Eye lid reconstruction plastic surgery presentation

Eyelid reconstruction including upper eyelid and lower eyelid reconstruction

1. EYE LID RECONSTRUCTION

2. 01 Anatomy Upper eye lid Lower eye lid Summary

3. Anatomy of eye lids Surface markings

4. Layers of eyelid: Skin Subcutaneous areolar tissue Layer of striated muscle (orbicularis oculi) Loose areolar tissue Layer or non striated muscle The fibrous layer (including tarsal plate) Conjunctiva Anterior Lamella Posterior Lamella

5. 07 SKIN Thinnest in the body Superior sulci Aponeurosis of LPS inserted into the skin Inferior sulci Skin being tethered to the underlying periosteum

6. EYELASHES 100 – Upper eyelid 50 –Lower eyelid Originate from anterior lamella in two or 3 irregular rows Protects eye from dust, foreign bodies and perspiration

7. Orbicularis Oculi Originated from the medial canthus and the bone of medial orbit and inserted at the lateral canthus and lateral orbital rim. Help in Forced lid closure Preseptal -In front of the orbital septum - pull lacrimal fascia laterally and create a relative vacuum in lacrimal sac Pretarsal - in front of the tarsal plate - Close lid and pull lacrimal puncta medially

8. Loose areolar tissue Loose connective tissue containing no fat Absent at medial and lateral angles, ciliary margin and sulci.

9. The fibrous layer- Orbital septum  Attached to the orbital margin Posterior to the medial palpebral ligament and lateral palpebral ligament. Fascial membrane which separates the eyelid structures from the deep orbital structures Barrier that helps prevent the spread of hemorrhages, infection, inflammation.

10. Tarsal plate Thin elongated plates of connective tissue Contribute to form and support the eyelids Closely related to the LPS, medial, lateral canthal structures Superior tarsus 8-10mm tapering to the sides Inferior tarsus 4 mm Attached by the medial and lateral canthal ligament.

11. The Ligaments The medi al palpebral ligament Attaches medial end of tarsi to lacrimal crest and frontal process of maxilla. The lateral palpebral ligament Attaches lateral end of tarsi to marginal tubercle of zygomatic bone.

12. Levator palpebrae superioris Origin - lesser wing of sphenoid bone anterior to the optic foramen becomes aponeurotic 5-7mm above the superior border of the tarsus and 10-14mm below the Whitnall’s ligament Insertion - aponeurosis on the anterior surface of superior tarsal plate, skin, lateral palpebral ligament, medial palpebral ligament

13. Levator palpebrae superioris The muscular portion of the levator is approximately 40 mm long The aponeurosis is 14–20 mm in length. The superior transverse ligament ( Whitnall ligament) is a sleeve of elastic fibers around the levator muscle located in the area of transition from levator muscle to levator aponeurosis

14. Arterial supply Lateral palpebral Artery--- Lacrimal artery Medial palpebral artery--- Ophthalmic Artery.

15. Venous drainage Medially – Ophthalmic and angular vein Laterally- Superficial temporal vein.

16. Nerve supply Supra orbital nerve (V1) Supra trochlear nerve (V1) Infra trochlear nerve (V1) Lacrimal nerve (V1) Lower eyelid Infra trochlear nerve (V1) Infra orbital nerve (V2)

17. P rinciples of reconstruction 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.

18. P rinciples of reconstruction 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

19. P rinciples of reconstruction In the reconstruction  of both anterior & posterior lamellae, at least one must have its own blood supply Techniques would depend on the size, location, configuration, & depth of the defect Superficial defect: only anterior lamella needs to be repaired Full thickness defect: needs reconstruction of both layers

20. Anterior lamella Flaps: Ad vancement, transposition, or rotational musculocutaneous flaps Full-thickness skin grafts

21. Posterior lamella Flaps: Tarsal conjunctival transposition, advancement or rotational flap Free autogenous composite tarsal grafts – Tarsal substitute grafts - sclera, nasal septal chondromucosa , hard palate mucosa

22. Defects upto 25-50% can be close directly +/- Canthal release Lateral Canthotomy Inferior Cantholysis

23. Upper Eyelid Reconstruction

24. Upper eyelid reconstruction Direct Closure +/- lateral cantholysis Tenzel Flap Sliding Tarsoconjunctival Flap. Posterior Lamellar Graft with local myocutaneous flap Cutler-Beard (Bridge) Flap Mustarde flap

25. Direct closure Advantages: Lash continuity Disadvantages: P tosis possible with tight closure

26. Direct closure Most important part = Reapproximation of tarsal plate 6-0 or 7-0 silk is used to reapproximate the tarsal edges The wound edges are made perpendicular to the lid margin

27. Direct closure If the eyelid tension is excessive with the trial suture, lateral cantholysis should be performed to minimize the risk of mechanical ptosis.

28. Tenzel rotational flap Central upper lid defects of up 40% to 60% of the original lid margin can be closed by this flap

29. Tenzel rotational flap A n inferior semicircular superiorly based flap is drawn from the lateral canthus extending laterally in a smile line

30. Tenzel rotational flap Diameter = 2 to 6mm ; extending inferiorly and temporally towards lateral hairline. A myocutaneous flap incision – scalpel; Bovie cutting needle - cut through the muscle fibers for hemostasis Lateral canthotomy incision = beneath skin incision and dissected till lateral orbital rim The superior tendon of the lateral canthal tendon is divided and the upper lid mobilized completely at the lateral aspect, detaching it from the lateral orbital rim.

31. Tenzel rotational flap The flap is then undermined and rotated inward The edge of the flap i s advanced to the medial edge of the defect and repaired with layered closure Suture the edge of the flap to the inner periosteum of the lateral orbital rim with fixation to the orbicularis

32. Sliding tarso conjunctival flap For Isolated medial or lateral defects in the upper lid with large defects Horizontally slide a section of conjunctiva and tarsus from the remaining lid segment into the defect c overing the external surface with a skin graft

33. Sliding tarso conjunctival flap Technique: Evert with Desmarre retractor Horizontal incision = tarsal plate – 4-5mm above lid margin – equal to width of defect Relaxing incision = vertically in tarsus upto upper fornix The upper lid tarsal-conjunctival flap is developed and horizontally moved into the defect

34. Cutler-Beard Bridge flap For complete upper lid defects Technique: Advancing a full-thickness flap from opposing normal lid into upper lid defect. Incision made in lower lid 4-5mm away from margin Bi-valved into anterior & posterior layers Ear cartilage is placed in between

35. Cutler-Beard Bridge flap

36. Cutler-Beard Bridge flap Flap is divided 4-6 weeks later. Skin and muscle is divided leaving conjunctiva. Conjunctiva is everted to make the lid margin-mucous membrane Correction of lower lid at a later stage

37. Lower Eyelid Defects

38. Lower lid defects Options available: Direct closure Tenzel rotational flap Local myocutaneous flap with free tarsoconjunctival graft Hewes procedure Hughes procedure Mustarde procedure

39. Direct closure: Preferred in: Older patients Less than 20% defect 10% defect in younger patients with less laxity Borderline cases: Lateral cantholysis incision Tight closure: Malposition & ectropion

40. Direct closure: Technique: 6-0 silk traction suture on either side- through gray line of riolan – Approximate both the edges Suture the tarsus with 7-0. Close the skin No need to repair conjunctival layer

41. Direct closure: Lateral slanting incision given towards the temporal region along the lines of RSTL to give a more aesthetic closure

42. TENZEL flap 40-60% wide defects can be closed Lateral semicircular myocutaneous flap rotated into the lid defect First : Freshen the margins of defect – tarsal plate is perpendicular to lid margin

43. TENZEL flap Step 1: Lateral cantholysis + semi-circular myocutaneous flap at lateral canthus ; f/b  Direct closure of primary defect Step 2: Fixation of advanced flap to form the lateral canthus Step 3: Supplementing the advanced skin-muscle flap laterally with conjunctival advancement + strengthening with periosteal flap/patch

44. TENZEL flap

45. TENZEL flap Step 1: Lateral cantholysis + semi-circular myocutaneous flap at lateral canthus ; f/b  Direct closure of primary defect Step 2: Fixation of advanced flap to form the lateral canthus Step 3: Supplementing the advanced skin-muscle flap laterally with conjunctival advancement + strengthening with periosteal flap/patch

46. TENZEL flap

47. TENZEL flap

48. Lateral myocutaneous flap with free tarso conjunctival graft

49. Lateral myocutaneous flap with free tarso conjunctival graft Step 1: outline of tarsoconjunctival graft straddling upper edge of tarsus Step 2: Harvest the tarsoconjunctival graft from inner eyelid surface Step 3: Graft sutured onto the defect Step 4: Advancing myocutaneous flap over the graft

50. Lateral myocutaneous flap with free tarso conjunctival graft

51. Lateral myocutaneous flap with free tarso conjunctival graft

52. Hewes procedure Also known as : transposition – transconjunctival flap For: Shallow defects, temporal half defects Based on : Superior tarsal artery

53. Hewes procedure Step 1: Tarsoconjunctival flap raised from inner surface- upper eyelid Dissection carried till lateral edge Step 2: Based on superior tarsal arcade, Flap is transposed into lower eyelid Step 3: Inset given Step 4: Cover with myocutaneous flap from cheek / graft

54. Hewes procedure

55. Hewes procedure

56. Hewes procedure

57. Flaps for total lower lid defects Hughes Flap Mustarde flap

58. Hughes procedure AKA- Advancement tarsoconjunctival flap Lid sharing flap 2 stages Suitable for : large defects more than 50% width

59. Hughes procedure Step 1: Elevating upper eyelid tarsoconjunctival flap Leave 4mm margin on the lid margin to give stability to upper lid Flap should be free of Muller’s muscle Step 2: Transpose the flap to lower lid defect and suture to posterior lamella Suture tarsal edge of flap to tarsal edges of defect Step 3: FTSG coverage / Cheek myocutanoeus flap / Blepharoplasty

60. Hughes procedure Step 4: Separation of the flap after 2-3 weeks

61. Hughes procedure

62. Hughes procedure

63. Mustarde Flap Large rotation skin-muscle flap Reliable to cover lower lid defects Advantage: Complete lowed lid cover in a single stage Max benefit when: vertical dimension >> Horizontal dimension

64. Mustarde Flap

65. Mustarde Flap Technique: Local infiltration- Excise the defect into a superiorly based triangle – along nasolabial fold Semicircular flap designed at lateral canthus till tragus of ear Height should be atleast till eyebrow level

66. Mustarde Flap Excise the medial triangle – Raise semicircular flap in submuscular plane below orbicularis oculi. Place a cartilaginous (nasal / ear) graft to reconstruct posterior lamella Advance the flap and fix at medial canthus, Followed by posterior lamella and lateral canthus

67. Mustarde Flap

68. Mustarde Flap

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