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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
Department of Ophthalmology
Harbor-UCLA Medical Center
Torrance, CA;

Associate Clinical Professor

Department of Ophthalmology
University of California
Irvine College of Medicine
Irvine, CA

2001
Thieme
New York • Stuttgart
FM. 3/22/01 2:47 PM Page iv

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
5 4 3 2 1
TNY ISBN 1-58890-027-4
GTV ISBN 3-13-127451-4
FM. 3/22/01 2:47 PM Page v

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

FM. 3/22/01 2:47 PM Page vii

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
Department of Ophthalmology
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
Department of Ophthalmology
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
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
FM. 3/22/01 2:47 PM Page ix
George O. Stasior, M.D., F.A.C.S.
Clinical Professor
Department of Ophthalmology
Albany Medical College
Albany, NY
David T. Tse, M.D.
Professor
Department of Ophthalmology
University of Miami
Bascom Palmer Eye Institute
Miami, FL
CONTRIBUTORS • ix
Sunil N. Vasani, M.D.
Clinical Instructor
Department of Ophthalmology
UCSD School of Medicine
La Jolla, CA
Ralph E. Wesley, M.D.
Clinical Professor of Ophthalmology
Vanderbilt University Medical College
Nashville, TN, and
Clinical Professor of Ophthalmology
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.

FM. 3/22/01 2:47 PM Page xii

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
OPHTHALMIC FACIAL ANATOMY
The expanding realm of the plastic and reconstructive
ophthalmic facial surgeon demands an intimate
understanding of eyelid, lacrimal, orbital, and facial
anatomy. With improvements in technique and instru-
mentation, traditional surgical boundaries are now
being surpassed. Hence, as always, the surgeon of the
21st century must have a strong foundation in clinical
and surgical anatomy to perform successful surgery.
OPHTHALMIC FACIAL SURFACE
ANATOMY
Facial Dimensions
The face has ideal aesthetic proportions. Artists have
long recognized the visually pleasing ratios of the spe-
cific vertical and horizontal facial dimensions. The
ideal facial dimensions are five eye widths wide and
eight eye widths high.1 The ideal face also has a
slightly oval shape.
Overall facial dimensions and proportions are crit-
ical in aesthetic and reconstructive surgery. The eyes
and corresponding areas of the upper and midface
represent key aesthetic units that must be visualized
in the context of overall facial features.
Topography and Cutaneous Landmarks
The eyebrows are a foundation for the eyelids. They
typically arch above the supraorbital rim and their
lower border should lie 1 cm above the lateral portion
of the orbital rim, with its highest point directly above
the lateral limbus.2 Eyebrow cilia are directed at dif-
ferent angles in the upper and lower eyebrow. In the
upper eyebrow, the cilia are directed downward from
Chapter 1
Don O. Kikkawa and Sunil N. Vasani
the vertical plane and in the lower eyebrow, they are
directed upward from the vertical plane.3 Medially,
all cilia are directed superiorly. Brow incisions should
be planned accordingly to preserve cilia. With aging,
repeated frontalis muscle contraction creates deep
horizontal furrows in the forehead. Vertical glabellar
furrows, medial to the eyebrow, result from repeated
corrugator muscle contraction, while horizontal
glabellar furrows result from the procerus.
The adult palpebral fissures measure 9 to 11 mm
vertically and 28 to 30 mm horizontally. Ideally, the
two medial canthi are separated by one horizontal
palpebral width. The upper eyelid is positioned at the
upper limbus and may cover 1 to 2 mm of the cornea.
The highest point of the upper lid margin is just nasal
to the central pupillary axis (Fig. 1–1). The upper eye-
lid crease is formed by the terminal interdigitations of
the levator aponeurosis along the superior tarsal bor-
der.4 Typically, the eyelid crease measures 10 to 12 mm
in women and 7 to 8 mm in men. Asians have a low or
ill-defined eyelid crease because of the low insertion
of the orbital septum on the levator aponeurosis.5
The lower eyelid normally rests at the inferior lim-
bus and its lowest point is just lateral to the pupil. The
lower eyelid crease is formed from cutaneous inser-
tions of the lower eyelid retractors. The retractors con-
sists of the capsulopalpebral fascia and the inferior
tarsal muscle. It begins medially 4 to 5 mm below the
eyelid margin and slopes inferiorly as it continues lat-
erally. The malar and nasojugal folds represent the
cutaneous insertion of the orbitomalar ligament.6 Hor-
izontal skin folds (laugh lines) that emanate from the
lateral canthal angle result from skin folding due to
orbicularis oculi. With aging as well as thinning of
1
CHEN01-001-020.I 3/22/01 1:20 PM Page 2
2 • OCULOPLASTIC SURGERY: THE ESSENTIALS
Supratarsal
sulcus
Punctum
Medial
commissure
Punctum
Nasojugal
fold
Nasolabial fold
FIGURE 1–1 Normal eyelid topography.
dermis, these laugh lines become static and rhytids
develop (“crow’s feet”). The lateral canthal angle is
normally 2 mm higher than the medial canthal angle,
giving the eyelids a slight upward flare.
Surface marking of the nasolacrimal duct is seen by a
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.
The Eyebrow
The eyebrows form a key landmark of the upper
facial continuum. The skin of the eyebrows represents
a transition zone between the thinner skin of the eye-
lids and the thicker skin of the forehead and scalp.
Evaluation of eyebrow position is critical in the plan-
ning of surgery of the eyelids.
The position of the eyebrows represents a dynamic
interplay between elevating and depressing forces. The
two forces are the elevators (frontalis) and the depres-
sors (orbicularis oculi, corrugator, and procerus). A
submuscular fat pad exists under the interdigitation of
the frontalis and orbicularis muscles.7 Termed the eye-
brow fat pad or retroorbicularis oculi fat pad (ROOF),
it continues into the eyelid as the posterior orbicularis
Superior
lid crease
Superior eyelid
skinfold
Lateral
commissure
Inferior
lid crease
Malar fold
fascia.8, 9 Eyebrow fat can be mistakenly identified as
orbital fat and can be debulked in certain patients with
prominent eyebrow bulk. Submuscular fat in the eye-
brow region (ROOF) is continuous with suborbicularis
oculi fat (SOOF) of the lower lid.
...
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 Eyelids
Eyelid skin is among the thinnest of the body and is
useful for hiding cutaneous incisions. Eyelid skin
is nearly devoid of subcutaneous fat. Eyelid develop-
ment occurs through a complex inductive interaction
between mesoderm and ectoderm (Fig. 1–2). Eyelid
anomalies occur secondary to arrests in various stages
of this process.
One of the key surgical landmarks of the eyelids is
the orbital septum. The orbital septum defines the
anterior extent of the orbit and the posterior extent of
the eyelids. It arises from the arcus marginalis, a white
fibrous line that arises circumferentially along the
CHEN01-001-020.I 3/22/01 1:20 PM Page 3
Mesoderm
Frontonasal
process
Non-fusion Fusion
Between
[medial and
Colobomas lateral processes]
Upper
eyelids
Separation
at 5 months
Failure or
incomplete separation
Ankyloblepharon
FIGURE 1–2 Eyelid development.
periosteum of the bony orbital margin. In the upper
lid, the orbital septum fuses with the levator aponeu-
rosis11 at or up to 10 mm from the superior tarsal bor-
der, and in the lower eyelid it fuses with the lower
eyelid retractors just inferior to the tarsus. The orbito-
malar ligament emanates from the arcus marginalis
of the inferior orbital rim, traversing through the
orbicularis oculi to insert into the dermis of the lower
lid. 12 This cutaneous insertion corresponds to the
malar and nasojugal skinfolds. With aging, the orbit-
omalar ligament elongates and the orbital septum
attenuates, allowing orbital fat to move anterior and
sometimes herniate below the inferior orbital rim.
EARL... Surgically, the orbital sep-
P tum may be identified by a traction test
to feel its firm attachments to the orbital rim.
The backbone of each eyelid, the tarsus, is composed
of dense fibrous tissue and houses the meibomian
glands. The tarsus measures 10 to 12 mm vertically in
the upper lid and close to 4 mm in the lower eyelid.13
Conjunctiva firmly lines the inner aspect of the tarsal
OPHTHALMIC FACIAL ANATOMY • 3
Complex Inductive Interaction
of Eyelid Development
Ectoderm
Maxillary
Skin Conjunctiva
process
Lower
eyelids
Normal
eyelids
plates and reflects onto the bulbar surface of the globe.
The medial and lateral canthal ligaments anchor
the eyelids horizontally to the orbital rims. The medial
canthal ligament inserts on both the anterior and pos-
terior lacrimal crests.14 The medial canthal ligament is
associated with Horner’s muscle (the deep head of the
pretarsal and preseptal orbicularis muscle) with both
of them inserting on the posterior lacrimal crest.
Lacrimal excretory pump function is dependent on
the contraction of Horner’s muscle, which draws the
eyelids medially and posteriorly. The lateral canthal
ligament inserts on Whitnall’s tubercle.
The tarsoligamentous band normally provides the
horizontal tension to keep the eyelids opposed to the
globe. Horizontal laxity that occurs with aging leads
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-
loaponeurotic system (SMAS). The orbicularis oculi is
divided into three parts: pretarsal, preseptal, and
orbital.16 The muscle of Riolan is a small portion of the
pretarsal orbicularis that corresponds anatomically to
the gray line.17
CHEN01-001-020.I 3/22/01 1:20 PM Page 4

4 • OCULOPLASTIC SURGERY: THE ESSENTIALS

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
of the retractors of the upper eyelid. It is tendinous in
its distal 14 to 20 mm and the transition from muscu-
lar to aponeurotic portions occurs at Whitnall’s liga-
ment. The aponeurosis inserts onto the anterior tarsal
surface via an elastic fiber attachment,18 and interdig-
itates into the orbicularis muscle fibers and dermis,
creating the upper eyelid crease. Medially and later-
ally the horns of the levator anchor to periosteum
with the lateral horn of the levator dividing the
lacrimal gland into orbital and palpebral lobes.
With advancing age, the levator rarefies and may
disinsert from the tarsal attachments leading to ptosis.19
EARL ... Medial dehiscence of the
P levator can lead to horizontal instability
that may create difficulty in adequately elevat-
ing the upper eyelid during ptosis surgery.
Another manifestation is the lateral shifting of
the tarsal plate.
Müller’s muscle arises from beneath the levator
palpebrae superioris, 15 mm from the upper tarsal
border. It consists of smooth muscle and is firmly
adherent to the conjunctiva. Müller’s muscle is inner-
vated by the sympathetic nervous system and inserts
on the superior tarsal border. It provides the upper
lid an additional 2 mm of lift. Recent studies have
shown that Müller’s muscle extends laterally between
the orbital and palpebral lobes of the lacrimal gland
along with the lateral horn of the levator. Hence it
may accentuate the lateral flare of the palpebral fis-
sure frequently seen in eyelid retraction associated
with thyroid eye disease.21
The lower eyelid retractors depress the lower eye-
lid in downgaze. They consist of the capsulopalpebral
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-
tors are commonly incised during the transconjunc-
tival surgical approach, but this leads to a relatively
low incidence of postoperative eyelid malposition
(Fig. 1–4).
CHEN01-001-020.I 3/22/01 1:20 PM Page 5

OPHTHALMIC FACIAL ANATOMY • 5

FIGURE 1–4 Clinical photo of transconjunctival dissection
of lower eyelid. Note forceps pointing to lower lid retractors.
PITFALL
Disinsertion of the lower lid retractors leads to
vertical lower lid instability and is part of the
pathophysiology of both involutional ectropion
and entropion. Clinically, this may be seen by
decreased excursion of the lower lid and a
white horizontal line in the inferior fornix.
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
inserts on the alar cartilage and the upper lip. It
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
overlies the infraorbital vessels and nerve to insert in
the upper lip. Its main action is to raise the upper lip.
The levator anguli oris muscle arises inferior to the
infraorbital foramen and inserts into the angle of
the mouth. It causes the expression of contempt and
deepens the nasolabial fold. The zygomaticus major
and minor clinically appear as one complex. They
arise from the zygoma close to the zygomaticomaxil-
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
Orbicularis oculi muscle
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
6 • OCULOPLASTIC SURGERY: THE ESSENTIALS
SMAS AND SOOF
Mitz and Peyronie described the SMAS, a distinct fibro-
muscular layer that spreads out in a fan-like fashion over
the face. The SMAS functions to transmit and distribute
the facial muscle contractions to the skin. The orbicularis
oculi muscle is part of the SMAS and has a distinct bony
attachment, the orbitomalar ligament.6 With aging, the
midfacial soft tissues become ptotic, resulting in the typ-
ical biconvex topographic appearance.23
Fat located deep to the orbicularis oculi and ante-
rior to the periosteum in the midface has been termed
the SOOF.22 Its descent contributes to the formation of
“malar bags.” The SOOF varies in thickness from
medial to lateral, being most prominent in the central
and lateral positions. In the midface it engulfs the
mimetic muscles and lies superficial to the periosteum.
EARL... With proper dissection in
P the SOOF plane, either subperiosteal or
preperiosteal, the entire midface can be ele-
vated and mobilized22, 24 (Fig. 1–6).
NERVES, LYMPHATICS,
AND VASCULATURE
Both internal and external carotid arteries supply the
eyelids and midface. The external carotid artery con-
tributes the facial artery, the superficial temporal
artery, and the infraorbital artery. The facial artery
courses from below the mandible and runs superiorly
and medially; it terminates as the angular artery in the
medial canthal region. The angular artery lies 6 to
8 mm medial to the medial canthus and 5 mm anterior
to the lacrimal sac. Lacrimal and anterior orbitotomy
incisions should be planned accordingly to avoid this
FIGURE 1–6 Clinical photo of suborbicularis oculi fat
(SOOF) in left lower lid. Suture being passed through SOOF
prior to advancement to orbital rim.
artery. The superficial temporal artery lies superficial
to the muscle plane of the temporalis muscle.
The internal carotid artery contributes to the eyelid
blood supply by the terminal branches of the oph-
thalmic, lacrimal, frontal, supraorbital, and nasal
arteries. The marginal and peripheral arcades of the
upper eyelid are formed by anastomosis between
the lacrimal and nasal arteries. The marginal arcade
is located 2 to 3 mm from the upper eyelid margin,
and the peripheral arcade lies along the upper tarsal
border near its attachment to Müller’s muscle. Eyelid
reconstruction with tarsoconjunctival pedicles and
tarsal fracture techniques should avoid interruption
of the arcades if possible. The dual arcade in the lower
eyelid is much less developed.
...
P EARL The location of the super-
ficial temporal artery in the subcutaneous
plane makes this a good landmark during tem-
poral artery biopsy.
The orbital and facial veins also anastomose in the
eyelids and midface. The angular, superior oph-
thalmic and supraorbital veins all communicate
superomedially in the orbit and hence can propagate
facial infection into the cavernous sinus.
Medially, lymphatic drainage from the eyelids and
conjunctiva drains into the submandibular nodes
and laterally into the preauricular nodes.
The eyelids are innervated by the facial nerve (cra-
nial nerve VII), the oculomotor nerve (cranial nerve
III), the trigeminal nerve (cranial nerve V), and sym-
pathetic nerves from the superior cervical ganglion.
Motor innervation of the levator palpebrae superioris
and Müller’s muscle, as well as sensory innervation of
the eyelids are discussed in the orbital section, below.
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-
poroparietal fascia to avoid injury to the nerve.
CHEN01-001-020.I 3/22/01 1:21 PM Page 7

OPHTHALMIC FACIAL ANATOMY • 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 Shape and Dimensions
The shape of the bony orbit approximates a four-
sided pyramid, which becomes three sided more pos-
teriorly, due to the absence of the orbital floor
posteriorly.25 In the adult, the medial walls of the orbit
are 25 mm apart and are parallel until they converge
near the orbital apex. The anterior end of the medial
wall lies 20 mm in front of the lateral wall. The
entrance to the orbit is rectangular, measuring 40 mm
horizontally by 32 mm vertically. In adults, the depth
from orbital rim to apex varies from 40 to 45 mm.
Orbital volume is roughly 30 cc, but varies with race
and sex.
Orbital Margins (Fig. 1–7)
The orbital margin is an incomplete circle and forms a
quadrilateral spiral due to the presence of the lacrimal
sac fossa medially. The superior orbital rim is formed
in its entirety by the frontal bone. At the junction of the
medial one third with the lateral two thirds of the supe-
rior rim is the supraorbital notch (in 75% of the popu-
lation) or foramen (in 25% of the population). The
medial orbital margin is formed by three bones: the
frontal bone, the posterior lacrimal crest of the lacrimal
bone, and the anterior lacrimal crest of the frontal
process of the maxillary bone. The inferior orbital rim is
derived from the maxillary bone medially and zygo-
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

8 • OCULOPLASTIC SURGERY: THE ESSENTIALS

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
adult. The upper one fourth of the lateral orbital rim is
formed by the zygomatic process of the frontal bone
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
step is found in cases of fracture.
...
P EARL Along the lateral aspect of
the frontal process of the maxilla, a fine
groove, the sutura notha, can be found.27 This
groove lodges a branch of the infraorbital artery,
and is important when performing external
dacryocystorhinostomy in that bleeding may be
encountered from this site.
...
P EARL Blunt trauma to the fore-
head can cause indirect traumatic optic
neuropathy due to the transmission of force
along the orbital roof to the optic canal.
Medial Orbital Wall
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
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
wall and the upper limit for bone removal during
orbital decompression. The optic foramen is located
approximately 50 mm posterior from the anterior
lacrimal crest.

Orbital Walls PITFALL

Seven bones take part in the formation of the orbit:
the frontal, sphenoid, lacrimal, ethmoid, maxilla,
zygomatic, and palatine (Fig. 1–8). Of these the sphe-
noid bone is present in three of the orbital walls and
contributes some of the most important structures.
Roof
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
3 mm thick anteriorly near the frontal sinus, but it
thins posteriorly.
Cerebrospinal fluid (CSF) leaks can occur
with dissection along the medial wall. The
anterior cranial fossa is located at an average
of 8.3 mm superior to a point 10 mm poste-
rior to the medial canthal tendon.28
Orbital Floor
The orbital floor is formed primarily from the maxilla,
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
behind the posterior wall of the maxillary
sinus. Orbital floor dissection posterior to the
inferior orbital fissure could damage this
major vessel.
Lateral Wall
The lateral orbital wall divides the orbit from the tem-
poralis muscle anteriorly and the middle cranial fossa
posteriorly. It is composed of the zygoma and the
greater wing of the sphenoid. Landmarks of the lat-
eral orbital wall include Whitnall’s lateral orbital
tubercle, and the zygomaticotemporal and zygomati-
cofacial foramina. The posterior boundary of the lat-
eral orbital wall is the superior and inferior orbital
fissures. Whitnall’s tubercle is located approximately
3 to 4 mm behind the orbital rim and 11 mm inferior
to the frontozygomatic suture.29 It is an insertion site
for the lateral canthal ligament, the deep pretarsal
orbicularis insertion, the lateral horn of the levator
aponeurosis, the check ligament of the lateral rectus
muscle, the superior (Whitnall’s) and inferior (Lock-
wood’s) transverse ligaments, and an expansion of
the superior rectus muscle sheath.30
During lateral orbitotomy, the zygomaticosphe-
noid suture is a natural breaking point for removal of
the lateral rim. If further removal of bone is desired,
deeper dissection within the greater wing of sphenoid
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 Deep lateral wall removal
can be safely done during orbital decom-
pression. Dural exposure can occur if the inner
aspect of the greater sphenoidal wing is
removed (Fig. 1–9).
OPHTHALMIC FACIAL ANATOMY • 9
FIGURE 1–9 Clinical photo showing marrow space of
greater wing of sphenoid during orbital decompression.
Lateral orbital rim and wall have been removed.
Orbital Apex (Fig. 1–10)
Three key orbital apex landmarks—the optic foramen,
the superior orbital fissure, and the inferior orbital fis-
sure—communicate with the intracranial cavity,
pterygopalatine fossa, and paranasal sinuses.
The superior orbital fissure lies between the greater
and lesser wings of the sphenoid. The annulus of Zinn
divides the fissure into three parts. The trochlear,
frontal, and lacrimal nerves, the superior ophthalmic
veins, and the recurrent lacrimal artery pass through
the upper part. The superior division of the third
nerve, the nasociliary nerve, the sympathetic root of
the ciliary ganglion, the inferior division of third
nerve, and the abducens nerve are in the middle sec-
tion. The inferior part has the ophthalmic veins.
The inferior orbital fissure is bounded laterally by
the greater wing of the sphenoid and medially by the
palatine and maxillary bones. The inferior orbital fis-
sure communicates with both the pterygopalatine and
infratemporal fossae. Blood from the temporalis fossa
can reach the orbit through this communication. The
maxillary division of the trigeminal nerve, the infra-
orbital artery, the inferior orbital vein, and autonomic
branches from the pterygopalatine ganglion pass
through the inferior orbital fissure.
...
P EARL The infraorbital artery
gives blood supply to the inferior rectus
and inferior oblique muscles. The surgeon
should be aware of these branches during infe-
rior orbitotomy.32
The optic foramen, located in the lesser wing of the
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

10 • OCULOPLASTIC SURGERY: THE ESSENTIALS

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
but can enlarge with pathologic processes. The optic
strut separates the optic foramen from the superior
orbital fissure. 33 The optic nerve is vulnerable to
injury within the canal.34, 35
Although the medial aspect of the optic canal is pri-
marily formed by the sphenoid, in approximately 50%
of cases posterior ethmoid air cells are present.25, 36
This variability should be considered when perform-
ing extracranial optic canal decompression and pos-
terior ethmoidectomy during orbital decompression.
The posterior ethmoidal foramen is an important
landmark in the orbital apex. The medial optic canal
ring, the opening of the optic canal, is located 6 mm
posterior to the posterior ethmoidal artery.37
Periorbita
The periorbita is a thick fibrous layer that internally
lines the bony orbit. Anteriorly, it is continuous with
the periosteum, and forms the arcus marginalis, the
origin of the orbital septum. In the orbital apex,
the periorbita lines the superior orbital fissure, the
inferior orbital fissure, and optic canal, and is contin-
uous with dura.
The periorbita provides a protective boundary for the
intraorbital contents from adjacent disease processes,
limiting spread of infections and tumors. The subperi-
orbital space is an excellent surgical plane because of
the ease with which the periorbita can be dissected from
the bone with minimal resulting hemorrhage.
Orbital Fascia
Studies by Koornneef38, 39 have shown that the globe
and orbital soft tissues are suspended in a complex,
organized connective tissue matrix (Fig. 1–11A). This
network is divided into three parts: Tenon’s capsule
(fascia bulbi), the extraocular muscles fascial sheaths
(Fig. 1–11A, 2), and the extensions and check liga-
ments that attach the muscle sheaths to the periorbita
and eyelids (Fig. 1–11A, 3).
Fascia Bulbi
Tenon’s capsule fuses with the bulbar conjunctiva
anteriorly, and is composed of fibroelastic tissue. It
CHEN01-001-020.I 3/22/01 1:21 PM Page 11

OPHTHALMIC FACIAL ANATOMY • 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
attached to the globe. Externally it attaches to the
fibrous septa of the orbital fat.
...
P EARL Anterior Tenon’s capsule,
when closed properly, provides the strong-
est barrier to extrusion of an orbital implant
following enucleation.
the levator, just at the transition from the aponeu-
rotic to the muscular portions of the levator 42
(Fig. 1–11B).
Lockwood’s ligament arises from the fused fascia
of the inferior rectus and inferior oblique muscles.43 It
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-
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
12 • OCULOPLASTIC SURGERY: THE ESSENTIALS
FIGURE 1–12 Clinical photo showing preaponeurotic
fat pad, right upper eyelid.
Superior orbital fat is divided into two distinct
compartments, the preaponeurotic and the medial fat
pads (Fig. 1–12). They are separated by the trochlea.
The preaponeurotic fat pad, which is more yellow in
color, extends laterally over the lacrimal gland to the
superior edge of the lateral rectus muscle. 47 The
medial fat pad, being firmer and pale white in color, is
associated with the medial palpebral artery and the
infratrochlear nerve. Deeper anesthetic placement is
usually required for removal of this fat pad during
blepharoplasty. Because of their close relationship to
the trochlea, superior oblique palsy and Brown’s syn-
drome have been reported from injury during upper
eyelid blepharoplasty.48
The inferior orbital fat can be divided into three
compartments.49 The medial fat pad is separated from
the central fat by the inferior oblique muscle. The
Preaponeurotic fat
Lacrimal
gland
Temporal
fat pad
Arcuate
expansion
of inferior
oblique
muscle
FIGURE 1–13 Clinical compartments of anterior orbital fat.
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
to approach the inferior orbital rim.
Vasculature
The ophthalmic artery, the first branch of the internal
carotid artery, provides the major blood supply to the
orbit. The external carotid artery also contributes via
the middle meningeal and maxillary arteries.
The main venous drainage system of the orbit
occurs via the superior and inferior ophthalmic veins,
which lie within the connective tissue septa. The larger
superior ophthalmic vein (SOV) arises superomedially
near the superior oblique tendon with contributions
from the angular, supraorbital, and supratrochlear
veins. It travels near the medial aspect of the superior
rectus muscle, then enters the muscle cone and
receives branches from ciliary and superior vortex
veins. The SOV then travels beneath the superior rec-
tus muscle along the lateral border of the muscle to
enter the superior orbital fissure and subsequently the
cavernous sinus. The SOV hammock is a connective
Trochlea
Nasal fat pad
Lacrimal sac
Nasal fat pad
Inferior oblique
muscle
Central
fat pad
CHEN01-001-020.I 3/22/01 1:21 PM Page 13
tissue structure seen on magnetic resonance imaging
(MRI), which supports the SOV in its course. The ham-
mock courses from the lateral rectus toward the super-
omedial orbital wall.50 The smaller, more variable,
inferior ophthalmic vein (IOV) forms along the orbital
floor from a plexus with contributions from the infe-
rior extraocular muscles and inferior vortex veins. The
IOV then courses posteriorly along the inferior rectus
muscle and then empties into either the SOV or inde-
pendently into the cavernous sinus.
Although the orbit has been traditionally thought
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
Orbital Nerves
Five of the twelve cranial nerves (CNs) supply the
orbit. Along with sympathetic and parasympathetic
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,
surrounded by circulating CSF, and containing neu-
roglial cells. The nerve has intraocular, intraorbital,
intracanalicular, and intracranial segments. The optic
nerve is formed by retinal ganglion cells axons and exits
the globe at the lamina cribrosa. This intraocular seg-
ment is 1 mm long and 3 mm in diameter.52 The intra-
orbital segment measures 24 mm, 6 mm longer than the
direct length between the sclera and the opening of the
optic foramen. This slack allows unrestricted globe
movement and some slack if proptosis should occur.
...
P EARL Globe tenting, a radiologic
sign, is seen with severe proptosis, caus-
ing optic nerve tethering on the back of the
globe.53 If the posterior scleral angle is less than
90 degrees, severe tension is present (Fig. 1–14).
FIGURE 1–14 Computed tomography (CT) scan of
patient with left orbital abscess. Note stretching of left optic
nerve with globe tenting.
OPHTHALMIC FACIAL ANATOMY • 13
The oculomotor nerve (CN III) divides into supe-
rior and inferior divisions within the cavernous sinus
prior to entering the orbit. The two divisions enter
the orbit through the superior orbital fissure, sepa-
rated by the nasociliary nerve. The superior division
supplies the superior rectus and the levator. The infe-
rior division enters the intraconal space beneath the
optic nerve and supplies the medial rectus, inferior
rectus, and inferior oblique. The branch to the infe-
rior oblique carries pupillomotor fibers to the ciliary
ganglion.
PITFALL
Injury to the nerve has been described in
patients undergoing repair of orbital floor
fractures, causing pupillary dilation.54
The trochlear nerve (CN IV) enters the orbit out-
side the annulus of Zinn through the superior orbital
fissure. It is unique in four aspects: it is the only motor
nerve to the extraocular muscles that remains outside
the muscle cone, it has the longest intracranial course,
it arises from the brainstem dorsum, and it completely
decussates.
The abducens nerve (cranial nerve VI) enters the
orbit through the superior orbital fissure within
the annulus. It travels between the optic nerve and the
lateral rectus muscle to innervate the muscles through
its inner surface.
The ophthalmic AV1 B and maxillary AV2 B divisions
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
through the superior orbital fissure and divides into
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-
moidal nerves, several long ciliary nerves, a sensory
root to the ciliary ganglion, and the infratrochlear
nerve.
CHEN01-001-020.I 3/22/01 1:21 PM Page 14
14 • OCULOPLASTIC SURGERY: THE ESSENTIALS
The maxillary division AV2 B enters the ptery-
gopalatine fossa through the foramen rotundum.
After branching as the zygomatic, sphenopalatine,
and posterosuperior alveolar nerves, the majority of
the nerve enters the orbit via the infraorbital fissure
as the infraorbital nerve. The zygomatic nerve
becomes the zygomaticofacial and zygomaticotempo-
ral nerves. The zygomaticofacial nerve exits through
its named foramina to supply the cheek, while the
zygomaticotemporal nerve passes through its named
foramen into the temporalis fossa to innervate the lat-
eral forehead. The infraorbital nerve exits the infraor-
bital foramen to supply the lower eyelid, the lateral
aspect of the nose, and the upper lip.
Sympathetic nerve supply to the orbit causes pupil-
lary dilation, Müller’s and inferior tarsal muscle con-
traction, vasodilation, and hidrosis. Sympathetic
nerve fibers begin in the superior cervical ganglion
and enter the cavernous sinus surrounding the inter-
nal carotid artery.
Parasympathetic nerves supply the ciliary muscle,
pupilloconstictor fibers, lacrimal gland innervation,
and vasodilatory fibers. Preganglionic fibers from the
Edinger-Westphal nucleus destined for the orbit
travel with the inferior division of the oculomotor
nerve and, as mentioned previously, course with
the nerve to the inferior oblique. They then synapse
in the ciliary ganglion before postganglionic fibers
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
thought is that lacrimal gland innervation is supplied
by the nervus intermedius portion of the facial nerve.
The ciliary ganglion is located between the lateral
rectus and the optic nerve approximately 15 mm pos-
Sphenoid sinus Ethmoidal
ostium ostia
Middle
turbinate
Inferior
turbinate
FIGURE 1–15 Lateral wall of the nose.
terior to the globe. Parasympathetic fibers synapse in
the ganglion, while sympathetic and sensory axons
pass through. Several short ciliary nerves exit the cil-
iary ganglion, the majority of which supply the globe
lateral to the optic nerve.
NOSE AND PARANASAL SINUSES
Because of the proximity to the orbit, paranasal sinus
diseases often present with orbital signs. Thus, it
behooves the orbital surgeon to be familiar with nasal
and sinus anatomy. The nasal cavity is divided into
two parts by the nasal cartilaginous septum and the
vomer of the ethmoid bone. The turbinates (inferior,
middle, superior, and sometime supreme) are located
on the lateral nasal wall, and the space below each
turbinate is named respectively. The inferior turbinate
is the largest, whereas the smaller middle and supe-
rior turbinates arise from the ethmoid bone. The mid-
dle turbinate is easily seen on external examination.
...
P
EARL The turbinates function to
moisturize the inhaled air, filter particu-
late matter, and provide resistance during
inhalation. Due to their importance, attempts
should be made to preserve them during naso-
lacrimal procedures.
The maxillary sinus is the largest of the sinuses.
Due to its predominantly inferior growth, the maxil-
lary sinus drains superiorly into the hiatus semilu-
naris just posterior to the uncinate process of
the middle meatus (Fig. 1–15). Relationships of the
Frontonasal
ostium
Frontonasal
duct
Ethmoidal bulla
Uncinate process
Semilunar hiatus
Maxillary sinus
ostium
Nasolacrimal
duct ostium
CHEN01-001-020.I 3/22/01 1:21 PM Page 15
FIGURE 1–16 CT scan (axial view) of ethmoid and sphe-
noid sinuses. Note opacification of right anterior ethmoidal
air cells.
maxillary sinus include the nasolacrimal duct medi-
ally, and the pterygopalatine fossa and maxillary
artery posteriorly. Creation of nasal antral window
can injure the nasolacrimal duct.
The ethmoid sinuses arise during the fifth month
of gestation and continue to expand until puberty.
The ethmoid sinus is the most exhuberant sinus and
it may pneumatize the frontal, sphenoid, palatine,
and lacrimal bones. The ethmoids are best visual-
ized as a box that is slightly wider posteriorly
(Figs. 1–16 and 1–17). Anterior and middle air cells
drain into the middle meatus, whereas posterior air
cells open into the superior meatus. Anterior eth-
moidal air cells can extend anteriorly past the pos-
terior lacrimal crest,25, 55 and may be encountered
during dacryocystorhinostomy.
PITFALL
Ethmoidectomy performed endoscopically or
externally can breach the lamina papyracea of
the medial orbital wall, placing the medial
rectus and optic nerve at potential surgical
risk.56
The frontal sinus expansion begins at about 6 years
of age and continues until adulthood. The frontal
sinus is divided by a midline septum and is a com-
mon site for mucocele development. It drains via the
nasofrontal duct.57
The sphenoid sinus is pneumatized to a variable
degree. Ethmoidal air cells may pneumatize the sphe-
noid sinus. It typically has a midline septum and
drains into the sphenoethmoidal recess. The lateral
wall of the sphenoid sinus has a close relationship
OPHTHALMIC FACIAL ANATOMY • 15
FIGURE 1–17 CT scan (coronal view) of ethmoidal and
maxillary sinuses. Note orbital strut found at the junction
of ethmoid and maxillary sinuses.
with the internal carotid artery, the optic nerve, and
the cavernous sinus.
GLOBE AND EXTRAOCULAR MUSCLES
The globe is located slightly superior and lateral to the
center of the anterior orbit. The front surface of the
globe is in the same plane as the superior, medial, and
inferior orbital rims but is anterior to the lateral rim by
12 to 18 mm. Changes in eye position occur with
aging when measured by exophthalmometry, orbital
width, and interpupillary distance.58 Exophthalmom-
etry readings generally increase until age 20. In the
elderly, interpupillary distance increases, most likely
due to atrophic changes.
All extraocular muscles arise from the orbital apex
except the inferior oblique. The four recti muscles
arise from the annulus of Zinn; the levator muscle and
superior oblique originate superomedially from the
lesser wing of the sphenoid; and the inferior oblique
arises from the orbital floor anteriorly, just lateral to
the lacrimal sac.
LACRIMAL SYSTEM (FIG. 1–18)
Secretory System
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
lacrimal gland is divided into a larger orbital lobe and
a smaller palpebral lobe by the lateral horn of the lev-
ator (Fig. 1–19).
The orbital lobe molds within the space between
the globe and the lateral orbital wall. The palpebral
lobe resides beneath the levator aponeurosis and is
separated from the conjunctiva by Müller’s muscle.
Lacrimal gland prolapse can occur with laxity of the
attachments, causing a noticeable bulge in the lateral
portion of the upper eyelid.
CHEN01-001-020.I 3/22/01 1:21 PM Page 16

16 • OCULOPLASTIC SURGERY: THE ESSENTIALS

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
through the palpebral lobe or stay very close to it, to
open into the superotemporal conjunctival fornix.
Both sympathetic and parasympathetic fibers
innervate the lacrimal gland. The lacrimal gland is
supplied by the lacrimal artery and from a branch of
the infraorbital artery. Recent studies show that the
lacrimal artery also supplies the lateral aspect of
Müller’s muscle.59
The accessory lacrimal glands of Krause and Wol-
fring lack parasympathetic innervation. Approxi-
mately 20 accessory lacrimal glands are present in the
superior conjunctival fornix, and about half that num-
ber are present in the lower eyelid. Because they do
not have parasympathetic innervation, the accessory
glands are thought to be basic secretors, with the main
lacrimal gland responsible for reflex tearing.60
Excretory System
Tear flow and excretion is a dynamic process depen-
dent on eyelid blinking. Tear excretion begins in the
puncta, which measure 0.3 mm in diameter and are
normally in firm opposition to the globe.
EARL... Usually not visible on ex-
P
ternal examination, if the puncta can be
seen without eyelid eversion, punctal ectropion
is present.
CHEN01-001-020.I 3/22/01 1:21 PM Page 17
Levator
aponeurosis
Orbital lobe
of lacrimal
gland
Ductules
Palpebral
lobe of
lacrimal gland
FIGURE 1–19 Orbital and palpebral lobes of lacrimal gland.
The upper and lower canaliculi measure 2 mm ver-
tically and 8 mm horizontally. Most of the time, the
canaliculi join to form a common canaliculus, located
within the central portion of the medial canthal liga-
ment (Fig. 1–20). The valve of Rosenmüller is a func-
tional valve present at the opening of the common
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
development of dacryocystitis. Recent studies have
found that the canaliculi bend posteriorly behind the
medial canthal ligament, then anteriorly to enter
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
The lacrimal sac is located within the bony lacrimal
fossa and is covered by periorbita and surrounding
fascia, making it technically external to the orbit. The
sac measures 12 mm vertically, with 4 mm of it being
superior to the medial canthal ligament. The
intraosseus nasolacrimal duct measures 12 mm and it
extends an additional several millimeters into the
inferior meatus.
REFERENCES
The authors wish to acknowledge Alexander Lee,
B.A., for his assistance with reference research.
1. Tolleth H: Concepts for the plastic surgeon from art
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2. Shorr N, Seiff SR: Cosmetic Blepharoplasty: An Illustrated
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OPHTHALMIC FACIAL ANATOMY • 17
Superior canalicus
Common canalicus
Valve of Rosenmüller
Lacrimal sac
Valve of Krause
Spiral valve of Hyrtl
Inferior canalicus
Valve of Taillefer
Nasolacrimal duct Inferior turbinate
Valve of Hasner
FIGURE 1–20 Nasolacrimal excretory system.
The nasolacrimal duct opens beneath the inferior
turbinate, but can extend to the nasal floor.62 The
valve of Hasner is typically present at the opening
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Because of this relationship, maxillary sinus masses
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EARL... Lacrimal sac swelling sec-
P ondary to infection typically occurs infe-
rior to the medial canthal ligament. Swelling
superior to the medial canthal ligament is a
warning sign of a lacrimal sac malignancy.
SUMMARY
Integrated knowledge of the superficial and deep lay-
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essential for the clinical practitioner who deals with
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orbit, and surrounding adnexa. This chapter provides
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CHEN02-021-040.I 3/26/01 8:23 AM Page 21
FUNDAMENTALS OF
OCULOPLASTIC SURGERY
Oculoplastic surgery draws upon a wide variety of
techniques and disciplines, but has emerged in recent
years as a distinct subspecialty. Although general and
periocular plastic procedures have been described as
early as the 6th or 7th century B.C., contributions from
other disciplines have led to a plethora of oculoplastic
techniques; such specialties including general plastic
and reconstructive surgery, otorhinolaryngology,
neurosurgery, neuroradiology, dermatology, and
radiation oncology.1, 2 Many oculoplastic procedures
are now available to treat any distinct surgical entity,
but adherence to the basic principles outlined below
will generally provide a good result with minimal
scarring and excellent aesthetics.
EVALUATION
Oculoplastic surgery is largely performed for func-
tional reasons, but aesthetic factors are invariably
involved. It is therefore important to evaluate the
patient from a medical, functional, aesthetic, and psy-
chological perspective.
An appropriate history and physical examination
is mandatory in all patients, with particular attention
directed toward factors that may cause problems dur-
ing or after surgery. Risk factors for intraoperative
hemorrhage should be sought, including hyperten-
sion, liver disease, anticoagulation therapy, and treat-
ment with vitamin E, aspirin, or nonsteroidal
antiinflammatory agents. Such medications should be
stopped at least 14 days prior to surgery, although
anticoagulants cannot always be discontinued—as,
for example, in patients with mechanical heart valves;
in these cases anticoagulation should be reduced to a
Chapter 2
Dipak N. Parmar and Geoffrey E. Rose
minimum acceptable level by an internist. Alterna-
tively, a rapidly reversible agent, such as intravenous
heparin, may be used to maintain anticoagulation
during the perioperative period, before full oral anti-
coagulation is resumed. Conditions that may cause
immune suppression and predispose to postoperative
infection should be sought, including diabetes melli-
tus, human immunodeficiency virus infection,
chemotherapy, or transplant-related immunosup-
pression. Specific inquiry for previous periocular
surgery, trauma, or radiation should be made, the lat-
ter alerting the physician to the possibility of induced
malignancy. A family medical history is important to
exclude hereditary disorders, such as malignant
hyperthermia and congenital ptosis.
A problem-oriented general, ophthalmic, and
oculoplastic examination should be performed and
this also provides a time to gain rapport with the
patient, a rapport vital to determining the patient’s
expectations for surgery and whether these can be
realistically achieved. Functional and aesthetic con-
siderations are closely linked in oculoplastic surgery
and so it is important to identify the patient who is
psychologically unstable.3, 4 Such cases are unsuitable
for aesthetic surgery and require a prompt reevalua-
tion of the indications for functional surgery.
Most nonorbital oculoplastic surgery is performed
under local anesthesia, with the option of monitored
intravenous sedation, and hence little preoperative
workup is required from the anesthetic aspect. Optic
nerve function may be assessed in orbital disease by
color vision testing, visual field analysis, and possi-
bly visual-evoked potentials, whereas lacrimal prob-
lems may entail dacryocystography. Computed
21
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22 • OCULOPLASTIC SURGERY: THE ESSENTIALS

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)

WOUND HEALING
An understanding of cutaneous wound healing is
important for the oculoplastic surgeon and has been
traditionally divided into two categories.7, 8 Primary
wound healing, or healing by primary intention,
occurs when wound edges are apposed as they are in
a sutured surgical wound. Conversely, secondary
wound healing, or healing by secondary intention,
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
by 4 weeks an equilibrium is reached. An acellular
“ground substance” produced during this phase is
essential for fibroblast proliferation and collagen syn-
thesis, being rich in chondroitin sulfate, hyaluronic
acid, and other mucopolysaccharides.
Maturation Phase (Week 4 to Several Years)
Fibroblasts leave the wound during this phase fol-
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

24 • OCULOPLASTIC SURGERY: THE ESSENTIALS

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-
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
a two-stage injection technique using a 28-gauge nee-
dle to initially inject a mixture of dilute local anes-
thetic before infiltrating with the complete mixture.
The first-stage injection consists of lidocaine 0.1% in
injectable saline solution, warmed to body tempera-
ture if possible, and is followed by the full-strength
second-stage injection a few minutes later.
Asepsis
Oculoplastic surgery is performed in a modern oper-
ating theater environment exercising standard meth-
ods of infection control. Aqueous povidone-iodine
solution is used to clean and prepare the skin,
although chlorhexidine may be substituted if the
patient is allergic to iodine. Because these substances
are irritating to the conjunctiva, it is important to irri-
gate the eye immediately if there is inadvertent
exposure.
Due to the extensive palpebral vascular supply, the
eyelids are remarkably resistant to infection. The role
of prophylactic antibiotics before and during surgery
is controversial, but may be of value in cases involv-
ing the sinuses, trauma, preoperative infection, or
orbital or lacrimal reconstruction.16, 17
1
2
3
FIGURE 2–3 Oculoplastic incisions showing (1) upper lid
skin crease approaches, (2) lateral canthal, and (3) transcon-
junctival.
Incisions
The ideal incision allows maximal access to the sur-
geon while minimizing visible scarring. A preopera-
tive discussion with the patient regarding the skin
incision is mandatory and the site marked before infil-
tration with local anesthetic.
A cutaneous scar can be avoided altogether by
using transconjunctival approaches for eyelid or
orbital surgery (Figs. 2–3 and 2–4).18 Alternatively, the
scar may be hidden by the hairline as is the case with
a coronal incision for endoscopic brow lifting. The
incision should be placed in preexisting skin creases
where possible, utilizing, for example, the upper lid
skin crease for surgery in the upper part of the orbit.19
Otherwise incisions should be aligned parallel to the
relaxed skin tension lines of the face (Fig. 2–5).20
The skin is held taut, to avoid beveling or irregular
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

FUNDAMENTALS OF OCULOPLASTIC SURGERY • 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

FIGURE 2–5 Relaxed skin tension lines of the face,
including periocular skin.
to the surface to reduce scarring. An exception is in
hair-bearing areas, such as the brow or scalp, where
the incision is angled parallel to the hair shafts to
avoid damage to the follicles. The incision is com-
pleted in a single steady motion, starting from the
lowest point of the operating field and working
upward, so as to avoid blood obscuring the view.
Consideration of the lymphatic drainage is impor-
tant before any lid surgery, since a poor lymphatic
outflow can adversely affect wound healing
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
always be sharp. The size of instrument chosen should
also be of appropriate strength, such that the rugged
Adson forceps is used for scalp flaps requiring trac-
tional manipulation, whereas the smaller, toothed
Jayle’s forceps are more suitable for eyelid work with
relatively stationary tissue handling. Similarly West-
cott spring-action scissors are extremely useful for fine
work, whereas the sharp straight scissors are better
suited for cutting tougher tissues, such as skin flaps or
large skin-muscle flaps. Fine skin hooks are of particu-
lar use in retracting tissue flaps with minimal trauma.
Orbital and lacrimal surgery demand sturdier
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
26 • OCULOPLASTIC SURGERY: THE ESSENTIALS
drills, and plating sets. Endoscopic surgical instru-
mentation now permits a further means of accessing
lacrimal and orbital structures, allowing transnasal
lacrimal surgery and posterior orbital work such as
orbital or optic canal decompression.22
A scalpel with a disposable supersharp blade, such
as the Bard-Parker 15, is excellent for most skin inci-
sions. Alternatively, the carbon dioxide laser or high-
frequency unipolar cutting electrocautery enable
virtually bloodless dissection and are appropriate in
revision surgery with markedly vascular scar tissue.
EARL ...
P Use toothed forceps of
appropriate size to avoid crushing tissue
during manipulation.
Hemostasis
The rich vascular supply of the eyelids and ocular
adnexa promotes healing and reduces the risk of
infection, but also makes hemostasis a challenge.
Excessive hemorrhage prolongs operating time and
may lead to a postoperative orbital hematoma, which
may impede wound healing or lead to visual loss.
A history of abnormal bleeding should be specifi-
cally sought and the patient’s medication list scruti-
nized. Aspirin and nonsteroidal antiinflammatory
drugs should be stopped at least 14 days before
surgery, although it may not be possible to discon-
tinue anticoagulants in certain patients. If surgery is
essential in these cases, admission to hospital and con-
version to intravenous heparin may be required, this
being stopped just prior to surgery and recommenced
postoperatively.
Perioperative blood pressure control should be
optimal, ensuring that patients continue to take their
medications if hypertensive, and hypotensive anes-
thesia may be required for complex orbital surgery.
Addition of vasoconstricting drugs, such as 1 : 100,000
epinephrine, to infiltration local anesthesia signifi-
cantly reduces intraoperative hemorrhage. Similarly,
topical intranasal cocaine 4%, intranasal oxymetazo-
line 0.05%, or conjunctival phenylephrine 2.5% or 10%
may be used during nasolacrimal or transconjuncti-
val surgery to markedly reduce hemorrhage at these
sites.
Intraoperative hemostasis is achieved using pres-
sure tamponade, cautery, and topical thrombogenic
drugs.23 Pressure tamponade represents the simplest
method, but has the disadvantage of taking a rela-
tively long time (up to 10 minutes) to achieve control
and often produces a rather fragile clot, which can be
easily dislodged.
Cautery allows immediate intraoperative hemo-
stasis with minimal tissue destruction and is achieved
using thermal, electrocautery, or laser modalities. Bat-
tery-powered high-temperature thermal cautery
(2200°C) is useful for oculoplastic surgery, unlike the
low temperature (1000°C) instrument, which is only
suitable for conjunctiva or fine ocular tissues.
High-frequency electrocautery (diathermy) can be
used for dissecting as well as cauterizing tissue,
depending on the electromagnetic waveform emanat-
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
or coagulation.24 Since current passes through the
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-
trode and allows direct coagulation of vessels that can
be held between the diathermy forceps. It is also use-
ful for shrinking prolapsed orbital fat during surgery,
which obviates the risk of bleeding associated with
excising fat. Bipolar electrocautery provides highly
localized coagulation and, therefore, is ideal when
working in the posterior part of the orbit where the
optic nerve would otherwise be at significant risk of
injury.25 The carbon dioxide laser can also be used for
cutting or coagulation, depending on the intensity
and duration of the beam, and is particularly useful in
the presence of vascular scar tissue.26
Topical thrombogenic agents are useful when hem-
orrhage is so diffuse that cautery is impractical, as
seen with the mucosal surface bleeding during an
external dacryocystorhinostomy. Examples include
absorbable gelatin foam (Gelfoam), charged collagen
products (Collistat, Helistat), oxidized cellulose (Sur-
gicel, Oxycel) and microfibrillar collagen (Avitene).
All may be left in the eyelids or orbit, apart from the
oxidized cellulose products, which cause unaccept-
able degrees of inflammation. Bone wax is extremely
useful to control bleeding from the bone and can be
applied directly to sites of hemorrhage, especially
during orbital surgery.
Suture Materials
A wide variety of sutures are available to the oculo-
plastic surgeon and these can be broadly classified
into absorbable or nonabsorbable types. They may be
braided or monofilament, and constructed from nat-
ural or synthetic material (Tables 2–1 and 2–2). Con-
siderations influencing choice of suture include tissue
type, wound tension, potential for tissue reaction and
infection, handling characteristics, patient tolerance,
and pigmentation.
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FUNDAMENTALS OF OCULOPLASTIC SURGERY • 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

28 • OCULOPLASTIC SURGERY: THE ESSENTIALS

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
(Figs. 2–8 and 2–9B).)
Wound edges should be approximated with slight
eversion, as they tend to invert during healing, and
this is particularly important with lid margin closure
where even slight inversion leads to an obvious notch.
When viewed in cross section an everting suture
should be of trapezoidal configuration, whereby more
deep tissue is included than skin (Fig. 2–9A).
Many techniques can be applied for effective clo-
sure, but it is important to adhere to the principles
outlined above: Interrupted sutures are effective when
there is little tension on the wound, and may be mod-
ified with a running technique for longer incisions.
Although the placement of these may be technically
challenging, a figure-of-eight suture may be used and
has the advantage of a lack of tissue reaction to the
buried component, which is removed at the same
time as the superficial portion (Fig. 2–9C).
The end-on vertical mattress suture and the near-far,
far-near sutures also provide excellent ways of elimi-
nating dead space and relieving tension (Fig. 2–9D,
E). These sutures tend to suppress local circulation
and should be alternated with simple interrupted
CHEN02-021-040.I 3/22/01 1:25 PM Page 29
A A'
C D
F
sutures if possible. The horizontal mattress suture is
useful in providing broad areas of support and is
quickly placed as, for example, at the retroauricular
donor site for skin grafting (Fig. 2–9F).
Subcuticular running sutures offer an aesthetically
desirable skin closure and serve to finely appose skin
A
FIGURE 2–10 Superficial skin closure using (A) subcuticular running suture or (B) half-buried horizontal mattress
suture at a tripartite junction.
FUNDAMENTALS OF OCULOPLASTIC SURGERY • 29
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
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.
edges, while minimizing the effect of suture materi-
als on the epidermis; they do, however, first require
tension-free subcutaneous closure (Fig. 2–10A). The
suture ends may be anchored, or left free for ease of
removal. Half-buried horizontal mattress sutures offer
an excellent way to close skin at a tripartite junction,
B
CHEN02-021-040.I 3/22/01 1:25 PM Page 30
30 • OCULOPLASTIC SURGERY: THE ESSENTIALS
serving to bring the tips together without actually
involving them in the suture bite (Fig. 2–10B).
EARL... Minimize scarring during
P wound closure by eradicating dead space
and relieving wound tension with deep sutures.
Evert wound edges slightly with the skin sutures.
A “dog-ear” is a relatively common problem due to
redundant tissue with unequal incisions and with cir-
cular or short elliptical incisions. The dog-ear may be
excised as a second ellipse, to elongate the wound, and
closed directly (preferably along the lines of relaxed
skin tension) (Fig. 2–11A, B). Another approach is to
use an “M-Y plasty,” to remove two small triangles
either side of the ellipse, with the tip at the end of the
linear incision (Fig. 2–11C).
Tissue Glue
Tissue glues, such as fibrin and cyanoacrylate-based
adhesives, represent an alternative to sutures for
wound closure.27, 28 The speed of application and the
lack of suture removal make this method ideal for
children. Glues can generally be used for superficial
lacerations, but may be combined with subcutaneous
sutures for deeper wounds; they cannot, however, be
used for eyelid margin wounds, because the wounds
are highly mobile and under considerable tension,
and they require precise alignment. Lower lid ble-
pharoplasty incisions have been successfully closed
with fibrin glue (Tissucol). Isobutyl cyanoacrylate
(Histoacryl) and the stronger, longer carbon-chained
FIGURE 2–11 Management of “dog-
ear” during wound closure. (A) Exci-
sion of ellipse with direct linear closure.
(B) Closure directed laterally toward
relaxed skin tension line. (C) M-Y plasty
directing closure along arms of Y.
2-octyl cyanoacrylate (Dermabond) have been used
for closure of eyelid skin grafts and facial lacerations
with impressive results.
WOUND CARE AND DRESSINGS
Appropriate wound management is essential for opti-
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
and ecchymosis, as well as inducing relative analgesia
through local hypothermia.
In most cases a firm, but not heavily pressured, pad
provides a compressive dressing that absorbs tissue
fluid or hemorrhage and protects the incision. It must
be readily removable should inspection of the eye be
needed, if severe and increasing pain suggests a sight-
threatening postoperative orbital hemorrhage. The
patient and staff should be advised to warn the sur-
geon of increasing postoperative pain, as evacuation
of the hematoma might be required to prevent com-
pressive optic neuropathy.
In contrast, orbital surgery in the anophthalmic
socket necessitates very firm dressings to discourage
edema or ecchymosis, which can be extensive in
major socket reconstruction. A thick eye dressing or
double eye pad is secured with a very firm elastic
adhesive strapping, using tincture of benzoin to
improve adherence if so wished. A head bandage
may be used to increase pressure on the operative site.
Scar Management
Adherence to the principles of wound closure out-
lined above is likely to minimize scar formation.
C
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FUNDAMENTALS OF OCULOPLASTIC SURGERY • 31

Occasionally, however, a hypertrophic scar develops
and this may be managed conservatively in the first
instance, using massage with topical lubricant or
steroid (such as triamcinolone) cream. A steroid
may also be injected intradermally, although this may
cause dermal atrophy and loss of pigmentation, a par-
ticular problem in heavily pigmented skins. Keloid
represents an exuberant healing response extending
into tissue surrounding the scar, and may be man-
aged in a similar fashion to hypertrophic scars. For-
tunately, keloid is almost never seen in eyelid skin,
the mechanism of this unique attribute not yet being
understood.29
Scar Revision
Scar revision should not be attempted until at least 6
months of wound healing have elapsed and the active
contraction phase has passed. A realistic outcome is
an improvement in the appearance of the scar, rather
than its complete removal. The methods available
include dermabrasion, excision with dermabrasion,
excision with platform techniques, and redistribution
of scar tension (Z-plasty or W-plasty).29
Dermabrasion is an excellent technique for smooth-
ing the rough edges of a skin graft using a power-
driven drill with a rounded burr to abrade the
epidermal layer and “sculpt” the scar. This may be
combined with simple excision of the whole scar and
advancement of surrounding tissue with direct
closure. In patients prone to scar formation, a dermal
platform technique can be used to minimize stimulation
of dermal fibroblast activity; only superficial scar tis-
sue is removed and underlying subcutaneous traction
bands are left undisturbed with this procedure.
Z-Plasty
This is a key technique for scar revision in both gen-
eral and ophthalmic plastic surgery and is essentially
a transposition flap (Fig. 2–12). The principle of the Z-
plasty is to increase the length of the skin and tissue
along the line of the original scar while shortening the
skin that lies at right angles to it. The tension lines are
thus redirected perpendicular to the original scar, ide-
ally toward the normal relaxed skin tension lines of
the face.
The central limb of the Z is placed along the scar
and parallel to the line of maximal tension. The
upper and lower arms of the Z are then placed at 60
degrees to the central limb, such that all limbs of the
Z are of equal length. Two equilateral triangular flaps
of equal size are thus created and then extensively
undermined to allow mutual transposition of the
apices. Subcutaneous traction bands are dissected
away and the flaps anchored with equal tension
distribution.
A conventional Z-plasty is often used to relieve
vertical contracture in injured eyelids, but may also
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
32 • OCULOPLASTIC SURGERY: THE ESSENTIALS
FIGURE 2–13 Modified Z-plasty technique to lower an
elevated brow, with limb lengths and angles set according to
the anatomically desired result. The end of the inferior limb
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
along the curve of the supraorbital rim and the flaps trans-
posed as shown, with care taken to avoid damage to lash
follicles.
margin (Fig. 2–13).21 In this way it offers an alterna-
tive to skin grafting and is particularly useful in
patients with extensive burns, in whom donor tissue
may be severely limited.
Multiple Z-plasties are useful when scars are too
long for a single Z-plasty to allow adequate tissue rota-
tion (Fig. 2–14). The initial incision is made along the
center of the scar with the upper and lower arms of the
Z at 60 degrees to it. Additional arms are created par-
allel to these and extended along the length of the scar.
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
lying along the scar line.
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.
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
invariably accompanied by loss of tissue and is there-
fore not ideal when surplus skin is unavailable.
RECONSTRUCTIVE SURGERY
The oculoplastic surgeon often faces the challenge of
eyelid reconstruction, typically following tumor exci-
sion. Primary closure is preferable if there is adequate
tissue available to maintain normal function and
appearance, although occasionally healing by sec-
ondary intent is utilized (see Wound Healing above).
A larger defect will generally require closure using a
tissue flap or free graft; the donor blood supply
remains intact in a flap, whereas in a graft it is sev-
ered and the tissue depends on vasculature from the
host site.
Skin Flaps
Tissue flaps allow more rapid restoration of eyelid
function than free grafts, because their donor site vas-
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-
ered with a free graft. Infection and pigment changes
are also less likely with a flap than with a graft.
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FUNDAMENTALS OF OCULOPLASTIC SURGERY • 33

A sliding flap allows tension-free primary closure of

FIGURE 2–15 W-plasty for repair of a straight scar. Tri-
angles become smaller at the end of the scar with tapering
of limb length to avoid puckering.
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
forms of advancement flap. The V-Y plasty can lengthen
skin along lines of tension by effectively adding tissue
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.
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34 • OCULOPLASTIC SURGERY: THE ESSENTIALS
FIGURE 2–17 Advancement flap for repair of round
defect medially on lower eyelid.
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
long limb of the Y, shortening the tissue that is parallel
to it, thus being particularly useful for correcting epi-
canthal folds (Fig. 2–18B).
A rotation flap is placed in the host site by rotating
the flap at its base and the remaining defect at the
donor site is closed directly (Fig. 2–16C). The semicir-
cular myocutaneous Tenzel rotation flap rotates tis-
sue from the lateral end of the upper eyelid to
reconstruct the lower eyelid.33
A transposition flap is similar to a rotational one,
except the flap is advanced into a nonadjacent defect.21
Examples are the bilobar flap (Fig. 2–16D), the Z-plasty,
the temporal flap, and the glabellar flap (Fig. 2–19).
A V-Y Plasty
Direction of
tissue shortage
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
perpendicular to it, length is added tissue shortage
with relief of tension.
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).
...
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
be seven to eight times the width of its pedicle.
Grafts
The eyelid is fortunate in possessing an extensive blood
supply that is highly supportive to grafted tissue and is
thus amenable to a wide range of grafting techniques.
Grafts may be autologous (from the same person),
homologous (from the same species, but different per-
son), or heterologous (from a different species).
Autologous grafts include skin, mucosa, tarsus,
dermis, fat, fascia lata, cartilage, and bone. Occasion-
ally homologous grafts of banked tissue are used, for
example, preserved fascia, irradiated sclera, cartilage,
or bone. However, the trend is increasingly to use
autologous material where possible, because this
avoids the risk of infectious disease transmission.
Length added
horizontally to
limb of “Y”
Length added
vertically subtracts
from limb of “Y”
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FUNDAMENTALS OF OCULOPLASTIC SURGERY • 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.
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36 • OCULOPLASTIC SURGERY: THE ESSENTIALS

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.
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FUNDAMENTALS OF OCULOPLASTIC SURGERY • 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
postoperative shrinkage (Fig. 2–22). Nasochondral
mucosa from the nasal septum may also be used, but
is much thicker and somewhat too rigid for conform-
ing to the globe; a further disadvantage can be
marked mucus production due to the presence of
numerous goblet cells in the graft.
PITFALL
Buccal or mucosal grafts undergo significant
contracture, whereas hard palate mucosal
grafts are much less susceptible to this.
Cartilage can be harvested from the posterior surface
of the ear, in addition to the nasal septum as
described above. It is particularly useful in posterior
lamellar reconstruction and as a spacer in cases of
long-standing lid retraction. Auricular cartilage is
obtained from the flattest portion between the helix
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
the graft to relax and flatten it.
Where replacement of both tarsal and mucosal ele-
ments is required, a chondromucosal graft, such as
hard palate or nasochondral mucosa, may be used.
Alternatively, auricular cartilage can be incorporated
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
38 • OCULOPLASTIC SURGERY: THE ESSENTIALS
into a buccal submucosal pocket.29 The graft is
allowed to vascularize for 3 to 4 weeks, and the com-
pound graft of auricular cartilage and buccal mucosa
can then be harvested.
Donor Sclera
Banked homologous donor sclera may be used in pos-
terior lamellar reconstruction, but is used infrequently
due to risk of transmission of infectious diseases from
the donor. In practice, alternative materials are avail-
able for almost all oculoplastic procedures in which
donor sclera was previously indicated. Donor sclera is
prepared according to standard protocol and, before
use, is rehydrated with an antibiotic solution. As
sclera lacks a mucosa, opinion is divided as to the
need for conjunctival cover following placement and,
as sclera is more flexible than tarsus, there may be
some instability of the reconstructed lid after its
usage.
Dermis-Fat Grafts
Autologous dermis-fat grafts can be readily harvested
from the patient’s lower lateral abdominal quadrant
or lateral thigh and provide a satisfactory means of
volume expansion in the mildly contracted anoph-
thalmic socket. The attached dermis is thought to
facilitate vascularization and reduces the atrophy
associated with free-fat grafts. It also serves as a use-
ful graft for filling facial soft tissue defects around the
orbit.34
Autologous Fascia
Autologous fascia is typically used in ptosis surgery
and is generally harvested from tensor fascia lata on
the lateral aspect of thigh. It is relatively easy to obtain
in the adult, but may be difficult in a child with a
short thigh. Temporalis fascia is also occasionally
used in eyelid reconstruction to create a lateral can-
thal ligament.
Bone Grafts
Autologous bone grafts are used for orbital wall
reconstructions and are typically harvested from the
iliac crest or cranium. When compared to alloplastic
materials, such as bone cement, bone grafts offer a
low rate of extrusion or infection, but have the disad-
vantage of graft reabsorption. Iliac crest bone is rela-
tively straightforward to obtain and is useful for
correcting orbital floor and roof defects.
Cranial bone is membranous, embryologically sim-
ilar to the orbit, and may therefore offer a greater sur-
vival of graft volume than iliac crest bone. Further
advantages are ease of access to the donor site during
major craniofacial reconstructions and minimal
donor-site morbidity, although it might be advisable
to perform this procedure with a neurosurgeon, in
view of possible intracranial complications.
Biomaterials
A wide range of alloplastic biomaterials are used in
oculoplastic surgery, all of which are designed to
cause minimal tissue reaction while attempting to
restore function.29, 35 Silastic sheeting is extensively
used to repair uncomplicated orbital floor fractures,
with Supramid sheeting and Teflon plates as alterna-
tives. Titanium miniplates are used for more complex
orbital fractures and allow rigid fixation to the orbital
rim and skeleton.
Many biomaterials are used in eyelid procedures,
including silicone rod for frontalis suspension and
Mersilene mesh frontalis sling in certain types of pto-
sis. Gold weights sutured to the tarsal plate are used
for lid retraction and lagophthalmos in facial nerve
palsies, whereas polytetrafluoroethylene (Gore-tex)
may be used as a spacer in eyelid reconstruction.
Volume augmentation in the orbit can be achieved
using many materials, including bone cement and
room-temperature-vulcanized (RTV) silicone. Soft tis-
sue expanders are temporary implants that allow
stretching of the overlying tissue following injection
and expansion with saline. They distribute surround-
ing tissue over a greater surface area and are removed
after adequate expansion is obtained.
A large variety of alloplastic materials have been
used as orbital implants for the enucleated or eviscer-
ated socket, including polymethylmethacrylate, sili-
cone, titanium, tantalum mesh, and glass (Fig. 2–24).
In recent years much interest has surrounded the use
of hydroxyapatite implants, which are made from
hydrothermally converted marine coral or by a syn-
thetic process, this material being porous and allow-
ing permeation by host fibrovascular tissue. An
integrated peg system allows subsequent linkage of
the ball movement to the overlying artificial eye. Early
results have been encouraging with regard to motil-
ity, although the rate of implant exposure, infection,
and peg-related complications is quite high. Porous
polyethylene implants are also available, become sim-
ilarly integrated in the socket, and allow placement of
a titanium motility peg.
EARL ... Intraoperative antibiotic
P prophylaxis is advisable for all cases where
biomaterials are being implanted, as postopera-
tive infection can be difficult to treat.
CHEN02-021-040.I 3/22/01 1:25 PM Page 39
FUNDAMENTALS OF OCULOPLASTIC SURGERY • 39
A B
FIGURE 2–24 Orbital implants made from (A) hydroxyapatite and (B) glass.
SUMMARY
This chapter reviewed the fundamental concepts of
oculoplastic techniques. Clinical circumstances and
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