHEN27-387-418.I 3/22/01 2:39 PM Page 412
A B
FIGURE 27–32 (A) A 32-year-old man with short history of enlarging mass in the left lacrimal gland area. (B) CT
scan shows smooth erosion of bone by mass in left lacrimal gland fossa. (C) Biopsy shows foci of epithelial elements
(lower field) that form tubular structures with adjacent areas with marked cytologic atypia consistent with malignant
mixed tumor.
Radiotherapy is palliative and not curative. Lym- is somewhat dependent on the histologic type. For
phoid tumors in the lacrimal gland are evaluated by example, benign papillomas tend to present at a
similar histopathologic and immunohistologic crite- younger age than carcinoma.
ria to those elsewhere in the orbit.
Malignant mixed tumor (Fig. 27–32) is composed Presentation
of aggregates of cells that resemble a pleomorphic Most patients with lacrimal sac tumors present insid-
adenoma. However, cytologic atypia and increased iously with symptoms of associated chronic
mitotic activity favor the diagnosis of malignant dacryostenosis or dacryocystitis, and in one study
mixed tumor over a benign pleomorphic adenoma 43% of tumors were found inadvertently at the time of
(benign mixed tumor). dacryocystorhinostomy.65 Tearing is a common com-
plaint with an associated lacrimal sac mass located
LACRIMAL SAC TUMORS above the medial canthal tendon (Fig. 27–33).66 Neo-
plastic masses are usually firm and noncompressible,
Lacrimal sac tumors should be considered in patient as compared to inflammatory swellings, which are
with an irreducible mass, especially if the mass often fluctuant and may reduce in size by the end of
extends superior to the medial canthal tendon.65–84 the day. Bleeding from the puncta, either sponta-
Bloody tears may be seen in inflammatory conditions neously or on pressure or irrigation of the sac, can
and are not definitive evidence of a lacrimal sac occasionally occur with lacrimal sac tumors, particu-
tumor. The age of presentation of lacrimal sac tumors larly as a late sign. However, other causes of bloody
CHEN27-387-418.I 3/22/01 2:39 PM Page 413
A B
FIGURE 27–33 (A) A 46-year-old patient with irreducible right lacrimal sac. The mass is firm and extends above
the medial canthal tendon. (B) Axial CT scan shows soft tissue density with invasion of bone. Patient had inverted
papilloma that was treated with complete extirpation of tumor and local radiation.
tears include vicarious menstruation, conjunctivitis, The canaliculus is lined by stratified squamous
vascular conjunctival tumors, hereditary hemorrhagic epithelium, whereas the lacrimal sac is lined by strati-
telangiectasia, ocular manipulation, epistaxis with ret- fied columnar epithelium with foci of ciliated respira-
rograde flow through the lacrimal drainage system, tory epithelium. Scattered goblet cells are present. In
conjunctival melanoma, pyogenic granuloma, hemo- the lacrimal sac, papillomas constitute the commonest
philia, autonomic nervous system dysfunction, and benign epithelial tumors, whereas oncocytic adeno-
focal dermal hypoplasia.67–69, 81 In most cases, blood mas and benign mixed tumors are less common.69
tears result from an inflammatory lesion within the Epithelial tumors of the lacrimal sac include papilloma
lacrimal sac that has caused erosion of the sac’s (squamous, transitional, mixed), carcinomas (squa-
epithelial lining. Pain is rare with lacrimal sac tumors mous, transitional, mixed, mucoepidermoid). Glandu-
unless there is secondary dacryocystitis.81 lar tumors of the lacrimal sac include adenoma,
oncocytoma, and adenocarcinoma. Mesenchymal
tumors of the lacrimal sac include fibrous histiocy-
EARL... Lacrimal sac tumors gener-
P
toma, hemangiopericytoma, fibroma/fibromyxoma,
and hemangioma.85 Lymphoid tumors of the lacrimal
ally present as a nonreducible, nontender,
sac are fairly common. Idiopathic inflammatory syn-
hard mass extending above the medial canthal drome may affect the lacrimal gland and it may be
tendon. Such masses are not generally fluctuant difficult to distinguish from chronic bacterial dacry-
and do not fully decompress at any time. ocystitis. Melanoma of the lacrimal sac is extremely
rare.
Ryan and Font67 histologically categorized papillo-
Proptosis usually occurs only when there is recur- mas as squamous, transitional, and mixed types, and
rent tumor or extension from a sinus tumor causing they may have an exophytic, inverted, or mixed
epiphora.70 Epistaxis is highly suggestive of a neo- growth pattern. Squamous papillomas contain acan-
plasm and is rarely encountered in inflammatory thotic stratified squamous epithelium. Transitional
lesions. Telangiectasia of the overlying skin favors cell papillomas are composed of stratified columnar
tumor, which may ultimately progress to erosion of the epithelium containing scattered goblet cells and cilia.
skin.70 Preauricular, submandibular or cervical lymph Mixed cell papillomas show features of both transi-
nodes, and ultimately distant metastases may occur.65 tional and squamous types. Transitional lesions are
Initially, the lacrimal system is patent to irrigation. composed of stratified squamous epithelium.
Secondary tumors may originate from the paranasal Lacrimal sac carcinomas may arise de novo or, less
sinuses, as stated above, from the orbit, or as metas- commonly, from a papilloma.80 Transitional cell carcino-
tases. The latter are rarely confined to the lacrimal sac mas histologically resemble transitional cell carcinoma of
alone.66 Inflammatory lesions such as pseudotumor or the bladder. Of carcinomas arising in the lacrimal sac,
granuloma may present as lacrimal sac masses. Unlike squamous and transitional cell carcinomas are the most
tumors, the former present with pain. common, but other types include adenocarcinoma,
CHEN27-387-418.I 3/22/01 2:39 PM Page 414
oncocytic adenocarcinoma, mucoepi-dermoid, poorly A localized mass on CT should prompt an initial

differentiated, and adenoid cystic carcinoma. Mucoepi- biopsy. The fact that the tumors are difficult to inter-
dermoid carcinomas arise from a mixture of squamous pret pathologically makes diagnosis based solely on
cells and goblet cells. Exophytic tumors grow into the frozen section unreliable. If clinically a mass is sus-
lacrimal sac lumen as fungiform masses with finger-like pected, a biopsy is taken. An osteotomy may provide
proliferations in the sac lumen. Endophytic (inverted) the tumor with an entrance into the nose. One might
papillomas grow into the sac wall as invasive acanthosis argue that a malignant tumor would require further
and proliferate in an inward direction. Lesions with extirpative surgery in any event, and therefore open-
endophytic features tend to be more invasive, leading to ing the nose would provide few disadvantages. Bone
recurrence and malignant transformation. involvement requires a lateral rhinotomy incision in
Oncocytic adenomas are less common benign conjunction with an otolaryngologist.
epithelial tumors, tending to occur in elderly
women.70–74 They are characterized by large epithelial
EARL ...
cells with abundant, finely granular eosinophilic cyto-
plasm. Oncocytic adenocarcinoma contains oncocytic
cells in an infiltrative pseudoglandular pattern with
P Definitive diagnosis of a
lacrimal sac tumor should be based on
permanent section biopsy prior to definitive
nuclear atypia.75 Benign mixed tumors of the lacrimal
therapy. A prebiopsy CT should be obtained.
sac are even rarer than oncocytic adenomas and con-
sist of proliferating cuboidal cells in a hyalinized
stroma. Treatment may include radical resection, radio-
In a pathologic review of 184 lacrimal sac tumors, therapy, or chemotherapy, depending on the type of
86 tumors originated from the epithelium; 46 were tumor.75–79 If there is no evidence of tumor, lacrimal
pseudotumors; 31 were mesenchymal and may drainage reconstruction may be performed at a sub-
include fibrous histiocytoma, fibroma, hemangioma, sequent date. Rootman82 has recommended Mohs’
hemangiopericytoma, angiosarcoma, and lipoma; 6 microsurgery for the treatment of such lesions. In any
were melanocytic; and 15 were lymphomas. Of the event, definitive wide surgical excision is the primary
latter tumors, fibrous histiocytoma is most common.67 treatment of choice for localized epithelial and mes-
Neural tumors (1%) may also occur. In clinical prac- enchymal tumors of the lacrimal sac.80 In such cases, a
tice lymphoid tumors may predominate. Lymphoid skin-muscle incision is made along the anterior
infiltrates of the lacrimal sac ranges from atypical lacrimal crest through the skin and muscle onto the
reactive lymphoid hyperplasia to non-Hodgkin’s B- periosteum, which is reflected out of the lacrimal sac
cell lymphomas. Seventy-three percent of the lym- fossa to approach the lacrimal sac. Dacryocystectomy
phoid infiltrates are malignant. is performed along with the surrounding periosteum
Lacrimal sac pseudotumors present similarly to and as far inferiorly into the nasolacrimal duct as pos-
acute dacryocystitis. A destructive process such as sible. All surrounding tissue, including adjacent
Wegener’s granuloma or midline granuloma is a less orbital and lateral nasal wall, is also removed. Exci-
likely possibility, and a necrotizing infective lesion sion of the bone, which constitutes the nasolacrimal
caused by a gram-negative anaerobe, fungus, or tre- duct, via a lateral rhinotomy may be indicated. If
poneme should also be considered. more widespread, exenteration, lymph node dissec-
tion, and resection of paranasal sinuses may be indi-
Management cated and performed by a head and neck surgeon or
A CT scan should be performed if the mass is hard an otorhinolaryngologist. Postoperative radiotherapy
and nonfluctuant. Injection of contrast material may is recommended for malignant epithelial tumours.
be helpful. CT of the orbit and sinuses is essential to Radiation of benign squamous papillomas may result
outline the mass and assess erosion or invasion into in malignant transformation. Recurrent lesions may
associated structures. Features suggestive of a require further surgery and adjuvant radiother-
lacrimal sac tumor include expansion of the lacrimal apy. 83–100 The treatment for lymphoproliferative
sac fossa, destruction of bone, and a mass extending lesions has been outlined above.
beyond the lacrimal sac. A chest x-ray and complete Papillomas, especially the inverted type, may recur
blood count with differential, erythrocyte sedimenta- with a frequency between 10 and 40%.80 The overall
tion rate, and renal and hepatic function tests should mortality in patients treated with a combination of
be done. If pertinent, antineutrophil cytoplasmic anti- wide surgical excision and radiotherapy was more
body and luetic serology may also be considered. If than a third of patients especially in those patients
the lesion is ulcerated, it should be swabbed for with recurrent tumors.80 Recurrence and mortality
microbiologic culture. rates for nonepithelial tumors are variable: benign
CHEN27-387-418.I 3/22/01 2:39 PM Page 415
fibrous histiocytoma has a good prognosis if comment and vascular tumors including lymphangioma,
pletely excised; lymphoid lesions are responsive to which has characteristic MRI features. Analysis of the
radiotherapy and chemotherapy, with outcome CT allows the surgeon to determine whether the dis-
depending on the extent and type of tumor; malig- ease process is intraconal, within the extraocular mus-
nant melanoma carries the worst prognosis, which is cles, or extraconal, within the bony wall of the orbit
little altered despite aggressive treatment. In any case, or adjacent sinus or arising from the lacrimal gland.
all lacrimal sac tumors require careful lifelong follow- Furthermore, CT demonstrates whether the process is
up, as recurrence and metastasis may occur many diffuse or focal. A diffuse process favors an inflam-
years after initial treatment. matory process or lymphoma, whereas a more local-
ized process is typical of a tumor. Similarly, bone or
sinus involvement may accompany certain inflam-
CONCLUSION matory processes such as Wegener’s granulomatosis
and large cell lymphoma in patients with AIDS but is
Evaluation of orbital disease is based on history and quite rare in orbital inflammatory pseudotumor and
ophthalmologic examination to define (1) the mucosal-associated lymphoid tumors. Tumors may
anatomic site and pattern of involvement, whether originate primarily in bone such as osteoblastoma or
diffuse or localized, and whether or not accompanied invade bone secondarily such as metastatic disease to
by a sinus and/or bone component; and (2) whether the orbit. Any rapidly growing tumor may undergo
the disease is a result of inflammation or tumor. The hemorrhage or necrosis, result in inflammation, and
initial radiologic examination is orbital CT with both mimic an inflammatory condition. Ultimately, orbital
axial and coronal views because the bone is visual- biopsy, which may be excisional when possible, is
ized. In some cases, the CT may be supplemented by necessary to establish the diagnosis and appropriately
MRI especially in tumors with possible brain involve- treat the problem.
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CHEN28-419-450.I 3/26/01 8:56 AM Page 419
Chapter 28
ORBITAL SURGERY
John W. Shore
Most descriptions of orbitotomy include discussion of

EARL... The most important step
P
two major types. Anterior orbitotomy refers to
surgery posterior to the orbital septum or deep to
for safe conduct of orbital surgery is for
Tenon’s capsule with dissection limited to the ante-
rior aspect of the orbit. Bone along the orbital walls or the surgeon to choose an incision that provides
rims is not removed. Lateral orbitotomy implies deep good visualization and adequate room to work.
orbital surgery in which the lateral orbital rim and lat-
eral wall is removed to gain access to the deep orbit. Exposure and visualization are perhaps the most
An arbitrary division of orbital surgery into these two important considerations. If a surgeon can see the
categories does not adequately describe what is orbital aerea and has room to use the surgical instru-
accomplished during orbital surgery today. A better ments, the other principles usually will be accom-
categorization is orbitotomy without bone removal plished. Thus, the surgeon’s choice of incision and
(anterior orbitotomy) and orbitotomy with bone type of orbitotomy are extremely important. The deci-
removal (lateral or posterior orbitotomy).1, 2 Regard- sion is based on a careful evaluation of the preopera-
less of the terms, there are several important princi- tive scans, [magnetic resonance imaging (MRI),
ples of orbital surgery that must be followed for any computed tomography (CT), ultrasound], the proba-
orbitotomy: ble pathology to be encountered (tumor, vascular
lesion, foreign body, etc.), the location and size of the
• The incision and approach to the orbit must pro- lesion, the goal of surgery (biopsy, resection, debulk-
vide adequate exposure so the orbital tissue can be ing, orbit enlargement, drainage, etc.), and the sur-
seen and safely manipulated with surgical instru- geon’s preference and experience. Lesions located in
ments. the anterior orbit and those that are visible are usually
• The incision and approach to the orbit should approached through an incision directly over or adja-
create the least possible disturbance of nonin- cent to the lesion. Bone is not usually removed and
volved orbital and adnexal tissue. closure is simply performed. In this scenario, orbito-
tomy without bone removal is the procedure of
• The incision and approach to the orbit should leave
choice. Large tumors, tumors located deep in the orbit,
the least visible scar possible.
and tumors located in inaccessible portions of the
• The incision and approach to the orbit should not orbit (superior nasal quadrant, adjacent to or wrapped
create a motility disturbance or visual loss, or oth- around the optic nerve, and orbital apex) usually
erwise defunctionalize orbital tissue or adnexal demand orbitotomy with bone removal for access,
structures if at all possible. exposure, visualization, and biopsy or tumor removal.
419
CHEN28-419-450.I 3/22/01 2:40 PM Page 420
PREOPERATIVE CONSIDERATIONS ORBITOTOMY WITHOUT BONE

A great deal of preoperative planning is required for
REMOVAL–ANTERIOR ORBITOTOMY
orbital surgery. The major consideration is to com- There are nine basic incisions that can be used to
plete a thorough preoperative assessment and to approach lesions in the anterior orbit. Technically, the
obtain the appropriate imaging studies for the case at procedures are straightforward and not overly risky if
hand. In this regard, both CT and MRI studies (and specific principles are followed. The principles for
possibly ultrasound, angiography, and other neuro- anterior orbitotomy include the following:
radiologic imaging procedures) may be needed. This
chapter does not cover orbital pathology or clinical- • Choose an incision that provides adequate room to
pathologic entities that dictate the need for biopsy, see, work, and accomplish the goals of surgery.
excision, or other nonsurgical modalities for treatment • Identify the relevant normal anatomy and strive to
of the lesion at hand. Surgery is merely one important remain oriented to the normal anatomy as the
component of care for a patient with orbital disease. tumor is approached. Carefully separate the tumor
One must have a thorough understanding of orbital from surrounding normal anatomy.
disease before planning surgery, as this will deter- • Avoid injury to normal anatomic structures during
mine the goals of the intended surgical procedure. dissection.
Once a decision to proceed with orbital surgery is • Maintain meticulous hemostasis during all phases
made, specific concerns involved in the safe conduct of the surgery.
of the surgery can be addressed. A preoperative and • Avoid sharp dissection except when needed. Use
intraoperative plan is developed and executed. Con- blunt dissection when possible. Dissection with a
sideration should be given to the following: cotton-tipped applicator may work well for some
encapsulated tumors.
• An assessment of the patient’s overall medical sta-
tus. If nutritional, constitutional, or local factors
(e.g., prior radiation therapy) exist, the operative
plan or preoperative preparation must include the PITFALL
means to optimize conditions for safe conduct of
the surgery. Do not traverse Tenon’s capsule from the
• The patient’s coagulation status, bleeding history, sub-Tenon’s space to the extra- or intraconal
and clotting parameters need to be checked and space at the level of the intramuscular septum
adjusted to minimize the risk of intraoperative or without carefully considering the conse-
postoperative bleeding. If vascular surgery is con- quences. An adherence syndrome may result.
templated, consideration should be given to the
administration of hypotensive anesthesia (see
above), or use of the carbon dioxide laser for dis-
section, resection, or debulking of vascular tumors. • Carefully identify and observe the levator aponeu-
• Perioperative systemic steroid administration is rosis and repair it to prevent the development of
helpful. The usual dosing begins prior to, or imme- blepharoptosis if the levator aponeurosis is
diately following, induction of general anesthesia. stretched, transected, or partially removed.
The steroids need to be administered prior to mak- • Reposit the orbital lobe of the lacrimal gland within
ing the skin incision for maximum effectiveness. the confines of the bony orbit, behind the orbital
Additional doses are given intravenously for the rim if it is found to have migrated due to the pres-
first 24 hours following surgery. If desired, oral ence of tumor, or dissection to remove tumor.
steroids may be continued briefly following hospi- Secure it to the arcus marginalis with an absorbable
tal discharge. suture. Do not resect any of the gland unless that is
• Prophylactic antibiotics are not administered rou- one of the intended goals of surgery.
tinely. Selective antibiotic use should be considered • Avoid injury to the lacrimal gland ductules when
in instances where indicated, for example, entry operating in the superotemporal quadrant of the
into an infected paranasal sinus cavity, orbital cel- orbit near the levator aponeurosis, or when work-
lulitis, and following orbital specimen culture after ing in the superolateral fornix.
drainage of orbital abscess. • Avoid sharp dissection, cautery, or excessive
• During surgery the cornea should be protected retraction in the region of the superior oblique ten-
from desiccation or injury from cautery, excessive don, trochlea, or the inferior oblique muscle if pos-
traction, or instruments. A protective corneal shield sible. If dissection in that area is necessary, strive
should be used when possible. to keep the field dry and directly observe each
CHEN28-419-450.I 3/22/01 2:40 PM Page 421
ORBITAL SURGERY • 421
structure before cutting or cauterizing tissue. Injury through small incisions. Large incisions are required
to the superior oblique tendon, trochlea, or inferior to remove medium- to large-size tumors. Incisions for
oblique muscle can lead to motility problems that removal of these tumors generally should be placed
are difficult, if not impossible, to repair. in more cosmetically acceptable locations, for exam-
• If the conjunctiva is resected, consider replacing it ple, eyelid crease, sub-brow, and the inferior fornix.
with a conjunctival free graft, conjunctival flap, or The direct skin approach is also excellent for draining
mucosal graft following tumor resection. abscesses and or removing small foreign bodies. If a
direct incision is to be used, attention should be paid
Orbitotomy without bone removal is the most com-
to orienting the incision to conform to the relaxed skin
mon orbitotomy procedure performed. It does not
tension lines as per any other periocular or facial
provide adequate visualization or room to work in all
skin incision. In general, an incision directly over the
types of orbital surgery, however. Some tumors are
lesion should be avoided when a more cosmetic
too large, or too deep to be approached surgically by
option exists, for example, a lesion in the upper eyelid
anterior orbitotomy without bone removal. The deci-
near the eyelid crease. Here, a simple eyelid crease
sion to remove bone may be difficult at times. The
incision is better. When a direct incision is used in the
general rule is to err on the conservative side and
upper or lower eyelid, do not close the orbital sep-
remove bone if there is any possibility that the goals
tum. Merely redrape the orbicularis oculi muscle and
of surgery can’t be accomplished by anterior orbito-
the overlying skin and close the skin. When direct
tomy alone. At times it is possible to plan for anterior
incisions are used in the vicinity of the lower eyelid,
orbitotomy, but approach the orbit through one of the
consider tightening the lower eyelid at the outer can-
incisions described below that has an option for bone
thus to reduce the risk of lower eyelid malposition
removal during the case if it becomes obvious that
developing postoperatively.
additional room to operate is needed. To accomplish
this, one must also be familiar with the options for
orbitotomy with bone removal (see Orbitotomy with
EARL ...
Bone Removal, below).
The incisions that are commonly used for orbito-
tomy without bone removal follow.
P The upper eyelid crease
incision is one of the most useful incisions
for gaining access to the superior orbit.
Direct Incision
An incision directly over the tumor can be used Eyelid Crease Incision
almost any time the tumor can be observed or pal- The eyelid crease incision is one of the most useful
pated directly deep to the skin (Fig. 28–1). This inci- incisions for anterior orbitotomy in the superior
sion is ideal when biopsy, not removal, is planned. It orbit. Cosmetically, it leaves a very acceptable scar.
can also be used to excise tumors that can be removed One can gain access to and remove small or large
tumors in the anterior half of the superior orbit
through this incision. One can also dissect superiorly
in a plane anterior to the orbital septum, to gain
access to the superior and lateral orbit in a subpe-
riosteal plane. The optic nerve is accessible from a
superotemporal approach without bone removal.3
The same dissection can be used to expose the super-
olateral, lateral, and inferolateral bony walls of the
orbit for orbit enlargement surgery in patients with
proptosis due to Graves’ ophthalmolopathy. The
lacrimal gland is accessible for biopsy or removal
through this incision as well. The incision can be
used to gain access to the deep orbit by exercising a
bone removal option if wider exposure becomes nec-
essary. One can even convert to an eyelid margin
orbitotomy if more room is needed in the anterior
FIGURE 28–1 A cutaneous incision placed directly over orbit in the region of the levator complex or superior
a subcutaneous tumor is used to remove an orbital dermoid fornix (described below).
filling the left lacrimal sac fossa and compressing the The approach to the optic nerve through the eyelid
lacrimal sac. crease incision is representative of this orbitotomy
CHEN28-419-450.I 3/22/01 2:40 PM Page 422
A B
FIGURE 28–2 (A) The eyelid crease incision for anterior orbitotomy provides excellent exposure of the optic nerve
from a lateral approach. (B) The position of the orbital retractors provides exposure of 1 cm of optic nerve directly
behind the globe.
(Fig. 28–2). The preparation and positioning of the removed. The arcus marginalis is closed. The orbicu-
patient through an eyelid crease incision is the same as laris oculi muscle and deep subcutaneous tissue are
for lateral orbitotomy. In fact, the entire operation is closed in layers with absorbable sutures. The skin is
exactly the same until the point where bone of the lat- closed and Steri-stripped.
eral orbit is to be removed (see Orbitotomy with Bone
Removal—Lateral Orbitotomy, Eyelid Crease Incision, Sub-Brow Incision
below). Once the arcus marginalis has been placed on The sub-brow incision is less useful for anterior
traction with sutures and distracted inferonasally, the orbitotomy, but can be incorporated into a modified
periorbita is incised posterior to the orbital lobe of Lynch incision to access the superior nasal quadrant
the lacrimal gland. The gland can usually be seen of the orbit. It is also useful when draining the super-
deep to the periorbita and appears as a pale, lobulated onasal, superior, or superolateral subperiosteal space
structure distinct from the more yellow-appearing of hematoma or suppuration (Fig. 28–3). Through this
orbital fat. An orbital retractor or a malleable brain incision, frontal sinus trephination can also be per-
retractor is inserted to retract the orbital fat and globe. formed. The incision and dissection is described
Anterior and inferior traction is used initially and then below (see Orbitotomy with Bone Removal—Lateral
a second retractor is place to separate the orbital fat as Orbitotomy, Sub-Brow Incision).
the orbital portion of the optic nerve is approached. A
“hand-over-hand” retractor dissection technique is Lynch Incision
used to move fat away from the nerve. This means the The Lynch incision is a classic approach to the super-
retractors are inserted, removed, and reinserted again onasal orbit.4 It can be used to biopsy lesions in the
and again. Gentle traction is applied with each inser- anterior two-thirds of the orbit at that location. Also,
tion until the optic nerve is reached. One- by three- it can be used to remove small to medium-size
inch neurosurgical cottonoid sponges placed between tumors in the anterior half of the superonasal orbit,
the blades of the retractors and the fat help immensely for drainage of blood and pus in this region, for
with the dissection. They are also absorbent and pro- nasoethmoid fracture repair, and for entry to the eth-
vide hemostasis. As the nerve is approached, bipolar moid sinus for ethmoidectomy or to the frontal sinus
cautery should be avoided as injury to the long and for trephination (Fig. 28–4). The incision can be
short posterior ciliary nerves can occur when cautery extended laterally to connect with the sub-brow inci-
is used in the intraconal space directly posterior to the sion (see above) or inferiorly to expose the lacrimal
globe. If a thorough release of the arcus marginalis has sac and nasolacrimal duct once the medial canthal
been accomplished, there is plenty of room to visual- tendon is separated from its bony attachments. This
ize the optic nerve for fenestration, biopsy of perioptic approach to the orbit is described below (see
tumors, and removal of small to medium-size tumors Extended Lynch Incision).
lateral to and adjacent to the nerve within 1.5 cm of
the globe. Closure is quick and straightforward. Subciliary Lower Eyelid Incision
Hemostasis is assured (see Deep Orbital Surgery The subciliary lower eyelid incision is useful for
Techniques, Hemostasis, below). The retractors are approaching lesions in the inferior lateral orbit,
CHEN28-419-450.I 3/22/01 2:40 PM Page 423
A B
C D
FIGURE 28–3 (A) A 13-year-old girl presented with

orbital cellulitis, orbital suppuration, and crepitance due to
intraorbital gas and pansinusitis on the left. (B) Manage-
ment required simultaneous trephination of the left frontal
sinus for irrigation and orbitotomy without bone removal
for drainage and culture. A sub-brow incision approach
with a Lynch extension was chosen for access. (C) The cuta-
neous incision was interrupted centrally to avoid injury to
the supraorbital nerve. (D) Following drainage of the sup-
purative process, a Penrose drain was placed and exited
through the lateral aspect of the wound. (E) The skin healed
uneventfully and the sensory status of the supraorbital
E nerve was not affected.
particularly those traversing the orbital septum or rest-

EARL... The inferior fornix incision
ing on the anterior aspect of the inferior orbital rim.
More centrally located tumors can also be approached
through this incision. It is an excellent option for pal-
P is the preferred approach to the inferior
orbit in most instances.
pable or visible lesions in the inferior orbit in lieu of
the direct approach described above. The major disad-
vantage is the large, blepharoplasty-like musculocuta-
neous flap that must be developed to expose the orbit. Conjunctival Incision
Concerns about midlamellar wound contracture neces- Some orbital tumors present as a subconjunctival
sitate horizontal lower eyelid tightening as an adjunct mass and extend deep into the orbit. Conjunctival der-
to prevent postoperative lower eyelid malposition. The moids, orbital dermoids, ectopic lacrimal gland cysts,
very same portions of the orbit are usually accessible lipodermoids, herniating orbital fat, and lymphomas
through the inferior fornix transconjunctival orbito- are examples of such tumors. These lesions can be
tomy with or without cantholysis (see below). approached by direct incision of the conjunctiva
CHEN28-419-450.I 3/22/01 2:40 PM Page 424
A B
C D
FIGURE 28–4 (A) A 37-year-old Indian man presented with proptosis due to the presence of a large mass in the
superior nasal quadrant of the left orbit (B) . (C) A Lynch approach was used to remove the hemangiopericytoma. An
inferior or lateral extension was not required. (D) A cryoprobe was used to apply anterior traction on the tumor as it
was gently removed. A medial fornix/transcaruncular incision would not have worked in this situation because the
tumor was located anteriorly in the orbit and was compressing the superior oblique muscle from a medial direction.
overlying the lesion. Following biopsy or tumor If conjunctiva is not available for grafting, split-
removal, the conjunctiva is closed with fine sutures. If thickness buccal mucous membrane grafts (for the
the conjunctiva is sacrificed, a conjunctival graft from globe), full-thickness buccal mucous membrane grafts
another quadrant of the ipsilateral globe or from the (for the eyelid), or a suitable allograft may be used
opposing globe may be necessary (Fig. 28–5). This is for coverage.
particularly true in the following circumstances:
Medial Limbal Conjunctival Approach to the
• Greater than 1.5 cm of conjunctiva is sacrificed (rel- Intraconal Space
ative indication).
The conjunctival approach to the orbit is also a good
• Removal of the conjunctiva leaves one or more of option for biopsy or removal of medially located
the of the recti muscles or tendons exposed. intraconal tumors adjacent to the optic nerve in the
• The conjunctival resection extends to or exposes anterior half of the orbit. The entry is through a limbal
one or more of the fornices. peritomy incision. The conjunctiva and Tenon’s cap-
• The palpebral conjunctival epithelium and adjacent sule is elevated by blunt dissection, and the medial
bulbar conjunctival epithelium are involved in the rectus muscle tendon is exposed. The medial rectus
resection. If at least one epithelial surface remains muscle is disinserted off the globe and tagged with an
intact, adhesions will not form. If both surfaces are absorbable suture on a spatula needle as used in
denuded of an epithelial covering, adhesions will extraocular muscle surgery. The intramuscular sep-
form. Such adhesions can impair proper function- tum need not be divided adjacent to the superior or
ing or movement of the eyelid or lead to ocular inferior edge of the medial rectus muscle unless mus-
motility dysfunction. cle recession or resection is planned. A traction suture
CHEN28-419-450.I 3/22/01 2:40 PM Page 425
through the medial rectus insertion stump is used to equator of the globe. This landmark is followed pos-
rotate the globe laterally. The long posterior ciliary teriorly and Tenon’s capsule is entered posterior to
nerve is seen within the scleral coat along the medial the equator of the globe. The entry must be posterior
A B
C D
E F
FIGURE 28–5 (A) A 17-year-old girl with Goldenhar’s syndrome presented with a lipodermoid of the left lateral
orbit and temporal globe. The tumor involved the conjunctiva and extended posteriorly into the orbit behind the
equator of the globe. (B) A transconjunctival approach to the tumor was planned and the orbit entered. The resection
was limited to the anterior orbit, but conjunctiva over the lateral rectus was removed along with the anterior portion
of the tumor. The lateral fornix was denuded of conjunctiva as part of the debulking process. (C) A conjunctival free
graft taken from the superior lateral quadrant of the uninvolved right eye provided coverage for the lateral rectus mus-
cle and was used to reconstruct the lateral fornix. (D, E) Postoperatively, the ocular alignment was unaffected and the
ocular motility full. A similar case healed by secondary intention and resulted in a dry eye and eyelid/glove syn-
drome with restricted ocular movement, diplopia, and adhesive blepharoptosis. (F) The scars are evident in the area
over the lateral rectus muscle.
CHEN28-419-450.I 3/22/01 2:40 PM Page 426
to the equator so as to prevent an adherence syn- Dissection in the subperiosteal space posteriorly
drome from developing postoperatively. The fat is leads to the anterior and then the posterior ethmoidal
retracted and the lesion or optic nerve is exposed by neurovascular bundles. These vascular structures
careful dissection. As mentioned above, cautery appli- must be ligated or clipped and hemostasis assured
cation when operating in the intraconal space adja- before any further work is attempted. Loss of vascular
cent to the optic nerve or posterior globe is to be control at this stage will obscure the surgical field and
avoided if at all possible. Once optic nerve fenestra- prevent safe dissection. The frontoethmoidal suture
tion or tumor removal/biopsy is complete, the wound serves as a landmark for orientation. Bone cephalad
is closed. Hemostasis is assured. The medial rectus to this bony suture is adjacent to the anterior cranial
tendon is reattached to its original insertion on the fossa. Bone caudad to the suture abuts the ethmoid
globe, and the conjunctiva is closed. labyrinth. If hemostasis is assured, one can continue
the dissection to the annulus of Zinn where apical
Transcaruncular or Medial Fornix tumors medial to the optic nerve can be biopsied. If
Conjunctival Incision more room is needed for instrumentation, the lamina
An incision in the medial fornix at the level of the papyracea of the medial orbital wall can be removed
caruncle can be used to gain access to the medial orbit and a total ethmoidectomy performed. One must be
in a subperiosteal plane or in a plane between the very careful during ethmoidectomy to maintain the
periorbita and the orbital soft tissue (medial rectus proper orientation with respect to the landmarks
muscle, superior oblique muscle, and orbital fat). The mentioned above so as to avoid chipping or tearing
caruncle and the plica semilunaris need not be sacri- bone in the region of the fovea ethmoidalis. Cere-
ficed. In fact, they serve as landmarks for the incision brospinal fluid (CSF) rhinorhea and meningitis can
and to hide the scar following wound closure. result. In addition, one must be aware of the relation-
The incision begins in the superior fornix nasally, ship of the orbit and sinus when surgical instruments
just above the fold created by the conjunctiva of the are passed from the orbit to the sinus so as not to enter
plica semilunaris as it meets the caruncle. The the anterior cranial fossa. Endoscopic assisted eth-
canaliculus of the upper eyelid is adjacent to the inci- moidectomy performed by an ear, nose, and throat
sion site, so care must be exercised to avoid injury to (ENT) surgeon followed by bone removal along the
the lacrimal collecting system. The incision continues medial orbital wall is an alternative to ethmoidectomy
inferiorly in the aforementioned fold to the level of from the transcaruncular approach and is safer in
the inferior fornix. Tenon’s capsule is rather tenacious many instances.5 One should not proceed with this
in this region, yet with blunt dissection using the tip approach to the deep orbit unless the anatomy can be
of a small curved hemostat, the orbit can be entered seen and identified and three-dimensional orientation
quite easily. The dissection continues in a bloodless maintained.
field if the tips of the hemostat are angled slightly At times, additional space may be needed to move
toward the medial orbital wall. Dissection laterally instruments in and out of the incision and to remove
toward the belly of the medial rectus muscle should tumors. In this situation, the medial fornix incision
be avoided due to potential injury to the muscle and can be connected to an inferior fornix incision. The
the possibility of causing bleeding. Approximately origin of the inferior oblique muscle on the orbital
1 cm posterior to the incision line, the periorbita of the plate of the maxillary bone is elevated with a
medial orbital wall can be palpated against the bone periosteal elevator, and reflected laterally and supe-
of the posterior lacrimal crest and is seen as a white riorly. The entire inferior and medial orbit is now
fibrous sheet. Further dissection in this plane will exposed. The lacrimal duct may prevent full mobi-
place the surgeon’s instrument between the belly of lization of the orbital soft tissue, but if the periosteal
the medial rectus muscle and the periorbita. Muscle release along the inferior orbital rim and around the
biopsy can be performed if desired. Lesions in this lacrimal duct is thorough, a surprisingly large space
potential space can be biopsied or excised. for further dissection is created. The inferior oblique
It is safe to incise the periorbita vertically immedi- muscle need not be reattached to bone during closure,
ately posterior to the posterior lacrimal crest. The inci- as its orbital course remains undisturbed. Merely
sion in the periorbita parallels the posterior lacrimal reposit the orbit soft tissue on the bone of the orbit
crest. The subperiosteal space of the medial orbit is and the muscle will attach without direct anchoring.
then entered. The lacrimal sac and duct are located Closure following transcaruncular medial orbito-
anterior to the posterior lacrimal crest and are not at tomy is not difficult. Hemostasis is assured. The
risk of damage if the periosteal incision is made wound is irrigated, and the conjunctiva is closed.
directly over or immediately posterior to the poste- The medial canthal tendon (both limbs) are not dis-
rior lacrimal crest. rupted during entry to the orbit. Therefore, canthal
CHEN28-419-450.I 3/22/01 2:40 PM Page 427
fixation is not necessary. One important point relates aspect of the globe is reached. Tenon’s capsule is then
to the use of packing in the medial orbit to control divided as described above and the tumor approa-
bleeding during closure. Packing should never be ched directly. During the dissection in the sub-
placed in the medial orbit from the nasal or ethmoid Tenon’s space, care must be exercised to avoid injury
cavity to control bleeding. Postoperative swelling or to the superior oblique tendon and its insertion on
continued oozing of blood will invariably lead to the the globe. The tendon will be observed as the dissec-
development of an orbit compartment syndrome tion proceeds posteriorly. Blunt dissection, gentle
with compressive optic neuropathy and visual loss. retraction, and cautious use of bipolar cautery pro-
Packing is not advised in the anterior ethmoid vides an excellent view of the tendon as it traverses
labyrinth, but may be used with caution if needed. the orbit and attaches to the globe. The superior
The posterior ethmoid labyrinth should not be oblique tendon should not be detached from the
packed if there is an open communication between globe. The medial rectus muscle may be removed
the sinus and the orbit. and reattached as described above if necessary.
The closure is straightforward. After the medial
rectus muscle has been reattached to the globe, the
bulbar conjunctiva is closed. The conjunctival sutures
PITFALL need not extend past the superior fornix. The eyelid
margin incision is repaired in the standard manner
Do not use packing in the medial orbit to con- with tarsal sutures, eyelid margin sutures, and cuta-
trol bleeding. Maintain vascular control at all neous sutures.
times when dissecting in the medial orbit.
Convert to a larger incision if vision is com- Inferior Fornix Orbitotomy (“Swinging Lower
promised to the point that hemostasis can’t Eyelid Orbitotomy”)
be maintained without packing. Perhaps the most useful incision to approach tumors
in the anterior/inferior orbit is the inferior fornix
orbitotomy.6, 7 This procedure most often involves
simultaneous lateral canthotomy and cantholysis to
The transcaruncular approach can be used for provide better access to the inferior orbit. If limited
biopsy of anterior, mid-, and deep orbital tumors. It is exposure is all that is needed, however, lateral can-
a useful approach for balanced medial and lateral thotomy and cantholysis may be skipped (Fig. 28–7).
orbital decompression or orbit enlargement surgery If more room is needed during the surgery, bone can
in the setting of Graves’ ophthalmolopathy. It can be always be removed laterally by converting to a lat-
used as an approach for the repair of medial orbital eral orbitotomy with bone removal through one of
fractures. It is not a good incision to use for resection the incisions covered in the section on lateral orbito-
of vascular tumors or tumors that are known to bleed tomy, below. Also, an option exists for medial exten-
when surgically manipulated. sion of the inferior fornix incision to connect with a
medial fornix incision. This provides wide access to
Eyelid Margin Orbitotomy the inferior medial orbit. The inferior oblique muscle
The eyelid margin incision is an excellent one to use can be detached from the orbital plate of the maxil-
for removing medium-size tumors in the anterior lary bone to expose the entire orbital floor and medial
orbit that abut or are adjacent to the superior fornix. wall of the orbit if desired. The muscle should be
It can also be used to access tumors deeper in the removed by direct subperiosteal dissection rather
nasal quadrant by connecting it to a medial fornix than by incising the muscle within the soft tissue of
incision (see below). One must be careful to avoid the orbit. At the close of the surgery, the inferior
injury to the superior oblique tendon. The eyelid oblique muscle origin need not be sutured or other-
margin incision is oriented vertically from the mar- wise connected to bone. Merely reposit the orbit soft
gin of the eyelid and extends to the eyelid crease tissue on the bone of the orbit and the muscle will
(Fig. 28–6). The divided tarsus and conjunctiva are attach without direct anchoring.
placed on lateral and medial traction by the assistant The classic inferior fornix orbitotomy begins with a
or with traction sutures. The tumor can then be seen lateral canthotomy and inferior cantholysis
and removed. If dissection behind the globe is (Fig. 28–8). The skin incision is placed directly at the
required, the incision can be moved nasally and the lateral canthus and extends laterally and inferiorly for
conjunctival incision extended onto the globe and a distance of 1.2 to 1.5 cm. The incision should be
continued to the medial fornix. Dissection proceeds placed in a rhytid if possible and angled inferiorly
in the potential sub-Tenon’s space until the posterior with reference to the horizontal raphe at about 10 to
CHEN28-419-450.I 3/22/01 2:40 PM Page 428
A B
C D
FIGURE 28–6 (A) A 26-year-old black man presented with a right anterior mass that involved the superior fornix
medially and extended to the posterior aspect of the upper eyelid. (B) Computed tomography (CT) demonstrated the
anterior location of the tumor. (C) An eyelid margin splitting was performed and the cyst successfully exposed and
removed. (D) The eyelid healed uneventfully.
15 degrees. The incision can be extended over the lat-

eral orbital rim for a distance of 2.5 to 3.0 cm if neces-
sary, but this is usually not required. The purpose of
such an extension is to provide better access to the
bony rim and lateral or inferior walls of the orbit, usu-
ally for bone removal. The cantholysis must be com-
plete so that the lower eyelid swings free from the
attachments at the lateral orbital retinaculum. Septal
attachments must be severed to allow the eyelid to
move completely away from the globe. The lower
eyelid is then retracted caudally with retractors so
that the eyelid, conjunctiva, and lower eyelid retrac-
tors are stretched over the inferior orbital rim. The
inferior orbit is now exposed for dissection. One can
enter the orbit directly in the inferior fornix by incis-
ing the conjunctiva and dividing the lower eyelid
retractors. Alternatively, the incision can be moved
FIGURE 28–7 An inferior fornix incision without can-
up onto the posterior aspect of the lower eyelid and a
thotomy or cantholysis was used to remove this peripheral
preseptal approach to the inferior orbital rim can be
nerve tumor of the right orbit of a 27-year-old black man.
Care is exercised not to place excessive inferior traction on used. The fornix incision is quicker, and the closure
the lower eyelid margin, as an avulsion can result. In this sit- easier than the subciliary incision for anterior orbito-
uation, closure of the fornix conjunctival incision following tomy. The decision often depends on the location of
tumor is not necessary. Dissection in the central lower eyelid the tumor and the goals of surgery (biopsy, explo-
is meticulous to avoid injury to the inferior oblique muscle. ration, drainage, reconstruction, tumor excision, etc.).
CHEN28-419-450.I 3/22/01 2:40 PM Page 429
A B
FIGURE 28–8 (A) A 63-year-old

Caucasian man presented with bilat-
eral, subconjunctival, and anterior
orbital masses consistent with massive
lipomatous herniation. The approach to
the orbit was by way of a lateral canthal
release with inferior fornix anterior
orbitotomy for debulking and biopsy.
(B) The fat presented through the infe-
rior fornix incision and was excised.
(C) Canthal reconstruction with simple
closure of the conjunctiva and skin gave
a very acceptable cosmetic and func-
C tional result.
Although it is permissible to move the incision up lateral orbitotomy, below. The skin over the lateral
onto the posterior aspect of the eyelid, the conjuncti- orbital rim is closed in layers. The lower eyelid may
val incision should not be moved superiorly onto the be supported with a suture tarsorrhaphy if desired,
globe. The bulbar conjunctiva must remain intact. but this is usually not required.
ORBITOTOMY WITH BONE REMOVAL—

PITFALL
LATERAL ORBITOTOMY
Do not incise the bulbar conjunctiva during Many orbital tumors superior, lateral, and inferior to
inferior fornix transconjunctival orbitotomy. the optic nerve, whether intra- or extraconal, can be
reached by lateral orbitotomy or orbitotomy with
bone removal. Most commonly, the bone of the lat-
Dissection that begins on the surface of the eye can eral wall is removed to provide wide exposure. There
lead to adhesions forming in the vicinity of the infe- are many options, and the operation can be tailored
rior rectus muscle and Lockwood’s ligament. These to meet the clinical requirements of the case. The deci-
adhesions can result in motility disturbances postop- sion usually depends on the size and location of the
eratively. One must exercise caution when dissecting tumor, the suspected histopathology (incisional vs.
in the anterior orbit in the central lower eyelid or in excisional biopsy), the size and configuration of the
the vicinity of Lockwood’s ligament. The inferior orbit, and the personal preference of the surgeon.
oblique muscle traverses this area and can be seen
rather superficially in the anterior orbit. The muscle Skin Incisions
should be identified and avoided when dissection is There are four possible skin incisions that can be used
being performed in this portion of the orbit. to approach the lateral orbit: eyelid crease, extended
Following tumor removal, the closure is quick and canthal, sub-brow, and classic (Fig. 28–9). Each has
straightforward. The orbital septum need not be advantages and disadvantages. When selecting the
closed. The conjunctiva is closed with a running skin incision, the surgeon should be mindful of
absorbable suture. The canthus is repaired and can- the potential pitfalls of the orbitotomy itself. For
thal fixation achieved as described in the section on instance, on occasion additional bone may have to be
CHEN28-419-450.I 3/22/01 2:40 PM Page 430
soft tissue retraction. The wound can always be

extended during surgery if necessary.
The orbicularis oculi muscle is divided across the
A eyelid crease incision and at the lateral orbital rim. It
is important to elevate the muscle from the underly-
B
ing orbital septum and periosteum of the lateral
orbital rim in one unit as a musculocutaneous flap.
D C The orbital septum should be opened even though
preaponeurotic fat presents in the wound. Some fat
A-1 can be trimmed if necessary, or merely retracted by
E the assistant. Failure to open the septum hides the
upper eyelid anatomy, which is important to visualize
FIGURE 28–9 The skin incisions for orbitotomy are during lateral orbitotomy using the eyelid crease inci-
shown as follows: A, sub-brow incision; A-1, sub-brow incision. At this stage, 4-0 or 5-0 silk sutures can be placed
sion with medial extension; B, eyelid crease incision with through the orbicularis oculi muscle at the wound
lateral extension; C, classic lateral orbitotomy incision; and
edge for traction and exposure.
D, canthal incision. The incision is usually extended to
include a portion of C if bone is to be removed laterally. It
then becomes an extended lateral canthal incision. E, infe-
EARL... During orbitotomy through
rior fornix incision for inferior orbitotomy.
removed and the wound enlarged for visualization,

P an eyelid crease incision, the orbital sep-
tum should be opened and the preaponeurotic
vascular control, or tumor removal. The potential fat retracted so that the levator complex can be
need to gain additional room to operate may influ- observed during subsequent dissection.
ence the decision of where to place the incision.
Cosmesis is another important aspect. The eyelid
crease incision and the extended canthal incisions The most important steps in the dissection for the
give the best cosmetic results. The healed wounds of eyelid crease incision are as follows: The skin and
the sub-brow and classic incisions are only slightly muscle of the inferolateral edge of the wound must
more noticeable. be carefully dissected off the lateral orbital rim perios-
Planned bone excision vs. temporary removal and teum without injuring the lateral canthal tendon or
replacement of the bone of the lateral orbit may influ- penetrating the periorbita. The lateral portion of the
ence the surgeon’s decision with respect to placement eyelid crease incision crosses the orbital rim 7 to 8 mm
of the incision. If the lateral bony rim is removed and above the lateral horizontal raphe of the canthus. Dis-
not replaced, alternative means for canthal fixation section in a caudal direction directly over the bony
must be planned when the canthal incision is used. If rim, deep to the orbicularis muscle and lateral to the
the canthal tendon is not disturbed to gain access to anterior extension of the lateral canthal tendon creates
the bone of the lateral orbital rim, less attention to can- a pocket into which a Desmarres, Ragnal, malleable,
thal fixation is necessary. or orbital retractor can be inserted to aid retraction of
the skin muscle flap. Further dissection separates the
Eyelid Crease Incision orbicularis muscle from the underlying periosteum
This is the most cosmetic of the incisions providing circumferentially around the orbital rim. The white
access to the lateral orbit. Surprisingly it gives wide periosteum over the bone of the lateral orbit is easily
access to the lateral and superior orbit and can be used identified and cleaned of muscle fibers. If necessary,
to biopsy or remove most tumors in this area. It is an dissection of the suborbicular pocket can be contin-
excellent approach to use for optic nerve sheath fenes- ued along the rim of the inferior orbit to a position
tration. The inferolateral orbit and even the floor of the directly below the pupil.
orbit can be reached from the eyelid crease approach, Once the periosteum is exposed, a curvilinear
but the incision is better for bone removal, as in orbit periosteal incision is made along the rim parallel to
decompression or orbit enlargement surgery, than for and 3 mm lateral to the arcus marginalis. The incision
removal of tumors of the inferior orbit. begins 1 to 2 cm above to the frontozygomatic suture
The incision is placed in the eyelid crease of the and continues 3 to 5 mm inferior to the lateral raphe.
upper eyelid and extends over the lateral orbital rim Horizontal relaxing incisions are made in the
as an extended upper blepharoplasty incision. It is periostium at the caudad and cephalad extent of the
important to carry the incision far enough medially exposed orbital rim. The periosteum is reflected by
and laterally to allow adequate access to the orbit by subperiosteal dissection to the lateral extent of the
CHEN28-419-450.I 3/22/01 2:40 PM Page 431
bony orbital rim and medially to the arcus marginalis. achieve broad exposure of the orbital floor, and it pro-
The latter structure is sharply dissected off the orbital vides excellent access to the lateral and inferior orbital
rim at the entrance to the anterior plane of the orbit. rim for bone removal and hence, large tumor access.
The arcus marginalis is densely attached to the bone The major disadvantage of this approach to the orbit
in this area and must be carefully removed. It is not is the very careful attention that must be paid to can-
necessary to tag the laterally reflected periosteum for thal reconstruction following tumor removal. The rea-
later closure; however, the medial flap can be tagged son is that lateral support for the canthal tendon is
with traction sutures to gain better exposure to the disrupted during entry into the orbit. During upper
orbit. If bone is to be removed and discarded, the and lower cantholysis, the lateral canthal tendon is
arcus marginalis will serve as the new attachment divided. Also, the structural bony support for the ten-
point for the canthus. The planned attachment point don may be removed or displaced as part of the
can be tagged with a suture if desired. orbital surgery. This section covers the canthal
As the dissection proceeds into the orbit in the sub- approach to the lateral orbit and reconstruction of the
periosteal plane, the periorbita, lacrimal gland, and disrupted canthus.
lateral canthal tendon are protected. The lateral can- The extended canthal incision is an extension of the
thal tendon adheres tightly to the bony protuberance classic Berke lateral orbitotomy. In the extended can-
along the lateral orbital wall known as Whitnall’s thal incision approach, the skin incision begins directly
tubercle. The tendon and periorbita should be ele- at the lateral commissure and extends horizontally
vated as one structure during the subperiosteal dis- over the lateral orbital rim for a distance of 2.5 to
section. As the periorbita is elevated off the roof, 3.5 cm. A canthotomy and upper and lower cantholy-
lateral wall, and floor of the orbit, neurosurgical cot- sis are performed. The orbicularis oculi muscle and the
tonoid sponges are used to protect the periorbita and suborbicular fascia are divided at the lateral canthus,
prevent formation of a rent that results in fat pro- and a skin/muscle flap is elevated above and below
lapse. The dissection continues between the bone and the skin incision to expose the periosteum of the lat-
periorbita toward the orbital apex and can be contin- eral orbital rim and zygomatic bone. The upper and
ued to the level of the inferior and superior orbital fis- lower canthal tendons are tagged for retraction and for
sures respectively. At 1 cm inside the orbital rim, later reconstruction. The periosteum is divided and
three structures are encountered. The first two, the bone of the lateral orbital rim is exposed for
known as the zygomaticofrontal and zygomaticofa- osteotomy as described for the eyelid crease incision.
cial neurovascular bundles, exit the periorbita and Entry into the orbit is exactly as described for the
traverse the bony orbital wall through their respec- eyelid crease incision. Because the canthus is dis-
tive foramina. These neurovascular elements provide rupted, it is important to mark the arcus marginalis at
blood supply and sensation to the skin and soft tis- the lateral canthus so that the canthus can be attached
sues over the malar eminence and temporal region of to the arcus marginalis on the inner aspect of the
the face. These two structures must be sacrificed to orbital rim in the appropriate vertical plane to match
gain access to the deep orbit. Bipolar or unipolar the position of the contralateral canthal angle. This
cautery followed by application of bone wax to the step is more important if the bone of the lateral orbital
foramina controls the bleeding. Naturally the sensa- rim is to be removed permanently. If wider exposure
tion of the respective innervation fields are sacrificed of the inferolateral orbit and orbital floor is desired,
by this maneuver, but with time (6 to 12 months) sen- the conjunctiva of the inferior fornix is incised with
sation returns, sometimes to near normal. The third scissors and the periosteum of the inferior orbital rim
structure, which is often missed, is the lacrimal is exposed after dividing the lower eyelid retractor
branch of the zygomatic nerve. This nerve is com- mechanism. The inferior oblique muscle is protected
posed of postganglionic, efferent parasympathetic and retracted anteriorly, away from the surgical field.
fibers to the lacrimal gland. Although these fibers The entire lower eyelid and cheek can be elevated off
carry efferent signals for aqueous secretion, sacrifice the face of the maxilla in either a plane beneath subor-
of this nerve does not interfere with lacrimal function. bicularis oculi fat or in the subperiosteal plane. The
Once exposed, the bone of the lateral orbit rim and conjunctival fornix incision extends the exposure of
wall is ready for platting and removal or displace- bone to include 180 degrees of the orbital rim (from
ment (see below). the frontozygomatic suture to the anterior lacrimal
crest) for osteotomy. Such exposure may be needed for
Extended Lateral Canthal Incision access to large tumors of the skull base and for tumors
The extended lateral canthal incision is a useful or vascular lesions that traverse the orbit and extend to
approach to the lateral orbit. Of all possible incisions, the temporal and/or infratemporal fossa.
this incision provides the widest access to the orbit. It Following tumor removal and platting of the
can be combined with an inferior fornix incision to bones of the orbit, attention is directed to canthal
CHEN28-419-450.I 3/22/01 2:40 PM Page 432
reconstruction and soft tissue closure. If the conjunc- the temporal bone or spanning the defect in the
tiva of the inferior orbit has been opened, it is closed orbital rim can be used as a piton to anchor the can-
with a running 6-0 plain gut suture. The upper and thal tendon.
lower cruri of the lateral canthal tendons are carefully
identified and exposed by sharp dissection. Small Bone Present and Secured in Place with
tarsal strips are formed for the upper and lower eye- Titanium Plates
lids. A double-armed 5-0 Prolene suture on half-circle When the lateral orbital wall and bony rim that were
taper/cutting needles is passed through the tarsal removed during entry into the orbit have been plated
strips of the upper and lower eyelid respectfully. Can- back in proper alignment, but the arcus marginalis
thal fixation is then achieved by passing the Prolene and/or periorbita are missing or disrupted, several
sutures in one of several ways. options for lateral canthal fixation exist:
Missing Bone • In some cases, a titanium plate will be on the sur-
If bone is missing due to tumor excision, damage, or face of the bone, right at the lateral rim. The Pro-
trauma, osseous fixation is not possible. Nevertheless, lene sutures attached to the tarsal strips can be
canthal fixation can be achieved in several ways: passed though one or two holes of the miniplate,
or looped around the plate to secure the canthal
• If the arcus marginalis remains intact, it can be attachment. The problem here is the anterior and
used as an anchor for lateral canthal fixation. The lateral direction of canthal fixation. A gap between
Prolene sutures are brought through the arcus mar- the eyelids and the globe may occur as the pull of
ginalis as a horizontal mattress suture and tied the suture is not posterior enough to close the gap.
securely. The canthal angle is formed as the Pro- • A better alternative is to drill two pilot holes in the
lene sutures draw the eyelid margins together lateral orbital rim at the location of the lateral can-
against the arcus marginalis. A 7-0 Vicryl suture thal tendon just prior to performing the osteotomy.
placed through the gray line of the upper and A horizontal mattress configuration is maintained
lower eyelid further aligns the eyelid margins. as the pilot holes are drilled. Vertical positioning
Proper placement of the Prolene suture provides of the pilot holes must be observed so that the can-
the posterior direction necessary to make the eye- thal alignment will be symmetrical with the con-
lids snug against the globe. tralateral orbit. The holes can then be used to
anchor the Prolene sutures at the lateral orbital rim
after the bone of the rim is plated into position. The
...
P EARL The arcus marginalis can
be used to provide lateral canthal fixation
if bone of the lateral orbital rim has been sacri-
double-armed suture enters the bone from inside
the orbit and exits on the surface of the orbital rim.
The sutures are pulled tight and tied. This allows
excellent posterior pull by the sutures on the newly
ficed during lateral orbitotomy. constructed canthus, thereby making the eyelids
snug against the globe and reforming the lateral
canthal angle.
• If the arcus marginalis has been sacrificed and bone
is also missing, posterior fixation can be achieved
by passing the Prolene sutures through the lateral
EARL ... Pilot holes drilled in the
periorbita, deep in the orbit. It is not necessary to
pull the sutures tight. One merely provides the
proper direction and alignment for the canthus by
P bone of the lateral orbital rim prior to
bone removal provide proper alignment and
suture placement. Support for the reconstruction is purchase for lateral canthal fixation upon com-
achieved by means of a suture tarsorrhaphy. If fur- pletion of the deep orbital surgery.
ther immobilization is required, Botox can be
injected into the orbicularis muscle to prevent blink-
ing and eyelid movement during the initial stages Once canthal fixation is achieved, the soft tissues
of wound healing. This reconstruction is not as deep to the skin can be closed in layers using an
secure as fixation to the arcus marginalis. This is the absorbable suture. The skin is closed with an inter-
reason why the arcus marginalis should be pre- rupted or subcuticular monofilament suture.
served if possible when bone is removed and why
the exact attachment point should be marked with a Sub-Brow Incision
suture for identification as the orbit is entered. The sub-brow incision is very similar in concept to the
• If neither the arcus marginalis nor periorbita is pre- eyelid crease incision. The initial dissection planes are
sent, and bone is missing, a miniplate secured to slightly different and the incision is slightly longer.
CHEN28-419-450.I 3/22/01 2:40 PM Page 433
The major advantage of this incision is the wide expo- Classic Incision
sure of the superior and lateral orbit that is achieved. The classic incision for lateral orbitotomy was described
This incision is excellent for managing patients with many years ago and is occasionally used today. Lateral
lacrimal gland tumors, particularly when bone is to canthotomy is not performed. The incision provides
be removed during excision of the mass. The sub- limited access to the lateral orbit. The major advantage
brow incision can be extended to the medial canthal is that the canthal structures remain intact and there-
tendon as a modified Lynch incision if exposure of the fore canthal reconstruction is not necessary. The major
deep superior orbit or even the deep medial/superior limitations are that access to the anterior portion of the
orbit is planned (Fig. 28–10). In this situation, the orbit is poor and space for surgical manipulation is sub-
supraorbital nerve may have to be sacrificed. Bone optimal. Also, the view of the anterior orbital anatomy
along the frontal bar can be removed with this expo- is limited by the skin incision. The anatomy of the upper
sure and the frontal sinus cavity can be entered to eyelid and canthus cannot be visualized. Thus tumors
achieve wide exposure of the superior orbit without located in the anterior orbit that extend posteriorly are
anterior craniotomy. The sub-brow incision can also not easily excised through this incision. They are more
be used for anterior orbitotomy without bone readily excised by lateral or anterior orbitotomy
removal; however, bone must be removed if visual- through the incisions described above.
ization and access to the deep orbit is required. The The classic lateral orbitotomy incision is oriented hor-
only major disadvantages of this incisions are a long izontally and begins over the lateral orbital rim approx-
scar and loss of sensation in the distribution of supra- imately 0.5 to 1.0 cm from the lateral commissure.
orbital nerve if the incision is carried medial to the
supraorbital notch or foramen and the supraorbital
nerve is transected or cauterized.
A B
C D
FIGURE 28–10 (A) A 22-year-old man presented

with proptosis due to a large, posterior-medial cyst of
the right orbit (B). (C) A combined medial/lateral sub-
brow orbitotomy with bone removal at the lateral rim
was used to gain access to the deep medial orbit. A
dermoid splitting the medial rectus muscle was dis-
covered and removed. The wide exposure provided
by bone removal laterally with displacement of the
orbital contents into the temporal fossa simplified
E the dissection in the medial posterior orbit. The medial
rectus muscle was repaired and the wound closed.
(D, E) Ocular alignment and motility was unaffected postoperatively and the vision stabilized at a normal range.
The patient had forehead and scalp hypesthesia due to sacrifice of the supraoribtal nerve.
CHEN28-419-450.I 3/22/01 2:40 PM Page 434
Dissection through a 3.5-cm incision is continued to was removed. Today, osteotomies are performed in
expose the bone of the lateral orbital rim, zygoma, an unlimited variety of configurations to gain limited
and lateral wall of the orbit. Manipulating and retract- or wide access to the orbit depending on the require-
ing the edges of the wound in a medial, superior, and ments for the individual patient.
inferior direction exposes the periosteum. The
periosteal incision can then be accomplished in the Lateral Osteotomy
same areas as for lateral orbitotomy through any of The bone cuts are made with a fine microsurgical saw.
the skin incisions mentioned above. The periosteum is These instruments are widely available in most oper-
reflected, the orbit entered, and the bone cleaned for ating rooms. They may be electrically powered or
osteotomy in the usual manner. During this approach powered by air. The saw blades are thin and come in
to the orbit, it is sometimes necessary to retract the a variety of shapes and configurations. A blade is cho-
temporalis muscle or pack it out of the wound to gain sen that provides a fine or thin cut and involves min-
access to the bone of the lateral orbit for bone imal loss of bone. To remove the rim, one transverse
removal. If adequate bone is removed and the soft tis- cut is made immediately above the superior edge of
sues retracted or packed out of the surgical field, the the zygomatic arch and a second superior to the zygo-
exposure can be quite good. maticofrontal suture (Fig. 28–12).
Closure is simple and quick. Once the bone is
plated in position, the packing is removed. The soft
tissues collapse and partially close the wound. A PITFALL
drain may be placed to prevent hematoma formation.
The deep tissues can be closed in layers with an If possible, cuts immediately adjacent to the
absorbable suture. The subcutaneous tissue and skin zygomaticofrontal suture are avoided, as
are closed in layers. the suture could open during the osteotomy.
SURGICAL TECHNIQUE: OSTEOTOMY

The surgeon is then faced with two pieces of bone,
Once the bone comprising the lateral rim, inferior rim one only several millimeters long. Reconstruction uti-
(if necessary), lateral wall, roof, and floor of the orbit lizing the smaller bone fragment is difficult.
are exposed, the osteotomies are marked (Fig. 28–11)
and the bone cuts are made. Prior to the advent of
B
microplating techniques, osteotomies were performed
in a limited fashion, and only the lateral orbital rim
B A A
FIGURE 28–12 Once the bone of the lateral orbit is

exposed, drill holes for canthal fixation are placed in the lat-
eral orbital rim immediately anterior to the lateral orbital
tubercle. One transverse cut (A) is made immediately above
FIGURE 28–11 In conventional lateral orbitotomy per- the superior edge of the zygomatic arch and a second cut
formed through any of the incisions depicted, the marked (B) superior to the zygomaticofrontal suture. Following
bone is temporarily removed (A) or permanently removed osteotomy, the portion of the zygomatic bone (C) compos-
(B) The zygomaticotemporal (c) and the zygomaticofacial ing the lateral rim and lateral wall of the orbit can be out-
(d) foramina are depicted. fractured and displaced into the temporal fossa.
CHEN28-419-450.I 3/22/01 2:40 PM Page 435
The technique for making the bone cuts varies, but

some principles are recognized as being important.
The cuts could remain perpendicular to the bone. This
facilitates bone removal and eliminates the possibil-
ity that the bone will remain locked in position
because of a mitered cut. In addition, one needs to
make a clean inferior cut that avoids the reflection of
the zygomatic arch. It is easy to cut into the arch, and
that makes bone removal more difficult. Also, it is
important to make a clean cut entirely through the
bone of the lateral rim. Once the thick bone of the rim
has been cut, one can either grasp the rim with a large
front-biting rongeur and out-fracture the bone, or use
a chisel to osteotomize the bone of the lateral orbit
and then remove the bone.
Following osteotomy, the portion of the zygomatic
bone composing the lateral rim and lateral wall of the
FIGURE 28–13 Rongeurs are used to remove the bone
orbit can be out-fractured and displaced into the tem- of the lateral orbital wall. The limits of bone resection later-
poral fossa. Alternatively the temporalis muscle can ally are the reflection of the greater wing of the sphenoid
be sharply excised from the bone fragment and the bone at the pterion and the inferior orbital fissure. Some
bone placed in saline or wrapped in a moist gauze bleeding may be encountered as the bone is removed. The
sponge and placed safely on the back table. Follow- bleeding arises from the bone diploe. The bleeding is easily
ing tumor removal, the bone is placed in position and controlled with bone wax.
either sutured, wired, or plated in place. Today, with
the availability of fine microsurgical saws and mod- bone removal, the soft tissues of the temporal fossa
ern microplating systems available for reconstruction, are packed with neurosurgical sponges to maintain
the osteotomies can be placed precisely where visibility and to prepare for formal orbital work.
needed, and more importantly, tailored to provide Bleeding is controlled by packing of the soft tissue
access to the orbit where the pathology is located. and muscle in the temporalis muscle and by bone
Once the bony rim has been removed, a rongeur wax for the diploe of the sphenoid and zygomatic
can be used to trim additional bone from the lateral bones.
and inferior orbit (Fig. 28–13). The bone can be Once the orbital surgery is complete, the bones can
removed all the way to the posterior extent of the lat- be plated in proper position.8 Any commercially
eral wall of the orbit (reflection of the thick portion of available plating system can be used. Generally it is
the sphenoid bone). One can also remove the lat- best to use a microplating (1.3 mm or thinner) to
eral/inferior portion of the orbital floor to the level of maintain a low profile and avoid palpable hardware
the inferior orbital fissure. This provides a wide entry postoperatively. To be precise in terms of bone place-
into the orbit. If additional room is needed, the rim of ment, it is a good technique to preplace the screws for
the inferior orbit, superior orbit, or both can be the plates prior to osteotomy. The plates are molded
removed and plated in position at the end of the case. to the bone after the bony rim is exposed. The bone
It is difficult to make bone cuts that will allow the cuts are planned and marked. Microplates span the
superior rim, the inferior rim and the lateral rim to be planned cuts and drill holes are made for the screws
removed en bloc. Usually it is necessary to remove the and plates. The plates and screws are removed and
bones in separate pieces and then plate them sequen- passed to the back table for later use. The osteotomies
tially in position with a microplating system are then made and the drill holes protected for use at
(Fig. 28–14). Preplanned plating used holes for align- the end of the case.
ment drilled prior to making the bone cuts speeds the
reconstruction (Fig. 28–15).
As the osteotomies are made, the globe, periorbita, SURGICAL TECHNIQUE: REPAIR OF
eyelid, and lacrimal apparatus are protected with BONE DEFECTS, MISSING BONE
malleable retractors. The traction sutures and all
extraneous instruments and sponges are removed Orbital Rim Reconstruction
from the field so they will not be caught in the blade At times, there will be insufficient bone to fill the
of the saw or drill bits. Irrigation cools the bone to bony defect created by preparation for tumor
maintain viability. Care is taken during bone removal removal or en-bloc tumor removal. If bone is missing
so as not to drop or damage the bone flaps. Following in a nonfunctional part of the orbit, replacement is
CHEN28-419-450.I 3/22/01 2:40 PM Page 436
b a
Frontal bone
Greater wing of
FIGURE 28–14 (A) Bone cuts can be sphenoid bone
tailored to expose different parts of the
orbit. The lateral orbital rim (a) and the Cut edge of
sphenoid bone
lateral wall (b) of the orbit are removed
during conventional lateral orbitotomy. Temporal
If additional space is needed superiorly bone
(c) or inferiorly (d), additional bone cuts
can be made and the bone removed.
The bone is plated back into position
following completion of the deep
orbital surgery. The bone of the lateral
orbital wall (b) is usually discarded.
(B) Wide exposure of the lateral, supe-
rior, and inferior orbit can be achieved
if adequate bone is removed. Such bone
removal gives excellent exposure of the
skull base from the lateral approach. B
usually not required. For instance, bone from the lat- Such defects can be repaired utilizing a variety of
eral wall of the orbit posterior to the orbital rim is techniques and implants. One should recall that in
removed routinely. This bone is thin and does not orbit wall reconstruction, a scaffold and barrier func-
need to be replaced because loss of that bone does tion to support and isolate the soft tissues of the orbit
not impair functional movement of the eye or the is all that is necessary. It is not necessary to provide
position of the orbital tissues. In other situations, the structural support to absorb large mechanical forces
bone of the orbit serves a very important purpose, exerted by the muscles of mastication as in mandibu-
and when missing, interferes with function of the eye lar reconstruction. However, the substitute lateral
or orbit. The defect needs to be replaced with bone orbital rim must be strong enough to serve as an
or some other alloplast that serves the same purpose attachment point for the canthal tendon.
as the missing part. An example is the lateral orbital
rim. If the bone of the lateral orbital rim is missing, Bone Substitutes
there is no anchor for the lateral canthal tendon and The standard of care for the past 20 years has been to
there is no protection for the globe from temporally use autogenous bone grafts or alloplastic materials to
applied trauma. In addition, bone loss results in a replace bone lost as a result of comminuted fractures,
concavity at the lateral rim that may be palpable, tumor resection, or cyst removal. The present chal-
visually conspicuous, and cosmetically displeasing. lenge is to find biomaterials that are better suited to
In this situation, bone replacement or bone substitute this purpose. Ideally the material should promote the
is recommended. growth of new bone to rapidly replace and fill in the
CHEN28-419-450.I 3/22/01 2:41 PM Page 437
A B
FIGURE 28–15 (A) A small, curved titanium plate is positioned and holes drilled prior to performing the
osteotomies. The lines depicted here indicate where the bone cuts will be made. At the end of the orbitotomy, the
bone and plates are placed back into position and secured in place with titanium screws. (B) Once the bone cuts are
made, the bone, with the plate attached, is removed and passed to the back table.
defect, thereby restoring form and function. Autoge- must be mixed with water. As it sets up, it converts to
nous bone remains the graft material of choice (dis- pure HA and is therefore very useful as a bone sub-
cussed below). It is usually necessary, however, to stitute around the orbit. When mixed with water a
harvest the bone from a separate donor site, resulting paste results. The paste can be molded and contoured
in additional surgical morbidity, increased blood loss, to fit bony defects in the midface. The material is slow
and increased anesthesia and surgical time. The to set up and it is a problem during surgery, as one
search for suitable synthetic materials as an alterna- must wait for it to harden before further manipula-
tive to harvesting host bone has resulted in the devel- tion can occur. In addition, blood and fresh tissue that
opment of bone substitutes. Bone substitutes are those contact the substance delay its final hardening even
substances that are implanted and convert in-situ to more. BoneSource now comes with a hardening addi-
bone or bone-like materials. To date, particulate tive and this has improved suitability for surgical use
hydroxyapatite (HA) has been the most utilized allo- around the orbit.
plastic bone grafting material. It has a biocompatible
structure that is osteoconductive by providing an Embarc Embarc is prepared as a blend of crystalline
interface along which bone can migrate. Unfortu- and amorphous calcium phosphate precursors and
nately, it can be difficult to handle, tends to fall out saline. The material is designed for injection into areas
of areas where there is still active bleeding, and lacks where gaps occur around bone fracture sites. Once
osteoproductive (the ability to induce new bone growth injected it sets endothermically in 15 to 20 minutes.
in situ) characteristics, resulting in slow bone replace- Thus it has a relatively long working time. It fully
ment. Such materials include BoneSource (Howmed- resorbs once it sets and is replaced by bone (osteocon-
ica Leibinger Inc., Dallas, TX), Embarc (Walter Lorenz ductive). From dog studies it is known that the mate-
Surgical, Jacksonville, FL), Norian Skeleton Repair rial remodels to form new bone that for all practical
System/Craniofacial Repair System (SRS/CRS, purposes is as strong as original, unoperated bone.
Norian, Cupertino, CA), and NovaBone-CM (Porex This process takes approximately 12 weeks to occur.
Surgical, Inc. College Park, GA). These porous sub-
stances have taken the place of cranioplastic and Norian Norian is a fully resorbable calcium phos-
alloplastic rim substitutes. Each has a unique quality, phate crystal that forms normal bone by osteoconduc-
features, workability, and cost. tive means once hardened. The compressive strength of
this material as tested in vitro exceeds that of normal
BoneSource BoneSource is self-setting bone cement cancellous bone. The tensile strength is essentially equal
that incorporates calcium phosphate as the major to cancellous bone. The advantage of the Norian
component. The substance comes as a powder and SRS/CRS system seems to be enhanced strength of the
CHEN28-419-450.I 3/22/01 2:41 PM Page 438
material once set. This may not be an advantage or even silicon from the glass surface, which stimulates local
necessary for use in repairing facial defects around the osteoprogenitor cells to produce transforming growth
orbit. It may play an important role in other areas of factor-b (TGF-b). The TGF-b stimulates differentiation
bony reconstruction in the head and neck area. and growth of osteoblast stem cells, leading to a rapid
proliferation of bone in contact with the glass parti-
The above products are osteoconductive but not cles. The particle size ranges from 90 to 710 m, with
osteoproductive. This means new bone migrates along the active silica gel layer reaching an average thick-
the scaffolding provided by the bone substitute. An ness of 150 m, so that the smaller particles are used
osteoproductive material, on the other hand, induces up quickly. The remaining particles are incorporated
new bone growth in situ by a different mechanism. as part of the framework in the growing bone, even-
tually being broken down by osteoclasts. There is sub-
NovaBone-C/M NovaBone-C/M is now a bioactive stantial restoration of bone as early as 2 to 4 weeks,
silicate glass material available for bone replacement rather than the 12 weeks usually required by particu-
with favorable handling characteristics and good late HA in reaching a comparable result. In addition,
hemostasis, and it is both osteoconductive and osteo- the resulting substance is normal trabecular bone, not
productive.9, 10 In 1971 Hench and his colleagues at the a composite of bone reinforced by an alloplastic mate-
University of Florida described a new ceramic glass rial as seen with HA. In 1994 USBiomaterials obtained
that has the ability to bond to bone. This bioactive Food and Drug Administration (FDA) approval to
glass activates the genetically controlled metabolic release its Bioglass product as PerioGlas (distributed
repair of bone by stimulating certain stem cells to pro- by Block Drug, Jersey City, NJ), for regeneration of
duce potent mitogenic growth factors, which are con- periodontal bone. It has been used with good results
tinually absorbed and released from stem cells on the in over 450,000 cases of alveolar ridge augmentation,
glass surface to enhance the proliferation of new bone. postextraction site repair, and for filling intrabony
This new bioactive material was given the name 45S5 defects resulting from periodontal disease. This same
Bioglass (USBiomaterials, Alachua, FL). As a synthetic formulation of 45S5 Bioglass has recently been
bone graft material, particulate Bioglass has been approved by the FDA for craniofacial and maxillofa-
shown in animal studies to be nearly equivalent to cial application, and has been made available as Nov-
autogenous bone grafts. Bioglass is composed of sili- aBone-C/M (distributed by Porex Surgical, College
con dioxide, sodium oxide, calcium oxide, and phos- Park, GA).
phorus pentoxide containing low silica content (45%
by weight). When particulate Bioglass is mixed with Alloplastic Implants
saline or blood, hydroxyl groups within the sur-
Medpor Medpor, a porous polyethylene (PP) im-
rounding solution break the silicon-oxygen bonds
plant manufactured by Porex Surgical, (College Park,
within the glass particles releasing silicic acid. The
GA), is an excellent bone substitute for use in and
accumulating silicic acid condenses and forms a neg-
around the orbit. A piece of PP shaped from a block
atively charged gel at the surface of the glass that is
can be cut to the desired shape and plated in position.
rich in silica and calcium. This rapidly forming sur-
Alternatively, one of the orbital rim shapes provided
face gel allows the particles to from a cohesive mass
by the company can be trimmed to fit the defect and
that is easily spread and packed into a bony defects
either sutured or plated in position. The beauty of
and allows them to stay in place even if there are still
Medpor is its versatility and adaptability. It accepts
areas of active bleeding. Within several hours calcium
screws from any commercially plating set. Therefore,
phosphate is produced within the silica rich surface
a secure reconstruction can take place.11
gel forming a separate layer over its surface that then
crystallizes into hydroxycarbonate-apatite (HCA). Cranioplastic Cranioplastic has been used for
Collagen, mucopolysaccharides, and glycoproteins years as to fill bony defects in the cranium and it
from surrounding bone become incorporated into this works as a bone substitute for the orbital rim as well,
forming bioactive layer, mediating a direct chemical particularly in the superior/lateral orbit (Fig. 28–16).
bond with the crystal structure of the neighboring Cranioplastic is easy to work with. It should not be
host bone. It is this connective tissue bond between used if the paranasal sinus is exposed in the surgical
the glass particles and host bone that is critical in pre- field due to increased rate of infection. The recipient
venting movement of the interface during the early site is prepared by smoothing the bone with a high-
stages of bone formation, resulting in a “seamless” speed diamond burr. The defect is assessed and a
bridging of the defect with normal bone. template of the desired rim contour is made using
The growing layer of HCA crystals also mediates a sterile, unused radiographic sheet. Cranioplastic
further osteogenesis through a controlled release of tends to loosen and move if not fixated to the bone.
CHEN28-419-450.I 3/22/01 2:41 PM Page 439
Wire can be used to secure it, but titanium screws tion as the cranioplastic sets up. If cranioplastic is
placed in the bone and projecting into the defect that not anchored to the underlying bone, it can loosen
serve as an anchor for the cranioplastic is a much with time and a rocking motion or movement may
better solution. The screws should be seated so as be palpated.
not to project above the plane of the final surface of
the cranioplastic. The cranioplastic is mixed and Bone Grafting
molded to the desired shape to fill the defect. A Alloplastic and biomaterials are not the only means
slight overcorrection is planned. The cranioplastic is to reconstruct the orbital rims. Bone grafts can be used
cooled with saline irrigation as it sets up. This as onlay grafts or inserted into bony defects to create
process takes approximately 15 minutes. Once hard, the desired three-dimensional anatomy of the orbit if
the cranioplastic is shaved with a high-speed cutting one chooses. Outer-table calvarial bone is the usual
burr. The template is used to determine and adjust choice. It can be harvested by any number of tech-
the final shape. All shavings and debris from the niques and cut to fit the desired shape. Titanium
burring are irrigated from the wound prior to clo- plates from any properly sized and commercially
sure. The advantages of cranioplastic include cost, available plating systems are used to fix the pieces of
ease of application, permanence, and availability. harvested bone to the rigid facial bones. The process is
The disadvantages include absence of fibrovascular tedious, time consuming, and requires separate expo-
ingrowth, need to keep the cranioplastic away from sure in a second surgical field unless the calvarium is
the paranasal sinus cavity (increased rate of infec- already exposed in the surgical field (coronal
tion), and the heat generated by the exothermic reac- approach). In some cases, bone removed at the time of
A B
C D
FIGURE 28–16 (A) One year following orbital tumor removal that included frontal and zygomatic bone along
the superior and lateral orbital rim of the left orbit of this 49-year-old man, a palpable defect is visible clinically. (B) A
CT scan reveals the osseous defect. (C) A template of radiographic paper is constructed using a cadaver skull. The tem-
plate is sterilized for intraoperative use. (D) Once opening the previous sub-brow incision exposes the defect, titanium
screws are placed as bone pitons. (continues on next page)
CHEN28-419-450.I 3/22/01 2:41 PM Page 440
E F
FIGURE 28–16 (continued) (E) Cranioplastic is molded

to fit the defect and is anchored to the bone of the orbit by
the now submerged screws. Alternative or substitute bio-
materials that could have been used include Embarc,
Norian, and NovaBone. The sterile template is used to size
and trim the cranioplastic. (F, G) Twelve months following
wound closure and healing, the functional and cosmetic
G result is excellent.
orbitotomy can be adapted for use in bony rim recon- In this setting, it is usually best to delay the bony
struction (Fig. 28–17). reconstruction for 6 to 12 months and use autogenous
bone grafts, or an implant that allows fibrovascular
ingrowth. If immediate repair is necessary (large
...
P EARL Bone may be harvested
from the lateral orbit just cephalad to the
lateral reflection of the zygoma. A second graft
defect with herniation of orbital contents to an adja-
cent cavity) autogenous bone is probably the best
choice for reconstruction.
can be harvested from the zygomatic arch at the
takeoff from the lateral orbital rim. Orbital Wall Reconstruction
A large defect in the floor, medial wall, or roof of the
orbit may allow orbit contents to herniate into one or
The bone can be shaped and plated in position to more of the paranasal sinus cavities. This can lead to
create an orbital rim or fill a defect in one or more enophthalmos, hypo- or hyperglobus, dysfunctional
walls of the orbit. eyelid position or movement, restriction to ocular
movement and ocular misalignment with diplopia,
lacrimal or sinus drainage obstruction, and pain due
to pressure on the infraorbital nerve exerted by the
PITFALL herniating orbital contents. Defects in the orbital walls
can be repaired at the conclusion of orbitotomy.
One should use caution when using alloplas- Options include autologous bone grafts secured with
tic implants in the setting of malignancy, par- miniplates, or alloplastic implants secured with tita-
ticularly when adjunctive radiation therapy nium plates or screws. Bone grafts for the orbital walls
or chemotherapy is planned. Other relative are no different from those harvested for orbital rim
contraindications are infection, retained for- reconstruction. Again, the bone is rigid. Therefore, the
eign bodies, and history of prior radiation bone must be harvested to an appropriate size and
therapy, chronic fungal or bacterial sinusitis, trimmed to fit the defect. As the orbit is a multidi-
mensional truncated cone, fitting and securing the
and hypersensitivity to the planned implant
bone to establish a stable support with the desired
material. contour is difficult and definitely a challenge. Not
much support is needed to hold the soft tissue of the
CHEN28-419-450.I 3/22/01 2:41 PM Page 441
A B
C D
E F
FIGURE 28–17 (A) A 47-year-old man presented with an osseous lesion expanding the bone of the right superior
lateral orbital rim and extending into the superior lateral orbit. (B, C) A sub-brow incision was used to expose the dis-
eased bone superiorly and the normal bone of the lateral orbital rim. Before the diseased bone and the mass were
removed from the orbit en bloc, holes were predrilled for lateral orbital rim reconstruction. (C) Bone cuts were made
to remove the healthy bone in such a way that the bone could be used to reconstruct the rim once the diseased bone
was removed. The healthy bone of the lateral orbital rim was cut vertically in two equal pieces. The medial piece of
bone with the predrilled holes was saved for use as a free bone graft inferiorly. (D) The lateral fragment was saved for
use as a free bone graft superiorly. The bone and tumor were then removed leaving a large defect in the lateral and
superior orbital rim. (E) This defect was repaired with the two bone fragments. Note that the plates used were larger
than those used today. These stainless steel plates were the first plates available for craniofacial reconstruction.
Although slightly large, they accomplished the goal of bony orbital rim reconstruction by means of rigid fixation fol-
lowing tumor resection. (F) The final result was cosmetically and functionally pleasing. Pathology confirmed the pre-
operative clinical diagnosis of cholesterol (reparative) granuloma involving orbital bone and soft tissue.
441
CHEN28-419-450.I 3/22/01 2:41 PM Page 442
orbit in position; however, what is needed is some- • gentle retraction of the orbital soft tissue with peri-
thing to separate and isolate the orbital contents from odic release of pressure to allow vascular refill;
the contiguous paranasal sinus and intracranial cavi- • meticulous and gentle packing with neurosurgical
ties. Alloplastic implants of titanium or Medpor are cottonoid sponges that avoids orbit soft tissue com-
slightly easier to use and equally effective as outer pression;
table calvarial bone grafts. • avoidance of soft tissue compression against bone,
The microchannel implant manufactured by Porex particularly the soft tissue and bone near the orbital
Surgical (College Park, GA) is an excellent substitute apex; the principle holds true for all orbit soft tissue
for the medial wall or floor. The 2.3- to 4.0-mm chan- retraction, particularly when pressure can be
nels within the sized implant allow passage of a rigid exerted against bone or other solid structure;
fixation microplate that can be secured to stable bone • avoid pinching orbital tissue between two or more
along one or more of the orbital rims. The repair is retractors;
simple, quick, and stable over time. For defects in the • silicone vascular loops can be placed around
lateral wall or roof, repair may not be necessary. If extraocular muscles or large vessels for gentle
support or isolation is needed, a Medpor sheet or retraction and identification.
microchannel implant may be the ideal orbital wall
substitute. Dissection
Dissection in the deep orbit can be difficult due to the
prolapse of orbital fat around retractors. This tends to
DEEP ORBITAL SURGICAL TECHNIQUES reduce visibility and makes identification of anatomic
Once the orbit is exposed for deep orbital surgery by structures difficult. Once identified, structures tend to
bone removal, the surgeon must still expose the shift as the retraction changes. The retractors must
tumor, foreign body, or other anatomic structure and then be repositioned and the anatomic structure iden-
then remove it or perform a biopsy. The key steps tified once again. The target lesion may be very small
include retraction, dissection, tumor removal, hemo- and surrounded by critical vessels and nerves that
stasis, drainage, and closure. must be preserved. Finally, visualization may be dif-
ficult due to the need to view objects on an oblique
Retraction angle deep in the orbit. The following techniques are
For the most part, retraction to expose the deep orbit helpful when applied in deep orbital surgery:
is no different from retraction in other surgical field. • Have excellent lighting so that the anatomic struc-
tures can be seen.
• Consider use of the operating microscope to
PITFALL enhance visualization.
• Use moistened neurosurgical cottonoid sponges
However, prolonged or excessive vascular with identification strings attached to pack orbital
compression may lead to infarction of the fat and provide exposure of the tumor. A moist-
optic nerve due to occlusion of the small pial ened 1- by 3-inch cottonoid placed between a mal-
leable retractor and the soft tissue is excellent for
vessels that nourish the nerve or to occlusion
dissection and retraction, and can be used as a con-
of the central retinal artery. duit for suction. The tip of the suction catheter is
placed against the sponge. The orbital fat is left
undisturbed and does not clog the suction tip.
This can lead to transient visual blurring or even • Use the technique of “Coagulate and cut, coagulate
permanent visual loss. In addition, excessive traction and cut.” This involves the almost simultaneous
or pressure on the globe can lead to visual loss use of bipolar cautery and fine scissors to cauter-
through a vasculopathy at the level of the choroid, ize, divide, and separate tissue. It is a very useful
lamina cribosa, or orbital apex. The most likely way technique. Here the bipolar cautery on low setting
vascular occlusion occurs is prolonged retraction or is used to coagulate fat, small vessels and connec-
compression without periodic release of pressure to tive tissue. Immediately fine scissors are used to
allow vascular flow. This is particularly true when divide the coagulated tissue. One achieves precise
there is compression of the delicate orbital structure identification of tissue prior to coagulation as the
between two retractors, or between a retractor and a dissection proceeds. Thus visualization and hemo-
bony wall of the orbit. Excessive packing to keep orbit stasis is maintained during the dissection without
fat out of the field can also lead to vascular occlusion. moving or replacing retractors during the individ-
Retraction techniques that are appropriate in deep ual steps. As one makes progress the retractors are
orbital surgery include: changed in a dry field.
CHEN28-419-450.I 3/22/01 2:41 PM Page 443
• Use blunt dissection with blunt-tipped scissors to • Some tumors are solid and can be grasped with bit-
expose encapsulated tumors. Often a cleavage ing forceps. Some are sufficiently solid to allow
place exists between the tumor and surrounding traction sutures to be passed through them. Solid
soft tissue. Blunt dissection can be used very effec- tumors with good cleavage planes can be grasped
tively to expose such tumors. Cotton-tipped appli- and “rocked” back and forth to free them from sur-
cators can also be used in a similar fashion. The rounding orbital soft tissue. The rocking technique
normal orbital soft tissues are bluntly dissected off frees the tumor from surrounding tissue and
the tumor by gentle application of the tip of the moves it anteriorly in the orbit where it can be seen
cotton-tipped applicator in the cleavage plane and dissected further. Retractors, blunt surgical
created by the tumor capsule and the orbital fat. As instruments, and even cotton-tipped applicators
the dissection proceeds, retractors are moved to can be used to strip the soft tissue off the capsule of
distract the dissected and to maintain the separa- the tumor before it is removed.
tion of the fat from the capsule of the tumor. • If the tumor is so friable that it can’t be grasped or
secured with traction sutures, a temporary adhe-
Tumor Removal sion may be made with a cryoprobe. By partially
Some tumors, once exposed, may be difficult to freezing the tumor, a dense, temporary adhesion is
remove. Others “shell out” rather easily. There may made between the probe and the tumor. The dis-
be a variety of reasons for the difference in ease of section can then proceed as above. The cryoprobe
removal from one tumor to the next. For instance, and freeze ball should be limited to the tumor and
some tumors infiltrate surrounding tissues and freezing of remaining orbital tissue should be
obscure tissue planes. Such tumors may be difficult if avoided.
not impossible to remove. Based on tissue type and • Some benign but large orbital tumors can be exca-
clinical and radiographic features, biopsy rather than vated centrally to collapse the capsule and then the
removal may be indicated. Some tumors may be asso- capsule and residual tumor can be excised
ciated with inflammation. Scar tissue that obscures together. This is a valuable technique for removing
the tissue planes then forms in the surrounding tissue meningioma near the apex of the orbit that is not
and this makes tumor removal difficult. Cystic involving the optic nerve. Malignant tumors
tumors may be difficult to remove. First, they are should not be managed in this fashion.
often quite large. Next they may have very thin walls. • Vascular tumors can be coagulated with bipolar
The combination of the two may make removal with- cautery to shrink the tumor as hemostasis is main-
out rupture of the cyst wall difficult. If the cyst wall tained. The charred, avascular remains can then be
ruptures, the cyst collapses. The dissection then is excised. One needs to be careful not to coagulate
complicated by loss of the three-dimensional config- normal vessels and nerves during this process.
uration of the cyst. One way to maintain hemostasis and accomplish
It is not possible to discuss each type of tumor and the very same thing is by use of the CO2 laser for
describe the precise, suitable techniques that might vascular tumor removal. A certain amount of heat
apply for that tumor. However, there some general is generated by the cautery tips and the laser.
surgical principles that apply in deep orbital surgery Thus, slow meticulous dissection with frequent
that can be stated and described. These techniques are irrigation for cooling under direct observation is a
useful and should be exercised when possible: key to success.
• Slow growing and encapsulated tumors tend to • The goal for certain tumors may be biopsy rather
push normal orbital anatomic structures aside. A than excision. In many cases, biopsy can be
cleavage plan usually exists and can be developed obtained with scissors or scalpel. In other cases,
by blunt dissection and dissection with cotton- particularly when working deep in the orbit, at the
tipped applicators. Frequently wisps of connective orbital apex, or in tight spaces, biopsy by means of
tissues will adhere to the capsule. These connec- very fine cusp forceps is effective. Here a tiny bit-
tive tissue strands can be sectioned with scissors ing forceps designed for biopsy of sinonasal lesions
or simply brushed off the tumor capsule by blunt can be used in the orbit for biopsy.
dissection.
• Many tumors will have a vascular tuft at the base of Hemostasis
the tumor. The vessels can be coagulated under There are four reasons why maintaining hemostasis
direct visualization with a bipolar cautery and then during and following orbital surgery is important.
sectioned. Free suture ties are rarely necessary. It is First, one must be able to see deep in the orbit to
best to obtain and maintain vascular control as the safely complete the surgery. If blood obscures the
tumor is removed so the surgical field remains dry surgical field, it is easy to lose one’s orientation and
and the visualization excellent. cause damage to the eye, blood vessels, muscles,
CHEN28-419-450.I 3/22/01 2:41 PM Page 444
and nerves (including the optic nerve) during tumor tant technique to control bleeding following tumor
excision or exposure. excision when coagulation at the apex of the orbit
Second, once bleeding begins deep in the orbit, it is or within the bed of the tumor is to be avoided.
difficult to maintain a clear field and coagulate the Cottonoid neurosurgical sponges can be used to
bleeders with cautery. The fat in the field obstructs manipulate and move the thrombin-soaked
the tip of the suction catheter. Retraction becomes Surgicel as needed. This prevents the Surgicel from
more difficult and movement of the retractors and being aspirated into the suction tip as the residual
suction tip allows the bleeding vessel to retract in the blood is suctioned. The Surgicel sponges can
fat. If the bleeding continues within the fat, the tissues remain in the orbit if necessary.
become discolored and the tissue plans are distorted • Use other hemostatic products with care. One does
by the developing hematoma. Further dissection may not want to cause thrombosis unnecessarily.
be difficult or even unsafe. • Consider draining wounds when absolute hemo-
Third, if bleeding develops deep in the orbit, there stasis is uncertain. Do not rely on surgical drains
is no safe way to reliably use any type of cautery with- to prevent the development of the orbit compart-
out undue risk to neural structures. Even if the bleed- ment syndrome, however (see discussion of drains
ing vessel is seen, surrounding nerves (sensory and below). Drains are best utilized to prevent blood
motor) may be coagulated causing irreparable harm. from entering the deep orbit, not for draining the
Cautery in the deep orbit must be judicious, limited, deep orbit when vessels are still bleeding.
and applied only when there is excellent visualization • Request that the anesthesiologist avoid the
of the anatomy. Thus, coagulation before bleeding patient’s abrupt awakening and recovery from
begins is a very important principle. general anesthesia. Request early and deep extu-
Fourth, if hemostasis is not assured, bleeding fol- bation if medically possible. Have the anesthesiol-
lowing closure occurs in a closed space. An orbit ogist use medications that allow sedation and
compartment syndrome can develop and lead to a adequate analgesia following extubation. Strive to
rapid increase in intraorbital pressure. If the pressure avoid the patient’s coughing and bucking on the
exceeds the mean arterial pressure, vascular occlu- endotracheal tube. Such activity greatly increases
sion and infarction of the optic nerve, choroid, or the risk of bleeding in the recovery area and may
retina is possible. The visual result may be blindness prompt a return to the operating theater for acute
unless the cause is detected promptly and treated drainage of an evolving hematoma or orbit com-
immediately. partment syndrome.
There are a number of principles, strategies, and • Elevate the patient’s head following surgery.
techniques available to limit and control bleeding: • Use ice immediately to minimize swelling and
bleeding.
• Discontinue all antiplatelet medications 10 days
• Closely monitor the patient’s blood pressure in the
prior to surgery.
recovery and surgical wards. Treat hypertension
• Discontinue anticoagulant medication so as to have
aggressively.
the coagulation profile at a normal or near-normal
• Instruct the nursing staff and inform the patient that
range prior to surgery.
bending, stooping, and straining are to be avoided
• Continue all antihypertensive medications up to
during the first 24 hours following surgery.
and including the morning of surgery.
• Use a stool softener early in the postoperative
• Place the patient in a reverse Trendelenburg posi-
period to avoid constipation that leads to Valsalva
tion (head up) during surgery.
and straining.
• Consider hypotensive anesthesia when bleeding is
anticipated. This usually means that the patient
will have to be monitored invasively (arterial line, Drainage
central venous access, etc.), but it may be worth the If good surgical technique is used and hemostasis
extra effort if deep orbital bleeding is to be maintained throughout the case, drains are usually
avoided. Once the tumor has been exposed and not necessary following lateral orbitotomy. That is not
removed, or the vascular surgery completed, the to say that it is inappropriate to use them. In fact, if a
anesthesiologist may discontinue hypotensive drain is contemplated during the case, it is usually a
anesthesia. The surgeon can then monitor the sur- good idea to use it. One must not rely on surgical
gical field and look for bleeding prior to closure. drains in lieu of good surgical technique and ade-
• Soak Surgicel in thrombin at a concentration of quate hemostasis to prevent hematoma, however.
1:5,000 or 1:10,000 and place the small, thrombin- Drains are usually indicated when there is continued
soaked pledgets on the bleeding area to stop minor oozing throughout the case, when bone bleeding was
venous bleeding. This is a very useful and impor- encountered and continues during closure, and when
CHEN28-419-450.I 3/22/01 2:41 PM Page 445
muscle bleeding that is difficult to control is observed lumen drain (Penrose drain) is inserted deep into the
during wound closure. Usually such muscle bleeding wound. The drain exits the wound (not a separate
comes from the temporalis muscle, the orbicularis stab skin incision) and is sutured in place to prevent
muscle, or exposed bony trabeculae. Bone wax may retraction of the drain into the wound. The soft latex is
stop bone bleeding. In any event, if bleeding is likely, well tolerated by the delicate orbital tissues and pro-
or even remotely possible, a drain should be inserted. vides perfectly adequate drainage in almost every
Two surgical drainage techniques are available, suc- case where it is used. In certain cases—infection,
tion and dependent drainage. surgery in the setting of a patient with a bleeding
diathesis or who is anticoagulated—multiple drains
Suction Drains will be needed. If necessary the wound can be left
open or partially open and packed along with a drain
Large suction drains such as the Jackson-Pratt drain
with closure delayed for 24 to 48 hours. This assures
(round or flat) are generally not suited to deep orbit
good drainage, but does increase the possibility of
drainage. The suction pressure is too high and the vol-
infection. Delayed wound closure following drain
ume of blood too small for them to work effectively.
removal is often possible and may be preferable.
They are very useful in the deep temporal fossa, how-
Maintain antibiotic coverage on patients as long as
ever, and for larger flaps if the orbit is entered as part
drains are in place.
of a larger craniofacial resection or reconstruction.
This drain is excellent when used under large flaps or
when flaps are resting on bone. The drain effectively Closure
removes blood from such areas and prevents Closure following lateral orbitotomy is not compli-
hematoma formation. cated. The bony reconstruction has already been
Smaller suction drains such as the TLS system mar- covered as has canthal repositioning and reattach-
keted by Porex Surgical (College Park, GA) are excel- ment. Other important surgical techniques and prin-
lent for the eyelid and anterior orbit. The openings for ciples include:
blood entry will be occluded by orbital fat if placed
• One need not close the periorbita. Suturing the
deep in the orbit so they are not as effective in this
periorbita or applying of fascial grafts to isolate the
area. The tubing is soft and small. The suction is not
orbital fat within the periorbita are unnecessary. In
too harsh and the capacity is well suited for orbital
lieu of closing or grafting the periorbita, merely
surgery. Once can make a similar drain if a commer-
reposit the orbital fat within the orbit and against
cially marketed drain is not available. Take a 21- or
the bone or implant that has been inserted for bony
23-gauge butterfly intravenous catheter and cut off
reconstruction. Proceed with canthal repositing
the hub of the silicone catheter. Make small, diamond-
and attachment and soft tissue closure.
shaped holes in the edge of the catheter so blood can
• It is not necessary to suture the arcus marginalis or
access the lumen of the catheter. Place the catheter in
to cover the bony orbital rim with periosteum. If
the wound as per any drain. During wound closure
periosteum remains and can be closed, do so by all
keep the butterfly needle in the lumen of the suction
means. However, if periosteum is not available and
tip from wall suction. Transfer the butterfly needle to
canthal positioning and bony fixation by other
a sterile red-topped vacuum test tube once the wound
means is assured, merely redrape the soft tissue
is closed enough to provide a closed system. Suture
and close it in layers.
the drain in place.
Suction drainage is contraindicated when there is • It is usually not necessary to suture the tempo-
communication of the site to be drained and one or ralis muscle. It falls into position as the bone is
more paranasal sinuses or the cranial vault. First, it reconstructed and can be left to heal without
will be diffcult to maintain a closed system for the bony fixation.
suction drain to function. Second, suction drainage in • The orbicularis oculi muscle should be closed with
this situation may lead to orbit soft tissue or brain deep, fine, absorbable sutures; 6-0 Monocryl and
contamination from the surrounding, exposed PDS (Polydioxanone; Ethicon) are suitable choices.
paranasal sinus cavity. Finally, pressure differentials • Do not place deep sutures around a drain as it will
can develop around suction drains juxtaposed to anchor the drain, making subsequent removal dif-
defects in the cranial vault that can have disastrous ficult, if not impossible. Suture the drain to the skin
consequences. edge only.
• Close the skin.
Dependent Drainage • Consider placement of a temporary suture tarsor-
Most orbits are best drained by means of a dependent rhaphy laterally if swelling is minimal and hemo-
drain (without suction). Usually a small latex, hollow- stasis is assured. Leave sufficient space to monitor
CHEN28-419-450.I 3/22/01 2:41 PM Page 446
the vision and pupil through the palpebral fissure moidal neurovascular bundles. Gaining vascular con-
nasally. trol of these two large neurovascular structures is
• Use Steri-Strips to augment wound closure when essential to safe orbitotomy in the deep medial orbit.
possible. The vessels are divided following the placement of
clips or bipolar coagulation for hemostasis. This
allows exposure of the entire medial orbit from the
VARIATIONS ON CONVENTIONAL anterior lacrimal crest to the annulus of Zinn. Access
LATERAL ORBITOTOMY is excellent if the lateral orbit rim and wall are
removed and the periorbita freed circumferentially
There are several variations to lateral orbitotomy around the orbit to a distance 25 mm behind the
with bone removal that should be mentioned because orbital rim. Retraction places the one-third to one-half
they are very useful in certain clinical situations. of the orbital contents outside the confines of the orbit
Most involve the combination of lateral bone removal into the temporal fossa. The entire medial orbital
with more extensive orbit soft tissue exposure for space is opened for dissection.
tumor excision of large lesions, or lesions deep in the Entry into the orbit through the periorbita is made
orbit. posterior to the arcus marginalis and superior or infe-
rior to the medial rectus muscle. There is not much
Combined Lateral and Medial Orbitotomy
room to work in the orbit inferior to the medial rectus
When wide exposure is needed for removal of a muscle because access is limited by the presence of the
tumor deep in the nasal quadrant of the orbit, a com- lacrimal duct and sac. Tumors in the inferior nasal
bined lateral and medial orbitotomy can be used. quadrant of the orbit are best approached from the
Here the lateral orbital rim is exposed and the bone inferior fornix, medial fornix, or a combined approach
removed through one of the incisions described (inferior and medial fornix with canthotomy and
above. The periorbita may or may not be entered. Fol- cantholysis).
lowing bone removal the entire orbit can be mobilized As the orbital tissue confined within the periorbita
and moved laterally to gain access to the deep is retracted laterally into the temporal fossa, the medial
medial/superior orbit. There are several possible inci- rectus muscle can be seen through the periorbita as a
sions that allow access to the deep medial orbit. pink linear structure outlined by the yellowish-white
orbital fat. The periorbita is incised circumferentially
Extended Lynch Incision over the muscle and is reflected posteriorly toward the
The extended Lynch incision is perhaps the most use- apex of the orbit by relaxing incisions that parallel the
ful of the incisions for combined medial and lateral nasoethmoidal suture line. Once exposed, the medial
orbitotomy. It unroofs the entire superior and medial rectus muscle can be tagged with a silicone vessel loop
orbit. It is a good incision for removal of medium to for identification. Gentle traction on the vessel loop is
large tumors in the intraconal space nasal to the optic safe and allows further displacement of the orbit soft
nerve and for extraconal tumors that extend to the tissue for deep orbital dissection. Care must be taken
orbital apex.12, 13 not to tug vigorously on the medial rectus muscle so as
When planning this approach, one should use the to avoid bradycardia or even asystole by means of the
sub-brow incision for lateral orbitotomy. The incision oculocardiac reflex, however.
continues medially around the rim of the orbit, supe- After retracting the medial rectus muscle inferiorly,
rior to the notch for the trochlea. The capsule of the the superior oblique muscle belly is encountered.
trochlea must not be surgically violated. The dissec- Both the medial rectus muscle and superior oblique
tion sacrifices the supraorbital nerve and permanent muscle are surprisingly large and easily identified.
anesthesia of the forehead to the vertex of the skull The superior oblique muscle can be tagged with a ves-
results. It is very important to elevate the anterior and sel loop and retracted from the field as well. This
posterior attachments of the medial canthal tendon at exposes the deep orbit for dissection, tumor removal,
the level of the anterior and posterior lacrimal crest, or biopsy as indicated. The safest access is between
respectively. Care should be taken to avoid penetrat- the inferior border of the superior oblique muscle and
ing the ethmoid labyrinth unless entry is specifically the superior border of the medial rectus muscle.
desired. The lacrimal sac and duct are mobilized and Dissection in the deep nasal quadrant of the orbit
reflected laterally, but the sac and duct are protected must be meticulous and coagulation held to an
from injury with malleable retractors and soft cot- absolute minimum. The anatomy is difficult to visu-
tonoid sponges. The dissection for the medial orbit alize if this space is entered without first taking down
should be subperiosteal at first. This allows one to the lateral orbital wall and displacing the orbital con-
gain vascular control of the anterior and posterior eth- tents into the temporal fossa because the surgeon is
CHEN28-419-450.I 3/22/01 2:41 PM Page 447
viewing the soft tissue at an extreme oblique angle laterally is needed to make more room to work
and there is very little room to work. With adequate medially, a direct canthal approach to the lateral
soft tissue displacement, the space opens dramatically orbital rim provides exposure of the bone with a
and there is plenty of room to work. One must exer- small cutaneous incision.
cise extreme caution when working against bone in • Because bone removal is required laterally to pro-
the superior and nasal quadrant of the orbit. Penetra- vide more room nasally, the medial fornix incision
tion of the thin bone in this area places the surgeon’s will need to be extended to the inferior fornix to
instruments in the anterior cranial fossa. gain the necessary space for working in the deep
medial quadrant of the orbit. Because the inferior
fornix will be used for wider exposure, the direct
EARL... A good rule to follow is to
P always work away from the bone and
never apply pressure toward the roof or supe-
canthal approach to the lateral orbital rim with the
inferior fornix extension option (as described above)
is a natural choice. The eyelid crease and sub-brow
incisions do not allow adequate access to the infe-
rior/nasal wall of the orbit.
rior orbit to be effectively used in combination with
the medial fornix approach for tumor removal.
If the anatomic dissection to gain exposure is prop- • The eyelid crease approach for lateral wall bone
erly performed, and the soft tissue displaced ade- contouring is an excellent incision to use in combi-
quately, there is no need for pressure to be exerted nation with transcaruncular medial orbital wall
against the roof and medial wall of the orbit. If pene- decompression in patients with ophthalmic
tration does occur, careful observation for CSF leak- Graves’ disease in whom a balanced orbit expan-
age and possible intraoperative neurosurgical sion is desired.
consultation should be considered. • A good rule is to approach tumors located in the
Closure following combined medial and lateral superior nasal quadrant of the orbit through a
orbitotomy is straightforward. The soft tissue of Lynch-type incision and to use the medial fornix
the orbit is placed back inside the bony confines orbitotomy for medium or small tumors located in
of the orbit. The periorbita is not closed. The medial the anteromedial orbit, or medium to large tumors
canthal tendon remains attached. The periosteum is located in the inferomedial orbit.
closed at the level of the anterior orbital rim (where • The medial fornix incision is often ideal for tumors
the original periosteal incision was made). The lateral located in the medial quadrant of the orbit when
orbital rim is repaired as described for lateral orbito- biopsy and not excision is planned.
tomy (above), and the deep soft tissue of the wound • When working in the deep orbit through a rela-
and then the skin is closed. One or more Penrose tively small incision, visualization of the anatomy
drains may be used if postoperative collection of may be challenging for even the most experienced
blood within the orbit is anticipated. Suction drainage surgeon. If bleeding begins, the field may fill with
is not used deep within the orbit. blood, further obscuring the anatomy. It is impera-
tive that the surgeon visualize and ligate or cauter-
Transcaruncular or Medial Fornix Incision ize the anterior and posterior ethmoidal neurovas-
cular bundles prior to deep orbital exploration. If
The second useful procedure to access the medial
vascular control is lost and blood fills the field, a
orbit is the medial fornix or transcaruncular
surgeon can become disoriented and penetrate the
approach. This procedure is more commonly used as
deep orbital soft tissue, the anterior or middle cra-
an anterior orbitotomy alone without lateral bone
nial fossa, or the ethmoid sinus and cause serious if
removal; however, it can be combined with lateral
not life-threatening injury.
bone removal to provide more room for tumor
removal medially by dislocation of the orbit soft tis-
sue into the temporal fossa. There are specific points POSTOPERATIVE CONSIDERATIONS
that are important to remember with respect to com- The most important postoperative considerations are:
bined medial and lateral orbitotomy utilizing the
• Gentle awakening from general anesthesia (see
transcaruncular approach:
above)
• The transcaruncular approach to the orbit, as • Head elevation for the first 24 hours following
opposed to the conventional Lynch incision, is surgery
used to avoid a cutaneous scar. Thus, it makes lit- • Avoidance of nose blowing for 7 to 14 days if the
tle sense to hide the scar medially and make a sinuses have been entered and bone removed
large cutaneous wound laterally. If bone removal between the orbit and paranasal sinuses
CHEN28-419-450.I 3/22/01 2:41 PM Page 448
• Ice and systemic steroids to reduce swelling orbital anatomy, orbital pathologies, oculoplastic and
• The vision, pupils, and ocular motility should be reconstructive techniques of soft tissues and bony
monitored to watch for signs of an evolving orbit structures, and the appropriate diagnostic and treat-
compartment syndrome; if that syndrome devel- ment plans. The summary clinical pathways outline
ops, it must be treated aggressively by medical or the characteristics of orbitotomy without bone
surgical means depending on the severity as removal (Fig. 28–18) as well as lateral orbitotomy with
judged by clinical and radiographic findings. bone removal (Fig. 28–19).
There are other incisions and procedures that can
CONCLUSION be used to gain access to the orbit and skull base for
tumor resection, craniofacial reconstruction, skull
Orbital surgery is a demanding and specialized dis- base surgery, and management of trauma. They are
cipline that requires a thorough understanding of covered in Chapter 29.
Orbitotomy without bone removal
1 2 3 4 5 6 7
Direct Lid crease Sub-brow Lynch Lower eyelid Medial limbal Trans-caruncular
incision incision incision incision subciliary incision conjunctival (or medial fornix)
approach conjunctival incision
Optic nerve, Superior nasal quadrant; Superior-nasal orbit, Inferior Intraconal space, Anterior, mid- and
peri-optic tumor, superior, superior nasal, nasoethmoid sinus repair, orbital rim lesion near optic deep aspect of
and retrobulbar superior-lateral ethmoid and frontal sinuses nerve medial orbit, medial
space sub-periosteal space, (may combine with Sub-Brow) orbital fracture
frontal sinus drainage (subperiosteal or
(may combine with Lynch) between periorbita
and orbital tissues)
(may add lateral
orbitotomy)
9 8
Trans-conjunctival Eyelid margin

inferior fornix orbitotomy
(swinging lower lid)
Inferior orbital space Anterior aspect of

(may add lateral superior orbit
orbitotomy with bone (may add conjunctival
removal) (may add incision medially to reach
medial fornix incision to reach retrobulbar space)
inferior medial orbit)
FIGURE 28–18 Clinical pathway outlining the characteristics of orbitotomy without bone removal (anterior
orbitotomy).
CHEN28-419-450.I 3/22/01 2:41 PM Page 449
Lateral orbitotomy with bone removal
Lid-crease incision Extended lateral Sub-brow incision Classic incision

(extending over canthal incision (with extension over without lateral
Lateral orbital rim) (Berke lateral lateral orbital rim) canthotomy
orbitotomy)
Access to lateral orbit and Lateral orbit Wide exposure to Mid aspect of
superior orbit, optic nerve (may add inferior fornix to reach superior and lateral orbit lateral orbital space
sheath fenestration inferior orbit and floor) (e.g., lacrimal gland tumors
(through subperiosteal plane) (may add medial orbitotomy) with bone excision)
(may add Lynch incision
with removal of frontal bar to reach
deep superior and medial orbit)
FIGURE 28–19 Clinical pathway outlining the characteristics of lateral orbitotomy with bone removal.
REFERENCES
1. Henderson JW: The surgical approaches to orbital 8. Shore JW, Carvajal J, Westfall CT: Miniplate recon-
tumors. In: Orbital Tumors. Philadelphia: WB Saunders, struction of the lateral orbital rim following orbital
1980. decompression for thyroid eye disease. Ophthalmology
2. Maroon JC, Kennerdell JS: Surgical approaches to the 1992;99:1433.
oribt: indications and techniques. J Neurosurg 1984; 9. Oonishi H, Kushitami S, Yasukawa E, et al: Particulate
60:1126. Bioglass compared with hydroxyapatite as a bone graft
3. Tse DT, Nerad JA, Anderson RL, et al: Optic nerve substitute. Clin Orthop 1997;334:316–325.
sheath fenestration in pseudotumor cerebri: a lateral 10. Lovelace TB, Mellonig JT, Meffert RM, et al: Clinical
orbitotomy approach. Arch Ophthalmol 1988;106:1458. evaluation of bioactive glass in the treatment of peri-
4. Leone CR. Surgical approach to the medial retrobulbar odontal osseous defects in humans. J Periodontol 1998;
space. Am J Ophthalmol 1983;96:1. 69:1027–1035.
5. Metson R, Dallow RL, Shore JW. Endoscopic orbital 11. Rubin PAD, Bilyk JR. Shore JW: Orbital reconstruction
decompression. Laryngoscope 1994;104:950. using porous polyethylene sheets. Ophthalmology
6. Shore JW: The fornix approach to the inferior orbit. In 1994;101:1697.
Advances in Ophthalmic Plastic and Reconstructive 12. Bilyk JR, Dallow RL, Ojeman RG, Linggood RM, Shore
Surgery. Bosniak SF, ed. New York: Pergamon Press, JW: Management of lesions at the cranio-orbital junc-
1987. tion. In: International Ophthalmology Clinics: Orbital Dis-
7. Westfall CT, Shore JW, Nunery WR, Hawes MJ, Yarem- ease. Shore JW, ed. Boston: Little, Brown, 1992.
chuk MJ: Operative complications of the transconjunc- 13. McCord CD: A combined lateral and medial orbito-
tival inferior fornix approach. Ophthalmology 1991; tomy for exposure of the optic nerve and orbital apex.
98:1525. Ophthalmic Surg 1978;9:58.
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CHEN29-451-474.I 3/26/01 8:57 AM Page 451
Chapter 29
CRANIOFACIAL AND NEUROSURGICAL

APPROACHES TO THE ORBIT
M. Douglas Gossman, Dale M. Roberts, and George Raque
Craniofacial and skull base teams formally blend the on cadaver studies, our surgical experiences, and the
skills and perspectives of surgeons from the fields of teachings of pioneers and contemporaries from the
neurosurgery, plastic surgery, otorhinolaryngology, aforementioned disciplines, including noted orbital
and ophthalmology. This approach has improved the surgeons such as Kronlein, Dandy,3 Wright,4 Ken-
treatment of complex problems that occur at the nerdell and Maroon,5, 6 McCord,7 and others.
boundaries of these individual disciplines.1 The value Exposure planning is approached systematically by
of multispecialty expertise in the management of spe- subdividing the orbit into three major compartments:
cific orbital disorders has also been recognized.2 The anterior, central, and apical (Fig. 29–1). The anterior
work of these groups has led to numerous clinical extends from the orbital margins to the posterior
advances, among them the evolution of surgical globe, and the central from the globe to the tip of the
methods that create broad access to the cavities of the temporal reflection of the greater wing of the sphe-
skull base. When applied to the surgical management noid. The apical region begins midway between the
of the orbital neoplasm or vascular anomaly, these ethmoidal foramina and spans the remaining area of
methods allow treatment of lesions that are inacces- the posterior orbit. The compartments are further
sible when viewed from the perspective of conven- divided into superior and inferior regions by an imag-
tional orbitotomy models. inary horizontal plane bisecting the optic nerve, and
into medial and lateral divisions by a vertical plane,
SURGICAL OSTEOLOGY OF THE ORBIT also centered on the nerve.
The primary considerations in designing the cor-
No component is more important to the outcome of rect exposure of each compartment are the surgeon’s
surgical treatment of orbital lesions than sufficient optimal angle of view of the tumor and the area
osseous exposure. Well-designed approaches sur- needed for tissue dissecting. The scope of exposure is
mount the orbit’s conical geometry, and limit also influenced by characteristics of a given lesion that
trauma to its neurovascular tissue. Tessier, in treat- cannot always be accurately judged preoperatively.
ing congenital malformations of the face and skull, These include tumor vascularity, invasiveness, and
demonstrated that the walls of the orbit might be precise location relative to vital anatomic structures
removed and replaced or reconstructed, in most not clearly defined by preoperative imaging. There-
instances with low complication rates and without fore, extensibility is also an important feature of the
appreciable residual deformity. The cavities con- exposure plan, a fact eloquently stated by A. F.
tiguous to the orbit are frequently included in such Henry8: “Exposure p must be a match for every shift,
procedures.2 and therefore have a range, extensile, like the tongue
This section describes patterns of bone removal of a chameleon, to reach where it requires.” The
compatible with effective tissue dissection for specific paranasal sinuses are selectively included in exposure
regions of the orbit. The methods presented are based formulations to enhance dissecting space and provide
451
CHEN29-451-474.I 3/22/01 2:42 PM Page 452
Optic nerve
Apical
Superior medial Superior
temporal
Central
Inferior
Anterior Inferior
temporal
medial
A B
FIGURE 29–1 (A) The orbital cavity is separated into three compartments for the purpose of surgical planning. The
anterior extends from the superior orbital rim to the posterior aspect of the eye, the central continues from the eye to
a point midway between the anterior and posterior ethmoidal arteries, and the apical spans the remaining area of the
posterior orbit. (B) Two perpendiculars, centered on the optic nerve, further divide the orbital compartments into
superior, inferior, medial, and lateral quadrants.
drainage of the operative field. Their architecture is sinus may be absent. Similarly, the sphenoid sinus
discussed below. may consist of a single air cell or the central sphenoid
bone may be rendered an air cavity with a volume of
up to 30 cc.
SINUS ANATOMY
The air-filled paranasal sinuses surround the orbit on The Maxillary Sinus
its medial, inferior, and posteromedial, and, in some The maxillary sinus is pyramidal in shape and occu-
cases, its superior surfaces. Accordingly, they may be pies the body of the maxilla. The base of this pyra-
indispensable in supplementing orbital exposure. The mid forms the majority of the lateral wall of the
features of each sinus that are of surgical importance nose. The apex projects into the body of the zygoma.
are outlined below. Its roof forms the central portion of the orbital floor.
The sinuses develop embryologically as diverticu- The anterolateral wall is penetrated by the infraor-
lae of the nasal cavities. The maxillary appears first, bital foramen.
and is usually present during the third month of fetal
life, followed by the ethmoid sinus. The frontal sinus,
EARL ... The posterior wall abuts
which is a superior extension of the ethmoid air cells
into the frontal bone, is not in evidence until the sec-
ond or third year of life. It reaches adult dimensions at
P the infratemporal fossa and is often in
contact with the internal maxillary artery.
about 20 years of age. The ethmoid air cells extend
into the sphenoid bone, forming the sphenoid sinus. The thickened portion of the sinus roof, immedi-
ately superior to the posterior wall, is an important
EARL... Paranasal sinus anatomy is posterior anatomic landmark upon which bone grafts
P marked by extreme variability.
or implants are positioned during reconstruction of
the orbital floor (see Osseous and Soft Tissue Recon-
struction, below).
Size is the principal variant noted, particularly in The infraorbital nerve, artery and vein are sur-
the case of the frontal and sphenoidal sinuses. The rounded by a thin-walled canal that may be absent of
frontal bone may be completely pneumatized or the bone within either the sinus or the orbit.
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CRANIOFACIAL AND NEUROSURGICAL APPROACHES TO THE ORBIT • 453
EARL ... ...

P The anterior face of the
maxilla and the floor of the sinus are usu-
ally penetrated by the roots of the maxillary
P EARL The frontoethmoid suture,
penetrated by the ethmoidal foramina,
marks the level of the lateral roof of the eth-
teeth. These structures may not be covered by moid sinus.
bone, and therefore are prone to injury during
exposures through the oral mucosa.
The suture is a consistent landmark and is used
to maintain orientation during surgical dissection.
If followed posteriorly, it leads to the lesser wing of
The Frontal Sinus the sphenoid. The medial component of the roof and
The floor of the frontal sinus occupies a variable por- the cribriform plate lie inferior to the suture in some
tion of the roof of the orbit. The sinus drains via either cases. Its orientation is determined preoperatively
the anterior ethmoid air cells or a separate opening by coronal computed tomography (CT) (see Eth-
into the nose known as the nasofrontal duct. The moidectomy, below). All other paranasal sinuses
importance of this sinus in orbital tumor surgery is can be reached through the ethmoid sinus, an
dependent primarily on its size.9 important anatomic fact in surgical exposure of the
orbit and in providing surgical drainage of these
The Ethmoid Sinus
central cavities.
The ethmoid bone is a paired structure that forms the
midline floor of the anterior cranial fossa. The sinus The Sphenoid Sinus
consists of a midline perpendicular plate, a horizontal The sphenoid sinus may contain a septum, which is
cribriform plate, and the labyrinths. The perpendicu- only rarely in the midline. Communication between
lar plate descends into the nose to become part of the these cavities is unusual. The ethmoid sinus roof is
nasal septum. The pneumatized labyrinths are con- continuous with that of the sphenoid and may be fol-
tinuous with the cribriform plate superiorly, and infe- lowed posteriorly into the sinus.
riorly are positioned between the lateral wall of the The anterior loop of the carotid artery lies in the
nose and orbital plate of the ethmoid. The anterior carotid sulcus at the posterior lateral wall of the sinus,
articulation of the cribriform plate with the frontal inferior to the cranial aperture of the optic canal. The
bone creates the foramen cecum. cavernous sinus is also contiguous to the lateral wall.
The nasal surfaces of the labyrinths harbor the The bone of the lateral wall may be thin (0.5 mm) or
superior and middle turbinates. They compose the absent over the carotid artery and optic nerve. The
upper third of the lateral nasal cavity. thickness of the walls tends to be inversely propor-
The orbital surface, known as the lamina papyracea tional to the degree of sinus pneumatization.
or lamina orbitalis, forms the majority of the medial
wall of the orbit. It articulates anteriorly with the
...
lacrimal bone, inferiorly with the maxillary orbital
plate and orbital process of the palatine bone, superi-
orly with the frontal bone, and posteriorly with the
P EARL Carefully rendered CT
scans are essential prior to invasive sphe-
noid sinus surgery.
lesser wing of the sphenoid.
The anterior air cells are more numerous and drain
into the nose via the middle meatus (with the frontal INCISION SELECTION
and maxillary sinuses). The posterior air cells drain
into the nose at the superior meatus. The superior Adequate bone removal begins with proper selection
aspect of the air cells is crossed by grooves that trans- and judicious positioning of cutaneous incision(s).
mit the ethmoidal neurovascular bundles. They are Visible scarring is minimized by the placement of
converted to canals by union with the frontal bone at cutaneous incisions within the relaxed skin tension
the frontoethmoid suture. The superior surfaces of lines (RSTLs), muscular frown lines, or in concealed
some anterior cells are open but are closed by the locations such as posterior to the hairline and within
edges of the ethmoidal notch of the frontal bone.10 The the oral cavity (Fig. 29–2).12 Extensibility of the inci-
dual participation of the ethmoid and frontal bones in sion is also an important consideration when broad
formation of the roof of the labyrinths has resulted in areas of the skeleton are involved in the exposure
variety in clinical nomenclature. It has been referred plan. The critical technical aspects of the incisions
to in the surgical literature as both the cribriform plate commonly employed in orbital exposure are
and the fovea ethmoidalis.11 reviewed below.
CHEN29-451-474.I 3/22/01 2:42 PM Page 454
from the skin edges. The bicoronal incision extends

Bicoronal between the anterosuperior attachments of the auri-
cles, shifting gradually toward the hairline over its
central span (Fig. 29–2). A 7-mm strip of hair is
Lynch shaved along the course of the incision and antiseptic
(Betadine) gel is applied the hair adjacent to the inci-
Upper eyelid sion to keep it from the operative field.
crease The scalp incision is begun over the temporalis
muscle and is extended through the galea aponeurot-
Extended
lateral
ica (Fig. 29–3). Direct coagulation of the superficial
canthotomy temporal artery markedly reduces bleeding from the
skin edges as the incision progresses. Low-profile
Canthofornix Rayney clips applied to the skin and galeal edges may
further limit blood loss by occluding the epigaleal
Gingival-buccal vessels.
sulcus The incision continues through the loose areolar
fascia, which lies between the galea and the deep tem-
poral fascia. Dissection proceeds on the surface of the
deep fascia toward the temporal line, where the fascia
and pericranium fuse. This dense condensation is
FIGURE 29–2 The soft tissue incisions employed in sharply incised below the galea close to the bone to
preparation for removal of the orbital bones include (1) the minimize injury to the branches of the facial nerve.
bicoronal, (2) upper eyelid crease, (3) extended lateral can- Medial to the temporal lines, the flap is elevated in
thotomy, (4) canthofornix, (5) gingival-buccal sulcus, and the plane between the galea and pericranium.
(6) Lynch. The deep temporal fascia is followed (below the
temporal fat pad) as the dissection lateral to the tem-
Bicoronal Incision poral line proceeds inferiorly to the zygomatic arch
(Fig. 29–3). As the zygomatic process of the frontal
The lateral, medial, and superior orbital rims are vis-
bone is approached, the deep temporal vein enters the
ible through the completely developed bicoronal
operative field from the muscle. It is transected after
scalp flap. The medial and lateral orbital apex may
application of bipolar electrocautery. At approxi-
also be reached, and this exposure avoids the facial
mately this point (2.0 cm above the superolateral
scar of the Lynch procedure in sphenoethmoid
orbital rim), dissection medial to the temporal lines is
surgery. It is our incision of choice for cranio-orbital
converted to a subperiosteal plane and proceeds to
procedures and when both the medial and lateral
the orbital rims, glabella, and nasion.
orbit must be exposed. Other important advantages
The lateral aspects of the flap are elevated by
of the incision include ample surgical access to the
extending the dissection to the lateral orbital rim and
anterior and middle cranial fossae and extensibility,
over the deep temporal fascia to the level of the zygo-
allowing, for example, the harvest of bone grafts for
matic arch. Division of the temporal fat pad (which is
reconstruction without secondary exposure.
continuous with the buccal fat pad) and incision of
Correct positioning of the patient facilitates intra-
the periosteum on the posterior surface of the arch
operative efficiency. In most cases a horseshoe head-
protects the temporal branch of the facial nerve (Fig.
rest offers adequate stability of the head and creates
29–3).
an open operative field. If self-retaining retraction
devices are to be employed, they may dictate the
method of head restraint required (see Soft Tissue
...
Techniques and Tumor Resection Methods, below).
The lumbar drain is placed prior to positioning the
patient on the headrest, if exposure of the anterior
P EARL Continued protection of
the facial nerve is afforded by maintaining
a subperiosteal dissection plane during exposure
or middle cranial fosse is planned. The patient’s of the arch’s anterior surface.
head is placed at the foot of the operating table,
which allows ample room for foot switches and
other equipment. The supraorbital nerve, when contained within the
Preinjection of the incision area with epinephrine- supraorbital foramen, prevents full inferior develop-
containing solution (e.g., 0.5% Xylocaine and epi- ment of the flap, unless the inferior margin of the fora-
nephrine in a 1 : 400,000 dilution) minimizes bleeding men is removed with a small (2.0 mm) osteotome.
CHEN29-451-474.I 3/22/01 2:42 PM Page 455
Galea
Loose (areolar) tissue
Periosteum
Superficial
temporal
artery Dura
Temporal lune
Deep temporal fascia
Meningeal artery
Superficial
temporal
fascia Superficial layer
(galea Deep temporal fascia
Deep layer
aponeurotica)
Outer
Table of skull
Inner
Skin
Deep temporal artery
Subcutaneous Temporalis muscle

areolar tissue
Temporal fat pad
FIGURE 29–3 The anatomy of the temporal segment of the bicoronal scalp flap: (1) superficial temporal artery,
(2) temporoparietal fascia (galea aponeurotica), (3) deep temporal fascia, (4) temporalis muscle, (5) superficial layer of
deep temporal fascia, (6) temporal fat pad/buccal fat pad, (7) periosteum, and (8) temporal line.
When the neurovascular bundle lies within a notch, a drain may be used to prevent hematoma formation.
delicate periosteal elevator can release it. Subpe- Surgical staples are preferred for skin closure for their
riosteal dissection then proceeds over the nasal bone ease of removal.
and maxilla to the medial canthal tendon. Elevating
the periosteum of the medial orbital wall, beginning Upper Eyelid Crease Incision
at the posterior lacrimal crest, produces an unob- The upper eyelid crease incision conforms to the
structed view of the orbital plate of the ethmoid. The RSTL and provides adequate access to the anterosu-
frontoethmoid suture may be followed to the apex. perior orbital space and rim (see Anterior Orbital
Release of the temporal fascia from its orbital mar- Compartment Surgery, below). 13, 14 When used to
gin and reflection of the temporalis muscle from the expose the superior orbital rim, the skin and the
zygoma and the temporal bone exposes the lateral orbicularis oculi muscle are divided at the level of
orbit. The temporalis muscle is separated from the the crease, and then reflected from the septum to the
bone by electrodissection to minimize bleeding. A 2.0- rim. The septum is then opened near the rim if the
cm remnant of the muscle is left attached to the tem- lesion is located within the orbit. For access to a
poral line to simplify its reattachment during closure. lesion situated between the frontal bone and the peri-
Removal of the lateral rim and outer table of the orbita, the periosteum is incised peripheral to the
greater wing of the sphenoid gives access to the supe- arcus marginalis and a subperiosteal dissection plane
rior orbital fissure and lateral apex. In preparation for is initiated.
subsequent soft tissue dissection, the scalp flap is held
in position by right-angled retractors, or by self- Extended Lateral Canthotomy
retaining elastic retractors (DermaHooks, Weck Clo- The so-called extended lateral canthotomy (ELC)
sure Systems, Research Triangle Park, NC). Closure offers broad soft tissue exposure of the lateral orbital
of the bicoronal incision begins with approximation wall, including the lateral aspect of the superior and
of the galea with reabsorable suture. A closed suction inferior orbital rims. The skin incision in the ELC is
CHEN29-451-474.I 3/22/01 2:42 PM Page 456
carried from the lateral canthus in the RSTL for some

2.0 cm. It penetrates to the temporalis fascia and
periosteum.
Release of the anterior and posterior crus of the
lateral canthal tendon and the septal and muscular
attachments of the eyelids to the orbital rim allows
sufficient soft tissue mobility to fully expose the lat-
eral, superolateral, and the inferolateral orbit. With
the exception of the posterior crus of the lateral
canthal tendon, these attachments can rarely be iden-
tified visually. Lying deep to the orbicularis oculi
muscle, they may follow the rim to the inferior orbit.
They are recognized tactilely by palpation with the
needle electrocautery tip as firm bands between the
lateral eyelid and the orbital rim. Definition of these
structures is enhanced by firmly drawing the eyelids
away from the lateral rim. Abrupt anterior move-
ment of the lateral eyelids immediately follows their
transection.
Canthofornix Incision
The canthofornix incision (CFI) is an alternative to the
cutaneous subciliary incision for exposure of the infe-
rior orbital rim and floor. It is, in essence, an ELC with
a conjunctival extension.15 After release of the fascial
attachments of the eyelids to the lateral orbital rim,
the eyelids are separated at the lateral raphe, exposing
the lateral conjunctival fornix.
Delicate rake retractors having sharp teeth are used
to hold the eyelid away from the globe to fully reveal
the fornix. The conjunctiva and inferior tarsal muscle
FIGURE 29–4 Marking the position of the drill prior to
are incised with needle electrocautery in the depths transection of the posterior crus of the lateral canthal ten-
of the fornix. During the forniceal incision a malleable don assures restoration of the canthus to the correct posi-
retractor protects the eyeball. Ragnelle-Davis retraction following the canthofornix or extended lateral
tors replace the rakes before the incision is extended canthotomy incisions. During reconstruction, holes are
to the orbital rim. They are also used for subsequent extended through the zygoma, exiting 4 to 5 mm posterior
eyelid retraction. to the rim on the plane of the canthus. Sutures attached to
Restoring the lateral canthus to its anatomic posi- the lateral tarsal plates are guided to the surface and tied.
tion during reconstruction may prove difficult due to
the sutures are tied, the canthus is restored to its cor-
the absence of visible anatomic reference points. If
rect position (Fig. 29–4). Conjunctival closure requires
only the inferior eyelid is released, as in an exposure
only two buried absorbable sutures.
limited to the inferior orbital rim, the superior crus
of the canthal tendon provides a landmark that
assists in repositioning of the eyelid.
EARL ...
When both eyelids are released, as in lateral orbito-
tomy, a partial-thickness hole is placed in the zygoma
adjacent to the canthus. During closure, the hole is
P Advantages of the CFI
include reduced bleeding from the con-
junctival incision compared to the transcuta-
continued through the orbital wall, exiting on the neous subciliary incision and near-total
same plane, about 5.0 mm posterior to the rim. A sec- concealment.
ond hole is drilled, exiting at the same point. A dou-
ble-armed 4-0 Polydek suture, on an ME-2 needle, is
directed through the lateral margin of each tarsal Complications include potential injury to the
plate. Each suture arm is then carried through one of globe, entropion, and canthal dystopia, as just
the predrilled holes with a snare, fashioned by folding discussed. A hard plastic lens and a malleable retrac-
a short section of 30-gauge surgical wire in half. When tor are used to protect the globe during the fornix
CHEN29-451-474.I 3/22/01 2:42 PM Page 457
incision. Postoperative entropion may be more likely Superior Lesions

when the incision is positioned at the inferior tarsal The upper eyelid crease incision provides access to
border rather than in the conjunctival fornix. the superior spaces of the anterior orbit. If the supe-
rior rim obstructs visualization of lesions that lie
Gingival-Buccal Sulcus Incision
within the orbital “vault,” it is removed by an
The buccal sulcus incision completely exposes the osteotomy that extends from the supraorbital fora-
inferior body of the zygoma, the maxilla, and the men to the zygomatic process of the frontal bone (Fig.
lateral nasal wall. The mucosa is infiltrated with 29–5). A saw or osteotome may execute it.
epinephrine-containing anesthetic solution. The oral After tumor removal or biopsy the rim is replaced
incision is placed well above the attached gingiva, and stabilized by absorbable miniplate fixation. If the
at the approximate level of the apices of the maxil- lesion cannot be totally removed and is producing a
lary teeth. If the incision is made in the gingiva close functional mass effect, reconstruction may be
to the teeth, the wound will be difficult to close. The deferred to decompress the area. A visible deformity
parotid salivary duct is protected as it enters the oral rarely results.
cavity adjacent to the maxillary molars. Extension of the lesion into the central orbital
After vasoconstriction, the mucosa is incised with a space requires more extensive bone removal if the
scalpel and then extended to the maxilla with a needle objective is complete excision. Conventional
cautery. Degloving of the face of the maxillary antrum hemifrontal craniotomy in conjunction with removal
is performed with a periosteal elevator, or a surgical of the entire superior orbital rim, the fronto-orbital
sponge, to the level of the infraorbital nerve (see The craniotomy, provides exposure for the removal of an
Maxillary Sinus, above). A periosteal elevator is used anterior lesion with centromedial extension. Centro-
to release the periorbita and muscle from the orbital lateral extension of an anterior lesion is exposed by
rim, joining the oral incision with the CFI. superolateral orbitotomy (Fig. 29–5). The bicoronal
incision is usually preferred for exposure of this
OSSEOUS EXPOSURE TECHNIQUES orbital quadrant.
An extracranial approach to the anterocentral and
Anterior Orbital Compartment Surgery anteromedial orbit may be used if the frontal sinus
Anterior orbital lesions are contiguous to the globe extends over the operative area. In this technique the
and, if confined to this compartment, are often acces- anterior wall and floor of the sinus are removed. A
sible with little or no bone removal. However, the roof Caldwell view of the frontal sinus is obtained and a
of the orbit ascends from the rim into the anterior cra- template defining the boundaries of sinus is made
nial fossa, creating the superior “vault.” This space is from clear x-ray film. It is sterilized and placed on
difficult to visualize when the eye is proptotic or the exposed frontal bone in the anatomic position of the
highly myopic and bone removal may be required sinus. A sterile lead pencil is used to inscribe the out-
(Fig. 29–5). line of the sinus on the bone (Fig. 29–6).
Superior
orbital rim
Superolateral
Lateral
Inferolateral
Medial
Inferior
Inferomedial
FIGURE 29–5 The basic extracranial orbitotomies include (1) the superior orbital rim, (2) superolateral, (3) lateral,
(4) inferolateral, (5) inferior, and (6) inferomedial. The drawing on right illustrates cross-sectional view of the superior
orbital rim.
CHEN29-451-474.I 3/22/01 2:42 PM Page 458
plates. The osteotomy gaps are filled with hydroxya-

patite if necessary (Norian, Cupertino, CA).
Lateral Lesions
The upper eyelid crease incision offers excellent expo-
sure for lateral lesions that lie above the canthal ten-
Frontal bone
don, as in the case in dermoid tumors at the
frontozygomatic suture.14 However, if the lesion
descends into the inferior orbit, the ELC provides bet-
ter exposure.
Inferolateral Lesions
Biopsy or removal of anteriorly placed inferior lesions
rarely requires bone removal because the soft tissues
can be displaced into the superior vault, which in
most cases provides adequate surgical access to this
space. The inferior orbital compartment is reached via
the CFI, which also permits removal of the inferior
rim, should increased exposure of the inferior orbital
compartment be needed.
Inferomedial Lesions
A 180-degree, fornix-based conjunctival flap and
disinsertion of the medial rectus tendon provides
access for biopsy or tumor removal. Alternatively, a
transcaruncular approach to the anteromedial com-
partment may be employed if the lesion is medial to
the muscle. Neither approach, however, affords excel-
lent visibility or room for dissection, due to the pres-
ence of the medial orbital wall.
FIGURE 29–6 If the frontal sinus is extends over the cen-

EARL ...
tral orbital compartment, a transsinus approach to the com-
partment may be used. The shape of the sinus is first
inscribed on the frontal bone using a template. Pilot holes
are then placed internal to the outline and joined with a
P Visibility of the medial
orbital compartment can be improved by
removal of the lateral orbital wall, which allows
side-cutting burr or saw (top). The anterior wall of the sinus lateral translocation of the globe.7
and the roof of the orbit are removed (bottom).
Removal of the inferior rim in conjunction with the

The inferomedial frontal sinus is entered with a lateral wall further enhances exposure of inferior
3-mm cutting burr at the nasofrontal angle. The open- anterior compartment (Fig. 29–5).
ing is enlarged with a small rongeur and the osteotomy
is extended along the anterior floor of the sinus. The
sinus interior is in view. Central Orbital Compartment Surgery
A series of pilot holes are drilled in the frontal The central orbit is a common site of tumor origin or
bone 2.0 mm internal to the inscribed outline of the extension. Large lesions of the lateral, inferior, and
sinus (this maneuver minimizes the chance of medial quadrants can usually be removed by
intracranial penetration during the subsequent extracranial orbitotomy because dissection may be
osteotomy). The holes are connected by side-cutting carried between quadrants with reasonable safety.
burr. The anterior wall of the frontal sinus is removed During dissection three-dimensional awareness of the
followed by the floor, exposing the anterior and cen- position of the optic nerve is maintained and the soft
tral orbital spaces. tissues are protected. Lesions of the superomedial
During reconstruction the anterior wall of the sinus quadrant, however, are rarely accessible by purely
and orbital roof are stabilized by fixation with mini- extracranial bone removal.
CHEN29-451-474.I 3/22/01 2:42 PM Page 459
Superolateral Lesions A second osteotomy is carried through the inferior

Lateral orbitotomy, executed through either the lateral orbital wall and anterior zygomatic arch, join-
bicoronal or ELC incision, exposes the centrolateral ing the previous bone incision. Removal of the lateral
orbital spaces. The ELC is the preferred incision if wall is continued with the resection of the dense tri-
bone removal may extend to the inferolateral orbit, angular mass of the greater wing of the sphenoid. Ini-
because it offers better exposure of this region. Fol- tiated with a curette or rongeur, final resection is
lowing canthotomy, the temporalis muscle is sepa- completed with a fine cutting burr, aided by loupe
rated from the zygoma and sphenoid and the magnification, to facilitate recognition of the inner
periorbita is separated from the orbital surface of the table of the middle cranial fossa. The Aesculap recip-
lateral wall. rocating saw, actuated by foot switch, is preferred for
Orbitotomy is initiated with a bone incision that orbital osteotomy because it is easily manipulated in
first traverses the zygomatic process of the frontal the limited confines of the orbit and it destroys mini-
bone and, turning inferiorly, follows the zygomati- mal bone during the incision (Aesculap South San
cosphenoid suture to the inferior orbit (Fig. 29–7). An Francisco, CA).
assistant protects the orbital tissues with a malleable A relatively large lesion may be removed through
retractor. this exposure if it is peripheral to the muscle cone and
well demarcated from orbital tissue, for example,
pleomorphic adenoma of the lacrimal gland (Fig.
29–8). In the removal of such lesions, soft tissue
A B
FIGURE 29–7 (A) The extended lat-

eral canthotomy incision offers broad
exposure for removal of the lateral
orbital wall, reaching from the supero-
lateral (arrow) to the inferolateral orbit
(arrow) (lateral wall removed). (B) The
lateral orbitotomy consists of transverse
superior and inferior bone incisions that
are joined by a vertical cut along the
zygomaticosphenoid suture. (b=lat-
eral orbital rim, c=lateral orbital wall.)
Inferolateral and superolateral exten-
sions (shaded) of the lateral orbitotomy
may be seamlessly incorporated into
the basic lateral orbitotomy during the
procedure (top). (C) Selected removal of
the outer table of the greater wing of the
sphenoid (stippled) completes the expo-
C sure (bottom).
CHEN29-451-474.I 3/22/01 2:42 PM Page 460
FIGURE 29–8 Superficial lesions of the lateral orbital FIGURE 29–9 Lesions that occupy the lateral compart-
compartments that are well demarcated from the orbital soft ment abutting the optic nerve and globe are most safely
tissue, for example, pleomorphic adenoma of the lacrimal removed by two-quadrant exposure, which allows displace-
gland, are efficiently removed via lateral orbitotomy alone. ment of the lesion and a direct view of the tumor and optic
nerve during dissection. Optimal exposure of such lesions is
provided by the frontozygomatic craniotomy (see Fig. 29–18).
dissection begins anteriorly. As the tumor is displaced
laterally from the orbit, normal medial tissues can be
seen and protected. MD988—13 mm), an osteotomy extends from the hole
across the upper maxilla and through its zygomatic
process. A perpendicular cut, lateral to the inferior
EARL ...
P The lateral orbitotomy orbital foramen, is then made through the rim and a
second cut separates the body of the zygoma from the
alone may offer insufficient exposure if the
arch. Through the conjunctival incision, a bone inci-
lesion is within the muscle cone and apposed to sion is continued through the orbital floor to the infe-
the globe and optic nerve because the medial sur- rior orbital fissure, paralleling the infraorbital canal. A
face of the tumor cannot be visualized (Fig. 29–9). metal ribbon retractor, controlled by the assistant,
An inferolateral orbitotomy that permits dis- protects the globe and other orbital tissues. A 3.0-mm
placement of the lesion inferiorly into the maxil- osteotome is used to complete release of the lateral
wall of the maxillary sinus (Fig. 29–10). The anterior
lary sinus may surmount this barrier (Fig. 29–10).
sinus wall, orbital rim, and floor are removed as a unit
through the oral incision.
Concomitant disinsertion of the lateral rectus may
also be necessary. If dissection superior and medial to
the tumor still cannot be performed under direct view
with this added exposure, a frontozygomatic cran-
iotomy is recommended (see Fig. 29–18). We feel that
a tumor extending to the midline of the orbit is more
effectively exposed by the frontozygomatic approach
that is depicted in Figure 29–18.
Inferolateral Lesions
Inferior lateral quadrant exposure is achieved by com-
bining the lateral orbitotomy described above with
the removal of the inferior orbital rim lateral to the
infraorbital foramen. The CFI and the gingival-buccal
sulcus incisions are used to obtain necessary exposure
of the zygoma, maxilla, and orbital rim and floor.
Following removal of the lateral orbital wall, as
described above, inferolateral orbitotomy is initiated
through the oral incision by placing a burr hole infer- FIGURE 29–10 The inferolateral orbitotomy provides
olateral to the infraorbital foramen (Fig. 29–10). two-quadrant exposure for removal of inferolateral and
Using the microreciprocating saw blade (Aesculap, inferocentral lesions.
CHEN29-451-474.I 3/22/01 2:42 PM Page 461
Two-quadrant exposure allows the surgeon to see osteotome. The posteroinferior margin of the canal is
the tumor and the normal tissue superior and medial also transected by osteotome. The anteroinferior
to it, as the lesion is displaced inferolaterally. The aspect of the foramen is removed by delicate cutting
exposure of the maxillary sinus expands the area burr (Fig. 29–11).
available for surgical manipulation. The sinus also A medial osteotomy is next extended from the
provides drainage of the operative field, further upper pyriform aperture through the frontal process
improving visibility. of the maxilla to the lacrimal bone using the microrec-
iprocating saw. Pilot holes may be placed along the
Inferomedial Lesions intended incision, making the osteotomy easier to
The inferomedial orbitotomy includes removal of the perform with the delicate saw blade. Resuming at the
medial inferior orbital rim and floor, the anterior wall posterior lacrimal crest, the bone incision is continued
of the maxillary sinus, the upper pyriform aperture, by osteotome along the maxillary-ethmoid suture.
and the inferior aspect of the frontal process of the The posterior attachments of the orbital floor are sev-
maxilla, and exposes the inferomedial quadrant (Fig. ered. Bone around the lacrimal sac and upper naso-
29–11). It is executed through the CFI and gin- lacrimal duct is removed with delicate forceps and the
givobuccal sulcus incisions. Ethmoidectomy may sup- entire osseous segment is removed through the con-
plement the exposure. junctival incision. The lacrimal probe is replaced by
A burr hole is placed in the maxillary face infero- silicone tubing, which is retained during the early
lateral to the infraorbital foramen, and the microrec- postoperative period to minimize the likelihood of
iprocating saw blade is placed into the sinus. An lacrimal stenosis. Additional exposure is obtained by
incision is carried medially across the face of the adjacent ethmoidectomy and/or lateral orbitotomy
antrum and through the pyriform rim (coursing (Fig. 29–11).
anterior to the nasolacrimal duct and superior to the
root of the canine tooth). A lacrimal probe is placed Superomedial Lesions
within the nasolacrimal duct prior to osteotomy. The frontal sino-orbitiotomy offers extracranial expo-
The next cut is made perpendicular to the infraor- sure of the superomedial central orbital space if the
bital foramen and extended through the orbital rim. It frontal sinus is of sufficient size (Fig. 29–6). Otherwise,
then follows the infraorbital canal to the posterior limit fronto-orbital craniotomy is required to achieve visu-
of the floor. The canal is unroofed and the neurovas- alization of the superomedial surface of the tumor
cular bundle is atraumatically displaced, allowing and protect the optic nerve during dissection. The
division of the inferior wall of the canal by delicate frontal bone and superior orbital rim are removed,
allowing retraction of the frontal lobe to expose the
floor of the frontal fossa.
Using the bicoronal incision, the scalp is reflected
to the canthal tendon medially and to the zygomatic
arch laterally. Medial and lateral frontal burr holes are
placed 3.0 cm above the orbital rim and anterior to the
coronal suture (Fig. 29–12). Mannitol is given and/or
cerebrospinal fluid is released via a lumbar drain to
relax the dura before the craniotomy is performed.
After removal of the frontal bone, the dura is reflected
from the floor of the frontal fossa and protected by
cottonoids and a retractor.
Osteotomy of the orbital rim, or frontal bar, is
begun at the inferomedial burr hole using the
Aescalap reciprocating saw. A companion osteotomy
is extended from the inferolateral burr hole to the
lateral orbital rim. A 3.0-mm burr hole is centered in
the anterior floor of the frontal fossa about 1 cm
posterior to the rim, and a transverse osteotomy using
FIGURE 29–11 The inferomedial orbitotomy provides
a satisfactory viewing angle for removal of most central,
the microreciprocating saw completes release of
inferomedial, and selected apical orbital lesions. The maxil- the orbital rim (Fig. 29–12). The remaining floor of the
lary sinus provides expansion and drainage of the opera- frontal fossa is removed and saved for subsequent
tive field. Ethmoidectomy may provide supplemental reconstruction. The roof of the ethmoid sinus and air
exposure (shaded) and may be executed endoscopically or cells may be removed to further broaden the opera-
through the orbital exposure. tive field.
CHEN29-451-474.I 3/22/01 2:42 PM Page 462
FIGURE 29–13 From the frontal perspective the form of

Frontal view the apex resembles an acute triangle whose apex points to
the optic foramen.
The functional outcome of tumor excision within

the apex improves with wide bone exposure, the
design of which is facilitated by a thorough under-
standing of its three-dimensional osseous anatomy.16
The union of the frontal bone and lesser wing of the
sphenoid marks the roof of the extreme posterior
orbital apex. When this area is observed from the
frontal perspective, the inward slope of the lateral
margin of the superior orbital fissure and medial wall
produces a shape that resembles an acute triangle.
The base is formed by the lateral margin of the supe-
rior orbital fissure and the apex points toward the
optic foramen (Fig. 29–13).
When viewed from a perspective that is frontolat-
Top view eral and coaxial with the long axis of the optic canal,
the shape of the apex resembles an isosceles triangle
FIGURE 29–12 Frontal craniotomy (a) alone rarely (Fig. 29–14). The apparent change in form occurs
offers adequate space for tumor dissection. Removal of the
superior orbital rim (b) widens the operative field and per-
mits execution of the techniques required in the removal of
deeply positioned lesions of the centromedial, lateral, and
anterior apical compartments.
Removal of the frontal bone provides an unob-

structed view of the superomedial quadrant of the
orbit with ample room for surgeon and assistant to
maneuver. The exposure allows use of self-retaining
retractors and the operating microscope.
Apical Compartment Surgery

Only that of the neighboring cavernous sinus rivals
the density of the neurovascular structure within the
orbital apex. The surgeon’s view of the dissecting area
is more severely limited by the osseous architecture
than in other compartments, which renders the apex, FIGURE 29–14 From a frontolateral perspective coaxial
in particular its medial quadrants, the most challeng- with the optic canal, the apical form resembles an isosceles
ing of the surgical orbital regions. triangle.
CHEN29-451-474.I 3/22/01 2:42 PM Page 463
because the maximum lateral projection of the orbital

EARL ... Transfrontal orbitotomy
P
plate of the ethmoid lies some 9.0 mm anterior to the
inferior limit of the superior orbital fissure (approxi-
offers an unobstructed view of the super-
mately at the posterior medial maxillary sinus). Pos-
terior to this coordinate, the inferomedial wall of the omedial apex, facilitating atraumatic develop-
apex shifts slightly toward the midline. ment of a plane separating the tumor from the
optic nerve and the nerves of the superior
Medial Lesions orbital fissure.
The shortcomings of extracranial approaches to the
posterior orbital apex have been noted.17–19 Adequate
room for soft tissue manipulation is difficult to achieve Even a transcranial approach noted above, however,
by these methods, most of which are modifications of does not completely overcome the limited posteroinfe-
the inferomedial orbitotomy that has been previously rior operative field created by lateral protrusion of the
described.7, 20 The lateral projection of the posterior posterior medial wall. A solution to this anatomic bar-
medial wall prevents direct visualization of lesions in rier lies in the conversion of the triangular form of the
the posteromedial apex during extracranial approaches posterior apex to a rectangle by transcranial sphe-
that follow the medial wall (Fig. 29–15). Methods to noethmoidal orbitotomy (Fig. 29–16).
improve visualization of the region include transnasal Bone incisions to enlarge the surgical field are
endoscopy.21 Dailey et al22 developed the LeForte first inscribed with a sterile pencil. The posterior
1 orbitotomy to improve visualization of the infero- orbital plate of the ethmoid and contiguous air cells
nasal apex. The most critical limitation of these is removed first, followed by the ethmoid notch of
methods, however, is the absence of a direct view of the frontal bone. A delicate rongeur or the microrec-
the posterior, superior, and lateral margins of the iprocating saw may remove the bone (use of the saw
tumor, which hinders protection of the optic nerve dur- may allow the roof, and at times the lateral wall of
ing dissection and the control of orbital tributaries of the sinus, to be reused in reconstruction). A cot-
the internal carotid artery. tonoid protects the dura covering the olfactory bulb
during removal of the ethmoid roof.
Sphenoidotomy opens this sinus, allowing re-
moval of its roof under direct vision. The operating
microscope may be used during the bone incisions.
If the tumor extends to the cavernous sinus or mid-
dle fossa or if it enters the orbit from these locations,
removal of the anterior clinoid and additional lat-
eral exposure of the middle cranial fossa may sup-
plement this approach (Fig. 29–17).23
FIGURE 29–15 Inferomedial apex lesion with visual

loss. Preoperative imaging indicated possible dural origin in
the anterior middle cranial fossa. The lesion extended medi-
ally into the ethmoid and sphenoid sinuses and possibly
into the anteromedial cavernous sinus. Angiography failed
to demonstrate direct supply of the lesion by the internal
carotid artery. The exposure, illustrated in Fig. 29–17,
included partial unroofing of the optic canal and intracra-
nial exposure of the adjacent carotid artery, prior to orbital
dissection to permit rapid access in the event of unexpected FIGURE 29–16 The triangular form of the posterior
supply to the tumor (Wayne Villanevua, M.D.). The tumor orbital apex may be converted to a rectangular one by use of
proved to be a cavernous hemangioma. the contiguous ethmoid and sphenoid sinuses.
CHEN29-451-474.I 3/22/01 2:42 PM Page 464
a The anterior and posterior ethmoidal arteries exit

through the frontoethmoid suture and lie on the ceil-
ing of the sinus with or without a covering of bone.
The anterior foramen, posterior foramen, and optic
canal lie, respectively, 12, 24, and 30 mm posterior to
the anterior lacrimal crest. Anatomic variation is com-
mon in and around the ethmoid sinus, as previously
mentioned, and the positions of the ethmoidal foram-
c b ina frequently do not conform to these guidelines. A
middle ethmoidal foramen has been reported.24 The
arteries may also be inconstant, and multiple poste-
d
rior foramina may be found.25, 26
The roof of the ethmoid sinus is continuous with
that of the sphenoid sinus, allowing the surgeon to
follow the bone safely into the sphenoid as noted
above. The medial wall of the optic canal may lie
within the posterior ethmoid air cells.
FIGURE 29–17 Transcranial sphenoethmoidal orbito-
tomy. Visualization of tumors located inferiomedial to the Cottonoids, soaked in a vasoconstricting agent,
optic nerve and in close proximity to the internal carotid placed between the lateral wall of the nose and the
artery is provided by combined frontal cranio-orbitotomy nasal septum protect the septum during creation of
(shaded) and sphenoethmoid orbitotomy (a, c) (see Figs. 29–15 the drainage window after sphenoethmoidectomy,
and 29–16). The approach permits effective soft tissue dissec- and serve as a surgical landmark.
tion within the posterior, inferior apex with minimal traction
on the optic nerve. It can be readily extended to include expo- Lateral Lesions
sure of the internal carotid artery (d). Addition of a pterional
bone flap (b) provides access to the cavernous sinus. There are numerous effective options for exposure of
the lateral orbital apex. Due to the generous operative
Transcranial sphenoethmoidal orbitotomy expands field created by removal of the lateral orbital wall,
the surgical field, allowing a direct view of the infero- extracranial exposures are more often suitable than in
medial apex (Fig. 29–16). This ability to see the poste- the medial apex.27 This is especially true for large
rior and lateral margins of a tumor located in this lesions that extend to the apex from the anterior and
region improves the safety and efficiency of soft tissue central spaces. In such cases, dissection of the tumor is
dissection compared to extracranial methods. It per- begun anteriorly and, as it is laterally displaced, a
mits the surgeon to direct the majority of the force of direct view of the contiguous normal tissue is obtained.
dissection to the lateral tumor margin and away from If the lesion lies in the inferolateral quadrant between
vital normal tissues as the tumor is displaced into the the lateral and inferior rectus muscles, subtotal removal
sinus cavity. Devices that assist soft tissue retraction of the zygoma and lateral maxilla greatly expands the
can be used, and drainage of the operative field is operative area. Viewing angle and the drainage of
excellent. the field via the maxillary sinus are improved by this
extension of the osseous exposure (Fig. 29–10).
Ethmoidectomy Successful exposure of tumors positioned deep
The external ethmoidectomy has been described within the lateral apex, including those with limited
many times and may be reviewed in standard texts of cavernous sinus extension, has been reported via the
sinus surgery. Some general points pertinent to its use lateral approach combined with partial removal of the
in both extracranial and intracrainal exposures of the lateral mass of the greater sphenoidal wing.28, 29 If the
orbit are discussed here. tumor is concealed and extends to or beyond the mid-
The frontoethmoid suture marks the roof of the line, lateral orbitotomy does not allow direct view of the
ethmoid sinus; however, the medial limit of the crib- critically important adjacent normal tissue. Frontal cran-
riform plate may lie on or below this plane and its iotomy provides an alternative approach that improves
location must be determined from preoperative CT. the view of this area, but substantial pressure must be
Beginning the ethmoidectomy at the superior border exerted on adjacent tissue to displace the lesion from
of the lacrimal bone in extracranial procedures allows the orbit to frontal fossa. Two-quadrant exposure can
a direct view of the roof of the ethmoid throughout be obtained by combining the lateral orbitotomy with
the procedure. This improved view permits the frontal craniotomy, the frontozygomatic approach, and
ethmoidectomy to be carried safely to the posterior has been shown to improve the functional outcome of
ethmoid and into the sphenoid if necessary. lesion removal in this area (Fig. 29–18).
CHEN29-451-474.I 3/22/01 2:42 PM Page 465
FIGURE 29–19 Cranio-orbital meningioma.
tumor removal proceeds, an ever-improving view of

normal soft tissues adjacent to the tumor should be
FIGURE 29–18 Frontozygomatic orbitotomy.
obtained. If this is not the case, the osseous exposure
is extended.
Superficial lesions displace normal tissue toward
The operative field created by this method permits
the midline of the orbit. A plane between them is usu-
dissection between the tumor and normal tissue under
ally readily established as the leading edge of the
direct vision. Dissection forces can be directed later-
tumor is maneuvered from the orbit. Deeply posi-
ally or superolaterally away from the optic nerve and
tioned tumors, however, must be reached by dissec-
superior orbital fissure. The operating microscope
tion through normal tissue, preferably in areas devoid
and self-retaining retraction devices can be employed,
of neural structure when possible (e.g., beneath the
and there is ample room for the surgeon and assistant
lateral and medial recti rather than over their supe-
to work efficiently. A pterional bone flap supplements
rior margin).
the fronto-orbital exposure if the lesion occupies both
Techniques that minimize soft tissue trauma dur-
the orbit and the middle cranial fossa (Figs. 29–19 and
ing this phase of the procedure include the use of
29–20).30 If the lesion extends into the lateral orbit from
loupe magnification (4.0µ) and coaxial lighting or an
cavernous sinus, Dolnec’s exposure is used.22
operating microscope. Gentle blunt dissection, precise
Cranio-Orbital and Sino-Orbital Lesions retraction, and tissue protection by the use surgical
patties (cottonoids) are additional means of reducing
Further discussion of exposures designed for tumors
trauma during tumor isolation (Johnson and Johnson,
that enter the orbit from the cavernous or paranasal
Raynham, MA).
sinuses can be found in recent volumes devoted to
skull base surgery.31, 32
SOFT TISSUE TECHNIQUES AND TUMOR

RESECTION METHODS
Successful tumor removal begins with properly
designed bone exposure. This exposure creates an
advantageous operating position for the surgical team
that includes a direct view of both the lesion and vital
contiguous normal tissue (or the immediate area of
such tissue), and adequate room for the performance
of surgical maneuvers. Techniques that promote effi-
cient tumor removal with minimal trauma to normal
tissue are highlighted in this section.
The aim of soft tissue dissection is the gradual dis- FIGURE 29–20 Cranio-orbital tumors extending from
placement of the lesion from the orbit to a contiguous the middle cranial fossa to the lateral orbital compartments
cavity that is created by the excision of bone. As require modified pterional and frontolateral approaches.
CHEN29-451-474.I 3/22/01 2:42 PM Page 466
The orbital adipose tissue conceals both tumor and

vital neural tissue. Its resilience propels it into the sur-
gical field as pressure is applied during dissection.
Control is established by delicate entry into the fat,
initiated with blunt dissectors, such as the Penfield
elevators (numbers 3 and 4), and, as the surgical plane
is developed, cottonoids are inserted to atraumatically
restrain the fat (see below).
As dissection advances, periodic saline irrigation
and suction (applied to cottonoids, not the orbital tis-
sue) helps to identify hemorrhagic points and main-
tain a clear surgical field. Wetfield cautery is delivered
through delicate, insulated bayonet forceps. When the
tumor is reached, it is grasped and gently displaced
from the orbit as counterdirectional forces are ap-plied FIGURE 29–21 Thin-walled cystic tumors may require
to contiguous orbital tissue. Cottonoids are inserted added exposure and/or special dissection methods, as they
into the void that is created between the tumor and are prone to rupture.
the adipose tissue. Blood supply to the tumor is inter-
rupted by first skeletonizing the feeding vessels. Bipo- may have been released. The free wall of the cyst is
lar coagulation is then applied to the vessels close to then resected and the irrigation is repeated. This
the surface of the lesion. This process is continued maneuver creates space for dissection, reducing the
until the tumor is completely isolated from neighbor- area of bone removal required, and permits direct
ing tissue. traction on the remaining wall, resulting in easier
Effective retraction is critical during tumor separation from adjacent orbital tissue.
removal, and must be capable of rapid and repeated
alteration of position. Retraction instruments are OSSEOUS AND SOFT TISSUE
applied to the cottonoids rather than unprotected nor- RECONSTRUCTION
mal tissues. There is no substitute for the four hands of
an experienced surgeon and cosurgeon as a retraction Successful and efficient osseous and soft tissue recon-
system. The retractionist’s role is equal to that of the struction is guided by basic craniofacial tenets. Bone is
surgeon, executing maneuvers that maintain exposure not discarded for the sake of expedience during the
and advance tumor resection by coagulation, suction- exposure phase. Fragmentation of the orbital walls is
ing, and strategic application of countertraction. A avoided whenever possible. Leaving rims and roof or
self-retaining retraction system is a valuable adjunct floor fragments in continuity expedites reconstruction
to this process, and the Budde Halo retractor system by avoiding protracted efforts to restore contour.
(OMI Surgical Products, Cincinnati, OH) provides del- Shaping and positioning miniplates and predrilling
icate retractor blades that are suitable for orbital tis- the bone for subsequent application of these devices
sue. To preserve tissue perfusion, retraction is relaxed during the exposure phase consistently shortens total
when maximum exposure is not required. operating times.
Cystic lesions pose unique technical difficulties dur- When bone must be discarded during exposure,
ing dissection, particularly those containing irritative split calvarial grafts that are shaped to match the orig-
material such as the dermoid and epidermoid (Fig. inal thickness and contour of the area being recon-
29–21). Being thin-walled, they are prone to rupture structed replace it. The use of iliac crest and rib grafts
during dissection and may require more generous is less desirable due to their high rates of reabsorp-
bone exposure to permit optimal view and manipulation. If craniotomy was performed, grafts are readily
tion of the lesion. Adjacent tissues frequently adhere obtained by expanding the ostectomy and removal of
to one of the orbital surfaces of the dermoid cyst, due the inner table from the calvarium. The outer table is
to microfistulization of its contents, and development replaced, restoring skull contour. Following extracra-
of a satisfactory plane of dissection is challenging. nial approaches, suitable grafts are obtained from the
When dense adherence to normal tissues is outer table lateral to the midline and posterior to
encountered, aspiration of the cyst contents may be the hairline. Harvesting of split calvarial grafts
preferable to uncontrolled rupture during attempts to should not be attempted without substantial experi-
isolate it. Aspiration is followed immediately by ence under the supervision of a surgeon who is
irrigation of the entire field to remove material that expert in the technique.
CHEN29-451-474.I 3/22/01 2:42 PM Page 467
Following intracranial approaches the integrity of

EARL... Alloplastic materials such
P
the dural interface between the cranial cavity and the
orbit is established by suture and/or replacement
as acrylic, polyethylene sheeting, and
with autogenous or alloplastic materials if dura was
hydroxyapatite may suffice for reconstruction of resected. To help establish a watertight seal, the dural
the orbital floor if sufficient bone is not available. surface may be coated with fibrin glue (Baxter Health-
These materials may also be chosen for cranial care, Deerfield, IL). Fascia or muscle may also be
reconstruction under similar circumstances. placed over the reconstituted floor of the frontal fossa
to further stimulate formation of a fibrous seal. Inter-
mittent drainage of cerebrospinal fluid (CSF) via a
The principles of orbital floor reconstruction apply lumbar drain is employed in selected cases.
regardless of the material used: the orbital bilge pos- Removal of the roof of the ethmoid and sphenoid
terior to the orbital rim is restored and the upward sinus requires that communication between the cra-
slope and medial cant of the orbital floor is re-created. nium and the nasal cavity be sealed with split calvar-
Two-point fixation by resting the graft or implant on ial grafts, if the original bone is not available. Prior to
the preannular shelf and securing it to the anterior reconstruction of the sinuses, however, sinus drainage
orbital rim by miniplates and/or lag screws assures into the nasal cavity must be established. Diseased or
stability. A smooth surface is placed toward the injured mucosa is removed along with damaged air
orbital tissues. Exposed mesh is avoided because soft cells to provide unobstructed gravity drainage. If the
tissue ingrowth makes repeat dissection difficult and ostia have been damaged, a generous window in
fibrous tissue adherence to the mesh may interfere the lateral nasal wall may be necessary. Middle
with ocular motility. turbinectomy is not recommended because it is an
Several plating systems are currently available important anatomic landmark, and nasal crusting
and none has a clear advantage over the other in often follows its complete removal.
orbital reconstruction. Absorbable systems are attrac- A pericranial flap, harvested from the deep surface
tive because plate removal is obviated when rela- of the bicoronal flap, is placed over the roof of the
tively short-term stability is needed. For this appli- reconstructed sinuses to further isolate the cranium
cation only the BioSorb FX modular system, at pre- from the nasal cavity.33 A fat graft may be placed
sent, offers plates that can be shaped without heat- within the sinus to reduce the risk of pneumo-
ing to adjust contour (Bionix Implants, Blue Bell, PA) cephalus. Bone edges are tightly apposed over the
(Fig. 29–22). frontal sinus when the superior orbital and frontal
bone are replaced to prevent leakage of air into the
cranial cavity. Gaps remaining at the osteotomy sites
may be filled by hydroxyapatite.
If there is concern that postoperative tissue edema
may compress the optic nerve, posterior medial wall
reconstruction may be waived to provide decompres-
sion. Similarly, in the case of benign but unresectable
apical tumors, apical decompression may forestall
further visual loss for several years.
IMAGING
Preoperative Imaging
Computed tomography in both axial and coronal
planes provides adequate information for the preop-
erative planning of orbital tumor exposure. Magnetic
resonance imaging (MRI) is also employed in the eval-
uation of lesions of the optic nerve and of lesions at
the interface of the orbital and cranial cavities. The
absence of bone signal may create false positives and
negatives in this region. MRI is especially valuable in
FIGURE 29–22 Absorbable miniplates are used to delineating tumors of the cavernous sinus, which is
stabilize orbital segments not subject to muscular forces. poorly imaged by CT. A carotid angiogram is obtained
CHEN29-451-474.I 3/22/01 2:42 PM Page 468
if the lesion is thought to be an arteriovenous malfor- steroid dosages (e.g., dexamethasone 10 mg every
mation or if the relationship of the lesion to the carotid 6 hours) and close visual monitoring are continued
artery must be known to plan the exposure (Fig. for 48 hours after surgery and rapidly tapered there-
29–15). If a varix is suspected, its vascular nature may after. As a further precaution against delayed com-
not be demonstrated unless jugular compression is pressive optic neuropathy, postoperative drainage of
performed during the venous phase of the angiogram. the sphenoid and ethmoid sinuses is assured by cre-
ating a window in the lateral nasal wall near the supe-
Intraoperative Imaging rior meatus. These methods have been used in five
Most orbital lesions can be localized by dissection patients with preoperative optic neuropathy due to
during surgery. However, deeply situated cystic an apical neoplasm. Postoperative vision was either
lesions, because of their compressibility, may be diffi- improved or maintained at preoperative levels in all.
cult to isolate. In this rare case intraoperative MRI Transient neuropathy of the extrinsic muscles of
may play a useful role for this purpose if available. the eye is common after intraorbital dissection. The
levator palpabrae superioris is prone to postoperative
dysfunction following even brief retraction. These
COMPLICATIONS occurrences should be presented to the patient as
The potential for morbidity in the surgical manage- expected outcomes of tumor removal from the central
ment of orbital tumors exists because of the close and apical compartments.
proximity of neural tissue and neoplasm, and unpre- Recovery of upper eyelid function may require sev-
dictable anatomic variations. Lesions in the apex and eral months, but no patient has required subsequent
those occupying both the cranial cavity and orbit pose ptosis repair. Extraocular muscle function is typically
the greatest risk of postoperative neurologic deficit. recovered within 6 months, but may take longer. Sur-
The methods described in the preceding pages gical repair should be deferred until the degree of
have been used in the management of 81 orbital ocular deviation is stable for at least 3 months, but not
lesions. Complications to date include transient motor earlier than 6 months unless the muscle has been den-
neuropathy (ten), permanent sensory neuropathy ervated. Nerve grafting may be attempted in such
(five), transient optic neuropathy (two), facial contour cases if a sufficient residual segment of motor nerve
abnormality and/or enophthalmos requiring sec- remains.
ondary repair (three), sinusitis (two), CSF leak (two),
CSF leak requiring repeat craniotomy (one), and ORBITAL EXENTERATION
pneumocephalus (one). Potential complications in-
clude superior orbital fissure syndrome with perma- Invasive lesions arising at the skull base, for which the
nent paralysis of the muscles extrinsic and intrinsic to primary therapy is surgical, may require exenteration
the eye, blindness, meningitis, intracranial hemor- of the orbital contents. Orbital exenteration methods
rhage, and stroke. are described in chapter 25. In this section a method of
Transient optic neuropathy was associated follow- exenteration will be presented that preserves the eye-
ing extracranial removal of a large inferior apical lids, conjunctiva, and lacrimal drainage apparatus.
schwannoma and after intracranial removal of a sphe- If the neoplasm spares the anterior orbit, complete
noorbital fibrous dysplasia. Postoperative edema resection of the involved tissue without sacrifice of
and/or optic nerve traction during dissection was the eyelids is possible. Retention of the lids allows
suspected in both cases. Vision returned to preopera- rehabilitation by a conventional ocular prosthesis and
tive levels following treatment with high-dose corti- subsequent ptosis repair by fascia-lata suspension.
costeroids. This approach may produce an aesthetic result that
Following this experience, the transcranial sphe- exceeds that attained through the use of a silicone
noethmoid orbitotomy was developed for removal of facial prosthesis.
tumors from the medial apical quadrants. The broad This technique may be performed entirely through
operative field enables dissection vectors to be the bicoronal incision during craniotomy. Following
directed toward the midline, minimizing pressure on removal of the abnormal tissue from the posterior
the ophthalmic artery and optic nerve, as previously orbit, the posterior surface of the globe is exposed by
noted. The cavities also provide drainage of fluids blunt dissection. Dissection is then carried to the
during tumor removal, which improves visibility. corneal limbus in the quadrants between the rectus
Intraoperative steroids are employed during muscles. Posterior traction is then placed on the globe
removal of tumors from the orbital apex, and the and the rectus muscles are detached. Ciliary artery
operative field is decompressed if dissection around bleeding is controlled by bipolar cautery. A transtenon
the optic nerve has been prolonged. Relatively large peritomy is performed at the corneal limbus. The
CHEN29-451-474.I 3/22/01 2:42 PM Page 469
levator is transected near the origin of its aponeuro- from the frontalis muscle (Fig. 29–24). If the frontal
sis. The globe is then removed. branch of the facial nerve is dysfunctional, ptosis
If a craniotomy was performed, the orbital rims are repair is deferred until the eyebrow is returned to its
reconstructed after cranial reconstitution and transfer anatomic position. The fascia is fixed to the perios-
of the temporalis muscle to the orbit. The muscle will teum during the subsequent ptosis correction.
only rarely reach the midline. Dividing it into two The foregoing method of eyelid preservation
components with preservation of the deep temporal cannot be used if postoperative adjuvant radiation
artery allows the section contiguous to the orbit to of the orbit is required. The radiation damages the
reach to the medial orbital wall in many cases. conjunctiva, which results in forniceal contracture,
A dermis fat graft may be used to supplement the and a prosthesis cannot be comfortably worn. In
orbital volume provided by the temporalis muscle. A these cases conventional exenteration with preser-
pericranial flap or temporoparietal flap may be placed vation of only eyelid skin and orbicularis muscle is
over the anterior face of the graft, providing an addi- suggested.
tional source of blood supply.34 The volume deficit
created by translocation temporalis muscle is then TREATMENT OF CONGENITAL
reconstructed with an acrylic or polyethylene implant. MICROPHTHALMIA
If temporalis muscle resection is required due to
tumor invasion, a free flap is used to restore orbital Conventional treatment of congenital microph-
and temporal soft tissue volume, followed by osseous thalmia may take many forms, but usually consists
reconstruction (Fig. 29–23). of replacement of the vestigial eye with a fixed vol-
Prosthetic rehabilitation is delayed until soft tissue ume orbital implant that is periodically replaced by
healing is complete, usually 6 to 12 months. Addi- progressively larger implants. Conjunctival conform-
tional supplementation of the orbital tissue volume ers of increasingly larger size are concurrently
may be required. When volume is satisfactory, the applied to the growing conjunctival fornices. This
prosthesis is crafted. process achieves noticeable improvement but is pro-
Reconstruction is completed by ptosis repair, using tracted, and eyelid and facial skeletal growth is dys-
autogenous fascia lata to suspend the upper eyelid morphic in many cases.35
A B
FIGURE 29–23 (A) Following orbital exenteration in the treatment of a recurrent sphenoid wing meningioma the
temporalis muscle was resected. (B) The orbital walls were reconstructed and a gracilis muscle free flap reconstructed
the soft tissue deficits created by posterior orbital exenteration and resection of the temporalis muscle (John Derr
M.D./Joe Banis M.D.). The eyelids, conjunctiva, and lacrimal drainage system were preserved.
CHEN29-451-474.I 3/22/01 2:42 PM Page 470
FIGURE 29–24 Postoperative appearance of the patient

shown in Fig. 29–23 after supplemental orbital dermis fat
graft, fitting of an ocular prosthesis, brow lift, and autoge-
nous fascia lata tarsofrontalis suspension.
The use of a tissue expander in unilateral microph-

thalmia has been shown experimentally and in clinical
practice to induce eyelid, orbital, and contiguous facial FIGURE 29–25 Expansion of the micro-ophthalmic orbit
skeletal growth that closely approaches the normal is achieved by an expander system inserted into the muscle
hemiface. 36 The process is completed over a 10- to cone of the orbit and connected via subtemporalis tunnel to
12-month period and requires two outpatient surgical an infusion port, positioned over the temporoparietal skull.
procedures. (Used with permission, Gossman.37)
Patients with significant facial deformity without
visual potential are candidates for orbital expansion. expander is inserted into the orbit, beginning with
Antibiotic prophylaxis is administered intravenously the silk tie. The suture is guided to the lateral orbital
prior to the procedure. Evisceration is performed osteotomy with a hemostat, passing under the infe-
under general anesthesia and all uveal tissue is rior border of the lateral rectus muscle. The suture
removed. The sclera is divided into four sections that and tubing are withdrawn from the orbit and the
are separated from the optic nerve. A rectus muscle expander is guided to the desired position within
remains attached to each section. the muscle come by tension on the tubing.
An abbreviated lateral canthotomy incision is used The scleral sections are joined over the collapsed
to expose the temporal fascia, which is detached from expander with interrupted 6-0 polydioxanone sutures
the zygoma. The temporalis muscle is separated from (sutures are tied on the anterior scleral surface to pre-
the area of the zygomaticosphenoid suture. A 3.0-mm vent rupture of the expander during inflation) and the
round window is placed in the lateral orbital wall conjunctiva is closed with the same suture. An acrylic
anterior to the suture, to allow the expander’s inflation conformer is shaped to fit snuggly into the conjuncti-
tubing to exit the orbit. val fornices. A complete temporary tarsorrhaphy is
A vertical temporoparietal scalp incision is carried created to allow the subsequent increases in orbital
to the periosteum about 5.0 cm above the ear. The pressure to be transmitted to the eyelids, without
temporalis fascia is separated from the skull at the extrusion of the expander or conformer.37 The infla-
temporal line and a submuscular tunnel is created to tion tubing is guided through the submuscular tun-
the lateral orbit for subsequent passage of the inflation nel and joined to an inflation port. All connections are
tubing (Fig. 29–25). secured with silk ligatures. Residual air and saline are
The integrity of a custom-made expander (PMT, evacuated from the expander and the scalp and can-
Chanhassen, MN) is evaluated by inflating it with thotomy are closed with absorbable suture.
saline. Residual air is evacuated and the precise Inflation of the expander is begun 3 months after
volume of saline required to reach a diameter of placement. The volume of saline to be injected is
22.0 mm is determined. A silk ligature is placed apportioned into 10 to 12 equal fractions that are
around the distal end of the inflation tubing and the injected monthly. The ocularist is involved when the
CHEN29-451-474.I 3/22/01 2:42 PM Page 471
injections are begun. A prosthesis is fashioned when additional eyelid growth is desired, removal of the
the socket will accommodate one of satisfactory size. expander may be deferred and additional saline injec-
The prosthesis is enlarged every 3 to 4 months as tions added empirically.
needed.
Three months after the final injection, the expander
and its pseudocapsule are removed through a con- CONCLUSION
junctival incision. The tubing is removed through the
scalp incision. A hydroxyapatite or other perforated Surgical teams will continue to be challenged during
implant is inserted and is typically 22.0 mm in diam- the treatment of orbital tumors by inherent limitations
eter. The sclera is closed over the implant and the con- of imaging technology, dissection methods, and
junctiva is closed. Prosthesis fitting follows in 4 anatomic variation among individual patients. Mini-
weeks. mally invasive procedures, especially those based on
Ten patients ranging in age from 6.0 months to endoscopic techniques, offer the potential for reduced
6.0 years have been managed by this method without morbidity and quicker postoperative recovery. How-
serious complication. In this group, the preoperative ever, in areas of critical neurovascular structure, safety
eyelid dimension deficit ranged from 12% to 26%, and functional outcome are improved by wide osseous
which was reduced to a range of 0% to 5.0% after exposure that permits rapid shifts in the angle of view,
expansion. The preoperative orbital dimension deficit dissection orientation, and instrumentation. The appro-
range for the group was 8.0% to 25%. The postopera- aches presented in this chapter can be executed effi-
tive the range was 0.5% to 7.3%. The duration of the ciently with low risk by surgical teams possessing
inflation period correlated inversely with the magni- neurosurgical, craniofacial, and ophthalmologic exper-
tude of reduction of the dimension deficit. Inflation tise, and may be combined or modified to suit the
periods of 10 and 12 months produce the best result. If exposure a given lesion may require. (Fig. 29–26).
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CD, ed. Philadelphia: Lea & Febiger, 1985:194. Syst 1997;10:536–541.
10. Williams PL, Warwick R, eds: Gray’s Anatomy, 36th ed. 20. Kennerdell JS, Maroon JC, Celin SE: The posterior infe-
Philadelphia: WB Saunders; 1980:335. rior orbitotomy. Ophthalmic Plast Reconstr Surg 1998;
11. Calceterra TC: Antral-ethmoidal decompression of 4:277–280.
endocrine exophthalmos. Ann Ophthalmol 1971;3: 21. Sethi DS, Lau DP: Endoscopic management of orbital
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CHEN29-451-474.I 3/22/01 2:42 PM Page 472
Location of lesion in orbit
Anterior Central Apex

compartment compartment compartment
Superior Lateral Medial Inferior Medial Lateral

bone removal
extends to
inferior lateral
Lid crease E.L.C. Trans- C.F.I. orbital rim
caruncular
Bicoronal E.L.C. C.F.I.
Superior Supero-
orbital rim lateral Superior Inferior Superior Inferior
(anterior orbital rim
orbitotomy)
1, 2
Frontal Transfrontal Frontal Lateral Inferior

orbital sphenoethmoidal zygomatic orbitotomy lateral
craniotomy orbitotomy craniotomy orbitotomy
(close to
optic nerve)
Superior Inferior
Medial Lateral Medial Lateral
Bicoronal Bicoronal 1 E.L.C. C.F.I. C.F.I.
Frontal Frontal- Fronto- Lateral Infero- Ethmoidectomy Infero- Lateral Infero-

sino-orbitotomy orbital zygomatic orbitotomy medial medial plus orbitotomy lateral
craniotomy craniotomy 2 or orbitotomy lateral orbitotomy
infero-lateral orbitotomy
orbitotomy (combined)
1 When removal of superior orbital rim or frontal bone is indicated.

2 Lesion within muscle cone or an extraconal lesion extending to optic nerve.
E.L.C., extended lateral canthotomy; C.F.I., canthal-fornix incision.
FIGURE 29–26 Craniofacial and neurosurgical approach to the orbit: clinical pathway.
472
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22. Dailey RA, Dierks E, Wilkins J, Wobig JL. LeFort 1 30. Al-Mefty O, Smith RR: Tailoring the cranio-orbital
orbitotomy: a new approach to the inferonasal orbital approach. Keio J Med 1990;39:217–224.
apex. Ophthalmic Plast Reconstr Surg 1998;14:27–31. 31. Donald PJ, ed: Surgery of the Skull Base. Philadelphia:
23. Dolenc VV: Approaches to techniques of surgery Lippincott-Raven, 1998.
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Kobayashi S, eds. Operative Skull Base Surgery. New Base Surgery. New York: Churchill Livingstone, 1997.
York: Churchill Livingstone, 1997:207–236. 33. Fukuta K, Potparic Z, Sugihara T, Rachmiel A, Forte
24. Lyons BM: Surgical anatomy of the skull base. In: Don- RA, Jackson IT: A cadaver investigation of the blood
ald PJ, ed. Surgery of the Skull Base. Philadelphia: Lip- supply of the galeofrontalis flap. Plast Reconstr Surg
pincott-Raven, 1998:19. 1994;94:794–800.
25. Harrison DFN: Surgical approach to the medial orbital 34. Antonyshyn O, Gruss JS, Bist BD: Versatility of tempo-
wall. Ann Otol Rhinol Laryngol 1981;90:415–419. ral muscle and fascial flaps. Br J Plast Surg 1988;41:
26. Whitnall E: The Anatomy of the Human Orbit and 118–121.
Accessory Organs of Vision. Huntington, NY: Kreiger, 35. Gossman MD, Pollock RA: Acute orbital trauma. In:
1979:311. McCord, CD Jr, Tanenbaum M, Nunery W, eds. Oculo-
27. Gierek T, Pilch J, Maizel K, Markowski J: The assess- plastic Surgery. Philadelphia: Raven, 1994:515–551.
ment of the lateral orbitotomy by Kronlein-Reese-Berke 36. Tucker SM, Sapp N, Collin JRO: Orbital expansion of
in surgical treatment of primary non-malignant orbital the congenitally anophthalmic socket. Br J Ophthalmol
tumors. Klin Oczna 1999;101:115–118. 1995;7:667–671.
28. Goldberg RA, Shorr N, Arnold AC, Garcia GH: Deep 37. Gossman MD, Mohay J, Roberts DM: Expansion of the
transorbital approach to the apex and cavernous sinus. human microphthalmic orbit. Ophthalmology 1999;106:
Ophthalmic Plast Reconstr Surg 1998;14:336–341. 2005–2009.
29. Carta F, Siccardi D, Viola C, Maiello M. Removal of 38. Gossman MD, Bowe BE, Tanenbam M: Reversible
tumours of the orbital apex via a postero–lateral suture tarsorrhaphy for eyelid malposition and ker-
orbitotomy. J Neurosurg Sci 1998;42(4):185–188. atopathy. Ophthalmic Surg 1991;4:237–239.
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CHEN30-475-489.I 3/26/01 8:58 AM Page 475
Chapter 30
MANAGEMENT OF ORBITAL INJURIES

Stuart R. Seiff
CONSIDERATIONS IN ORBITAL TRAUMA of choice to more completely evaluate orbital trauma.

Fine-cut CT shows bony anatomy well, in addition to
Ophthalmologists are particularly well suited to man- foreign bodies and soft tissue abnormalities. The
age orbital trauma. Interest and knowledge of ocular sinuses and optic canals are best evaluated by CT as
and orbital anatomy equip them well to deal with well.2, 3 These studies are relatively fast and can be
these injuries. efficiently done on patients with severe injuries.4 Typ-
ically, 1-mm axial cuts through the orbits and sinuses
should be requested. Coronal reformations can be
EARL... It is important to realize
P that patients with orbital injuries have
suffered severe head trauma.
generated off of these axial images quite nicely; how-
ever, it may be more efficient to perform direct coro-
nal imaging if the patient’s condition permits. For
traumatic injuries, contrast is usually not necessary.
Magnetic resonance imaging (MRI) is less useful for
Assessment of the airway and mental status is a the acute evaluation of orbital trauma. Bony detail is
priority. The patient should be evaluated for signs of lost and image sections are generally thicker, with less
neurologic and other bodily injury. The status of the detail than CT. Also, these studies take longer and are
eye itself should be determined, including visual acu- less appropriate for potentially unstable patients. How-
ity, motility, pupillary reactions, visual field, intraoc- ever, wooden foreign bodies and soft tissue changes,
ular pressure, as well as evaluation of the anterior and such as nerve injury, may be best seen with MRI.5, 6
posterior segments of the globe. Finally, an orbital These studies are typically deferred until the patient is
exam should be performed including examination for stable.
lacerations, enophthalmos, canthal dystopia, lid posi-
tion, palpable bony step-offs, and midface stability. PATTERNS OF ORBITAL FRACTURES
As a general rule, patients who have suffered
orbital trauma should be evaluated radiographically. There are several patterns of orbital fractures. These
If there is a low suspicion of a fracture or any signifi- need to be recognized as indications for repair and
cant orbital injury, plain radiographs of the orbit techniques vary.
should suffice. Waters (posteroanterior) and submen-
tovertex views are particularly useful in demonstrat- Le Fort Fractures
ing metallic foreign bodies, sinus opacification, and The maxilla comprises one component of the orbital
orbital rim and zygomatic arch disruption.1 When sig- architecture. Therefore, it is important for the orbit-
nificant head trauma has occurred, large-cut (5-mm) al surgeon to understand the patterns of maxillary
axial computed tomography (CT) is appropriate to fractures. Le Fort determined the areas of structural
help rule out intracranial injury. CT is also the study weakness of the maxilla and this led to the Le Fort
475
CHEN30-475-489.I 3/22/01 2:43 PM Page 476
marks of this fracture pattern. The Le Fort III fracture

is also known as craniofacial disjunction. This is typ-
ified by a fracture extending through the zygomati-
cofacial suture and nasofrontal sutures, across the
floor of the orbit and the pterygoid plate. These frac-
tures are often bilateral and effect a complete bony
separation of the face from the cranium (Fig. 30–2).
EARL ...
Type III
Type II
P These fractures are the
result of significant midface trauma, and
ocular injuries, including ruptured globes, are
not uncommon. The Le Fort fractures, particu-
Type I larly the Le Fort III, can produce free-floating
midface fragments.
The mobility of these can often be demonstrated

with digital manipulation. In Le Fort III fractures,
FIGURE 30–1 Patterns of Le Fort I, II, and III fractures. movement of the midface fragment posteriorly can
compromise the airway, leading to the practice of
prophylactic intubation or tracheostomy in the man-
classification of fractures of the maxilla7 (Fig. 30–1). agement of these cases. Severe hemorrhage can also
These fractures typically occur when blunt trauma is be encountered with these fractures and must be
applied to the middle third of the face. aggressively controlled.
The Le Fort I (transverse or Guerin’s) fracture
occurs above the level of the teeth, coursing inferi- Treatment
orly across the maxilla. This fracture causes minimal Most Le Fort fractures have some degree of instability
disruption of orbital structures. However, the Le Fort and displacement. In such cases, repair is indicated,
II (pyramidal) fracture typically involves the lacrimal which includes reduction of the fracture and fixation.
bone, and the floor of the orbit medially, and extends This can be accomplished through intermaxillary fix-
inferiorly through the zygomaticomaxillary suture ation with arch bars. The use of miniplate fixation of
line and along the lateral wall of the maxilla. Posteri- the orbital and maxillary components is now fre-
orly, this fracture extends through the pterygoid quently appropriate. Many Le Fort fractures require
plate into the pterygomaxillary fossa, one of the hall- emergent intervention for stabilization if the airway
A B
FIGURE 30–2 (A) Patient with bilateral Le Fort III fractures after motorcycle accident. Note the traumatically
induced telecanthus as a result of the fractures. The patient also suffered bilateral anterior corneal scleral lacerations.
He had also undergone an emergency tracheostomy for airway management. (B) Axial computed tomography (CT)
scan demonstrates fractures involving both pterygoid plates (arrows).
CHEN30-475-489.I 3/22/01 2:43 PM Page 477
MANAGEMENT OF ORBITAL INJURIES • 477
A B
FIGURE 30–3 (A) Patient with left zygomatic complex

fracture. Note left lateral canthal inferior displacement and
flattening of the malar eminence. (B) Axial CT scan of right
zygomatic complex fracture. Note discontinuity of right zygo-
matic arch compared to left (arrow). Extensive soft tissue
swelling is present. (C) Axial CT scan of right zygomatic com-
plex fracture. Note the discontinuity of the lateral orbital wall
and rotation of the lateral orbital rim. These reflect the pres-
ence of inferomedial orbital rim and superolateral orbital rim
fractures, permitting the rotation. The soft tissue swelling is
C also present.
is threatened. More definitive repair may be deferred floor, or enophthalmos greater than 2 mm are indica-
for 14 to 21 days. tions for repair.
Zygomatic Fractures
...
Zygomatic complex (trimalar, tripod) fractures
involve fractures of the zygoma at three of its articu-
lations with adjacent bones: medially (typically at the
P EARL Care must be taken in
using Hertel exophthalmometer readings
as the lateral orbital rim serves as a reference
zygomaticomaxillary suture), along the lateral orbital with these instruments, and this is displaced in
rim (typically at the zygomaticofrontal suture), and
most zygomatic complex fractures. Considera-
along the zygomatic arch. These three fracture sites
are necessary for the zygoma to rotate. Posterior dis- tion should be given to using a Naugle exoph-
placement of the fracture fragment may impinge on thalmometer in these cases, which uses the
movement of the mandible, causing difficulty with frontal bone as a reference.8
mastication. These fractures frequently involve the
orbital floor but are not true “blowout” fractures in
terms of etiology. Nonetheless, entrapment of orbital
contents and enophthalmos may occur. Bony step-offs EARL... Prophylactic use of antibi-
along the inferior and lateral rims may be palpable
and there is often inferior displacement of the lateral
canthus (Fig. 30–3).
P otics is currently discouraged in the pre-
operative period as the risk of infection is
relatively low and they may select for highly vir-
Treatment ulent pathogens in the rare case in which infec-
Indications for repair of zygomatic complex fractures tion occurs.
include displacement or instability of the fracture, as
well as difficulty with chewing. When the orbital floor
is involved, diplopia in a functional position of gaze, Timing of repair for zygomatic complex fractures is
a depressed fracture involving more than 50% of the important. Often, findings suggesting the need for
CHEN30-475-489.I 3/22/01 2:43 PM Page 478
FIGURE 30–4 Transconjunctival approach to zygomatic

complex fracture repair is started with a lateral cantholysis FIGURE 30–5 Repair of zygomatic fracture: The fracture
and lysis of the inferior limb of the lateral canthal tendon. fragment is reduced with an elevator behind the lateral
The conjunctiva and lower lid retractors are then opened orbital rim and zygomatic arch. The fragment is mobilized
along the entire length of the lower lid just below the tarsal by lifting, not prying.
margin. Dissection is performed inferiorly in the lower lid
between the orbital septum and orbicularis oculi muscle to point, the zygomatic arch and orbital rims should be
the arcus marginalis. At that point the periosteum is opened aligned. Typically, the inferior rim defects are visible
and dissection is carried superiorly onto the orbital floor.
through the orbital incision. The lateral rim fracture
Orbital structures that have prolapsed into the maxillary
sinus are replaced into the orbit. The inferior component of
frequently occurs at the frontozygomatic suture line.
the fracture is usually visible on the medial orbital rim. This can sometimes be reached via the lateral canthal
incision. If not, a second incision can be made under
the lateral brow. This can be used to approach the lat-
repair, such as diplopia, may spontaneously resolve, eral fracture and provide access to elevate that bony
and other indications may appear (e.g., flattening of fragment. Once proper access to the lateral rim has
the malar eminence or enophthalmos). It is best not to been achieved, an elevator is passed along the lateral
operate during times of maximum edema but prior rim and under the zygomatic arch at its anterior ori-
to the adhesion of displaced bone fragments and scar- gin (Fig. 30–5). Firm anterior pressure, not prying, is
ring of soft tissues into bony defects. Therefore, most applied to the elevator to align the lateral and inferior
surgeons suggest repair between 10 and 21 days. fragments. Once these are positioned, they are fixated
Repair of zygomatic complex fractures has been with miniplates (Figs. 30–6 and 30–7).10 At this point,
described by Gilles and others. Useful modifications the orbital contents are supported as described below
are available.9 The inferior orbital rim and floor can for orbital floor fractures and the wounds are closed.
be exposed via an infraciliary or transconjunctival
approach (described below). Orbital contents should
be elevated out of any floor defects (Fig. 30–4). At this
FIGURE 30–7 The inferior medial component of the

FIGURE 30–6 The lateral component of the fracture is fracture is plated. The orbital contents are then supported
plated in position. by an implant, in this case porous polyethylene.
CHEN30-475-489.I 3/22/01 2:43 PM Page 479
FIGURE 30–9 Coronal CT scan demonstrating left supe-

rior orbital defect as a result of penetrating injury with a
FIGURE 30–8 Coronal CT scan demonstrating right wooden spoon handle. Note intracranial changes along path
superior orbital defect as a result of blunt trauma. Note sug- of foreign body.
gestion of inferior brain herniation on scan, which was
repaired at the time of surgery.
cause severe late sequelae. Blunt frontal trauma can
cause fractures of the orbital roof (Fig. 30–8), but pen-
Orbital Roof Fractures etrating injuries of the orbit can also cause such frac-
Fractures of the orbital roof are often referred to as tures (Fig. 30–9). Radiographs should be used in
orbital roof blowout fractures. This is probably inap- evaluating the patient for possible retained foreign
propriate as orbital contents typically do not move bodies (Fig. 30–10).
outward; to the contrary, bone fragments usually shift
into the orbit. The head injuries that produce roof Treatment
fractures are severe. The physician must evaluate Repair of orbital roof fractures is complex and best
these patients for intracranial involvement both clini- avoided if possible. The fracture itself usually does
cally and radiographically. Injuries to the frontal lobe not need repair but associated problems may need
area can initially have few clinical signs, but may intervention. 11 Bone fragments may impinge on
A B
FIGURE 30–10 (A) Plain radiograph demonstrating intracranial foreign body as the result of a penetrating orbital
injury. (B) Pen tip noted in (A).
CHEN30-475-489.I 3/22/01 2:43 PM Page 480
Apart from CSF leaks and posterior wall frontal

sinus fractures, which may require urgent interven-
tion, it is best to wait 6 to 8 weeks before deciding to
move forward with repair. Many of the early findings
will spontaneously resolve if given adequate healing
time. These fractures normally cannot be approached
through the orbit. The fractures and dural tears often
allow the brain to prolapse into the orbit and it is
extremely difficult to manage this through an orbito-
tomy. A frontal craniotomy has been found to pro-
A vide the best exposure. The frontal lobes are retrac-
ted, allowing removal of bone fragments, repair of
dural defects, repair of sinus fractures, and recon-
struction of the orbital roof, if appropriate. Although
this seems to be an aggressive approach, it actually
provides the best results and, in experienced hands, is
the safest. Nonetheless, postoperative ptosis and
diplopia are common, and frequently require 3 to 6
months to resolve.
Orbital Blowout Fractures

Orbital blowout fractures refer to fractures of the
orbital floor and medial wall wherein the involved
bones expand away from the orbital contents, or
“blow out.” The medial wall may be the most com-
monly involved due to the thin lamina papyracea
along the medial aspect of the orbit.12 However,
symptoms are unusual and these fractures may, in
large degree, go undetected. Entrapment of extraocu-
B lar muscles may occur but this is unusual, possibly
due to the extensive support for the medial wall pro-
FIGURE 30–11 (A) Right orbital roof fracture as the
result of a motorcycle accident causing ptosis and vertical
vided by the baffling of the ethmoid air cells.
diplopia. (B) Reformatted CT demonstrating bone fragment
compression of levator-superior rectus complex.
...
extraocular muscles, producing diplopia or ptosis
P EARL Orbital emphysema poses
a particular risk with these fractures and
has been reported to cause blindness due to cen-
(Fig. 30–11). The fragments may also tear dura, leading
to a cerebrospinal fluid (CSF) leak. This may manifest tral retinal artery occlusion or optic nerve com-
as rhinorrhea (if the leak is into a sinus) or persistent pression.13–16 Patients must be cautioned against
superior conjunctival chemosis. Fractures of the orbital nose blowing for several weeks (Fig. 30–12).
roof can involve the frontal sinus, as well.
Relative increases and decreases of air in the orbit
EARL... Posterior wall frontal sinus
P fractures increase the risk of meningitis,
especially in the presence of dural tears.
have been observed to cause fluctuations of vision for
several days.17 Some patients have been noted to vol-
untarily force air into the orbit through these traumatic
passages for extended periods of time, causing orbital
swelling and vision loss, in an effort to gain medical
Sinus fractures can also lead to late mucocele for- attention or disability. This has been described as an
mation. Interestingly, orbital roof fractures can be ocular form of Munchausen’s syndrome.18, 19
associated with either enophthalmos due to orbital Blowout fractures of the orbital floor are more
volume expansion or pulsatile proptosis related to commonly symptomatic. These fractures may pro-
communication between the anterior cranial fossa and duce anesthesia due to damage to the infraorbital
the orbit. Nonpulsatile proptosis can acutely be nerve, enophthalmos from traumatically induced
related to posttraumatic edema, as well. orbital expansion, and diplopia from entrapment of
CHEN30-475-489.I 3/22/01 2:43 PM Page 481
resolves.27–29 As with zygomatic complex fractures,

repair should be undertaken within 10 to 21 days
after injury.
Multiple surgical approaches have been described
for the repair of orbital floor fractures. A transcuta-
neous approach along the nasojugal line provides the
most direct access to the inferior orbital rim. How-
ever, it can lead to a disfiguring scar. Therefore, the
infraciliary (blepharoplasty) or transconjunctival inci-
sions tend to be preferred as they leave more cosmet-
ically acceptable scars. With the infraciliary approach,
the incision is made approximately 1 mm below the
inferior lash line, extending from the punctum to
the lateral canthus. Dissection is carried out in a plane
between the orbicularis muscle and the orbital sep-
tum, inferiorly to the arcus marginalis, just below the
inferior orbital rim.
FIGURE 30–12 Severe orbital emphysema associated Alternatively, the transconjunctival approach is
with medial orbital blowout fracture. started with a lateral canthotomy and lysis of the infe-
rior limb of the lateral canthal tendon. The incision is
orbital contents. Most frequently, tissues around the made through the conjunctiva and the fusion of the
extraocular muscles become entrapped in the bone lower lid retractors and orbital septum just below
fragments, rather than the muscles themselves.20 the tarsus. This is continued to a point inferior to the
However, when muscles are actually trapped in the lower punctum. Traction sutures are placed in the lid
fragments, ischemia of the muscle may occur, result- margin and in the cut edge of the posterior lamella.
ing in poor inferior rectus function on a long-term This aids with dissection inferiorly between the orbic-
basis.21, 22 ularis muscle and the orbital septum, similarly to the
When diplopia is present with orbital fractures, infraciliary incision.
forced duction testing has historically been advocated At the level of the arcus marginalis, the orbital
to determine the extent of extraocular muscle restric- septum fuses with the periosteum. At this point, the
tion. Unfortunately, this is less useful in the era of periosteum is opened with a blade and elevated off of
orbital CT imaging and can be unreliable. However, the orbital rim. At the edge of the rim, the periorbital
there are anecdotal reports of freeing entrapped tis- elevation is started and continued posteriorly
sues with this technique, resolving the restriction. (Fig. 30–13). The orbital floor fracture is identified,
Intraoperative forced duction testing can be useful in which is typically medial to the infraorbital nerve in
comparing the pre- and postrelease ductions. How- its groove. Care is taken to gently elevate any
ever, these results must be used with caution as entrapped orbital contents out of the defect in a
edema may confound the findings.
The mechanism of injury in orbital blowout fractures
is the subject of some controversy. Smith and Regan23
postulated that increased hydraulic pressure caused by
a blow to the orbital contents caused the orbital walls to
“blow out”. However, Fujino24–26 and others later
showed that a deforming force applied to the orbital
rim could produce similar fractures of the orbital floor
with entrapment of orbital contents without significant
elevation of intraorbital hydraulic pressure.
Treatment
Indications for repair of orbital blowout fractures
include diplopia in a functional field of gaze that per-
sists 7 to 10 days after injury, relative enophthalmos
greater than 2 mm, or a fracture that involves greater FIGURE 30–13 The transconjunctival approach. The
than 50% of the orbital floor, as this is likely to lead to periosteum is opened at the arcus marginalis and elevated
clinically significant enophthalmos when the edema onto the orbital floor.
CHEN30-475-489.I 3/22/01 2:43 PM Page 482
hand-over-hand process, typically using a malleable In this technique, the maxillary sinus is entered, the
retractor and the periosteal elevator. It is sometimes fracture located in the roof of the sinus, orbital con-
necessary to also elevate sinus mucosa as it may have tents pushed superiorly back into the orbit, and the
become adherent to the orbital structures. It is impor- maxillary sinus packed for several days to support
tant to find the posterior extent of the fracture. This the floor in an elevated position. The problems with
may be as far posterior as the posterior wall of the this approach include poor reduction of entrapped
maxillary sinus. orbital contents and unpredictable support of the
orbital structures once the packing is removed. Thus,
this technique is not currently very popular as a
EARL ...
P It is reasonable to work
this far posterior in the orbit but care
must be taken not to put pressure on the orbital
primary form of repair.
However, when orbital floor fracture repair is
delayed, orbital contents may become “stuck” in the
floor and medial wall defects. It can become difficult
apex contents with the end of the retractor. to reduce these scarred tissues back into the orbit
from above alone. Delicate structures may be torn by
pulling them back into the orbit. A dual approach, via
This is likely the cause of vision loss after blowout
the orbit and maxillary sinus, allows the contents to
fracture repair. Once the orbital contents are freed, it
be pushed from below and pulled from above, mini-
is necessary to support them across the floor defect.
mizing tissue trauma.
Many materials have been successfully used over the
Symptomatic medial wall fractures occur most fre-
years, including Supramid, silicone, absorbable mesh,
quently in association with orbital floor fractures.
bone, metal plates, and porous polyethylene (Med-
When a transconjunctival approach to the floor has
por) (Fig. 30–14). The selection of these materials
been used, access to the medial wall can be achieved
depends on the surgeon’s preference and presenta-
by extending this incision to include the caruncle (the
tion of the fracture. Once the implant is placed, the
transconjunctival-transcaruncular approach).30 In this
wound is typically irrigated with an antibiotic solu-
technique, the incision is extended medially through
tion and then the periorbita closed to a periosteal
the inferior conjunctiva and then superiorly through the
edge. With the infraciliary incision, the skin wound is
caruncle. Dissection through soft tissue is then
closed in one layer, similar to a blepharoplasty. For
directed medially toward the medial orbital wall just
the transconjunctival approach, the conjunctiva is
posterior to the lacrimal sac. The space between the
closed with a 6-0 plain gut suture in running fashion.
periorbita and medial wall is then entered and peri-
The lateral canthal angle is reformed with a 5-0
orbita elevation performed to join the dissection space
polyglactin suture to the superior limb of the lateral
established during the floor exploration. Entrapped
canthal tendon and skin sutures are used to close the
medial tissues are released and then a floor–medial
canthotomy.
wall implant is placed for support as described above.
The transantral approach to orbital floor repair has
In these cases, an implant should be chosen that can
been used as a primary surgical approach in the past.
be molded to include the curvature between the floor
and wall, such as a metal orbital plate or polyethyl-
ene (Medpor). Medpor can be heated gently in warm
saline and then curved to the proper shape. These
implants will usually remain stable without fixation;
however, they can be secured with screws or cyano-
acryate glue when necessary.31
When surgical approaches other than the transcon-
junctival are used to explore the orbital floor, the
medial orbit can be accessed via a Lynch incision. If
isolated symptomatic medial wall fractures are pre-
sent, these can be approached by a Lynch incision or
the transcaruncular technique described above.
Posterior Orbital Floor Fractures

FIGURE 30–14 The transconjunctival approach. The Orbital floor blowout fractures typically present with
periorbita is elevated and entrapped orbital contents freed a restrictive hypotropia on the affected side. How-
across the orbital floor. Implant material is placed over the ever, a subgroup of patients exhibit a hypertropia.
fracture site to support the orbital contents. This was originally postulated to be due to orbital
CHEN30-475-489.I 3/22/01 2:43 PM Page 483
roof fractures or paralysis of the inferior rectus mus- seems resonable to treat only those patients who
cle. However, Cole and Smith32 and Harley33 develop symptoms with highly successful dacryocys-
described this hypertropia in patients with orbital torhinostomies, rather than place tubes in the 75% of
floor fractures posterior to the equator of the globe. patients who won’t need them.
Seiff and Good34 found that these patients had a char-
acteristic looping of the inferior rectus into the COMPLICATIONS OF ORBITAL
fracture defect. This was best demonstrated on
oblique- sagittal CT reformations along the axis of the
FRACTURE REPAIR
inferior rectus muscle. The floor fractures were typi- The most feared complications of orbital fracture
cally depressed, extending to the posterior wall of the repair are blindness and anesthetic complications.
maxillary sinus. The inferior rectus looped inferiorly Clearly, patients should receive proper preoperative
and then rose to contact the globe at a steep angle. It anesthesia evaluation and the benefits of surgery/
was postulated that the hypertropia was caused by anesthesia weighed against the risks.
the inferior rectus catching on the posterior fracture
edge or an effective weakening of the muscle by a
steepening of the muscle’s angle of contact with the
globe (Fig. 30–15). These patients require elevation of PITFALL
the orbital contents to the posterior extent of the frac-
ture and bridging of the floor defect with an implant. Blindness is probably related to intraopera-
The motility abnormality typically begins to improve tive retraction of the globe or pressure on the
after surgery. optic nerve, resulting in ischemic injury.
Midface Fractures and Lacrimal Obstruction

Midface fractures can often involve the lacrimal out- Postoperative hematoma formation can also poten-
flow system. Most typically this occurs with Le Fort II tially cause blindness, either through a central retinal
and III fractures, as well as zygomatic complex frac- artery occlusion or ischemic optic neuropathy.
tures involving the inferomedial orbit. As many as Clearly, care should be exercised in retraction during
25% of patients with these fractures may develop surgery and the pupil should be monitored for signs
symptomatic lacrimal obstruction.35 Some authors of ischemia. There can be a tendency to “toe-in” with
have advocated prophylactic lacrimal intubation with the retractor when working posteriorly in the orbit.
silicone tubes in all such cases, but the efficacy of this This must be avoided as it can place pressure on the
has not been determined.36 On the other hand, it optic nerve. Postoperatively, the patient should
receive ice compresses and careful monitoring of
vision, rather than patching. If a hematoma forms
with vision compromise, evacuation of the hematoma
is indicated.
Additional complications include persistence or
worsening of preoperative conditions such as
diplopia, enophthalmos, malocclusion of the jaw, and
facial anesthesia. Attention to details of releasing
entrapped tissues and proper support of the globe
will minimize these problems. Infection and extrusion
of implanted materials are of concern in the manage-
ment of these fractures. Clearly, good sterile tech-
nique and intraoperative irrigation with antibiotic
solutions greatly aid in preventing postoperative
infection. However, care should always be exercised
in placing foreign materials in chronic contact with
the sinuses. Frequently, these become colonized
with bacteria and may become frankly infected over
time. Such infections are not uncommon after 5 to 10
FIGURE 30–15 In the posterior blowout fracture, the years and usually require removal of the implant.
inferior rectus muscle descends over the posterior fracture They do not always need replacement as sufficient
edge into the defect and then rises to contact the globe at a fibrosis is typically present to support the orbital
steeper than normal angle. structures. Implants often begin to migrate and
CHEN30-475-489.I 3/22/01 2:43 PM Page 484
FIGURE 30–17 CT demonstrating posttraumatic ocular

FIGURE 30–16 CT demonstrating orbital hematoma.
“tenting” of the right eye resulting from increased intraor-
extrude in the presence of such infections. Migration bital pressure.
of implants can also occur if not properly secured.
ORBITAL HEMATOMA When vision is compromised, immediate interven-

tion is needed. A lateral canthotomy with lateral can-
Orbital hematomas can occur in the setting of blunt thal tendon lysis should be performed in the
or penetrating trauma (Fig. 30–16). These hematomas emergency room.40 The patient should also be given
may occur rapidly or evolve over time. It seems that intravenous acetazolamide (500 mg) and mannitol
the more rapid the hemorrhage, the more likely it is to (0.5 gkg). These are effective in decreasing the
become vision threatening. It is unclear whether the intraocular pressure. They can be repeated after 10
vision loss is due to poor vascular perfusion of the minutes if there is not an adequate response. There is
optic nerve or retina, or both, or due to compression little role for paracentesis in these cases. However, if
of the nerve caused by increased intraorbital pres- vision does not begin to return, surgical decompres-
sure.21 Certainly, intraocular pressures in excess of sion of the orbit may need to be considered. Subpe-
80 mm Hg, compromising retinal blood flow, have riosteal hematoma has been reported to cause vision
been recorded in such cases by Schiøtz tonometry. loss. Surgical evacuation of such hemorrhages may be
The blood supply to the optic nerve itself is also likely appropriate.41
at risk in such cases.37
Early recognition of orbital hemorrhage is impor- PENETRATING ORBITAL TRAUMA
tant. These patients typically have severe proptosis,
ecchymosis, and subconjunctival hemorrhage. As The proper evaluation of penetrating orbital injuries
mentioned, intraocular pressure may be elevated to often depends on the patient history.
extremely high levels and the patient may complain
of decreased or “gray” vision. An afferent pupil defect
may be present.
PITFALL
EARL... The extreme proptosis can
P place the optic nerve on stretch. This can
be demonstrated on CT scan when the poste-
Entry-exit wounds can be misleading as to
the nature and extent of these injuries.
rior sclera forms an angle approaching 90

degrees. This has been termed ocular “tent- General trauma assessment is required for these
ing”. 38, 39 Vision is usually threatened in such patients given the possibility of intracranial involve-
cases (Fig. 30–17). ment and other injuries. Once the patient is stable, the
eye itself should be examined for injury, particularly
CHEN30-475-489.I 3/22/01 2:43 PM Page 485
corneal-scleral rupture, and managed appropriately. extremely important. Very low velocity objects, such
Then the orbit should be examined to assess the as BB’s, pose significant risk to the globe and optic
nature of the injury, evidence of entry or exit nerve, but do not usually cause severe injury to other
wounds, and the severity of any orbital hematoma orbital or adjacent structures.
that may be present.
Imaging techniques are critical to the management
of penetrating orbital injuries. Although plain skull
...
films are often obtained first and can provide useful
information, the study of choice is CT (Fig. 30–18).
Occassionally, MRI is needed in follow-up to localize
P EARL Conversely, the shock
wave of high-velocity bullets causes exten-
sive tissue damage remote from the actual path
a presumed foreign body of vegetable material. of the missile.
...
P EARL Orbital ultrasound has
proven useful in several cases where it was
difficult to determine if a foreign body had
This can be devastating for orbital and adjacent
structures.
The globe can be ruptured by direct passage of a
missile and this needs to be managed in the standard
become lodged in the sclera.
fashion. However, a high-velocity missile can propel
an intact globe anteriorly in an explosive fashion,
stripping the extraocular muscles from their inser-
Sharp trauma, as from knife wounds, can be par- tions. This can lead to an anterior ischemic syndrome
ticularly devastating to the orbital contents. Extraoc- several days after the injury. Injuries to the cranial
ular muscles, the optic nerve, and the globe itself are nerves, including the optic nerve, and extraocular
often damaged in the object’s path. These patients muscles are common. The passage of a bullet close to
clearly need radiographic evaluation as the injury the globe can also cause scoloptera retinae and como-
may involve structures adjacent to the orbit. Occa- tio retinae. Choroidal hemorrages and subsequent
sionally, we also find that pieces of the penetrating retinal detachments have been seen, and these
object may have been left behind. Unfortunately, patients need careful monitoring.
there is little to offer in the way of therapy beyond Unfortunately, little can be done to repair the
control of hemorrhage and general support. orbital damage. Orbital foreign bodies should typi-
Projectile penetration of the orbit frequently causes cally be left in place; removal is more likely to cause
damage to adjacent structures, making imaging damage than the retained foreign body itself.
A B
FIGURE 30–18 (A) Gunshot entry wound in the right temple. (B) Plain radiograph demonstrating bullet frag-
ments. CT scans were also performed.
CHEN30-475-489.I 3/22/01 2:43 PM Page 486
A B
FIGURE 30–19 (A) CT scan demonstrating pellet in right lateral rectus muscle. (B) Surgical removal of pellet.
(ischemia) or reversed (compression) with therapy. The

...
P EARL However, if the orbital for- literature suggest that between 25 and 35% have some
spontaneous improvement in vision.44–46
eign body is affecting function, such as
Data from previous uncontrolled studies suggest
within an extraocular muscle, or causing com- that high-dose corticosteroids46, 47 or surgical decom-
pression, consideration should be given to pression of the optic canal may improve the outcome
removal (Fig. 30–19). in selected cases.48–51
Recently, the International Optic Nerve Trauma
Study looked at the outcomes in 133 patients with
indirect traumatic optic neuropathy. Visual acuity
TRAUMATIC OPTIC NEUROPATHY increased by three or more lines in 57% of the
untreated patients, 52% of those treated with steroids,
Traumatic optic neuropathy can be caused by a direct and 32% of patients receiving optic canal decompres-
or indirect injury to the optic nerve. Direct injuries sion. Patients with no light perception also regained
typically arise from devastating penetrating orbital vision in many cases. The number of patients studied
trauma as described above. Unfortunately, little can was sufficient to rule out major effects in the treat-
be done for a transected optic nerve. ment groups; thus, no treatment has emerged as a
Indirect injury to the optic nerve typically occurs reasonable option for all patients with this condition.
in the setting of blunt frontal trauma. An afferent
pupil defect will be present with or without signifi-
EARL... It is reasonable to decide
cant vision loss.
P to treat, or not treat, traumatic optic neu-
ropathy on an individual patient basis.52
EARL... Fractures of the optic canal
P or adjacent bones are not necessary to
make the diagnosis, but may be present. Currently, intravenous methylprednisolone is a
recommended therapy, similar to that used in the
treatment of acute spinal cord injuries.53 A loading
Studies show that the energy resulting from a frontal dose of 30 mgkg is administered as soon after the
blow is focused at the orbital apex where it is absorbed injury as possible. Then, 5.4 mgkg is given each hour
by the optic nerve tissue.42 The exact mechanism of over the next 24 hours. If there is no visual improve-
injury to the nerve in any given case may be unclear. ment at that point, the methylprednisolone is
However, compression (via edema or bone fragments) stopped. If there has been improvement, the steroids
and ischemia may play a role. Instances of “contusion are continued for another 24 hours (48 hours total)
necrosis,” or crushed nerve, have been documented.43 and then stopped (Fig. 30–20).
Many such cases will not regain vision regardless of Surgical decompression of the optic canal is rec-
treatment. Others may have damage either limited ommended by some, although this and the preferred
CHEN30-475-489.I 3/22/01 2:43 PM Page 487
Blunt frontal trauma
Vision loss c/w optic nerve injury
CT imaging
No treatment Megadose methylprednisolone

Load 30 mg/kg IV
5.4 mg/kg IV q h x 24 h
Follow natural history
If no improvement If improvement
in 24 h in 24 h
Stop Continue
corticosteroids corticosteroids
to 48 h
No additional Consider surgical decompression No

treatment (if improvement not adequate) additional
from 1 to 7 days post injury* treatment
(if improvement
Consider risk benefit ratio adequate)
Decompress optic Decompress anterior Decompress intracranial

canal for edema canal for compression compression
Transorbital, trans-sinus Transcranial

approach approach
* In unusual circumstances of obvious compression of the optic nerve and failing vision,
urgent decompression may be appropriate under corticosteroid coverage.
FIGURE 30–20 Clinical pathway for the management of indirect traumatic optic neuropathy.
surgical approach remain controversial. In cases of in such cases.43 This has not been found to be true in
intracranial bone fragment compression, a transcra- more recent series46, 52
nial approach is likely to be most effective. In cases
where an intraorbital or intracanalicular bone frag- CONCLUSION
ment is noted, an anterior approach through the orbit,
ethmoids, and sphenoid sinuses is preferred. Simi- The management of orbital injuries continues to pose
larly, when no fragment is seen, but the goal of the challenges to ophthalmologists as well as orbital sur-
procedure is to relieve possible compression within geons. A meticulous understanding of orbital ana-
the canal, an anterior approach is suggested by most tomy and its variations, up-to-date knowledge of
authors.48, 54, 55 pathophysiologic mechanisms of injury to soft tissues,
Earlier studies had indicated that a delay in vision bone, and nerves, and a competent surgical skill level
loss after the injury may be a good prognostic sign, need to be combined in the evaluation and treatment
suggesting that intervention may be more successful of these patients with head and orbital trauma.
CHEN30-475-489.I 3/22/01 2:43 PM Page 488
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Index. 3/26/01 10:18 AM Page 490
Index
Page numbers followed by f and t represent figures and tables respectively
Abducens nerve, in orbital anatomy, 13 Anterior orbital compartment surgery, Bell’s palsy, facial reanimation surgery in,
Absorbable sutures, 27t 457–458, 457f–458f 110, 110f–111f
Accessory lacrimal glands, 16 Antibiotics, topical, laser skin resurfacing Benign essential blepharospasm. See
Accutane (isotretinoin), laser skin and, 184 Essential blepharospasm
resurfacing and, 184 Antivirals, laser skin resurfacing and, 201 Benign Essential Blepharospasm Research
Acne, after laser skin resurfacing, 191 oral forms, 185 Foundation (BEBRF), 119
Acquired immunodeficiency syndrome, topical preparations, 184 Bicoronal incision, in orbital lesion
Kaposi sarcoma of eyelid in, 239, Apex, orbital, 9–10, 10f surgery, 454–455, 454f, 455f
239f surgery involving, 462–465, 462f–465f Bio-eye system, 339
Acquired myopathies, ptosis in patients Apraxia of eyelid opening, 116 Biomaterials, in oculoplastic surgery,
with, 91 Artificial tears, in facial nerve paralysis 38–39, 39f
Acrochordon, periocular, 227 management, 106 Bleaching agents, laser skin resurfacing
Actinic damage, evaluation of, 198–199 Asepsis, 24 and, 185
Actinic keratoses, periocular, 233–234, Asian blepharoplasty Bleeding, after laser blepharoplasty, 174
234f complications of, 221–223, 222f, 223f Blepharophimosis, in children
Adenomas, periocular debulking of eyelid tissues in, 218–220, ptosis in, 91
pleomorphic, 231 218f, 219f treatment of, 98–99, 98f, 99f
sebaceous, 231 defined, 214 Blepharoplasty
Adnexal tumors, periocular, 230–231, described, 214–215 in Asian patients. See Asian
230f–231f in elderly patients, 220, 220f, 221f blepharoplasty
Aesthetics, thyroid ophthalmopathy and. suboptimal results from, 221–223, 222f, ectropion after, 63–64, 63f
See Orbital decompression 223f laser. See Laser blepharoplasty
AIDS patients, Kaposi sarcoma of eyelid technique of, 215–218, 215f–218f laser facial resurfacing after, 200, 200f
in, 239, 239f Asian patients lower eyelid. See Lower eyelid
Alloplastic implants, in orbital rim blepharoplasty procedure in. See Asian blepharoplasty
reconstruction, 38, 39f, 438–440, blepharoplasty upper eyelid. See Upper eyelid
439f–440f upper eyelid anatomy in, 211, 212f, blepharoplasty
Alveolar soft-part sarcoma, pediatric, 408 213–214, 213f–214f Westernizing, 213
Anesthesia, 23–24 Autogenous fascia lata suspension, for Blepharospasm, benign essential. See
for enucleation, 331 ptosis, 83, 83f Essential blepharospasm
for evisceration, 347–348 Autogenous materials Blepharospasm-oromandibular dystonia,
for laser skin resurfacing, 187 for grafts, 34 113, 116
Animation, muscles of, 126, 127f, 128, use in enucleation technique, 336, 337 Blink activity, control center for, 118
128f. See also Facial reanimation Autologous fascia, for ptosis, 38 Blowout fractures, orbital, 480–482,
Anlage tumor, retinal pediatric, 407–408 Axial proptosis, in orbital disease 481f–482f
Anophthalmic socket evaluation, 387 Blue nevus, periocular, 229
clinical pathway for evaluation and Azithromycin (Zithromax), laser skin Bone
treatment of, 384f resurfacing and, 184–185 orbital, 387
congenital, 382–383 surgical repair of, 435–442. See also
implants in. See Ocular implants, for Orbital lesion surgery, osseous
anophthalmic socket Balloon dacryocystoplasty, 272–274 exposure in
orbital volume and. See Orbital volume, for nasolacrimal stenosis, 275–276 tumors of, 401–402, 402f
inadequate Basal cell carcinoma, periocular, 235–236, Bone grafting, 38
ptosis in patients with, 91 235f–236f in orbital rim reconstruction,
surgical goals in, 369 Beam focus, in laser blepharoplasty, 166 439–440
490
Index. 3/22/01 2:46 PM Page 491
INDEX • 491
BoneSource cement, in orbital rim Children Corrugator muscle

reconstruction, 437 alveolar soft-part sarcoma in, 408 in eyebrow anatomy, 128, 128f
Bone substitutes, in orbital rim blepharophimosis in, 91, 98–99, 98f, 99f resection, in endoscopic assisted
reconstruction, 436–438 ectopic brain in, 404 eyebrow forehead lift, 131–133, 134f
Bony orbit expansion, for congenital encephalocele in, 404, 404f Cosmetic zones, in laser skin resurfacing,
ophthalmia, 382–383 intravascular papillary endothelial 188, 188f
Botulinum toxin (Botox) hyperplasia in, 404 Cranial nerves
for essential blepharospasm, 120–121, optic nerve glioma in, 391 in facial nerve paralysis, 103–104, 104f
121f orbital disease in, 387 in orbital anatomy, 13
versus surgical management, 121–122, extraconal, 401–402, 402f Cranioplastic implant, for orbital rim
122f orbital tumors in, 403–407, 403f–407f reconstruction, 438–439, 439f–440f
prior to laser facial resurfacing, 200–201, ptosis in, surgical options for, 90–91, 91f Creutzfeldt-Jakob disease, blepharospasm
201f retinal anlage tumor in, 407–408 in, 115
Brow. See Eyebrow with retinoblastoma, modified Cryotherapy
Brown-Beard split-level grafting, in upper enucleation technique for, 338 for distichiasis, 73
eyelid reconstruction, 255–256, 255f tumor imaging in, 405–406, 406f–407f for trichiasis, 70
Browplasty, 141–143, 142f–144f Cicatricial ectropion, 62–63, 63f Cutler-Beard bridge flap, in upper eyelid
Browpexy, internal, 125, 129–130, Cicatricial entropion, 43 reconstruction, 252, 253f
129f–130f surgical management of, 48–51, 49f–51f Cysts
Brueghel’s syndrome, 113f, 116 Ciliary muscle, parasympathetic nerve conjunctival, in anophthalmic socket,
supply to, 14 381
Ciprofloxacin (Cipro), laser skin periocular, 231–232
Calcification resurfacing and, 184
epitheliomas of Malherbe and, 230–231, Classic incision, in lateral orbitotomy,
231f 433–434 Dacryocystectomy, 285–286
localized dystrophic periocular, 233 Composite graft, in upper eyelid Dacryocystitis, 285
orbital and intraocular, 389–390 reconstruction, 252, 254–255, 254f Dacryocystography, digitally subtracted,
Caldwell-Luc maxillary antrostomy, for Computed tomography. See Imaging 268, 269f
thyroid ophthalmopathy, 321, 321f studies Dacryocystoplasty, balloon. See Balloon
Canalicular obstruction, 280–282, 281f–282f Computer pattern sequence, in laser facial dacryocystoplasty
Canaliculitis, 285 resurfacing, 203–204, 204f Dacryocystorhinostomy
Canaliculodacryocystorhinostomy, Congenital anophthalmia, 382–383 canalicular, 280–281, 281f
280–281, 281f Congenital ectropion, 64 conjunctival, 281–282, 281f–283f
Candida infections, after laser skin Congenital entropion, 42 for nasolacrimal duct obstruction
resurfacing, 191 Congenital orbital anomalies, 407–408 complete, 276–280, 276f–278f, 280f
Canthal ligaments, 3 microphthalmia, treatment of, 469–471, congenital, 274
Canthofornix incision, in orbital surgery, 470f Dacryoscintigraphy, 268, 268f
456–457, 456f Conjunctival cysts, in anophthalmic Debris, from laser skin resurfacing, 181,
Canthoplasty, for facial nerve paralysis socket, 381 181f, 182, 202
lateral, 106–107, 107f Conjunctival dacryocystorhinostomy, Debulking, of upper eyelid
medial, 107 281–282, 281f–283f in Asian blepharoplasty, 218–220, 218f,
Canthus Conjunctival fornix 219f
lateral. See Lateral canthal entries in anophthalmic socket, 377–380 in upper lid blepharoplasty, 140–141,
medial. See Medial canthal entries in enucleation, 334–335, 334f–335f 140f–141f
Carbon dioxide (CO2) laser, for facial resection, 360–361, 361f Deep temporal fascia, in eyebrow
resurfacing, 195–196 transcaruncular or medial incision anatomy, 126, 127f, 128f
Carcinoma, periocular in anterior orbitotomy, 426–427 De Gaper (painting by Brueghel), 113f
basal cell, 235–236, 235f–236f in combined lateral/medial Dehiscence
eyelid reconstruction and. See Full- orbitotomy, 447 of levator palpebrae superioris, 4, 4f
thickness eyelid reconstruction Conjunctival incision, in anterior of lower eyelid retractors, 60–62
Kaposi sarcoma, 239, 239f orbitotomy, 423–426, 425f Dependent drainage, in deep orbital
malignant melanoma, 236–238, 237f Conjunctival lacerations, repair surgery, 445
Merkel cell, 238–239, 239f techniques, 282–285, 284f Derma K dual mode laser, for facial
sebaceous, 238, 238f Conjunctival prolapse, as ptosis surgery resurfacing, 196–197, 208f
small cell, 238–239, 239f complication, 100 Dermatochalasis, 41
squamous cell, 236, 237f Conjunctivitis, giant papillary, in in elderly Asian blepharoplasty
Carotid arteries, 6 anophthalmic socket, 381 candidates, 220, 220f
Cartilage grafts, 37–38 Conjunctivorhinostomy, 281f, 286 Dermis, laser skin resurfacing and, 179,
in enucleation technique, 337 Contraction, in wound healing process, 180f
Cast placement, in correction of lower 23, 23f Dermis-fat grafts, 38
eyelid retraction, 162, 162f–163f Cornea autogenous, use in enucleation
Cataract, blepharospasm and, 117 in evisceration technique, 336
Cellulitis, after laser skin resurfacing, 191 excision. See Corneal excision for extruded implant in anophthalmic
Central orbital compartment surgery, sparing procedures, 348–350, socket, 377
458–462, 459f–462f 348f–351f for reconstruction after exenteration,
Cerebrospinal fluid leaks, 8 laser injury to, 173–174, 174f 365
Chalazion, periocular, 232, 233f Corneal abrasions, as ptosis surgery Dermoid cysts
Cheek defect, and eyelid reconstructive complication, 100 pediatric orbital, 403–404, 403f
technique, 258, 259f Corneal excision, in evisceration periocular, 231–232
Cheek elevation, in correction of lower procedure Digitally subtracted dacryocystography,
eyelid retraction, 159–160, 160f posterior equatorial sclerotomy, 351–352 268, 269f
Chemomyectomy, for essential posterior implant placement and, 352 Diplopia
blepharospasm, 123–124 relaxing scleral cuts, 350–351, 352f following orbital decompression, 324–325
Index. 3/22/01 2:46 PM Page 492
492 • INDEX
Diplopia (continued) as complication of surgical repair, Ethmoidectomy, 464

thyroid-related strabismus and, 297 51–52, 52f pitfalls in, 15
torsional, before and after strabismus conditions mimicking, 41 Ethmoid sinuses, anatomy of, 15, 15f, 453
surgery, 303 congenital, 42 Eversion
Direct closure evaluation of, 43–44 eyelid. See Ectropion
for eyelid defect repair, 244–245, 245f eyelid anatomy and, 41, 42t punctal, 59–60
for lateral canthal repair, 257, 258f involutional. See Involutional entropion Evisceration
Direct eyebrow lift, 125, 135–137, 137f marginal, 68–69, 68f–69f clinical pathway for, 353f
Direct incision, in anterior orbitotomy, medical management of, 44 contraindications for, 328–329
421, 421f pathophysiology of, 42–43, 43t described, 347
Dissection, in deep orbital surgery, 442–443 recurrence of, 51–52, 52f hydroxyapatite implant at time of,
Distichiasis, 41, 68, 68f spastic, 43 349–350, 351
treatment of, 71–73 surgical management of, 44–51, 45f–49f, indications for, 327–328, 347
Distraction test, in lower eyelid 51f postoperative care in, 352–353
evaluation, 150 clinical pathway for, 53f preoperative preparations for, 347–348
Divided nevus, of eyelid, 229, 229f Enucleation surgical steps in, 348–349, 348f–349f
Double convexity deformity, lower eyelid, anatomy of, 330–331 and sympathetic ophthalmia risk, 328
149, 149f in children with retinoblastoma, Ewing’s sarcoma, metastatic, 408
Double vision, thyroid-related strabismus modified technique for, 338 Excretory system, lacrimal gland, 16–17,
and, 297 clinical pathway for, 343f 17f
Downgaze, exotropia in, 303 with conjunctival fornix resection, Exenteration
Drainage, in deep orbital surgery, 444–445 360–361, 361f anatomy and, 357, 357f
Drugs, blepharospasm associated with, contraindications for, 328–329 clinical pathway for, 361f
117 described, 327 complications of, 362–364, 363f–364f
Dye disappearance test, 266 implants and. See Orbital implants described, 355
Dysthyroid compressive optic indications for, 327–328 and enucleation with conjunctival
neuropathy, 305–312 materials for, 329 fornix resection, 360–361, 361f
clinical pathway for, 312f with myoconjunctival attachments, indications for, 355–356, 355f, 356t
Dystonia, 113, 116 331–336, 332f–337f in orbital surgery, 468–469, 469f, 470f
physiology of, 331 postoperative care in, 361–362,
preoperative preparation for, 329–331, 362f–363f
Ear cartilage, autogenous, use in 329f–330f preoperative preparation for, 356–357
enucleation technique, 337 principles of, 331 reconstructive techniques following, 365
Ectopic brain, in children, 404 with socket ablation, indications for, 356t rehabilitation following, 364
Ectropion and sympathetic ophthalmia risk, 328 clinical pathway for, 366f
after entropion repair, 52, 52f techniques of, 329 subtotal, 359–360, 360f
after laser skin resurfacing, 189, 189f, future directions, 341–342 techniques of, 357–361, 358f–361f
193 modified, in pediatric retinoblastoma, total, 357–359, 358f–359f
after lower eyelid blepharoplasty, 156 338 wound coverage in, 360
laser technique for, 175 variations, 336–338 Exophthalmos, treatment options for, 325f
cicatricial, 62–63, 63f Epiblepharon, 41, 42, 67, 68f Exotropia in downgaze, after strabismus
congenital, 64 treatment of, 71–73, 72f–73f surgery, 303
disinsertion of lower eyelid retractors Epicanthal folds, 41 Extended lateral canthotomy, in orbital
causing, 60–62 Epidermal inclusion cyst, periocular, 231, lesion surgery, 455–456
horizontal eyelid laxity causing, 55–58 232f Extended Lynch incision, in combined
management of, 65f Epidermis, in laser skin resurfacing, 179, lateral/medial orbitotomy, 446–447
medial canthal tendon laxity causing, 180f External tarso-aponeurectomy of McCord,
58–59, 58f–59f desiccated debris from, 181, 181f 85–87, 86f, 87f
paralytic, 64 Epilation, for trichiasis, 70 Extraocular muscle enlargement, orbital
postblepharoplasty, 63–64, 63f Epileptic seizures, blepharospasm disease with, 400–401, 400f–401f
punctal, 16 associated with, 117 Extraocular muscles, 15
treatment of, 274, 275f Epiphora. See Tearing Eyeball, removal of. See Enucleation
punctal eversion with, 59–60, 59f–60f Epithelial breakdown, as exenteration Eye-bank sclera, 337–338
Elderly patients, Asian blepharoplasty in, complication, 364, 364f Eyebrow
220, 220f, 221f Epithelial tumors, periocular, 227–228, age-associated changes, 128, 129f
Electrolysis, for trichiasis, 70 227f procedures suitable for, 141–143,
Electromyography, in blepharospasm Erbium:YAG laser, for facial resurfacing, 142f–143f
differential diagnosis, 116 196 anatomy of, 1, 2, 4f, 125–126, 127f–128f,
Embarc, for orbital rim reconstruction, 437 Erythema, after laser skin resurfacing, 128
Emphysema, orbital, 480, 481f 192–193, 192f, 197, 197f, 206 in frontalis suspension for ptosis
Encephalitis, 116 Essential blepharospasm, 114 correction, 97
Encephalocele, in children, 404, 404f defined, 113, 115 procedures involving, 129–137. See also
Endoscopic procedures differential diagnosis of, 115–117, 115t individual procedures
eyebrow forehead lift, 125, 130–133, etiology of, 117–119 decision tree for, 145f
131f–135f, 135 evaluation of, 114–115 in females, versus males, 143–144, 145f
laser-assisted dacryocystorhinostomy, historical perspective on, 113–114, 113f lateral brow, 141–143, 142f–144f
279–280, 280f patient control over, 119 used with upper eyelid
Enophthalmos, 389 treatment options for, 119, 119t blepharoplasty, 125, 141–143,
Entropion circuit in, 118f, 119 142f–143f
after lower eyelid blepharoplasty, 156 conservative, 119f, 119t and upper eyelid, 125
cicatricial. See Cicatricial entropion interventional, 119t, 122f Eyebrow forehead lift, endoscopic
classification of, 42–43 medical, 119–121, 119f, 120t, 121f, 122f assisted. See under Endoscopic
clinical features of, 43 surgical, 121–124, 122f–124f procedures
Index. 3/22/01 2:46 PM Page 493
INDEX • 493
Eyebrow ptosis taping of, in facial nerve paralysis Free myocutaneous grafts, in upper eyelid
decision tree for management of, 145f management, 106 reconstruction, 256
development of, 128, 129f topography of, 2f Frontalis muscle
in facial paralysis patient, surgical tumors and lesions of. See Periocular in eyebrow anatomy, 126, 127f
management of, 109, 109f skin lesions suspension, for ptosis correction, 96–98,
Eyelash abnormalities. See Trichiasis upper. See Upper eyelid 97f
Eyelid crease with autogenous fascia lata, 83, 83f,
in Asian population, 211, 213 97–98
postoperative problems, 222–223, 223f Face using silicone (silastic) rod, 84–85,
types of, 213–214, 214f reanimation, 110, 110f–111f 84f–85f, 96–97, 97f, 100
in blepharoplasty surface anatomy of, 1–5 Frontal sinus
complications of, 222–223, 223f topography of, 1–2, 2f anatomy of, 453
techniques for creating, 215–218, Facial expression, muscles of, 5, 5f expansion of, 15
215f–217f Facial nerve, 6 Frown lines, incisions within, 453, 454f
dynamic versus static, 217 anatomy of, 103–104, 104f Full-thickness eyelid reconstruction
as ptosis surgery complication, 100 branches of, 5, 5f, 104f canthal defects
Eyelid crease incision eyebrow anatomy and, 126, 127f lateral, 257–258, 258f–259f
in anterior orbitotomy, 421–422, 422f misdirection of, 117 medial, 256–257, 257f
in lateral orbitotomy, 430–431 vulnerability of, 104 clinical pathways for, 261f
upper, in orbital surgery, 455 Facial nerve paralysis combination defects, 258, 259f, 260
Eyelid defects, repair techniques described, 103 factors in, 243–244
advanced. See also individually named etiology of, 104–105 lower eyelid, 247–251
techniques evaluation of, 105–106 clinical pathway, 261f
for lower eyelid, 247–251 management of, 106–110, 107f–111f repair techniques in, 244–247
for upper eyelid, 251–256 clinical pathway for, 111f upper eyelid, 251–256
combination defects, 258, 259f, 260 presenting symptoms of, 105 clinical pathway, 261f
direct closure, 244–245, 245f Facial reanimation surgery, 110, 110f–111f Full-thickness skin grafts, 36
lateral cantholysis, 245–246, 246f Facial resurfacing in medial canthal reconstruction,
lateral canthus and, 257–258, 258f–259f history of, 195 256–257
medial canthus and, 256–257, 257f lasers used in, 195–197. See also Laser Functional blepharospasm, 117
Tenzel semicircular flap, 246–247, 246f skin resurfacing
Eyelid laxity Fasanella-Servat procedure, 77, 78–80,
horizontal. See Horizontal eyelid 79f–80f Galea, in eyebrow anatomy, 126, 127f
laxity Fascia Ganglion block, superior cervical, for
repair of orbital, 10–11, 11f essential blepharospasm, 123, 124f
in involutional entropion, 45 temporal, in eyebrow anatomy, 126, Giant papillary conjunctivitis, in
lower eyelid blepharoplasty with, 127f, 128f anophthalmic socket, 381
152–153, 153f Fascia bulbi. See Tenon’s capsule Gingival-buccal sulcus incision, in orbital
risks associated with, 150 Fascia lata, autogenous surgery, 457
Eyelid margin destruction, 41 for ptosis, 83, 83f, 97–98 Glabellar flap, in medial canthal
Eyelid margin orbitotomy, 427, 428f use in enucleation technique, 336–337 reconstruction, 257, 257f
Eyelid opening, apraxia of, 116 Fascial sheaths, orbital, 11, 11f Glass orbital implant, 38, 39f
Eyelid retraction Fat Glioma. See Optic nerve glioma
correcting. See under Reconstructive eyebrow, caution with, 2 Globe, 15
surgery, of eyelid orbital, 11–12, 12f laser injury to, 173–174, 174f
for facial nerve paralysis retro-orbicularis oculi brow. See Retro- removal of. See Enucleation
lower, 107–108, 108f orbicularis oculi brow fat structures supporting, 11
upper, 108–109, 108f–109f suborbicularis oculi. See Suborbicularis Globe tenting, 13, 13f
thyroid disease and. See under Thyroid oculi fat Glomus tumor, periocular, 228
disease Fibroblastic phase, in wound healing, 22 Gold weights, 38
Eyelid(s) Fibroconnective tissue septae, 11, 11f Grafts/Grafting
anatomy of, 2–4, 4f, 41 Fibroma, ossifying, 401–402, 402f in anophthalmic socket
development of, 2, 3f Fibrous dysplasia, 401–402, 402f for exposed implant, 375–376
everted. See Ectropion Fine-needle aspiration biopsy, orbital for extruded implant, 377
and eyelash abnormalities. See lesions, 394 for inferior conjunctival fornix
Trichiasis Fistulas, as exenteration complication, reconstruction, 379–380, 379f
full-thickness reconstruction of. See 362–363, 363f cartilage, 37–38
Full-thickness eyelid reconstruction Fitzpatrick’s skin type classification for cicatricial ectropion repair, 63
inner double, 213–214, 214f scheme, 185, 185t, 197 dermis-fat. See Dermis-fat grafts
inverted. See Entropion Flaps, for reconstructive surgery, types of, failure of, as exenteration complication,
in levator aponeurotic resection, 94, 95 32–34, 33f–35f. See also specific forms 363
lower. See Lower eyelid of flaps full-thickness. See Full-thickness skin
outer double, 213–214, 214f Floor, orbital. See Orbital floor grafts
protractors in, 3 Forced duction tests, in thyroid-related in medial canthal reconstruction,
retractors in, 2, 4, 5f, 41, 42t, 43f strabismus, 298, 298f 256–257
disinsertion of, 60–61 Forehead trauma, optic neuropathy and, 8 mucous membrane. See Mucous
reinsertion of, 61–62 Foreign body, orbital, 486, 486f membrane grafts
removal pitfalls, 5 Fornix (fornices) split-thickness. See Split-thickness skin
sparing during exenteration, 359–360, in enucleation technique, 334–335, grafts
360f 334f–335f types of, 34, 36–38
spasm of. See Essential blepharospasm resection, 360–361, 361f in upper eyelid reconstruction, 252,
symmetrical supraplacement in orbital shallow inferior conjunctival, in 254–256, 254f, 255f
decompression, 321 anophthalmic socket, 377–380 Granuloma, periocular pyogenic, 228
Index. 3/22/01 2:46 PM Page 494
494 • INDEX
Graves’ disease. See Thyroid disease inflammatory processes, 396–398, Irrigation

Graves’ orbitopathy, orbital 396f–398f in congenital nasolacrimal obstruction,
decompression for. See Orbital lymphoid tumors, 398–400, 399f–400f 269, 271, 271f
decompression optic nerve meningioma, 392–393, 392f in nasolacrimal stenosis, 274–275
Gray line, visibility of, 57 of orbital injuries in tearing patient, 268
with foreign body, 486, 486f Island myocutaneous flap, in medial
hematoma, 484f canthal reconstruction, 257
Habit spasm, 116 ocular “tenting,” 484f Isotretinoin (Accutane), laser skin
Hasner, valve of, 17, 17f posterior blowout fracture, 483f resurfacing and, 184
Healing by secondary intention, medial in orbital tumor exposure, 467–468 Itching, after laser skin resurfacing, 192,
canthal defect, 256 of pediatric orbit, 405–406, 406f–407f 207
Hemangioma, periocular in tearing patient, 268, 269f
capillary, 228, 228f in thyroid ophthalmopathy evaluation,
subcutaneous pediatric, 405, 405f 315–317, 316f Jaw-winking ptosis, 90
cavernous, 228 in thyroid-related strabismus, 298–299, Jones I/Jones II tests, 266–268
Hematoma 299
orbital, 484, 484f Impetiginization, after laser skin
upper eyelid, after laser blepharoplasty, resurfacing, 191 Kaposi sarcoma, periocular, 239, 239f
174 Incident angle, in laser blepharoplasty, “Kissing nevus,” 229, 229f
Hemifacial spasm, 116 166 Krause, accessory lacrimal glands of, 16
Hemorrhage Incisions, 24–25, 24f–25f. See also
intraorbital or subconjunctival, 388 individually named incisions
orbital, 388 for anterior orbitotomy, 421–429 Lacerations, conjunctival, 282
Hemostasis, 26 depth of, in laser blepharoplasty, 166, Lacricath system, use in nasolacrimal duct
in deep orbital surgery, 443–444 166f obstruction, 272–274
in laser blepharoplasty, 166–167, 166f for orbital lesion surgery, 453–457 Lacrimal glands, 16, 17f
Herpetic infections, after laser skin Induced ocular hypertension test, in obstruction of, 483
resurfacing, 191, 207 thyroid-related strabismus, 298 Lacrimal gland tumor, 408–412
Hertel exophthalmometer, 477 Infection risk causes of, 408
Hidrocystomas, periocular, 231 after laser blepharoplasty, 174 differential diagnosis o, 410–411,
Hordeolum, periocular, 232 after laser skin resurfacing, 191 411f
Horizontal eyelid laxity clinical pathway for, 191f as exenteration complication, 363–364,
evaluation of, 55–56, 55f, 56f epidermal debris and, 182, 202 364f
surgical techniques in treatment of, prophylactic measures, 184–185 management of, 411–412, 411f–412f
56–58, 56f–57f Inferior forniceal antroethmoidal presentation of, 408–410, 409f–411f
Horizontal shortening, in correction of decompression, 319–321, 319f, 320f special considerations in, 410
lower eyelid retraction, 160–161 Inferior fornix orbitotomy, 427–429, 428f, Lacrimal irrigation test, 268
Horizontal tarsal kink syndrome, 42 429f Lacrimal patency tests, 266–268
Hotz procedure, 50 Inferior ophthalmic vein, 13 Lacrimal pump
Hughes tarsoconjunctival flap, in lower Inferior rectus, in strabismus surgery, failure, management of, 274
eyelid reconstruction, 247–249, 299–302, 300f–302f physiology of, 264
248f postoperative complications of, 303 Lacrimal sac, 17
Huntington’s disease, blepharospasm in, Inferior turbinate infracture, 271–272, 272f lymphoid tumors of, 394
115 Inflammatory disease, orbital, 306f–398f, Lacrimal sac tumor, 412–415, 413f
Hutchinson’s freckle, periocular. See 396–398 Lacrimal system
Lentigo maligna Inflammatory lesions, periocular, 232–233 anatomy of, 263–264, 263f, 264f
Hydrocortisone cream, laser skin Inflammatory phase, in wound healing, 22 evaluation of, 264–269. See also Tearing
resurfacing and, 185, 192 Infracture, inferior turbinate, 271–272, 272f excretory, 16–17, 16f, 17f
Hydroxyapatite orbital implant, 38, 39f Inner canthus. See Medial canthal entries in eyelid reconstruction, 244
at enucleation, 338–341 Inner double eyelid, 213–214, 214f obstruction in. See Nasolacrimal duct
at evisceration, 349–350, 351 Innervation obstruction
Hyfercation, for trichiasis, 70 following orbital decompression, 325 pump physiology in, 264
Hyperpigmentation, after laser skin orbicularis oculi, 7 secretory, 15–16, 16f
resurfacing, 191–192 Instruments, for oculoplastic surgery, surgical treatments for, 274–286. See also
Hypertrophic scarring, after laser 25–26 specific procedures and conditions
blepharoplasty, 174–175, 175f laser blepharoplasty, 166, 166f Lagophthalmos
Hypoglobus, following orbital Internal browpexy, 125, 129–130, as ptosis surgery complication, 99
decompression, 325 129f–130f surgical procedure for, 64
Hypopigmentation, after laser skin Intraconal tumors, 390–394, 391f, 392f Laser blepharoplasty
resurfacing, 193, 206, 207f Intraocular calcifications, 389 clinical pathways for, 176f
Hysterical blepharospasm, 117 Intraorbital hemorrhage, 388 described, 165
Intravascular papillary endothelial hemostasis in, 166–167, 166f
hyperplasia, pediatric, 404 incision depth in, 166, 166f
Imaging studies Intubation instrumentation for, 166, 166f
in dysthyroid compressive optic bicanalicular, for conjunctival laceration lower eyelid (transconjunctival),
neuropathy, 306, 308f, 311f repair, 282–284, 284f 170–173, 170f–173f
of lacrimal gland enlargement, 411f in dacryocystorhinostomy, 279 clinical pathway for, 176f
orbital, 485, 485f in nasolacrimal duct obstruction, 272, complications of, 175
in orbital disease evaluation, 387–390, 273f technical considerations in, 166
388f–389f, 389, 390 in nasolacrimal stenosis, 275 upper eyelid, 167–169, 167f–169f
diffuse tumors, 395f–396f Involutional entropion, 42–43, 43f clinical pathway for, 176f
with extraocular muscle enlargement, pathophysiologic mechanisms in, 42t complications of, 173–175, 174f–175f
401, 401f surgical management of, 44–45, 45f wound healing after, 167
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INDEX • 495
Laser epilation, for trichiasis, 70 preoperative evaluation of, 150–151, Median forehead flap, in upper eyelid
Laser skin resurfacing, 179–183, 179f–183f, 150f reconstruction, 255
197 with repair of eyelid laxity, 152–153, 153f MEDPOR (Medpor) polyethylene
CO2 laser for, 195–196 transconjunctival, 153–155, 154f–155f implant, orbital, 339, 340f
complications of, 191–193, 191f–192f, laser use for, 170–173, 170f–173f, 175, for rim reconstruction, 438–440,
206–207, 207f 176f 439f–440f
Derma K dual mode laser for, transcutaneous, 151–152, 151f–153f Meibomian glands
196–197 Lower eyelid posterior lamella graft, in carcinomas of, 238, 238f
erbium:YAG laser for, 196 involutional entropion repair, metaplasia of, 70
postoperative wound care in, 182–183, 50–51, 51f Meige’s syndrome, 113, 116
182f–183f, 185, 185t, 189–191 Lower eyelid retraction Melanoma, periocular, 236–238, 237f
long-term follow-up, 206 after strabismus surgery, 303 Melanosis, oculodermal, 230
open versus closed, 205–206, 205f anatomy of, 156–157 Melanotic freckle, periocular. See Lentigo
preparations and dressings for, for facial nerve paralysis, 107–108, 108f maligna
190–191, 190t and postblepharoplasty ectropion, Melanotic neuroectodermal tumor of
principles of, 190t 63–64, 63f infancy, 407–408
preoperative considerations in, 183–203, in thyroid disease, surgical Melasma, laser treatment of, 207
184t, 185t, 186f management of, 294–295 Meningioma
techniques of, 187–189, 188f, 190f Lower eyelid retractor repair, in entropion cranio-orbital, resection of, 465–466,
laser settings, 203–205 anterior approach to, 45–47, 46f, 47f 465f
Laser-tissue interactions, in laser skin posterior approach to, 47–48, 47f, 48f optic nerve. See Optic nerve
resurfacing, 179–181, 179f–, 181f Lymphangioma, periocular, in children, meningioma
Lateral canthal incision, extended, in 405, 405f, 406 Meningitis, as exenteration complication,
lateral orbitotomy, 431–432 Lymphatics, in facial anatomy, 6–7 363
Lateral canthal reconstruction, 257–258, Lymphoid tumors Meningocele, in children, 404, 404f
258f–259f lacrimal sac, 394 Merkel cell carcinomas, periocular,
in correction of lower eyelid retraction, orbital, 398–400, 399f–400f 238–239, 239f
161, 161f Lynch incision Metaplasia, of Meibomian glands, 70
with lower lid involvement, 260 in anterior orbitotomy, 422, 424f Metastasis(es)
versus medial canthal reconstruction, extended, in combined lateral/medial Ewing’s sarcoma, 408
243, 244 orbitotomy, 446–447 neuroblastoma, 408
with upper lid involvement, 260 Methyl methacrylate, for reconstruction
Lateral cantholysis, for larger eyelid after exenteration, 365
defects, 245–246, 246f “Madame Butterfly” procedure, 64 Microphthalmia, congenital, treatment of,
Lateral canthoplasty, for facial nerve Magnetic resonance imaging. See Imaging 469–471, 470f
paralysis, 106–107, 107f studies Midface
Lateral canthotomy Malar folds, 1 anatomy of, 5, 5f
for correction of lower eyelid retraction, Malherbe, calcifying epitheliomas of, fractures of, 483
158–159, 158f–159f 230–231, 231f Milia, after laser skin resurfacing, 191
extended, in orbital surgery, 455–456 Malignant lesions, periocular, 234–239, Monocanalicular stent, for conjunctival
“Laugh lines,” 1–2 235t. See also individual types laceration repair, 284–285
Le Fort fractures, 475–477, 476f Marginal entropion, 68–69, 68f–69f Motility-enhancing orbital implant. See
Lentigines, laser treatment of, 207, 208f Marginal rotation technique, in Hydroxyapatite orbital implant
Lentigo maligna, periocular, 234, 234f involutional entropion repair, Mucous membrane grafts, 36–37, 36f–37f
melanoma arising from, 237 48–50, 49f for inferior conjunctival fornix
Levator aponeurotic repair, for ptosis, 77, Margins, orbital, 7–8, 7f reconstruction in anophthalmic
80–81, 81f, 82f, 93–96, 94f–96f Margin-to-reflex distance, in ptosis socket, 379–380, 379f
evaluation and timing for, 89–90 assessment, 75–76, 76f Müller’s muscle, 4, 4f
maximal advancement. See Whitnall Matrix metalloproteinases, in wound lacrimal system and, 15
sling healing process, 23 in levator aponeurotic repair, 94, 94f,
Levator function, surgical options for Maturation phase, in wound healing, 95f
ptosis based on, 76–77, 89 22–23 Müller’s muscle conjunctival resection
Levator palpebrae superioris, 4, 4f Maxilla, Le Fort fractures of, 475–477, 476f in facial paralysis management, 110
medial dehiscence, 4, 4f Maxillary bone, 317 for ptosis, 77
Lids. See Eyelid(s); Lower eyelid; Upper role in orbital decompression, 318 evaluation and timing for, 89–90
eyelid Maxillary nerve, 13, 14 technique, 77–78, 78f–79f
Lid-splitting procedure, for distichiasis, Maxillary sinus, anatomy of, 14–15, 14f, Muscle(s). See also individually named
71–73 15f, 452–453 muscles
Lockwood’s ligament, 11, 11f, 61, 148 McCord, external tarso-aponeurectomy, extraocular, 15
Lower eyelid, 1 85–87, 86f, 87f eyebrow, 126, 127f, 128, 128f
age-related changes in, 148–149, 149f Mechanical epilation, for trichiasis, 70 eyelids, 4f, 5f, 13–4
anatomy of, 147–150, 148f–149f Medial canthal reconstruction, 256–257, midface, 5, 5f
defects of. See Eyelid defects 257f Müller’s. See Müller’s muscle
malposition after blepharoplasty. See lateral canthal reconstruction versus, of Riolan, 3
Scleral show 243, 244 Mustarde cheek flap, in lower eyelid
subciliary incision in anterior with lower lid involvement, 260 reconstruction, 249–251, 249f, 250f
orbitotomy, 422–423 with upper lid involvement, 260 Myectomy, for essential blepharospasm,
Lower eyelid blepharoplasty Medial canthal tendon laxity, 58–59, 122–123, 122f, 123f
complications of, 155–156 58f–59f Myoconjunctival attachments, enucleation
management, 156–162. See also Scleral Medial canthoplasty, for facial nerve with, 331–336, 332f–337f
show paralysis, 107 Myocutaneous flaps
described, 147 Medial spindle, in punctal eversion repair, in correction of lower eyelid retraction,
postoperative care in, 155 59–60, 60f, 274, 275f 159–160, 160f
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496 • INDEX
Myocutaneous flaps (continued) Oculodermal melanosis, 230 Orbital fractures, 475–483

in medial canthal reconstruction, 257 Oculomotor nerve, 6, 13 blowout type, 480–482, 481f–482f
for reconstruction after exenteration, 365 Ophthalmia, sympathetic, 328 Le Fort patterns, 475–477, 476f
in upper eyelid reconstruction, 256 Ophthalmic nerve, 13 midface, 483
Myokymia, ocular, 116 Ophthalmoplegia, progressive external, orbital roof, 479–480, 479f–480f
Myopathies, acquired, ptosis in patients blepharospasm in, 115 posterior floor, 482–483, 483f
with, 91–92 Optic foramen, 9–10, 10f repair complications, 483–484
Myotonic dystrophy, 117 Optic nerve, 13 zygomatic, 477–478, 477f–478f
during enucleation, 333–334, 334f Orbital hematoma, 484, 484f
Optic nerve glioma, 391–394, 392f, 393f Orbital hemorrhage, 388
Nasal cavity, anatomy of, 14–15, 14f Optic nerve meningioma, 391–392, 392f Orbital implants, 328f
Nasojugal folds, 1 management of, 394 coupling of, 339–341, 340f, 342
Nasolacrimal duct, 2 Optic nerve tumors, 391–394, 392f in enucleation, 334, 334f
Nasolacrimal duct obstruction Optic neuropathy exposure of, prevention and
complete, management of, 276–280, in Graves’ disease. See Dysthyroid management, 340–341
276f–278f, 280f compressive optic neuropathy hydroxyapatite. See Hydroxyapatite
congenital form, evaluation and transient, after orbital lesion surgery, 468 orbital implant
management of, 269, 271–274 traumatic, 486–487 motility and, 338–339, 342
Nasolacrimal stenosis, 274–276 clinical pathway for, 487f pegging of, 339–341, 340f, 342
Neck, laser treatment of, 204 Orbicularis oculi, innervation of, 7 posterior placement after evisceration,
Necrotizing fasciitis, after laser Orbit 352
blepharoplasty, 207 apex of, 9–10, 10f preoperative counseling about, 329–330,
Nerves bony anatomy of, 317–318, 317f, 318f 329f–330f
in facial anatomy, 6–7 congenital anomalies involving. See prion disease risk and, 330
injury to, 6 Congenital orbital anomalies secondary, 339–341, 340f
orbital, 13–14, 13f during enucleation, 333–334, 334f titanium motility post with, 339–341,
Neuroblastoma, metastatic, 408 exenteration of, 468–469, 469f, 470f 340f
Neurodegenerative diseases, fascia of, 10–11, 11f types, 327, 327f
blepharospasm in, 115 fat around, 11–12, 12f wraps for, 341, 342f
Neuroendocrine carcinoma, periocular, foreign body in, 486, 486f Orbital lobe, lacrimal gland, 16, 17f
238–239, 239f lesions of, surgical management. See Orbital pain, 388–389
Neurofibromas, periocular, 232, 232f Orbital lesion surgery Orbital rim reconstruction, 435–440,
Neurofibromatosis margins of, 7–8, 7f 439f–441f
optic gliomas associated with, 391 medial strut of, 11 augmentation, for thyroid
ptosis in pediatric patient with, 91, 91f nerves of, 13–14, 13f ophthalmopathy, 323–324,
Nevi, periocular, 228–230, 229f periorbita, 10 323f–324f
Nonabsorbable sutures, 27t secondary tumors of, 402–403, 403f Orbital roof, 8
Nonoptic nerve tumors, 390–391, 391f shape and dimensions and, 7 subperiosteal dissection and, 7
Norian, in orbital rim reconstruction, soft tissues of, 11–14 traumatic optic neuropathy and, 8
437–438 surgical osteology of. See Orbital lesion Orbital roof fractures, 479–480, 479f, 480f
Nose, nonosseous tumors originating in, surgery, osseous exposure in Orbital septum, 2–3
402 tumors of. See Orbital tumors in Asian blepharoplasty, 216, 216f
NovaBone-C/M, in orbital rim ultrasound of, 485, 485f cauterization risks, 152
reconstruction, 438 Orbital calcifications, 389–390 Orbital space, removal of contents from.
Numbness Orbital compartment surgery See Exenteration
facial, 105 anterior, 457–458, 457f–458f Orbital surgery, 434–446, 434f–437f, See
following orbital decompression, 325 apical, 462–465, 462f–465f also Orbitotomy
central, 458–462, 459f–462f clinical pathways for, 472f
Orbital decompression complications of, 468
Obstruction for dysthyroid compressive optic imaging studies in, 467–468
canalicular, 280–282, 281f–282f neuropathy, 309–310, 309f, incision selection for, 453–457
nasolacrimal duct. See Nasolacrimal 310f–312f, 312 orbital exenteration and, 468–469, 469f,
duct obstruction for thyroid ophthalmopathy. See 470f
Occupational safety requirements, for Thyroid ophthalmopathy, orbital osseous exposure in, 451–452, 452f
laser skin resurfacing, 186–187, 186f decompression for osseous and soft tissue reconstruction
Ocular disease, blepharospasm associated Orbital disease in, 466–467, 467f
with, 117 distribution of, 387 techniques of, 457–466
Ocular examination evaluation, 387 anterior compartment, 457–458,
in facial nerve paralysis evaluation, 106 extraconal, 401–403, 402f–403f 457f–458f
in ptotic patient, 75 with extraocular muscle enlargement, apical compartment, 462–465,
Ocular implants, for anophthalmic socket 400–401, 400f–401f 462f–465f
exposure of, 375–376 forms of, 388–390 central compartment, 458–462,
with inadequate orbital volume, inflammatory processes, 396–398, 459f–462f
370–375, 370t, 371f–374f 396f–397f for cranio-orbital and sino-orbital
secondary with osseous exposure. See Orbital lesions, 465
for implant extrusion management, lesion surgery for soft tissue and tumor resection,
376–377, 378f Orbital emphysema, 480, 481f 465–466, 466f
for implant migration management, Orbital fat removal, in orbital Orbital trauma, 484–487, 484f, 485f, 487f
372f, 375 decompression, 320 considerations in, 475
inadequate orbital volume and, Orbital fissure, 9, 10f fractures. See Orbital fractures
374–375, 374f Orbital floor, 8–9 Orbital tumors, 387, 388f
Ocular myokymia, 116 dissection complications associated in children, 403–407, 403f–407f
Ocular “tenting,” 484, 484f with, 9 congenital, 407–408
Index. 3/22/01 2:46 PM Page 497
INDEX • 497
diffuse, 394–396, 395f–396f Pentagonal wedge resection, for trichiasis, indications for, 89
intraconal. See Intraconal tumors 70–71, 71f levator function and, 76–77
lymphoid, 398–400, 399f–400f Periocular skin lesions. See also individually postoperative care in, 99
removal of, 443 named lesions preoperative preparation for, 92–93
Orbital volume, inadequate, in benign, 226–233, 226t–227t risks associated with, 92t
anophthalmic socket clinical versus pathologic diagnoses, Punctal ectropion, 16
with implant, 374–375 225t treatment of, 274, 275f
without implant, 370–373, 370f, 371f. See histopathology of, 225 Punctal stenosis, treatment of, 274
also Ocular implants, for malignant, 234–239, 235t Pupillary dilation, cause of, 13
anophthalmic socket preinvasive, 233–234, 233t, 234f Pyogenic granuloma, periocular, 228
Orbital wall, 7f, 8, 8f Periocular tumors
lateral, 9, 9f adnexal, 230–231, 230f–231f
medial, 8–9 epithelial, 227–228, 227f Radiography. See Imaging studies
reconstruction of, 440, 442 malignant, 234–239, 235t Radiotherapy, for dysthyroid compressive
subperiosteal dissection and, 7 vascular, 228, 228f optic neuropathy, 307–309,
Orbitomalar ligament, 3 Periorbita, 10, 11 307f–308f
Orbitotomy Pharmacotherapy, for essential Reading difficulty, after strabismus
anterior (without bone removal), 419 blepharospasm, 119–120, 120t surgery, 303
clinical pathway for, 448f Pigmented retinal choristoma, 407–408 Reconstructive surgery, 32–39
incisions for, 421–429 Pilomatricomas, periocular, 230–231, 231f after exenteration, 365
principles of, 420–421 Polyglactin mesh, for orbital implants, in anophthalmic socket, 378–380, 379f
eyelid margin, 427, 428f 341, 342f correcting lower lid retraction, 158–162,
inferior fornix, 427–429, 428f, 429f Polyp, periocular fibroepithelial, 227 158f–163f
transconjunctival, inferior orbital fat Porous polyethylene implant, orbital, 339, full-thickness defects. See Full-thickness
in, 13, 13f 340f eyelid reconstruction
vascular supply and, 9 for rim reconstruction, 438 Rectangular debulking, of eyelid tissue,
lateral (with bone removal), 9, 9f, 419 Posterior equatorial sclerotomy, for 218–220, 218f, 219f
clinical pathway for, 448f corneal excision in evisceration Reflex blepharospasm, 115
incisions for, 429–434 procedure, 351–352 Rehabilitation, after exenteration, 364
variations on, 446–447 Posterior orbital floor fractures, 482–483, clinical pathway for, 366f
medial, 446–447 483f Relaxed skin tension lines, incisions
postoperative considerations, 447–448 Preaponeurotic fat pad, upper eyelid, 12, within, 453, 454f
preoperative considerations, 420 12f Relaxing scleral cuts, in evisceration
principles of, 419 in Asian blepharoplasty, 216 procedure, 348–351, 348f–351f
safety considerations in, 419 debulking of, 218–220, 218f, 219f Retinal anlage tumor, pediatric, 407–408
swinging lower eyelid, 427–429, 428f, Preseptal fat, in Asian patients, 213, 213f Retinal choristoma, pigmented, 407–408
429f Pretarsal fat, in Asian patients, 213, 213f Retinoblastoma, pediatric, modified
Orofacial-cervical dystonia, 113, 116 Pretarsal orbicularis excision, in Asian enucleation technique for, 338
Oropharynx, nonosseous tumors blepharoplasty, 217, 217f Retraction technique, in deep orbital
originating in, 402 Prion disease, orbital implant and, 330 surgery, 442
Osseous exposure, orbital. See Orbital Probing Retractor repair, in entropion. See Lower
lesion surgery, osseous exposure in in congenital nasolacrimal obstruction, eyelid retractor repair, in entropion
Ossifying fibroma, 401–402, 402f 269, 271, 271f Retro-orbicularis oculi brow fat, 2, 141,
Osteotomy, in orbital surgery, 434–435, in nasolacrimal stenosis, 274–275 142f
434f–437f in tearing patient, 268 age-related changes in, 148, 149f
Ota, nevus of, 230 Procerus muscle excision of, 141–143, 142f–144f
Outer canthus. See Lateral canthal entries in eyebrow anatomy, 128, 128f Rhinophyma, laser treatment of, 207, 208f
Outer double eyelid, defined, 213–214, resection, in endoscopic assisted Rhomboid-type flaps, for lateral canthal
214f eyebrow forehead lift, 131–133, 134f repair, 258, 259f
Overcorrection Progressive external ophthalmoplegia, Rhytids, laser skin resurfacing for, 187,
as ptosis surgery complication, 100 blepharospasm in, 115 198–199, 199f
in strabismus surgery, 302–303 Proptosis Botox injection prior to, 200–201, 201f
O-Z plasty, 34, 35f after strabismus surgery, 302 Riolan, muscle of, 3
in orbital disease evaluation ROOF. See Retro-orbicularis oculi brow fat
axial, 387 Roof, orbital. See Orbital roof
Pain, orbital, 388–389 bilateral, 389 Rosenmüller, valve of, 17, 17f
Palatine bone, orbital floor, 317 Ptosis Rotational flaps, for lateral canthal repair,
Palpebral fissures, 1 bilateral, 77 258, 258f–259f
Palpebral lobe, 16, 17f congenital, surgical correction of, 90–91, Round eye. See Scleral show
Papilloma, periocular squamous, 227 91f
Parallel eyelid crease, 213–214, 214f described, 75
Paralytic ectropion, 64 evaluation of, 75–77 Safety issues, in laser skin resurfacing,
Paranasal sinus(es) synkinetic (“jaw-winking”), 90 186–187, 186f
anatomy of, 14–15, 15f Ptosis surgery, 77–87 Sarcoidosis, periocular, 233, 233f
nonosseous tumors originating in, 402 in anophthalmic socket, 380–381, 380f Sarcoma, pediatric, 408
Parasympathetic nerve supply, to ciliary clinical pathways for, 87f, 101f Scar/Scarring
muscle, 14 complications of, 99–100 after laser blepharoplasty, 174–175, 175f
Parkinson’s disease, blepharospasm in, 115 contraindications for, 89t after laser skin resurfacing, 193
Patch grafting, for exposed implant in evaluation and timing for, 89–92 management of, 30–31
anophthalmic socket, 375–376 in facial paralysis management, revision of, technique, 31–32, 31f–32f
Patient expectations, from laser skin 109–110, 110f Sclera, eye-bank, 38, 337–338
resurfacing, 198, 199 historical perspective on, 89 Scleral cuts, relaxing, in evisceration
Penetrating orbital trauma, 484–485, 485f incision planning for, 92–93, 93f procedure. See Relaxing scleral cuts
Index. 3/22/01 2:46 PM Page 498
498 • INDEX
Scleral show, management of Squamous cell carcinoma, periocular, 236, Sympathetic ophthalmia, 328
evaluation and planning in, 157–158 237f Synkinesis, 117
lower eyelid retraction anatomy in, Static symmetry, as anophthalmic surgery Synkinetic ptosis, 90
156–157 goal, 369 Synthetic wraps, use in enucleation
McCord algorithm for, 163 Stent, for conjunctival laceration repair, technique, 337
SOOF anatomy in, 157 284–285 Syringomas, periocular, 231, 231f
surgical correction in Steroids, for dysthyroid compressive optic chondroid, 231
concept, 157–158 neuropathy, 306–307, 307f laser treatment of, 207, 207f
technique, 158–162, 158f–163f Stone-Jordan orbital implants, 327, 327f
Sclerotomy, posterior equatorial, for Strabismus
corneal excision in evisceration following orbital decompression, 325 Taping of eyelids, in facial nerve paralysis
procedure, 351–352 thyroid-related, 297–299 management, 106
Sebaceous carcinoma, periocular, 238, 238f Strabismus surgery Tardive dyskinesia, 116–117
Sebaceous hyperplasia, periocular, 231 fibroconnective tissue septae in, 11 Tarsal strip, for horizontal eyelid laxity
Seborrheic keratosis, periocular in thyroid disease patient, 299–303, management, 57–58, 57f
acanthotic, 227–228, 227f 300f–302f Tarsoconjunctival flap, in eyelid
Secondary intention, healing by, medial Strawberry nevus, periocular, 228, 228f reconstruction
canthal defect, 256 Streptococcal infections lower lid, 247–249, 248f
Secondary wound healing, 23, 23f after laser blepharoplasty, 174, 207 upper lid, 251, 252f
Secretory system, lacrimal, 15–16, 16f, 17f after laser skin resurfacing, 207 Tarsoligamentous band, 3
Seizures, blepharospasm associated with, Sub-brow incision, in orbitotomy Tarsorrhaphy, facial nerve paralysis and,
117 anterior, 422, 423f 106
Septum, orbital, in surgery, 3 lateral, 432–433, 433f Tarsus, 3
Shirmer’s testing, 266 Subciliary lower eyelid incision, in operations involving, for trichiasis, 71,
Silicone (silastic) rod suspension, for anterior orbitotomy, 422–423 72f
ptosis, 84, 84f, 96–97, 97f Subconjunctival hemorrhage, 388 Tear function tests, 266
complications from, 100 Submuscular fat in the eyebrow region. Tearing
technique of, 84–85, 84f–85f See Retro-orbicularis oculi brow fat clinical pathway for management of,
Sinus(es) Suborbicularis oculi fat, 2, 6, 6f 267f
anatomy of, 452–453 age-related changes in, 149 diagnostic testing in, 266–269, 268f–270f
involvement in orbital disease, 387 anatomy of, 148, 148f, 149f, 157 differential diagnosis of, 265t
tumors of, 401–402, 402f Subperiosteal myocutaneous flap, in lacrimal system evaluation prompted
Skin correction of lower eyelid retraction, by, 264–265
classification scheme, 185, 185t 159–160, 160f patient examination in, 265–266, 267f
of eyelid, 2 Subperiosteal volume augmentation, in and workup, 268, 270f
periocular, small cell carcinomas of, anophthalmic socket, 374–375, 374f Tear trough abnormality, lower eyelid,
238–239, 239f Subtotal exenteration, 359–360, 360f 150
Skin flaps, types of, 32–34, 33f–35f. See also indicati§ons for, 356t Temporal fascia, in eyebrow anatomy,
specific forms of flaps Suction drainage, in deep orbital surgery, 126, 127f, 128f
Skin folds, around eye, 1–2 445 Temporal forehead lift, 125
Skin resurfacing. See Laser skin Superficial musculoaponeurotic system, Temporalis muscle
resurfacing 3, 6 use in facial reanimation surgery, 110,
Skin tag, periocular, 227 age-related changes in, 149 110f–111f
Skin thickness, in laser skin resurfacing, eyebrow anatomy and, 126, 127f use in reconstruction after exenteration,
188, 188f in lower eyelid anatomy, 148, 149f 365
Sliding tarsoconjunctival flap, in upper Superficial temporal fascia, in eyebrow Tendon laxity, medial canthal, 58–59,
eyelid reconstruction, 251, 252f anatomy, 126, 127f, 128f 58f–59f
Small cell carcinomas of skin, periocular, Superior cervical ganglion block, for Tenon’s capsule, 10–11
238–239, 239f essential blepharospasm, 123, 124f in anterior orbitotomy, 418
SMAS. See Superficial Superior ophthalmic vein, 12–13 Tenon’s layers, during enucleation,
musculoaponeurotic system Supervoltage radiotherapy, for dysthyroid 334–335, 334f–335f
Snap test, in lower eyelid evaluation compressive optic neuropathy, Tenzel semicircular flap, for eyelid defect
for blepharoplasty, 150, 150f 307–309, 307f–308f repair, 246–247, 246f
for laser skin resurfacing, 184 Suprabrowpexy, 135–137, 137f Teratoma, pediatric orbital, 407
Soft tissue expansion, for congenital Supraorbital nerves, in eyebrow anatomy, Terminal tarsal rotation operation, for
ophthalmia, 382 126, 127f trichiasis, 71
Soft tissues, orbital, 11–14 Supratrochlear nerves, in eyebrow Tetanus/Tetany, 117
in orbital lesion surgery, 465–466 anatomy, 126, 127f Thermal relaxation time, in laser skin
Solar keratoses, periocular, 233–234, 234f Sutura notha, 8 resurfacing, 181
SOOF. See Suborbicularis oculi fat Suture(s) “Three-snip” procedure, for punctal
Spasm for involutional entropion repair, 44–45, stenosis, 274
blepharospasm. See Essential 45f Thyroid disease
blepharospasm ligation method in elderly Asian eyelid retraction associated with,
habit, 116 blepharoplasty patients, 220 surgical management of, 289–295,
hemifacial, 116 materials for, 26–27, 27t 290f–294f
Spastic entropion, 43 stabilization in correction of lower optic neuropathy in. See Dysthyroid
Sphenoid sinus, anatomy of, 15, 15f, 453 eyelid retraction, 162, 162f–163f compressive optic neuropathy
Spitz nevus, periocular, 229 for wound closure, 28–30, 29f, 30f strabismus in. See Strabismus;
Splinting, in correction of lower eyelid “Swinging lower eyelid orbitotomy,” Strabismus surgery
retraction, 162, 162f–163f 427–429, 428f, 429f Thyroid ophthalmopathy
Split-thickness skin grafts, 36 Sympathetic nerve supply anatomy of, 317–318, 317f, 318f
for reconstruction after exenteration, 365 in eyelids, 6 orbital decompression for
Spurious blepharospasm, 117 to orbit, 14 complications, 324–325
Index. 3/22/01 2:46 PM Page 499
INDEX • 499
indications, 316 described, 67 Valves, of Hasner and Rosenmüller, 17, 17f

inferior forniceal antroethmoidal, traumatic, 69 Vascular tumors, periocular, 228
319–321, 319f, 320f treatment of, 70–73, 71f–73f Vasculature, in facial anatomy, 6–7
maxillary ostium role in, 318 clinical pathway for, 73f orbital, 12–13
and orbital anatomy, 318, 318f Trichilemmomas, periocular, 230 Vision loss, following orbital
orbital fat removal in, 320 Trichoepitheliomas, periocular, 230, 230f decompression, 324
orbital rim augmentation, 323–324, Trigeminal nerves Volume augmentation, orbital, 38
323f–324f in eyebrow anatomy, 126, 127f subperiosteal, in anophthalmic socket,
postoperative care, 324 in eyelids, 6 374–375, 374f
pre- and postoperative appearance, in orbital anatomy, 13
325f Trochlear nerve, in orbital anatomy, 13
preoperative evaluation, 315–316 Tumors Wall, orbital. See Orbital wall
surgical procedures, 319–324, 325f facial, laser treatment of, 207–208, Wedge resection, pentagonal, for
symmetrical supraplacement of 207f–208f trichiasis, 70–71, 71f
eyelids in, 321 intraconal, 390–394, 391f, 392f Westernizing blepharoplasty, 213
transantral antroethmoidal, 321–323, optic nerve. See Optic nerve tumors Wetfield cautery, in Asian blepharoplasty,
321f–323f orbital. See Orbital tumors 216
treatment options in, 325f periocular. See Periocular tumors Whitnall’s ligament, 11, 11f
Tissue, in laser skin resurfacing, 179–182, Turbinates, function of, 14 Whitnall sling, for ptosis, 82–83
179f–181f Tutoplast, use in enucleation technique, Wies procedure, 48–50, 49f
Tissue flaps, types of, 32–34, 33f–35f. See 338 Wilson’s disease, blepharospasm in, 115
also specific forms of flaps Two-wall antroethmoidal decompression, Wolfring, accessory lacrimal glands of, 16
Tissue glue, 30 for thyroid ophthalmopathy, 316 Wound care and dressings, after
Tissue handling, 25–26 oculoplastic surgery, 30–32. See also
Tissue heating, in laser skin resurfacing, Laser skin resurfacing,
180–181 Ultrasonography. See Imaging studies postoperative wound care in
Tissue penetration, in laser skin Undercorrection Wound closure
resurfacing, 180 as ptosis surgery complication, 100 after blepharoplasty, 217–218, 217f
Titanium motility post, with orbital in strabismus surgery, 302–303 in deep orbital surgery, 445–446
implant, 339–341, 340f Upper eyelid, 1 principles of, 27–30, 28f
Torsional diplopia, before and after anatomy of, Asian versus Caucasian, Wound contraction, 23, 23f
strabismus surgery, 303 211, 212f, 213–214, 213f–214f Wound dehiscence, after laser
Total exenteration, 357–359, 358f–359f debulking of, in upper lid blepharoplasty, 174
indications for, 356t blepharoplasty, 140–141, Wound healing
postoperative care in, 361–362, 362f–363f 140f–141f after laser skin resurfacing. See Laser
Tourette’s syndrome, 116 defects. See Eyelid defects skin resurfacing, postoperative
Trabecular carcinoma, periocular, and eyebrow, 125 wound care in
238–239, 239f Upper eyelid blepharoplasty matrix metalloproteinases in, 23
Transantral antroethmoidal in Asian patients. See Asian phases in, 22–23
decompression, 321–323, 321f–323f blepharoplasty secondary, 23, 23f
Transantral transoral decompression, 317 described, 137–138 Wound infection. See Infection risk
Transconjunctival blepharoplasty, lower eyebrow procedures used with, 125 W-plasty, for scar revision, 32, 33f
eyelid, 153–155, 154f–155f lateral brow, 141–143, 142f–143f Wrinkles. See Rhytids
laser use for, 170–173, 170f–173f in females, versus males, 137–138, 138f,
clinical pathway for, 176f 145f
complications of, 175 goal of, 125, 137 Xanthelasma, periocular, 233, 233f
Transcutaneous blepharoplasty, lower laser use for, 167–169, 167f–169f
eyelid, 151–152, 151f–153f clinical pathway for, 176f
Trapezoidal debulking, of eyelid tissue, complications of, 173–175, 174f–175f Y-V plasty, 33–34, 34f
218–220, 218f, 219f technique of, 138–141, 138f–141f
Trauma Upper eyelid dermatochalasis, decision
orbital. See Orbital trauma tree for management of, 145f Zeis gland carcinomas, periocular, 238,
trichiasis resulting from, 69 Upper eyelid retraction 238f
Tretinoin (Retin-A(r)), laser skin for facial nerve paralysis, 108–109, Zithromax (azithromycin), laser skin
resurfacing and, 185, 201 108f–109f resurfacing and, 184–185
Triangular debulking, of eyelid tissue, in thyroid disease, surgical Z-plasty, for scar revision, 31–32, 31f–33f
218–220, 218f, 219f management of, 289–295, 290f–294f Zygomatic arch, eyebrow anatomy and,
Trichiasis, 41 Upper eyelid tarsal advancement flap, in 126, 127f, 128f
anatomy of, 67, 68f involutional entropion repair, 50, Zygomatic bone, orbital floor, 317
classification of, 67–70, 68f–69f 50f Zygomatic fractures, 477–478, 477f, 478f
Index. 3/26/01 10:19 AM Page 500

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FM.

3/26/01 8:59 AM Page i

William P. Chen, M.D., F.A.C.S.

Senior Attending Surgeon

Associate Clinical Professor

Thieme New York

Library of Congress Cataloging-in-Publication Data

Chen, William Pai-Dei

1. Ophthalmic Facial Anatomy, Don O. Kikkawa and Sunil N. Vasani ……………………………………… 1

2. Fundamentals of Oculoplastic Surgery, Dipak N. Parmar and Geoffrey E. Rose ………………………… 21

3. Entropion, Jan W. Kronish …………………………………………………………………………………… 41

4. Ectropion, David T. Tse and Ann G. Neff …………………………………………………………………… 55

5. Trichiasis, Jeffrey A. Nerad and Annie Chang ………………………………………………………………… 67

6. Ptosis Management: A Practical Approach, Steven Dresner ……………………………………………… 75

8. Facial Nerve Paralysis, Steven Dresner ……………………………………………………………………… 101

12. Laser Blepharoplasty, Jemshed A. Khan……………………………………………………………………… 165

13. Laser Skin Resurfacing, Jemshed A. Khan …………………………………………………………………… 179

15. Asian Blepharoplasty, William Chen ………………………………………………………………………… 211

18. Lacrimal System, Marc J. Hirschbein and George O. Stasior………………………………………………… 263

19. Thyroid Ophthalmopathy: Eyelid Retraction, J. Justin Older …………………………………………… 289

20. Thyroid Opthalmopathy: Restrictive Myopathy, Sherwin J. Isenberg …………………………………… 297

23. Enucleation, William Chen …………………………………………………………………………………… 327

24. Evisceration, William Chen …………………………………………………………………………………… 347

25. Exenteration, William Chen…………………………………………………………………………………… 355

27. Orbital Diseases, Joseph A. Mauriello Jr. …………………………………………………………………… 387

28. Orbital Surgery, John Shore…………………………………………………………………………………… 419

30. Management of Orbital Injuries, Stuart R. Seiff …………………………………………………………… 475

Index ………………………………………………………………………………………………………………… 490

Richard L. Anderson M.D. Samuel A. Gallo, M.D.

Kimberly A. Klippenstein, M.D. Dipak N. Parmar, B.Sc(Hons.), M.B.B.S.,

Joseph A. Mauriello, Jr., M.D. George Raque, M.D.

George O. Stasior, M.D., F.A.C.S. Sunil N. Vasani, M.D.

David T. Tse, M.D. Ralph E. Wesley, M.D.

William P. Chen, M.D., F.A.C.S.

OPHTHALMIC FACIAL ANATOMY

2 • OCULOPLASTIC SURGERY: THE ESSENTIALS

FIGURE 1–1 Normal eyelid topography.

OPHTHALMIC FACIAL ANATOMY • 3

Complex Inductive Interaction

FIGURE 1–2 Eyelid development.

4 • OCULOPLASTIC SURGERY: THE ESSENTIALS

Inferior oblique Orbicularis muscle

OPHTHALMIC FACIAL ANATOMY • 5

FIGURE 1–5 Muscles of facial expression and branches of facial nerve.

6 • OCULOPLASTIC SURGERY: THE ESSENTIALS

P the SOOF plane, either subperiosteal or

vated and mobilized22, 24 (Fig. 1–6).

The frontal branch is one of the most com-

OPHTHALMIC FACIAL ANATOMY • 7

The orbicularis oculi is innervated by temporal,

Superior Lateral Medial Inferior Superior Lateral Medial Inferior

Sutura notha Upper limit Mark for Posterior Inferior

Branch of Anterior and

FIGURE 1–7 Orbital walls and margins.

8 • OCULOPLASTIC SURGERY: THE ESSENTIALS

lies at the junction of the medial one third and lateral

Orbital Walls PITFALL

OPHTHALMIC FACIAL ANATOMY • 9

and the zygoma anterolaterally. Along the course of

10 • OCULOPLASTIC SURGERY: THE ESSENTIALS

Superior orbital Inferior orbital Optic

22 mm length 20 mm length 8–10 mm

Annulus of Zinn Zygomatic–N Optic nerve (IInd N)

(Divides fissure) Infraorbital–N Meninges