2. Eyelid Anatomy/Reconstruction

3. Eyelid
• Thin skin, areolar tissue,
orbicularis occuli ms., tarsus,
levator palpabrae superioris,
Muller’s ms., septum orbitale,
fat and conjunctiva
• Skin – thin, elastic, moderately
adherent to orbicularis over
the tarsus, becomes more
loose and mobile in the
preseptal and orbital regions
• Becomes thicker at the
junction of the skin of the
cheek and eyebrow at the bony
orbital margin

4. Embryology
• 2 ectodermal folds containing a core of
mesenchyme
• Ectoderm: eyelashes and lacrimal glands
• Mesoderm: muscles & tarsal plate

5. Blood Supply
• Via marginal & peripheral arcades
– Upper marginal arcade - via ophthalmic artery
– Lower marginal arcade - via facial artery branches
– Medial peripheral network - via anastomosis from
ICA & ECA systems
– Lateral peripheral network - via branches of STA &
lacrimal artery

8. Innervation
• Periorbital sensation : V1 & V2 branches
• Orbicularis: temporal & zygomatic branches of
facial nerve

11. Eyelid Cross Section

13. Orbicularis oculi
• Surrounds the palpaberal fissure
• Responsible for lid closure
• Divided into palpebral & orbital regions
• Palpebral region subdivided into pretarsal &
preseptal parts

14. Orbicularis oculi

15. Orbital Septum
• Facial membrane which separates the eyelid
structures from the deep orbital structures
• Barrier that helps prevent the spread of
hemorrhages, infection, inflammation
• Attaches to the orbital margin at a thickening of the
periosteum called the arcus marginalis
• Arcus is also the point of confluence of the facial
bones periosteum and the periorbita

16. Orbital Septum
• Upper lid: OS inserts
onto the levator
aponeurosis 2-5mm
above the superior
portion of the tarsus
• Lower lid: OS inserts
into the lower edge of
the tarsus

17. Orbital Septum
• Laterally: OS anterior to the lateral canthal ligament
• Medially: OS posterior to Orbicularis oculi & anterior to
Superior oblique/Trochlear pulley & inserts into the posterior
lacrimal crest
• Superomedially: AM forms the inferior part of the
supraorbital groove
• Inferomedially: OS attaches to the anterior lacrimal crest &
inferior orbital rim
• Recess of Eisler: potential space along the lateral half of the
orbital rim where OS originates just inferior to the orbital
margin

18. Orbital Septum

19. Medial Canthus
• Tripartite apparatus:
– Vertical component -
suspension & fixation
of the medial canthus
– Horizontal
components
contribute little to
stability

20. Lateral Canthus
• Attaches to: upper &
lower tarsal plates,
orbicularis oculi,
fibrous portion of OS
• Inserts to: lateral
orbital tubercle of
Whitnall (5mm behind
the rim)

21. Tarsal plates
• Thin elongated plates of
connective tissue
• Contribute to form and support
the eyelids
• Closely related to the LPS,
medial, lateral canthal structures
• Superior tarsus 10-12mm
tapering to the sides. Inferior
tarsus 3.8-4.5 mm
• The meibomian glands are
approx 20 in each lid within the
substance opening in a row of
tiny dots corresponding to the
Grey line – mucocutaneous
junction

22. Pre-aponeurotic fat

23. Upper eyelid retracters

24. Levator palpebrae superioris
• Striated muscle (CN III)
• Origin: lesser wing of sphenoid
anterior to the optic foramen
• Length: 40-45mm (including
10-15mm aponeurotic
extension)
• Aponeurosis attaches to the
lower 7-8mm of the anterior
tarsus & sends fibres through
the orbicularis to the skin -
upper lid crease
• Total excursion 10-15mm

25. Muller’s muscle
• Smooth muscle
(sympathetic)
• Posterior to levator
• Length 10mm &
inserts into tarsal
plate
• Excursion 2-3mm
• Horner’s syndrome

26. Lower eyelid retractors
• Capsulopalpebral
head of the inferior
rectus
• Muller’s muscle

27. Conjunctiva
• Marginal: lid margin
to anterior skin
• Tarsal: adherent to
the tarsus
• Orbital: posterior to
Muller’s muscle
• Bulbar: extends
posterior to the fornix

28. Lacrimal system
• Controls the tear secretion
• Basic and Reflex secretors
• Basic secretors – three sets of glands
Limbal: mucus secreting goblet cells – produce a
mucoprotein layer covering the cornea
Conjunctival: Accessory lacrimal glands of Krause
and Wolfring located in the s/c tissue
Tarsal: Oil producing Meibomian glands and the
palpaberal glands of Zeis and Moll. Outermost
precorneal lipid layer helps stabilize the tear film and
retards evaporation
• Reflex Secretors - main lacrimal gland (orbital & palpebral
lobes)

29. Lacrimal system

30. Lacrimal drainage system
• Upper and Lower puncta open 5-7
mm from the canthal angle at the
apex of the papilla
• Ampulla – vertical portion of the
canaliculus – dilated portion just
prior to the transition to a
horizontal direction
• Horizontal portion measures
approximately 8mm and converge
to form the common canaliculus to
enter the sac, may enter
separately
• Lacrimal sac is located in the
lacrimal fossa just posterior to the
medial canthal tendon
• Nasolacrimal duct passes
downward inferiorly to open into
the inferior meatus

31. Lacrimal drainage system

32. Eyelid Reconstruction
• Aims:
– To reestablish functional eyelids
– Adequate protection of the eyeball
– Reasonable cosmesis

33. Eyelid Reconstruction
• Requirements:
– Smooth mucous membrane internal lining to maintain lubrication of
the ocular surface and avoid corneal irritation
– Skeletal support to provide adequate lid rigidity and shape but also
allow molding to the globe
– Stable eyelid margin to keep eyelashes & skin away from cornea
– Proper fixation of the medial & lateral canthal attachments of the lids
for eyelid stability & orientation
– Adequate muscle to provide tone & power for closure
– Supple, thin skin to allow eyelid excursion
– Adequate levator action to lift the upper lid above the visual axis

34. Eyelid Reconstruction
• Anterior & Posterior lamella
• Anterior lamella:
– Skin & orbicularis oculi
– Dynamic closure of upper & lower lids
– Lacrimal pump mechanism
• Posterior lamella:
– Tarsal plates
– Conjunctival lining

35. Eyelid Reconstruction
• Anterior lamella:
– Flaps - advancement, transposition, or rotational
musculocutaneous flaps
– Full thickness skin grafts

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

37. Eyelid 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

40. Mustarde Flap
-Cheek rotation
-Deep eyelid defects
>75%
-Often problems with
sagging lower lid,
ectropion, entropion,
epiphora, flap
necrosis, facial nerve
injury.

50. Can close defects up to 25-50% directly +/-
Canthol release.
Approximate Margin first, if tight then
proceed to:
Lateral
Canthotomy
Inferior
Cantholysis

51. Tenzel Slide
-Up to 70% defects of
lower eyelid
-best if tarsal plate
remnant at each end
-good in elderly with
poor other eye
-McGregor Flap is
similar but
incorporates a Z-Plasty

52. Hughes (TarsoConjunctival Flap)
-“Like with like”
-Shallow defects up to 100% of margin
-4mm Tarsus needed for stability
- Need good other eye!

53. SOURCE OF CHONDRO- MUCOSAL GRAFT

54. Hughes Flap
(For Posterior
Lamella)
FTSG
(For Anterior
Lamella)

55. Tripier Flap
-Shallow defects up to
100% of lower lid
-Can be lined or unlined
-But, Tendency to sag
and for margin to retract
-Medially, Laterally or
Bipedicle
-?Treacher Collins
Coloboma

56. Reverse Hughes
-No support but ?good results
-Note: Another type of flap good for up to 70% of margin is the upper lid horizontal
advancement tarsoconjunctival flap with a skin graft.

57. Cutler-Beard 1955
-up to 100% of eyelid margin, divide at 8 weeks
-Incision 4 to 6mm below lid margin
-Lacks support, modify with ear cartilage deep to orbicularis

58. Mustarde Lid Switch
-Laterally based is unreliable
-Medially based is a 2 stage procedure

65. Full Thickness Skin Graft harvested
from left preauricular area