Eyelid reconstruction
â˘Download as PPTX, PDFâ˘
2 likesâ˘1,122 views
Eyelid reconstruction
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Eyelid reconstruction
Similar to Eyelid reconstruction (20)
More from Dr Sourabh Shankar Chakraborty
More from Dr Sourabh Shankar Chakraborty (20)
Recently uploaded
Recently uploaded (20)
Eyelid reconstruction
- 2. ⢠The palpebral fissure 29â32 mm horizontally 9â12 mm vertically ⢠Lateral canthus 1â2 mm higher than the medial canthus. ⢠The upper eyelid usually covers the upper 1â2 mm of the iris ⢠the lower eyelid rests at the level of the inferior limbus.
- 3. ⢠An anterior lamella,skin and orbicularis oculi muscle, and ⢠A posterior lamella, formed by the tarsus and the conjunctiva
- 4. ⢠The orbicularis oculi is divided into pretarsal, preseptal (both lying in the eyelid) and orbital (around the eyelids) portions
- 7. ⢠The upper tarsus measures 10â12 mm, ⢠The lower tarsus measures 4â5 mm ⢠The edges of the tarsi are firmly attached to the eyelids margins, ⢠The Meibomian glands are embedded within the tarsus posterior to the eyelashes. ⢠Between the duct orifices and the lashes is the âgray lineâ,
- 10. ⢠The orbital septum extends from the edges of the tarsi to the orbital rims, attaching to the edge of the rim ⢠Sharing a common origin with the orbicularis retaining ligament
- 11. ⢠The Whitnallâs ligament sends medial and lateral horns to attach to the zygomatic bone laterally and the medial canthal ligament and the posterior lacrimal crest medially. ⢠The levator aponeurosis inserts into the anterior surface of the tarsus, sending fibrous attachments through the orbital septum and the orbicularis muscle to skin to form the upper eyelid crease.
- 12. ⢠The deep part of the levator muscle is MĂźllerâs muscle, which is sympathetically innervated
- 13. ⢠Medially, the medial canthal ligaments arise from the medial edge of the upper and lower tarsus, and ⢠Formed of anterior and posterior limbs that attach to the anterior and posterior limbs of the lacrimal crest
- 15. ⢠Congenital anomalies, ⢠Neoplastic processes/Ablative surgical procedures, ⢠Trauma
- 16. Principles ⢠Through evaluation of the defect and function of the lid. ⢠Components that have been compromised should be properly identified and documented ⢠Thorough preoperative ophthalmologic examination, including visual acuity and field testing, as well as a Schirmer test, ⢠Transverse incisions will help to camouflage scars, and symmetry with contralateral structures;Vertical incisions should be avoided so as to obviate contracture and distortion of eyelid function.
- 17. ⢠Debridement of nonviable tissue ⢠When approximating lid margins, alignment of all layers must be achieved. ⢠Suture material and knots to avoid direct contact with the surface of the cornea and globe. ⢠Reconstructive ladder should be appreciated
- 18. Periocular zones
- 21. ⢠greater than 75% by lower-lid switch flap / a cheek rotationâadvancement ⢠Involve other surrounding zones include a forehead flap, a Fricke flap, or a glabellar flap
- 26. Lower lid (50-75%) ⢠Transposed (Mcgregor) Flap in Eyelid Reconstruction
- 28. Superiorly Based Tarsoconjunctival Advancement (Hughes, Landholt, KĂśllner) Flap for Reconstruction of The Lower Eyelid
- 29. Cheek Rotation Skin (MustardĂŠ) Flap to The Lower Eyelid
- 33. Cheek Rotation Skin (Imre) Flap to The Lower Eyelid
- 35. Cheek V-Y Advancement Skin Flap to The Lower Eyelid
- 36. Nasolabial Skin Flap to The Lower Eyelid
- 37. Forehead Skin Flap for Total Upper and Lower Eyelid Reconstruction
- 39. V-Y-S-Plasty for Closure of A Circular Defect of The Medial Canthal Area
- 40. V-Y Glabellar Skin Flap to The Medial Canthal Region
- 43. ⢠If the tendon is intact but minor laxity is appreciated, simple plication is recommended ⢠If the insertion of the tendon is not intact, canthopexy is recommended ⢠the medial aspect of the upper and lower tarsal plates can be sutured to the nasal periosteum taking care to place the point of fixation below the anterior lacrimal crest.
- 45. Lateral Canthal Reconstruction: Zone IV ⢠lateral canthal tendon ⢠all reconstructions include a canthal support procedure or canthopexy. ⢠Complete disruptions of the canthus require a canthoplasty ⢠Reconstructing the superficial component of these defects include a cheek advancement flap or full-thickness skin graft.
- 46. ⢠anchoring the medial end of the remaining ligament to either the periosteum at the level of the Whitnall tubercle or to the bone directly, using small drill holes in the orbital rim
- 47. Reconstruction of Periocular Defects: Zone V ⢠Zone V defects are defined as those outside of but contiguous with zones I to IV ⢠they can affect lid position and function
- 48. Complications ⢠Early :- ⢠corneal abrasion, ⢠chemosis (which can often be limited by a Frost stitch or temporary tarsorrhaphy), ⢠hematoma, ⢠flap/graft failure.
- 49. ⢠Late :- ⢠Corneal exposure, ⢠canthal laxity. ⢠lid malposition, ⢠abnormal lacrimal drainage, and ⢠an unsatisfactory cosmetic result.
Editor's Notes
- The mucosal lining is the palpebral conjunctiva. The conjunctiva forms an uninterrupted layer as it arises from the skin at the free edge of one lid and extends over the globe to the free edge of the Other form the anterior covering of the globe, the bulbar conjunctiva. The apexes of the folds are known as the superior and inferior fornices. Separating the anterior and posterior lamella is the tarsofascial layer. This layer arises from the orbital rim and begins proximally as the orbital septum, formed by the confluence of the periosteum of the orbit and the periosteum of the facial bones. Distally, the orbital septum fuses with the lid-retracting membrane. In the upper lid, this is the levator palpebra aponeurosis; in the lower lid, it is the capsulopalpebral fascia.
- The lacrimal system functions to bathe with and drain the globe of tears (Fig. 39.2). It consists of the lacrimal gland and microscopic accessory glands, which secrete the tears, and the lacrimal ducts or canaliculi, the lacrimal sac, and the nasolacrimal duct, which provides nasal drainage The lacrimal gland proper is composed of two lobes: the main orbital lobe and the smaller palpebral lobe. They are situated in the lacrimal fossa of the superolateral orbit and upper lateral eyelid, respectively The ducts of the palpebral lobe empty into the upper lateral half of the superior fornix. The ducts of the orbital lobe pass through the palpebral lobe before exiting
- The gray line serves as an important landmark; the plane between the anterior and posterior lamella of the eyelids. corresponds to a terminal extension of the orbicularis muscle The proximal edge of the plate serves as the insertion for the Mueller muscle, which is innervated by the sympathetic nervous system. The proximal edge of the inferior plate serves as the insertion for a membrane formed by the confluence of the capsulopalpebral fascia and inferior orbital septum With an origin on both the inferior oblique and rectus muscles, the capsulopalpebral fasciaâŚ.. They secrete an oillike substance onto the conjunctiva, which facilitates gliding of the lid over the globe The glands, which number approximately 10 to 20 on the lower lid and 20 to 40 on the upper lidâŚ. acute (hordeolum or stye
- Inferiorly, extends for 1â2 mm on the anterior surface of the inferior orbital rim
- the Whitnall ligament, which is formed by the fascial condensation of the levator aponeurosis. The Lockwood ligament is the lower-lid analog of the Whitnall ligament.
- The lateral canthal tendon is formed by the confluence of the upper and lower crura, which arise off their respective tarsal plates and create a complex structure known as the lateral retinaculum, inserting onto the Whitnall tubercle. This key anatomic bony prominence lies 2 mm within the lateral orbit, below the lacrimal fossa
- In hyperthyroidism, sensitization of MĂźllerâs muscle leads to upper eyelid retraction and pseudoproptosis. On the other hand, in Hornerâs syndrome loss of this muscle action leads to ptosis.
- For large defects (those greater than 75%), the Mustarde lower lid switch flap is an option.9 A large full-thickness portion of the lower eyelid is rotated based on the marginal vessels to fill the upper eyelid defectâŚ. This flap is typically delayed up to 6 weeks before pedicle division and insetâŚThe disadvantage is that it sacrifices a significant portion of the lower eyelid that must then be reconstructed with cheek advancement and posterior lamella grafts.
- two-thirds full-thickness defects of the lower eyelid that can be created in the form of a V, reduction of tension by dividing the slip of the lateral canthal ligament to the lower eyelidâlateral canthotomyâŚ. With the V-shaped defect outlined on the eyelid, When the lateral canthotomy has been carried out, the conjunctiva provides no resistance to medial advancement and does not need to be formally divided⌠The plates can be effectively sutured together with interrupted 6-0 chromic catgut on an atraumatic needle, placing the knots on the muscle side of the tarsal plate
- The tarsoconjunctival flap for lower eyelid reconstruction supplies the deficient lower lid with conjunctiva for lining and tarsus for structural support. This posterior lamella flap should be combined with a free skin graft (or skin flap) to create the new anterior lamella of the lower lidâŚ. Application of this technique is limited, in that the vertical height of the upper lid tarsal plate measures 10 to 12 mm, and if more than 7 mm of this tarsal plate is removed, the upper lid may itself become crippled and deformed. Therefore, this technique is most useful for repair of lower lid defects that are no more than 5 to 7 mm in vertical height The best results are obtained when the horizontal extent of the defect is less than the distance from the inner to outer canthusâŚ.. Defects of the lower lid that extend horizontally the full length of the lid and vertically to the inferior orbital rim are better repaired by the bipedicle or bucket-handle flap (Tripier) techniqueâŚWhen the lower lid defect exceeds 7 mm vertically and half the horizontal lid length has been resected, the Tenzel semicircular flap gives excellent resultsâŚWhen all the lower lid must be removed, including the base of the lid past the inferior orbital rim, the MustardĂŠ cheek rotation flap A horizontal incision is made through the conjunctiva and tarsus of the upper lid 3 to 3.5 mm from the lid margin down to the submuscular fascia of the orbicularis muscles. The vertical limbs of the incision are extended in this P.43 same plane into the superior conjunctival cul-de-sac. Dissection in this area is best accomplished with a moistened cotton-tipped applicator, because MĂźller's muscle bleeds quite profusely unless the lid has been infiltrated with epinephrineâŚ. Inclusion of the upper lid retractor muscles, whose blood supply is derived from branches of the dorsal nasal, frontal, supraorbital, and lacrimal arteries in the flap pedicle, largely obviates any chance of sloughâŚ. no special attempt is made to separate MĂźller's muscle and the levator aponeurosis from the base of the flapâŚa horizontal advancement flap of skin can be brought in either medially or laterally to cover the tarsoconjunctival flap.
- In defects involving from one-quarter to one-half of the eyelid, a comparatively small cheek rotation is required If the reconstructed area is wider than about 6 mm, reconstructed part of the lid with a small composite nasal septal graftâŚ.. to use a cheek rotation flap to carry the thin skin that lies lateral to the lateral canthus into the region of the reconstructed eyelid. The incision line of the flap should curve upward and outward from the lateral canthus. The length of the cheek incision, as well as the amount of undermining to be carried out, is determined on a trial-and-error basis by constantly checking whether the flap can be rotated across to fill the defect.
- The composite septal graft is held in position using running 6-0 Prolene sutures to coapt the nasal mucosal edges to conjunctiva
- The area of the Imre flap can be extended to embrace all tissue from the lower lid downward and from the nasolabial crease laterallyâŚ. The McGregor flap (Chapter 12) should be considered as a first option for lower lid reconstruction, because it is simpler to execute, includes potions of the lateral orbicularis muscle
- For total reconstruction of the lower lid, the length of the incision is about five times the distance from the tip of the flap to the new lid margin. The original Burow's triangle is converted into a crescent-shaped skin defect at the base of the flap. The flap is widely undermined beyond the line extending from the lateral canthus to the temporal side of the crescent-shaped defect (Figs. 14.1C and 14.2). If there is enough conjunctiva available, it can be used to line the upper margin of the flap
- The medial and lateral extent of the Y limbs should be the canthal ligaments, to prevent retraction and possible ectropionâŚThe width of the flap is the same as the width of the defect, and the height of the flap is 11Ăş2 times greaterâŚ. The flap is advanced upward until it reaches the desired position of the eyelid border without tension. It is anchored medially and laterally to the orbital periosteum with two nonabsorbable sutures.
- The laterally based transverse musculocutaneous flap is a safe, reliable, simple flap that can be used to reconstruct defects of the lateral two-thirds of the lower lid of up to 15 to 20 mm in vertical height.
- The melding of the V-Y advancement with the double rotation flaps of the S-plasty enhances the reparative efficacy of treatment of circular defects, with particular relevance in the medial canthal territory
- Depending on the width of skin available between the eyebrows, a flap designed in the form of an inverted V can be used to cover a defect at the medial canthus of up to 15 mm in diameterâŚOne of the simplest and most satisfactory techniques for doing such reconstructions is to bring down the thick glabellar skin as a V-Y flap in a one-stage operation. Depending on the width of skin available between the eyebrows, a flap designed in the form of an inverted V can be used to cover a defect at the medial canthus of up to 15 mm in diameter (Fig. 27.1). In conjunction with other flaps, such a flap may be employed to cover even larger areas. The flap is incised down to the galea aponeurotica, leaving an adequate pedicle on the bridge of the nose. The vertical dimension of the flap should be about three times the breadth at its lowest part. Once the flap has been slid down to cover the defect, it will be found that the forehead wound can be closed in the form of an inverted Y.
- The V-Y glabellar flap is an excellent choice for reconstruction of deep lesions of the medial canthal area
- can be secured with a wire loop, which is passed and anchored in a transnasal fashion âŚ. If the medial retinaculum is detached from the bone, it must be .reattached via the posterior reflection on the lacrimal crest posterior to the lacrimal sacâŚ.. Methods for fixation include sutures to the periosteum, drill hole fixation, bone anchors, and in cases of bone deficiency, transnasal wires or to a gap spanning plate.
- laxity of the lateral canthus, even when corrected, has a tendency to recur over time. Thus, a slight overcorrection should be the goalâŚIn both situations, the goal is to overcorrect the tissue laxity as recurrent laxity is expected.
- When the upper portion of the tendon is intact, a lateral canthal sling is used to provide support and tighten an otherwise lax lower lid (6). Finally, when completely obliterated, the lateral canthal ligament can be reconstructed via a lateral tarsal strip procedure. The tarsal plates are sutured to a strip of orbital periosteum raised for this purpose
- combine a nasal septal cartilageâmucosal graft for the posterior conjunctival-tarsal layer and a transposition myocutaneous flap from an adjacent area for the anteriorâŚcutler beard width of the flap should match the width of the upper eyelid defect, and vertical full-thickness incisions are made to the inferior fornix at this width. The flap is advanced posterior to the remaining lid margin and s~red into the upper eyelid defect with a multilayer closure. The conjunctiva can be separated from the musculocutaneous flap, and a cartilage graft can be placed for added support as this flap typically has little or no tarsus within it.2 The flap is divided at approximately 6 weeks with 2 mm excess vertical height. (1) a two-stage reconstruction with obstructed vision between stages, (2) disturbance to the lower eyelid that may require future revision and/or lid-tightening procedures, and (3) lack of lashes in the reconstructed segment. 8 A superiorly based semicircular flap of up to 6 em in diameter is designed and advanced medially The conjunctiva is also undermined and advanced to provide the lining of the flap. This flap is ideally suited for those defects that encompass 40% to 60% of the upper eyelid lamella. Hughes sliding tarsoconjunctival flap from the lower lidâŚ.. In elderly patients, whose lids have more laxity, defects up to 30% of the horizontal lid dimension may be closed primarily but may require a lateral canthotomy for a tension-free repairâŚ. A sliding tarsoconjunctival flap bor¡ rows tissue from the uninjured portion of the ipsilateral upper eyelid. This flap is an option for posterior lamella defects involving the medial or lateral aspect of the upper eyelidâŚ.. The .inferior incision for this horizontally based .flap is 4 mm above the lid margin and extends to create a .flap that is equal to the defect size. The superior incision is designed to fit the defect, and a vertical relaxing incision is required in the tarsal plate to allow for advancement.2 A full-thickness skin graft is required for coverage of this flap to reconstruct the anterior lamellaâŚ. In central wounds, a tarsoconjunctival flap can be developed from the lower eyelid as is done for lower eyelid reconstruction in the Hughes procedure.ââŚ.. The Cutler-Beard bridge .flap is a full-thickness composite .flap from the lower eyelidâŚ. A transverse full-thickness incision is made approximately 5 mm inferior to the lid margin in the lower eyelid, which allows flap elevation without compromising vascularity to the remaining lower eyelid
- The lower eyelid is anatomically analogous to the upper eyelid, that is, where the capsulopalpebral fascia is homologous to the levator aponeurosis and the inferior tarsal muscle is homologous to Muellerâ˘s muscleâŚ.. The main difference is that the lower eyelid is shorter and the tarsal plate is 4 mm in vertical height compared with 10 mm in the upper eyelid.
- Fricke flap (Fig. 39.7) is a unipedicled myocutaneous transposition flap composed of the skin and preseptal portion of the orbicularis oculi muscle of the upper lidâŚ. The Tripier flap is a bipedicled flap from the upper eyelid transposed to reconstruct lower eyelid defects. This flap includes preseptal orbicularis oculi muscle. The Fricke flap is similar but is a unipedicled flap and is adequate for defects that extend to the mid-lower eyelid or just beyond If a myocutaneous transposition flap is raised on both the medial and lateral pedicle, a bipedicled myocutaneous transposition flap (Tripier) is generatedâŚSmall full-thickness lower lid defects are closed primarily. Care is taken to align and repair the tarsal plate. As in partial-thickness defects, a lateral inferior cantholysis may be required to prevent tension
- Full-thickness defects that are 50% or less of the lower eyelid can be approached with the inferiorly based Tenzel semicircular flap.8 The semicircular incision extends superiorly and laterally with a diameter of 3 to 6 em depending on the defect size and tissue laxity. Dissection is in a submuscular plane, and the inferior ramus of the lateral canthal tendon is divided to allow medial rotational advancementâŚ. Hughes tarsoconjunctival flap procedure6 from the upper lid which is best for defects greater than 50%, including total lower eyelid reconstructions. The flap is developed starting 4 mm above the upper eyelid margin to avoid compromising upper eyelid integrity and consists of a segment of tarsus and conjunctiva. The width is designed to match the missing posterior lamella segment of the lower eyelid and advanced into the lower eyelid defect.
- cheek flap include dermal anchorage to the inferior orbit to ensure tension-free closure,
- The lacrimal papilla, puncta, canaliculi, plica semilunaris, caruncula lacrimalis, and tripartite insertion of the medial canthal tendon are all located within this square centimeter of tissueâŚ. In this procedure, the inferior arm is âtuckedâ under the canthus
- This flap is useful in replacing the absent central two-thirds of the lower eyelid used to repair horizontally oriented losses of the lower eyelid, both marginal and nonmarginal, of less than 10 to 15 mm in vertical heightâŚ.. The flap is outlined with the inferior edge corresponding to the supratarsal fold from point A to point B (Fig. 17.1A). These two points are located above the medial and lateral canthi, respectively, where the fold disappears. The superior incision ( CD) is made parallel to line AB (Fig. 17.1A), creating a bipedicled flap approximately 10 to 15 mm wide, depending on the amount of redundant tissue present in the preseptal area. A wider flap may be used, but this will require a skin graft to close the donor areaâŚ. When closing a marginal defect, the undersurface of the flap must be grafted with a composite chondromucosal Graft. The bipedicle upper eyelid flap is a safe and reliable flap that can be used to reconstruct defects of the central two-thirds of the lower eyelid up to 15 to 20 mm in vertical heightâŚ. The Tripier flap was further modified by converting the skin component into an island on a bipedicled orbicularis oculi muscle Described below is a skin island orbicularis oculi musculocutaneous flap obtained from the suprabrow area and used for reconstruction of the lower eyelid. The pivot point should be at the same horizontal level as the outer canthus or palpebral fissure. An arc of rotation is established that will allow the flap to sweep over the entire territory of the lower lid. A tunnel is made beneath the lateral canthal skin for the entry of the flap toward its final destination
- It is important to realize that the marginal eyelid vessels lie about 3 mm from the lid margin and immediately beneath the layer of the orbicularis muscle.
- This flap consists of an inferiorly based full-thickness lower lid flap (skin, orbicularis muscle, orbital septum, lower lid retractors, and conjunctiva) advanced beneath the lower lid margin to replace the upper lidâŚ. The tumor is excised. Moderate traction is placed on the lid remnants to narrow the width of the defect. A full-thickness incision is made through the lower lid at the tarsal edge. Vertical full-thickness incisions are made to a depth of the fornix. Relaxing skin triangles are excised. B: The flap is advanced upward behind the marginal bridge and sutured in two layers into the upper lid defect. The lower edge of the bridge can be loosely closed. C: After 6 to 8 weeks, the lid fissure is recreated by a full-thickness scissor cut arched downward about 2 mm. This cut should be beveled forward in order to have the conjunctiva slightly lower than the skin. D: The base of the flap is returned to its anatomic position and sutured in two layers. The skin and conjunctiva are approximated with a running suture of 6-0 catgutâŚ. The flap is divided with scissors in a downward arch, anticipating retraction of approximately 2 mm. The absence of tarsus not only causes the lid to retract, but also favors development of entropionâŚ. the dividing incision should be beveled forward, leaving excess conjunctiva to be rotated over the new lid marginâŚobstructing vision for 6 to 8 weeks; the lack of a skeleton (tarsus) in the new lid margin, resulting in a tendency to entropion; the potential for damage to the lower lid margin; and the absence of lashes in the reconstructed lid.
- Because the thickness of a flap from the nasojugal area is greater than that of upper eyelid skin and orbicularis, more stability is provided to the reconstructed lid and this decreases the need for tarsal replacementâŚIts base is centered over the angular vessels and lies above the level of the medial canthal ligament, allowing the flap to reach 90° of transpositionâŚTo rotate the flap into the upper lid, more torsion is necessary than in rotation to the lower lid; this is achieved by having the upper arm of the flap base extend more onto the surface of the nose, allowing for rotation into the upper lid