Eye lid reconstruction techniques

1. ANATOMY OF EYELID &
EYELID RECONSTRUCTION
Dr. Satish Kumar.S.
I yr MCh Resident . KMCH.

3. FUNCTIONS
• Spreads secretions over eye – preventing drying of cornea.
• Spreads tear film
• Blink reflex

4. ATTITUDE
• POSITION
• Eye open
• Upper lid – 1/6th cornea
• Lower lid – touches limbus
• PALPEBRAL APERTURE
• 10-11 mm vertical
• 28-30 mm horizontal

5. LID MARGIN
• 2 mm
• Medial lacrimal part
• Lateral ciliary part

6. LAYERS OF EYELID
• Skin
• Subcutaneous areolar tissue
• Layer of striated muscle (orbicularis oculi)
• Loose areolar tissue
• Layer of non striated muscle
• The fibrous layer—including tarsal plate
• Conjunctiva
Anterior Lamella
Posterior Lamella

8. SKIN
• Thinnest
• Superior sulci
- aponeurosis of LPS inserted into the skin.
• Inferior sulci
- skin being tethered to the underlying periosteum.

9. EYE LASHES
• 100 - upper lid
• 50 - lower lid
• Originate from anterior lamella
in two or three irregular rows.
• Protects eye from dust, foreign
bodies and perspiration

10. THE ORIBICULARIS OCULI
Orbital - Originated from the medial
canthus and the bone of medial orbit
and inserted at the lateral canthus and
lateral orbital rim.
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

11. LOOSE AREOLAR TISSUE
• Loose connective tissue containing no fat.
• Absent at medial and lateral angles,
ciliary margin and sulci.

12. MULLER’S MUSCLE
• Smooth muscle (sympathetic)
• Posterior surface of the
levator muscle & inserts
at superior tarsal border

13. 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.

14. 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.

15. THE LIGAMENTS
• The medial 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.

16. 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

17. 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

18. CONJUNCTIVA
• Palpebral part
• Thin mucous membrane lined by non keratinized stratified squamous
epithelium.
• Margin of eyelids - continuous with the skin.

19. ARTERIAL SUPPLY
• Lateral palpebral Artery---
Lacrimal artery.
• Medial palpebral artery---
Ophthalmic Artery.

20. VENOUS DRANAGE
• Medially – Ophthalmic and angular vein
• Laterally- Superficial temporal vein

21. NERVE SUPPLY
Upper eyelid
• 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)

22. LYMPHATIC DRAINAGE

23. THE LACRIMALAPPARATUS

24. LACRIMAL GLAND
• Yellowish soft lobulated serous gland.
• Consists of
Large Orbital Part
Smaller Palpebral Part

25. PARS ORBITALIS
• Shape and size of an almond.
• Lodged in the lacrimal fossa in the anterolateral part of the roof of the
orbit
• Posterior to the orbital septum

26. PARS PALPEBRALIS
• ⅓ size of the orbital part.
• Lodged in the lateral part of upper eyelid.
• Continuous with the orbital part around the lateral margin of the
aponeurosis of the levator palpebrae superioris.

28. DUCT SYSTEM
• 12 short, slender ducts.
• from the lower surface of the gland.
• Open into the lateral part of the superior
fornix of the conjuctiva.

29. LACRIMAL CANALICULI
• Two slender ducts 10 mm in
length.
• Lacrimal Punctum on the
Lacrimal Papilla.
• Drain the lacrimal fluid into the
Lacrimal Sac.

30. LACRIMAL SAC
• Small sac lodged in the lacrimal
groove.
• 12 mm in length - blind upper and lower
ends.
• Continuous with the Nasolacrimal duct.
• Bounded by medial palpebral ligament
anteriorly and lacrimal part of orbicularis
oculi posteriorly.

31. NASOLACRIMAL DUCT
• 12 mm long runs
• through the nasolacrimal canal.
• Runs downwards, backwards and
laterally to open into the inferior
meatus of the nose.
• Guarded by lacrimal fold - valve
preventing nasal secretion from
ascending up into the duct.

32. EYELID RECONSTRUCTION

33. INDICATIONS FOR EYELID
RECONSTRUCTION
• To re-establish functional eyelid
• Adequate protection of the eyeball
• Reasonable cosmesis

34. BASIC GUIDELINES
FOR EYELID RECONSTRUCTION
• Both the visible and invisible tissue shortage must be evaluated
• When the eye is still present, reconstruction of an eyelid or even a part
of it requires a minimum of three elements
• an outer layer of skin
• an inner layer of mucosa
• a semi-rigid skeleton interposed between them

35. • One layer should carry its own blood supply and the other can be a
free graft.
• The reconstructed eyelid must conform to the curvature of the globe.
• Anchorage both medially and laterally should be to the bony orbit.

36. • The horizontal size of the defect which needs reconstruction must be
determined by bringing the medial and lateral edges closer under some
tension to determine the reduced defect size
• Lacrimal drainage reconstruction can be done simultaneously or
secondarily.
• For upper eyelid, borrow from forehead / lower eyelid
• For lower eyelid borrow from cheek / forehead

38. CLASSIFICATION OF SIZE OF DEFECTS

39. METHODS OF RECONSTRUCTION FOR
UPPER EYELID DEFECTS
Small defects
• Direct closure
• Direct closure with lateral cantholysis
• Direct closure with a semicircular flap (Tenzel’s)
Moderate size defect
• Mustarde’s lid switch flap
• Cutler–Beard reconstruction
Large size defect
• Cutler–Beard method
• Mustarde’s lid switch flap

40. METHODS OF RECONSTRUCTION FOR
UPPER EYELID DEFECTS
• Anterior lamella: Fricke’s flap
• Posterior lamella: free mucous membrane graft , Tarsoconjunctival
flap

41. METHODS OF RECONSTRUCTION FOR
LOWER EYELID DEFECTS
• Small defects up to 30%
• Direct closure
• Direct closure with lateral cantholysis
• Direct closure with Tenzel’s semicircular flap

42. METHODS OF RECONSTRUCTION FOR
LOWER EYELID DEFECTS
• Moderate sized defects up to 50% of the lid length
• Posterior lamella
• Hughes’ (modified) tarsoconjunctival
• Anterior lamella
• Advancement of cheek skin
• Full thickness skin graft
• Tripier flap unipedicle

43. DIRECT CLOSURE

44. CANTHAL RELEASE

45. TENZEL FLAP

46. PEDICLE FLAP FROM LOWER LID
(MUSTARDE LID SWITCH)

47. CUTLER BEARD PROCEDURE

49. TEMPORAL FOREHEAD FLAP
(FRICKE FLAP)

50. TRIPIER FLAP

51. HUGHES FLAP

52. MUSTARDE’S CHEEK ROTATION
TRANSPOSITION FLAP

53. SLIDING TARSOCONJUNCTIVAL FLAP
(medial or lateral posterior lamella defect)