Download Preoperative Patient Evaluation

1270-11604-33871 port traz 30/11/06 12:46 P gina 1
1270-11604-33871 ocular
30/11/06
15:04
Página 2
Cirujanos
Plástikos
Mundi
P
Preface
R
E
F
A
C
E
This manual is a guide for periocular surgery to be performed
&
A
K
under the limited circumstances of developing countries.
The reality is an abundance of patients and a lack of manpower,
material, and literature.
N
O
W
L
E
D
G
E
M
E
N
T
2
1270-11604-33871 ocular
1/12/06
11:18
Página 3
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
Acknowledgements
P
R
The goal of reconstructing eyelid defects is to restore the normal anatomy and
E
function of the eyelid. This can be a challenging endeavor, especially with larger
F
defects and those that involve the lateral and medial canthi. Various reconstructive
A
techniques have been developed and the choice of technique will often depend on
what portions of the eyelid are missing and the size of the defect. Due to the complex
anatomy and function of the eyelid and the delicate nature of the tissue, a thorough
C
E
&
understanding of the surgical anatomy is necessary. This anatomy will be reviewed
here and many of the basic reconstructive techniques will be described, which will
A
allow for the successful reconstruction of most eyelid defects encountered by the
K
reconstructive surgeon.
N
O
We thank “Primal Pictures” for their impressive anatomic templates.
W
L
I want to express my gratitude to Dr. Glenn Jelks and his wife, Dr. Elisabeth Jelks.
Glenn is an elite professional in the field of periocular reconstruction, without his
large experience and great patience answering my never ending questions during the
elaboration of this manual, all this would not have been possible
E
D
G
E
M
E
Dr. Fco. Javier Beut Cabrera
N
President & Founder
Cirujanos PlástiKos Mundi
T
3
1270-11604-33871 ocular
30/11/06
15:04
Página 4
Cirujanos
Plástikos
Mundi
INTRODUCTION
I
Some words about the oculoplastic surgery history
N
T
R
O
D
U
C
T
I
O
N
Although the Greeks created rational medicine, their work was not always or even
fully scientific in the modern sense of the term. Like other Greek pioneers of science,
the doctors were prone to think that much more could be discovered by mere
reflection and argument than by practice and experiment. For in their time there was
not yet a distinction between philosophy and science, including medicine.
Hippocrates was the first to separate medicine from philosophy and disprove the idea
that disease was a punishment for sin. Much of the traditional treatment for injuries
and ailments practiced by the Greeks stemmed from folk medicine, a characteristic
shared by the Greeks with other societies to this day.
One of Hippocrates’ predecessors was Alcmaeon of Croton who operated on the eye
4
1270-11604-33871 ocular
30/11/06
15:04
Página 5
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
and discovered ‘passages’ linking the sense organs to the brain, which he recognized
as the seat of thought and feeling (followed by Plato but not Aristotle). Alcmaeon was
probably the first physician to formulate the doctrine of health as a balance among
the powers of the body, these powers being constituent fluids with definite qualities
and causal properties.
If the work of Hippocrates can be taken as representing the foundation of Greek
medicine, then the work of Galen, who lived six centuries later, is the apex of that
tradition. Galen crystallised all the best work of the Greek medical schools which had
preceded his own time. It is essentially in the form of Galenism that Greek medicine
was transmitted to the Renaissance scholars.
Galen, for all his mistakes, remained the unchallenged authority for over a thousand
years. After he died in 203 CE, serious anatomical and physiological research ground
to a halt, because everything there was to be said on the subject had been said by
Galen, who, it is reported, kept at least 20 scribes on staff to write down his every
dictum.
Galen’s mistakes perpetuated fundamental errors for nearly fifteen hundred years
until Vesalius, the sixteenth century anatomist, although he regarded his predecessor
with esteem, began to dispel Galen’s authority.
Modern medicine began in 1543 with the publication of the
first complete textbook of human anatomy, De Humanis
Corporis Fabrica by Andreas Vesalius (1514-1564), fig. 1.
Vesalius can only be compared with Hippocrates in stature
and importance. The great anatomist was a classicist by
education. He knew Greek and Latin to perfection. He
zealously studied the ancient authors and extolled them. In
this sense, Vesalius was a humanist. Fig 2, 3,4
This three authorities in the medicine embraced important points: philosophy,
persistence and exceptional ability. These qualities served to new generations to
develop and improve the service to the community world.
Recent concepts and techniques common to plastic surgery and ophthalmology
originated with the need for repair in the oculo-orbital region. Perhaps Sir John
Mustardé was the first to embrace both concepts followed by Dr. Tessier, Dr. Iliff
Thanks to "old" and "young" predecessors, oculoplastic surgery or plastic and
reconstructive surgery of the eye emerged as a new sub-specialty from the fan of
possibilities of reconstructive surgery.
Oculoplastic surgery, or plastic and reconstructive surgery of the eye, encompasses
eyelid surgery to change the structure and function of the lids, the tear duct system
and the eye socket.
5
I
N
T
R
O
D
U
C
T
I
O
N
1270-11604-33871 ocular
30/11/06
15:04
Página 6
Cirujanos
Plástikos
Mundi
A wide array of surgical procedures is included in this area: a key element of
oculoplastic surgery is surgical repair of injuries, not only to improve the appearance
of the eyelid, but even more importantly, to allow the eyelids to protect the eye
adequately.
I
ANESTHESIA
N
T
R
O
D
U
C
T
I
O
N
Preoperative Preparation
The eye should be anesthetized with tetracaine eye drops prior to prepping. A corneal
shield lubricated with antibiotic ointment is useful. The surrounding skin should be
prepped with Betadine but the solution should not be used to cleanse the wound.
The wound should be irrigated profusely with warmed saline. All dirt and foreign
particles should be cleansed, especially imbedded dirt which can cause permanent
discoloration and tatooing.
Wound edges should be minimally debrided of all necrotic tissue. Irregular edges
should be freshened to allow for straight surgical margins to suture together.
Identifiable landmarks such as eyebrows or eyelid margins should be sutured first.
Local anesthesia for repair of eyelid lacerations is best obtained by performing a
regional block. Anesthesia of most of the lower eyelid can be obtained by injecting
1cc of anesthetic into the infraorbital foramen. The foramen can be located 1cm
below the infraorbital rim in line with the supraorbital notch. Additional anesthetic
may be necessary laterally where the zygomaticofacial and zygomaticotemporal
nerves pass through the lateral orbital wall. Anesthesia of the upper lid is obtained by
blocking the supraorbital nerve as it exits through the supraorbital notch and the
supratrochlear nerve. Again, additional anesthesia may be necessary laterally because
of the lacrimal nerve. Anesthesia to the medial canthal area and lacrimal sac is
obtained by blocking the infratrochlear nerve by injecting above the medial canthal
tendon approximately 1cm deep.
Anestesia for traumatic eye surgery
In USA The National Eye Trauma System, a consortium of 43 regional eye trauma
centres committed to providing optimal clinical management of patients with severe
ocular injuries consider the most important factor determining the potential return
to useful vision is extent of the damage to the macula or optic nerve.
6
1270-11604-33871 ocular
30/11/06
15:04
Página 7
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
Eye trauma can be basically divided into less severe (corneal abrasions, extraocular
foreign bodies, burns, optical contusion, periocular laceration…) and severe injuries
(hyphema, ruptured globe, orbital/facial fracture, intraocular foreign bodies…).
The anaesthetic management of the patient can have an important effect on the final
outcome, and this begins with the history and physical examination. Eye injuries are
addressed only after basic life support has been established and the patient airway,
respiratory, circulatory, and neurologyc status is stable.
We must evaluate for other injuries, which could be more life theatrering, but lost of
vision can be a mayor catastrophe for both the individual and society so evaluation
and treatment must be a high priority in trauma patients.
Hypesthesia in specific areas around the eye may suggest fracture of the orbital floor,
sinus maxilar wall. Pain on mastication may imply fracture of the zygomatic arch.
Rhinorrhea may indicate cribiform plate lesion. The anaesthesiologist should be alert
to potential problems as blood pressure, arrhythmia, pneumothorax… and other
associated medical problems for each patient.
Fasting period of 6-8 hours when possible is encouraged, to reduce the risk of
pulmonary aspiration although does not guarantee an empty stomach: both the pain
and the narcotics given to control the pain may delay emptying.
Narcotics for pain control are given only after the patient cardiovascular and
neurologyc status is stable, since they can precipitate respiratory depression and
nausea and vomiting, fentanyl and mydazolam or diacepam can be used with close
monitoring of continuous oxygen saturation, atropine 0,4-0,6 mg may be used to
antisialogogyc and blocking reflex mediated bradicardia, diuretic manitol (1,5-2
g/kg) can be used to control IOP.
Drugs that depress central nervous system generally depress IOP (intraocular
pressure). Nitrous Oxide (N2O) is questionable because may raise IOP slightly. The
other anaesthetic agents: thiopental, etomidate and propofol lower IOP. Ketamine,
being a drug used a lot in the III World, can increase IOP in an indirect way by
increasing muscle tone and produce nystagmus and blepharospasmus. Narcotic,
benzodiacepines and droperidol lower IOP. Succinylcholine also increases IOP but
can be controlled with pre-treatment with diacepam (0,1 mg/kg iv) or clonidine (5
mg/kg oral 90 min before induction).
There is no election technique for general anaesthesia management but the most
important is to control haemodinamics in a stable course of the procedure, so
7
I
N
T
R
O
D
U
C
T
I
O
N
1270-11604-33871 ocular
30/11/06
15:04
Página 8
Cirujanos
Plástikos
Mundi
monitoring must include ECG, blood pressure, pulse oximetry and if possible end
tidal CO2 measurement.
I
Regional anaesthesia is an option as main technique supported with sedation or
supplementing the general anaesthesia. When reducing sympathetic tone regional
blocks can improve local and systemic haemodinamics, also stops the stress response
to surgery. So the question is if regional anaesthesia can be appropriate for the type
of surgery involved.
N
T
R
O
D
U
C
T
I
O
N
Amides group local anaesthetics (LA) are the standard for regional anaesthesia, the
election of a particular drug is up to the expected effect in a peripheral nerve block:
-Concentration:
lidocaine 0,5-1%
mepivacaine 1%
bupivacaine 0,25-0,5%
and new ropivacaine and levo-bupivacaine 0,25-0,5%
-duration of action:
lidocaine 60-120min
mepivacaine 2-3h
bupivacaine and levo-bupivacaine 4-10h
and ropivacaine 4h
-onset of action:
lidocaine and mepivacaine: 30-60seconds
bupivacaine, levo-bupivacaine and ropivacaine: 10-15min
-toxicity:
Allergic reactions are possible to any LA, but risk is very low.
Neurotoxiticy is supposed after unsupeccted intraneural inyection.
General toxicity is due to reach toxic blood levels witch are in a direct function of
total dose administered, so we must never go over recommended max. Dose for a
given LA, this dose is 5-6mg/kg of total dose for lidocaine and mepivacaine and 23mg/kg for bupivacaine, levo-bupivacaine and ropivacaine. This general toxicity is
life treathering and begins with neurological symptoms as metallic taste, tinitus…
progressing into SNC depressison convulsion and coma, cardiovascular toxicity needs
a higher initial blood level of LA and early symptoms are bradicardia and
hipotension, arrithmia and cardiac arrest. LA toxicity increases with hypoxemia and
hypercapnia. This toxicity is due to the LA effect blocking ions channels so cardiac
arrest is very difficult to reverse. This is why new LA insist on lower toxicity.
8
1270-11604-33871 ocular
30/11/06
15:04
Página 9
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
We use to mix two LA to get the best of each: short onset and lower toxicity
(*lidocaine and mepivacaine 2%) and long acting ( **bupivacaine, levo-bupivacaine
and ropivacaine 0,5) in 50% of volume for each so the final concentration is half of
the initial:
Lidocaine 2% 15cc + bupivacaine 0,5% 15cc = 30cc of lidocaine 1% and bupivacaine
0,25%.
I
We use to add adrenaline 1:200000 or 5mgr/cc for local vasoconstriction in order to
reduce bleeding, next minutes after injection must closely monitor blood pressure for
the risk of hypertension.
N
The place for LA injection is the pointed in the pictures following, if able a
neurostimulator can be used, if not we just inject LA volume in the supposed place
but without looking for parestesia because the risk of intraneural injection.
T
R
O
D
U
C
T
I
O
N
9
1270-11604-33871 ocular
30/11/06
15:04
Página 10
Cirujanos
Plástikos
Mundi
I
N
T
R
O
D
U
C
T
I
O
N
Oculomotors nerves
10
1270-11604-33871 ocular
30/11/06
15:04
Página 11
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
I
N
T
R
O
D
U
C
T
I
O
N
11
1270-11604-33871 ocular
30/11/06
15:04
Página 12
Cirujanos
Plástikos
Mundi
I
N
T
R
O
D
U
C
T
I
O
N
12
1270-11604-33871 ocular
30/11/06
15:04
Página 13
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
Preoperative Patient Evaluation
EXAMINATION AND EVALUATION
• Most important factor in detection of isolated fractures of the orbital wall is a high
index of suspicion
• R/O associated life threatening injuries (intracranial hemorrhage or subdural
hemorrhage).
• Location and mechanism of injury.
• Use of eyewear at time of injury.
• Patient’s prior ophthalmic history.
• Systematic comprehensive eye examination.
Symptoms and signs of a blow-out fracture
• Periorbital bruising.
• Subcutaneous emphysema.
• Infraorbital anesthesia.
• Diplopia usually on upward gaze.
• Enophthalmos or restriction of the globe.
• X-ray evidence of a fracture.
P
R
E
O
P
E
R
A
T
I
V
E
P
A
T
I
E
N
T
Early features of the injury
• Immediate limitation of elevation of the eye.
• Presence of the above in conjunction with intact orbital rim and parasthesia of the
infraorbital nerve.
• Alteration of the occular level.
• Presence of relatively denser fragments within the general opacity of the antrum in
conventional Waters projection.
Late features of the injury
• Restriction of movement (especially in vertical direction) or worsening of previous
limitation of this nature.
• Concomitant development of diplopia, most evident when looking upwards.
13
E
V
A
L
U
A
T
I
O
N
1270-11604-33871 ocular
30/11/06
15:04
Página 14
Cirujanos
Plástikos
Mundi
P
R
E
O
P
E
R
A
T
I
V
E
P
A
T
I
E
N
T
E
V
A
L
U
A
T
I
O
N
• Slight lowering of the ocular level.
• Enophthalmos.
• Deepening of the supratarsal fold.
• Narrowing of the palpebral fissure.
IMAGING OF ORBITAL TRAUMA
Plain Radiographs.
• CT Scan.
-Axial and coronal are best utilized for complete diagnosis
-2mm thick slices are required for detailed examinations.
-CT scan establishes the specifics of the injury and helps plan the surgical correction.
• 3-D CT scan. Has no real advantage over traditional scanning in the routine
diagnosis of orbital trauma.
• MRI.Useful in diagnosis of incarceration of orbital trauma.
ADDITIONAL INVESTIGATIONS
Forced duction test
• Local anesthetic solution is instilled into the conjuctival fornices and tendon of the
inferior rectus muscle is grasped by forceps through the conjunctiva and an attempt
made to rotate the eye upward.
• Resistance to free movement indicates that there is a mechanical obstruction.
• Likely reasons for mechanical obstructions:
1- Herniation of periorbital fat.
2- Incarceration and entrapment of muscle.
3- Impingement of bone fragments upon fat and muscle.
4- Fibrous tissue formation and adhesions.
5- Depression of orbital roof with or without 3 and 4 above.
Orbitography
• Injection of a radiopaque material contrast medium along the floor of the
orbit.
Electromyography
• Requires high standard of instrumentation and skills.
14
1270-11604-33871 ocular
1/12/06
11:18
Página 15
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
• Particular value in the differential diagnosis of a combined injury such as an incarceration
of the inferior rectus muscle in association of weakness of the superior rectus.
ORBITAL INJURIES
Diplopia
• True diplopia or blurred vision ?
• Monocular or binocular diplopia ?
• Monocular diplopia caused by uncorrected refractive errors, corneal opacity,
dislocated lens, cataract, and retinal detachment. Requires urgent ophthalmic
intervention.
• Binocular diplopia caused by orbital trauma with subsequent hemorrhage or
fracture, or by head trauma with ensuing cranial nerve palsy.
• Diplopia and restriction from edema or hemorrhage generally resolve within 1 to 2
weeks after the injury.
• If orbital surgery is indicated proceed with repair within 2 weeks to 1 month.
• Serial forced duction tests helpful in differentiating restriction from neuropathy and
paresis.
• Management of cranial nerve palsies consists of 6 months observation to allow for
spontaneous recovery.
• Consider strabismus surgery.
Face Anatomy
PLEASE, CONSULT OUR WEBSITE
www.cpmundi.org
15
P
R
E
O
P
E
R
A
T
I
V
E
P
A
T
I
E
N
T
E
V
A
L
U
A
T
I
O
N
1270-11604-33871 ocular
29/11/06
10:19
Página 16
Cirujanos
Plástikos
Mundi
E
Emergency Management
M
E
R
G
E
N
C
Y
M
A
N
A
G
E
M
E
N
T
- In the absence of an ophthalmologist, treatment of major ocular
injuries in normally is managed by the general surgeon and ideally is
limited to interim measures aimed at prevention of infection within the
eye. Systemic antibiotics and tetanus prophylaxis should be instituted at
the earliest opportunity in the preoperative period.
Any abnormality in the appearance of the eye injured by blast or
fragmentation weapons, or by severe blunt trauma, demands the following
course of action preparatory to evacuation:
1. Instruct the patient not to squeeze his eyelids.
2. Do not remove any penetrating foreign body protruding from the globe
or the conjunctival fornices, as ocular contents may be extruded.
3. Occlude both eyes, but avoid any pressure directly on the eyes. The
battle dressing tied around the head suffices.
4. Give systemic analgesics for moderate to severe pain.
5. Evacuate immediately as a supine litter patient to a forward hospital,
preferably with ophthalmology capability.
Where penetrating injury to the globe is suspected, the patient's eye can be
protected from his own reflex lid squeezing by administration of a Nadbath
block as follows: 1.0 cc of 2% xylocaine is injected using a 23 to 27 gauge
needle no longer than 10mm. The area immediately behind the ear is
palpated, and the needle is placed perpendicular to the anterior surface of the
mastoid in the triangular space formed by the ear anteriorly, the mandible
inferiorly, and the mastoid process posteriorly. The needle is advanced to the
hub, delivering the anesthetic to the facial nerve as it exits the region of the
stylomastoid foramen.
Ocular burns can be seen. Ultraviolet, thermal, and non-alkali chemical
burns are treated as for corneal abrasions. However, non-alkali chemical burns
require initial irrigation with tap water or saline solution for 10-15 minutes
under topical anesthesia.
With white phosphorous burns of the eye, instillation of 0.5% copper sulfate
solution identifies particles, which are otherwise presumptively located by foci
of smoke or by darkening the particles. Larger particles may require removal
with a needle or spud. The particles should be continuously irrigated to retard
their further oxidation (reignition) and resultant tissue damage. These
16
1270-11604-33871 ocular
29/11/06
10:19
Página 17
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
patients urgently require treatment by an ophthalmologist, in whose hands
continuous irrigation with ophthalmic antibiotics in Ringer's solution may be
performed by a percutaneous, indwelling, superior fornix angiocatheter, since
severe edema of the lids often prevents the conventional administration of
topical medication. Alkali burns may result from exposure to sodium
hydroxide, lye, quick lime, ammonia, and agents often found in degreasing
solvents. These burns represent an ocular emergency! Chemical penetration is
so rapid that irrigation with copious volumes of water or sterile saline must be
initiated within seconds. This irrigation must be continuous for at least 60
minutes. Irrigation ,should be continued until the pH remains below 8.0 for
at least rive minutes after irrigation ceases. An alkali burn is potentially
devastating and prognosis may be poor, especially if the cornea appears cloudy
or the conjunctive blanched. Atropine sulfate 1% and chloramphenicol
ointments should be applied 3-4 times a day. Phenylephrine, which will
further constrict blood vessels and worsen limbal ischemia, should not be
used. Steroid ointment should be used only in the most severe burns and only
during the first three days, as its use later may promote stromal melting. In an
effort to reduce erosion of the corneal stroma when evacuation must be
delayed beyond three days, N-acetyl-L-cysteine (MUCOMYST) may be
applied by dropper in a 20% solution as frequently as each hour. Prompt
evacuation is necessary
Lid and conjunctival debris should be carefully irrigated away. Any sterile
irrigating solution, including water, is acceptable. This should be followed by
generous topical application of fresh solutions of an ophthalmic antibiotic
(gentamycin sulfate, chloramphenicol or neomycin sulfatepolymixin B
sulfate) and atropine sulfate 1%. A sterile, four-by-four-inch gauze strip is
applied to keep the area clean, and additional protection is afforded by taping
a Fox (or similar type) shield over the injured eye. A pressure dressing should
be avoided as it may cause serious damage by expressing intraocular contents
through a penetrating wound. Since patching also helps provide an excellent
culture medium for bacteria, particularly Pseudomonas, topical antibiotic
solution is carefully reinstilled every four hours, and a fresh, sterile gauze
patch reapplied twice daily. Sterile irrigation of mucopurulent secretions from
the lid margins and conjunctiva should be carried out when the gauze dressing
is changed. The uninjured eye should be patched to reduce unwanted ocular
motion.
No ocular surgery should be performed. Particularly, no attempt should be
made to remove protruding or penetrating foreign bodies or to repair corneal
or scleral lacerations. Preferably, repair should be undertaken for lacerations
involving the lid margin or the nasolacrimal apparatus. Even an eye which
appears grossly irreparable may have surgery deferred, utilizing the same
17
E
M
E
R
G
E
N
C
Y
M
A
N
A
G
E
M
E
N
T
1270-11604-33871 ocular
29/11/06
10:19
Página 18
Cirujanos
Plástikos
Mundi
E
M
E
R
G
E
N
C
Y
M
A
N
A
G
E
M
E
N
T
regimen of sterile gauze dressings and antibiotics.
Until recently, the selection of systemic antibiotics has been beset with two
problems: (1) many drugs do not pass the blood-aqueous and blood-retina
barriers to give adequate intraocular tissue concentrations, and (2) earlier
drugs have had limited bactericidal spectra, especially for strains of
Pseudomonas aeruginosa. When ophthalmologic care must be delayed, the
following initial antibiotic regimen may be used if infection is suspected and
the wound is of such size and location that extrusion of intraocular contents
is not a risk:
Subconjunctival: Gentamycin 40mg
Cephaloridine 100 mg
or
Gentamycin 40mg
Methicillin 100 mg
Topical:
Gentamycin 9mg/cc
Bacitracin 5,000 u/cc
Systemic:
Cephaloridine, 1 gm. stat, IV then 500mg q 6 hr.
or
Methicillin 2gm, IM, q 8 hr.
Subconjunctival injection is best accomplished using topical proparacaine
(0.5%) anesthesia, a smallvolume syringe (2.5cc) and a short (5/8") 27 gauge
needle. The bulbar conjunctiva is engaged near the upper or lower fornix with
the bevel facing the globe, and the needle is advanced toward the fornix, the
injection being given while the needle tip is visible through the conjunctiva.
Subconjunctival injections are contraindicated if the wound is of such size and
location as to risk extrusion of intraocular contents. In such cases, only the
topical and systemic routes should be used, as noted above.
While ideally handled by an ophthalmologist, many of the following ocular
injuries can be managed well by surgeons or general medical officers:
1.
2.
3.
4.
Eyelid laceration, with and without margin involvement.
Deeply embedded corneal foreign bodies.
Ocular burns.
Ocular contusion injuries.
If evacuation or ophthalmologic care is delayed, repair of lid lacerations by a
non-ophthalmologic surgeon may be necessary. Evaluation of any lid injury
must include an evaluation for coexisting injury to the eyeball and penetrating
injury to the intracranial contents. Lacerations and avulsions near the medial
18
1270-11604-33871 ocular
29/11/06
10:19
Página 19
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
canthal tendon necessitate a careful examination for interruption of the
canaliculus. In the repair of any lid injury, it is necessary respect the complex
anatomy of the lid, exact anatomical realignment being necessary .It is
especially important that the levator muscle, the tarsal plate, and the medial
canthal tendon be precisely reapproximated, or severe functional and cosmetic
disabilities may ensue. Adequate coverage of the cornea is of critical
importance. The repair of lid injuries requires a knowledge of the anatomy of
the lid, fine ophthalmic instruments and sutures, and magnification provided
by either loupes or an operating microscope. Lid tissue should be preserved
wherever possible. Only tissue that is clearly necrotic should be debrided.
Totally avulsed lid segments should be reattached after cleansing. Lacerated
lids should be extensively irrigated and all foreign bodies removed.
Lid lacerations should be repaired in the following manner. Lacerations
through the skin horizontal to the lid margin can be repaired with 6-0 black
silk/nylon sutures. Lacerations that involve the lid margin itself must be
repaired precisely: 4-0 black silk suture should be used to approximate the
tarsal plates elsewhere and 6-0 black silk should be used to approximate the
anterior and posterior borders of the lid margin and the skin of the lid
elsewhere. Lid margin sutures should stay in for ten days. The lid should be
placed on stretch using the long arms of the 4-0 black silk sutures for at least
three days after the repair of the injury. A light pressure dressing should be
placed over the eye after the instillation of an antibiotic ointment. The cornea
must be checked each day. No elaborate reconstruction of the lids should be
performed in a combat zone, though every effort should be made to preserve
and reapproximate lid tissues at the time of the primary repair.
E
M
E
R
G
E
N
C
Y
M
A
N
Lacrimal Secretory System. It is necessary to recognize a prolapsed
orbital lobe of the lacrimal gland, distinguishing it from normal orbital fat.
The orbital lobe of the lacrimal gland is pinkish-gray in contrast to the
creamy-yellow color of orbital fat. The prolapsed orbital lobe should be
irrigated and reposited in its fossa by means of a 4-0 chromic suture passed
through the lobe and the periosteum lining the fossa.
Lacrimal Excretory System. It is critically important to identify
lacerations of the canaliculi so that they may be repaired properly at the time
of wound repair. The canaliculi must be stented, preferably with silicone
tubing. If silicone is not available, fine silver wire (eg. 3-0 or 4-0 Bowman
probe) can be bent in the form of a Johnson lacrimal rod and used as a stent.
In cases of midface trauma where the nasolacrimal duct may have been
interrupted, the entire lacrimal excretory system should be stented with
19
A
G
E
M
E
N
T
1270-11604-33871 ocular
29/11/06
10:19
Página 20
Cirujanos
Plástikos
Mundi
silicone tubing.
E
Orbit. A careful examination of the globe is mandatory in all cases of injury
M
E
R
G
E
N
C
Y
M
A
N
A
G
E
M
E
N
T
to the orbit. The globe is significantly injured in 25% of orbital fractures.
Retrobulbar hemorrhage must be detected and treated if it is producing
marked elevation of intraocular pressure and/or decreased visual acuity. If so,
a lateral canthotomy and cantholysis of the inferior crus of the lateral canthal
tendon should be performed. If these maneuvers do not produce an
improvement in intraocular pressure (i.e., decreasing it) and vision, the
hemorrhage must be released by an incision through the conjunctiva and
Tenon's capsule between the lateral rectus and the inferior rectus muscle
into the muscle cone. The incision should be made with sharp scissors, and
blunt tip scissors should be used to gently spread the orbital fat within the
muscle cone to permit the escape of blood. Pressure on the globe and optic
nerve during any surgery upon the orbit and its contents must be avoided.
Blindness can result from prolonged retraction pressure on the globe and
nerve. Intraorbital extraocular foreign bodies are best left undisturbed unless
they are large (greater than 1 cm in largest diameter) or are producing globe
or optic nerve dysfunction. Radiographic evaluation of orbital fractures
should include a stereo Waters' view and computerized tomography with
coronal and sagittal reformatting. The latter is especially important in the
evaluation of fractures of the optic canal. Blowout fractures of the orbital floor
in general do not require immediate repair. Forced duction testing should
always be performed before resorting to surgical repair. If surgery is
performed, ductions of the globe should be tested intraoperatively to help
prevent incarceration. of tissues incident to surgical manipulation.
Enucleation.
"Under no circumstances should an eye be excised by a general surgeon unless the
globe is completely disorganized."
In the unlikely circumstance that a patient with a severe ocular injury cannot
be evacuated within several days to a facility that has an ophthalmologist and
the ophthalmologist cannot be brought to the forward facility, primary
enucleation should be considered if the patient has no light perception using
the brightest available light source. Such a severe injury would most likely be
an extensive corneoscleral laceration with either prolapse or loss of intraocular
contents. However, even in the face of a severely damaged eye with no light
perception, cosmetic function may remain; therefore, consultation with an
ophthalmologist should be sought before such a definitive procedure is
20
1270-11604-33871 ocular
29/11/06
10:19
Página 21
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
undertaken.
Be assured that this policy of delay is perfectly safe as it relates to sympathetic
ophthalmia. Sympathetic ophthalmia (involvement of the uninjured eye)
never develops until at least ten days after trauma, and only very
exceptionally develops before 21 days.
"There is sufficient time for the patient to reach an ophthalmologist."
If the decision is made to remove the eye, the conjunctiva is incised at the
limbus to separate it from the globe. Using a combination of blunt and sharp
dissection, the four rectus muscles are exposed from their insertions as far
posteriorly as possible (usually 10-15mm). Tenon's capsule (the connective
tissue surrounding the globe) is separated from the globe in the four
quadrants between the rectus muscles. The extraocular muscles are then
cauterized and severed 2mm from their insertions on the globe.
Traction should be exerted on the globe in the anterior direction as a curved
Halsted clamp is placed behind the globe as deeply into the orbit as possible.
By blunt dissection, the optic nerve is isolated, clamped to crush the central
retinal vessels, and cut distal to the clamp. The globe is removed from the
orbit. Before the Halsted clamp is removed, hemostasis should be achieved by
direct cautery of the nerve stump. If available, it is most important to place a
silicone sphere no larger than 16mm in diameter in the position occupied
previously by the globe. The sphere should be placed within the muscle cone,
posterior to the posterior layer of Tenon's capsule, and a careful closure of
posterior Tenon's and anterior Tenon's, using interrupted 4-0 chromic catgut
sutures, is completed. The conjunctiva is closed horizontally with interrupted
5-0 plain catgut sutures. If available, a ring conformer should be placed
between the bulbar and palpebral conjunctiva to prevent obliteration of the
conjunctival cul-de-sacs which impairs the patient's subsequent wearing of a
prosthesis. A scleral ring, rather than a scleral shell type of conformer, is
preferred because the ring eliminates direct pressure on the conjunctival
suture line.
In the event that the patient still retains light perception or even better vision
in the face of a corneal or scleral laceration, primary closure of the wound
should be performed by the nonophthalmologist physician if the patient
cannot be treated by an ophthalmologist within a few days.
"The guiding principle is meticulous wound closure without debridement, except
for the excision of prolapsed intraocular tissue."
Magnification of any type will be of great assistance. Instruments should not
be introduced through the wound into the eye. If the laceration involves both
the cornea and sclera, the cornea should be repaired first. The smallest (7-0)
silk suture material available and the finest available instruments should be
used. The first suture should not be placed until the edges of the wound are
carefully aligned. Close attention to the limbal landmarks will assist in proper
21
E
M
E
R
G
E
N
C
Y
M
A
N
A
G
E
M
E
N
T
1270-11604-33871 ocular
29/11/06
10:19
Página 22
Cirujanos
Plástikos
Mundi
E
M
E
R
G
E
N
alignment. The curved needle is introduced almost perpendicularly into the
tissue about 2mm from the wound edge, and is taken to midstromal depth
(the cornea is less than 1 mm thick in most areas) from where it is directed
horizontally to the edge of the wound. The needle should penetrate the other
edge of the wound at midstromal depth, and exit the cornea 2mm from the
wound edge. The interrupted sutures should be placed every 2mm.
Scleral wounds should be closed similarly, using meticulous technique and
midstromal depth placement of sutures. Noncolored sutures are usually used
on the scleral wound, since these will remain buried after the conjunctiva is
closed.
As a final note, all individuals rendering care for ophthalmic injuries must be
aware of the frequent occurrence of combined neurosurgical and maxillofacial
injuries when the eye and orbit are involved. Optimal treatment in these cases
depends upon a well-coordinated team effort.
C
Y
M
A
N
A
G
E
M
E
N
T
22
1270-11604-33871 ocular
29/11/06
10:19
Página 23
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
Decision making in eyelid
reconstruction and periocular
areas including the face.
The eyelids act to protect the anterior surface of the globe from local injury.
Additionally, they aid in regulation of light reaching the eye, in tear film maintenance
by distributing the protective and optically important tear film over the cornea
during blinking, and in tear flow by their pumping action on the conjunctival sac and
lacrimal sac.
Ancillary procedures are always essentials when considering to reconstruct the eyelids
and periocular areas. Depending the zone , you have to consider:
-transnasal wiring
-medial and lateral canthopexy, canthoplasty
-cheek fixation to periosteum
-caniculoplasty
-microsilicone tube intubation (canalicular system)
The goals of eyelid reconstruction are 3-fold:
(1) to provide adequate eyelid function,
(2) to afford globe protection
(3) to achieve acceptable aesthetic results.
General Anatomy:
• Lids have 3 lamellaes
• Upper and Lower analogous
• Levator vs. Capsulopalpebral fascia
• Superior oblique vs Inferior oblique muscles
• Canthal tendons
• Medial Canthal pump
• Orbital fat and Septae
• Lacrimals glands
23
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
1270-11604-33871 ocular
29/11/06
10:19
Página 24
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
ZONE O
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
Introduccion
A. Pupillary Apertures or the pupil is a central aperture, which is surrounded by an
adjustable diaphragm, the iris. The function of the iris is to control the amount of
light entering the eye by controlling the diameter of the pupil, which can range from
1-8mm. The iris cannot save the eye from intense illumination but it moderates a
large range of luminosity encountered in everyday life. It therefore preserves useful
vision in variable situations.
B. Irides seen through Cornea
The iris is an adjustable diaphragm around a central aperture, the pupil. The function
24
1270-11604-33871 ocular
29/11/06
10:19
Página 25
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
of the iris is to control the amount of light entering the eye by controlling the
diameter of the pupil, which can range from 1-8mm. The iris cannot save the eye
from intense illumination but it moderates a large range of luminosity encountered
in everyday life. It therefore preserves useful vision in variable situations.
The iris is not flat as the lens cause it to bulge slightly. Therefore, it has a shape of a
shallow cone. It is found between the cornea and the lens and is immersed in aqueous
fluid. There are two smooth muscles involved with the iris. These are the ‘sphincter
pupillae’ and ‘dilator pupillae’ muscles.
The posterior and the anterior ciliary arteries supply the iris. The two branches
anastomose with each other around the iris to form the circulus arteriosus major and
minor.
Nerve Supply:
The nerves come mainly from the branches of the long ciliary rami of the nasociliary
nerve and from the short ciliary rami of the ciliary ganglion.
C. Sclera (Syn. Tunica Sclera)
The sclera is a dense layer that maintains the shape of the eyeball through the intraocular pressure. It is thickest posteriorly near the entry point of the optic nerve and
is thinnest at the equator and at the attachment sites of the recti muscles. The anterior
part is covered by conjunctiva, which is reflected from the deep surfaces of the
eyelids. The sclera is pierced, posteriorly, by the optic nerve and is continuous with
the nerve’s fibrous sheath. A larger central aperture allows the entry of the central
retinal artery and vein. Anteriorly, the sclera is directly continuous with the cornea at
the corneoscleral junction. The sclera is composed of dense collagenous tissue mixed
with random elastic fibers and interspersed with flat fibroblasts.
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
25
1270-11604-33871 ocular
29/11/06
10:19
Página 26
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
ZONE I UL
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
Introduccion
The functioning upper eyelid serves a more important role in globe protection than
the lower eyelid because the upper eyelid covers a greater area of the cornea. The
normal vertical excursion of the upper eyelid is approximately 12 mm, compared with
5 mm for the lower eyelid.
Globe protection requires appropriate coverage by the eyelids and adequate tear
lubrication. In upper eyelid reconstruction, an in-depth knowledge of the anatomy is
an absolute prerequisite for success.
26
1270-11604-33871 ocular
29/11/06
10:19
Página 27
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
2- Surgical therapy
The most common indication for upper eyelid reconstruction is defects due to
resection of malignancies. Less often, eyelid reconstruction is indicated for traumatic
injuries. In evaluating reconstructive demands for the upper eyelid, the anatomic
defects must be carefully appraised
In order to address the reconstructive options in an organized manner, eyelid defects
are divided into:
• 1 anterior lamellae - Skin and Orbicularis Oculi.
• 2 medial lamellae - Tarsus, O.S (Orbital Septum), Fat.
27
R
E
C
O
N
S
T
R
U
C
T
I
O
N
1270-11604-33871 ocular
29/11/06
10:19
Página 28
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
• 3 posterior lamellae – Lid Retractors (Levator Aponeurosis, Muller Muscle),
conjuntiva
and thickness defects according to size. : Partial Thikness PT and Full Thickness FT
inferior or superior to 50%.
Zone I-PT (Partial-Thickness)
-PT involving less than 50 %.
Partial-thickness defects smaller than 5 mm heal well by secondary intention.
Defects involving less than half of the upper eyelid can be closed with a variety of
local flaps. Closure is much easier in older patients with skin redundancy. The flaps
are raised as skin-muscle flaps. The incisions are placed along the natural creases of
the eyelid. In patients with superficial defects, remove the orbicularis fibers from
the base of the defect prior to flap rotation. Avoid excessive tension along the
wounds. The muscle layer is closed separately with 6-0 or 7-0 absorbable sutures,
and skin is closed with 6-0 or 7-0 monofilament or 6-0 fast-absorbing catgut
sutures. If excess tension causes lagophthalmos, other tissue, such as a skin graft,
must be brought in for reconstruction. The skin of the opposite eyelid skin and
preauricular area represent readily available sources for skin grafts.
-PT involving more than 50 %,
full-thickness skin grafting usually represents the best reconstructive option. When
performing skin grafts, do not remove the remaining orbicularis from the base of
the defect. The bolster is kept in place for 3 days. Respect the own areas of the
Upper lid.
Zone I -FT (Full-Thickness)
- FT involving less than 25%
Defects of the upper eyelid must be reconstructed in layers in order to allow normal
function. of the lid can be closed primarily. In older patients with significant skin
laxity, this percentage can be higher.
For primary repair, the tarsal edges are first prepared by forming vertically oriented
ends that can be directly approximated.
28
1270-11604-33871 ocular
29/11/06
10:19
Página 29
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
A Burow triangle of eyelid skin is excised above the tarsal edges, thus forming a
pentagonal defect. The lid is repaired in layers by first approximating the tarsal
edges at the lid margin (gray line). Preferred sutures are 6-0 silk sutures because
monofilament permanent sutures are not as soft and can cause conjunctival
irritation. Next, the tarsus is reapproximated using 6-0 polyglactic sutures. Use 23 interrupted sutures with knots tied superficially. The skin is closed with 6-0 silk
sutures. Keep the skin suture ends long so that they can be tied under the most
superior suture. This helps to keep the suture ends away from the conjunctiva. The
skin sutures are removed in 5 days, and the lid margin suture is removed in 7-10
days.
- FT involving up to 25 %
Larger defects of the lid can be closed with local tissue advancement with the aid
ALWAYS of:
• Lateral canthotomy
• Cantholisis of the superior crus .
Lateral cantholysis
may be performed to reduce tension on the wound with larger, borderline defects
and provides an additional 5 mm of advancement. This is done by splitting the
upper and lower lids at the lateral canthus with scissors. The scissors should then
be advanced inferiorly to "nibble" the lower limb of the tendon and periorbital
attachments for full mobility. The skin incision should be angled slightly
superiorly in case a rotational flap is necessary. Once primary closure of the lid
defect is obtained, the lateral canthus should be inspected to see if closure is
required. A 6-0 Vicryl buried stitch anchored to the periosteum may be needed to
bring the lower lid up into position. Often a 6-0 silk skin-muscle suture is all that
is required.
-1 A semicircular, or Tenzel.
In this procedure, extra skin is
rotated from the lateral orbit and
the defect is closed as described
in primary closure. The flap
starts from the lateral canthus
and extends as a semicircle
inferiorly to a diameter of 2 cm.
The skin is incised down to the
periosteum of the orbital rim.
29
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
1270-11604-33871 ocular
29/11/06
10:19
Página 30
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
The upper limb of the lateral canthal tendon is cut to facilitate flap rotation. A
Burow triangle is then removed from the superior edge of the defect to create a
pentagonal defect. The primary defect is closed as described in the previous section.
If tension at the wound edges is excessive, the orbital septum, the levator
aponeurosis, and the conjunctiva at the semicircular flap can be sequentially cut to
relieve tension. The semicircular flap is closed by first placing a 5-0 monofilament
permanent vertical mattress suture at the lateral canthus through a bolster. The first
limb of the suture is placed through the skin of the intact inferior lateral canthus
and then brought out at the skin of the semicircular flap. The short limb of the
vertical mattress is placed through the semicircular flap, the intact limb of the
canthal tendon, and then the skin of the intact eyelid. The remainder of the flap is
then closed with permanent sutures in interrupted fashion.
-2 A Sliding tarsal flap or
Tarsoconjuntival. In case with a large
nasal or lateral defect of the upper
lid, direct closure with semicircular
advancement flap (amblyopia in
childrens can occur) is not the best
solution.
An horizontally sliding section of the
the upper tarsus into the defect
covered with a skin graft. Is a better
option. Keep in mind the followings
stepst:
1 -evert lid remmnant wit a
Desmarres retractor
2- horizontal incision made in the tarsal plate 4 mm above lid margin and use
as template the width of the defect
3- move it to the defect 4- one edge is sutured to the remmants of lateral
canthal tendon or to periosteum
5- Superior edges of the flap sutured to edges of levator aponeurosis
6- FTSG sutured in place
7- Eyelid are closed with mattress sutures, left in place for a week
-FT involving up to 75 %
Defects involving more than 50% of the upper eyelid can be closed with:
30
1270-11604-33871 ocular
29/11/06
10:19
Página 31
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
-1 Local myocutaneous flap with
posterior lamellar graft
Patients with skin redundancy in the
upper lid and periorbital area, skin
muscle flap can be brought to cover
the external lamellar defect. Flaps can
be advacement or rotational.
Posterior lamellae is reconstructed
with free tarsal tarsoconjuntival flap,
palatal mucoperiosteal flap, nasal
mucoperichondrial flap, conjuntiva
advancement from upper fornix or
lower lid.
-2 Inferiorly based skin-conjunctival
or Cutler-Beard.The skin of the lower
eyelid is incised horizontally below
the inferior edge of the tarsus. The
length of the incision corresponds to
the size of the defect to be
reconstructed. Make a full-thickness
incision through :
- the skin,
- lid retractors,
- the conjunctiva.
"The cornea must be always protected to prevent inadvertent injury".
Full-thickness vertical incisions are made from the ends of the horizontal
incision. The vertical length of the incisions depends on the vertical dimension
of the upper eyelid defect and can be extended as far as the conjunctival fornix.
Closure of the defect can be accomplished with or without tarsal
reconstruction. If tarsal reconstruction is not undertaken, the skinconjunctival flap is passed under the lower eyelid tarsal bridge and secured to
the edges of the defect in 2 layers. Absorbable sutures with knots away from the
cornea are used to close the conjunctival layer. The skin-muscle layer is closed
with permanent monofilament sutures, which are removed in 5-7 days.
In the Cutler-Beard flap, the missing tarsus is typically not recreated, but when
tarsal reconstruction is planned, several options are available for tarsal
replacement, including:
31
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
1270-11604-33871 ocular
29/11/06
10:19
Página 32
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
-a free tarsal graft from the contralateral upper eyelid,: The tarsal graft is
harvested from the cephalic border of the intact tarsus. The upper eyelid is
inverted, and the cephalic border of the tarsus is identified. The horizontal
dimension of the graft is then marked. The vertical dimension of the graft is 5
mm at the cephalic border. At least a 5-mm caudal wedge of tarsus must be
preserved to prevent secondary deformity of the donor side. The incision is through
the conjunctiva and tarsus. Care must be taken to avoid damage to the
overlying upper eyelid retractor and the skin. The donor area can be left open
to heal. The harvested tarsus is denuded of conjunctiva and placed in between
the skin and conjunctiva of the lower lid flap. The lateral edges can be secured
to the remnants of native tarsus
-septal cartilage
-auricular cartilage.
The second stage of the Cutler-Beard flap is performed in 6-8 weeks. During
the second stage, the flap is divided and the upper eyelid is contoured to match
the contralateral eyelid. Protect the cornea while the flap pedicle is divided
sharply at the level of the new lid margin. The incision is beveled superiorly to
obtain more conjunctiva than skin. Ensure that the extra length of conjunctiva
is 1-2 mm; this will be wrapped around the edge of the newly formed lid
margin. The inferior edge of the lower tarsal bridge is sharply reopened, and
the flap remnant is contoured for proper no-tension closure. The wound is
closed in layers. Obviously, the reconstructed upper eyelid will lack lashes.
-3 Pedicle flap from lower lid margin.
The original techniche was described by Mustardé (Elliptical flap) for total upper
lid reconstruction of for those who are seeking to restored the eyeslashes. In this
technique the margin of the lower lid in transfer to the upper lid in a two-staged
procedure.
-The flap is based in the central portion of the lid (stretchability of canthal tendons)
32
1270-11604-33871 ocular
29/11/06
10:19
Página 33
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
-Marginal artery MUST BE INCLUDED
-All tarsus from lower lid MUST BE INCLUDED.
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
22- Supratrochlear artery
24- Infratrochlear artery
25- Peripheral arcade
26- Marginal arcade
32- Inferior marginal arcade
The marginal artery is located at the base of the tarsus (average 3,8 mm tarsus). So
the flap must be at least 5mm in height-Flap MUST BE RECTANGULAR
-The end of the flap is rotated and margin to margin attachement made.
-DO NOT CAUTERIZE VESSELS, near the base
-DON´T APPLY pressure bandage
-Separate the flap no before 4/6 weeks
Alternative techniques may be used:
-free graft, for vertical full thickness defects (Anterior and Posterior lamellae)
-composite graft (Putterman, Beyer-Machule)
-Periorbitals flaps (median forehead flap, temporalis or Fricke flap)
33
R
E
C
O
N
S
T
R
U
C
T
I
O
N
1270-11604-33871 ocular
29/11/06
10:19
Página 34
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
ZONE II LD
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
Introduccion
The lower lid is separated into an anterior lamella, consisting of
1- orbicularis muscle and skin, 2- medial lamellae Tarsus, O.S,Fat and a 3- posterior
lamella, consisting of lid retractors and conjunctiva. The anterior lamella has an
attachment laterally on the external surface of the lateral orbital rim, whereas the
posterior lamella has its attachment inside the lateral orbital rim on the lateral orbital
tubercle . It is important to preserve the relationship of these attachments with lateral
canthal procedures such as canthoplasty. When tightening the anterior lamella, any
posterior lamella laxity must also be addressed with tightening or resection to avoid
buckling of a redundant lid
34
1270-11604-33871 ocular
29/11/06
10:19
Página 35
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
Anterior lamella
Skin+Orbicularis Oculi
Mid-lamella
Tarsus + OS + FAT
Posterior lamella
Lid Retractors +
Conjunctiva
Lower border tarsus + conjunctival fornix
Inf. cul-de-sac
Tendinous insertion inf. rectus m. onto globe
Capsulopalpebral fascial head off inf. rectus m.
Trauma is the most common cause leading to reconstruction of the lower lid. Basal
cell carcinoma (BCC) is the second most common cause for eyelid reconstruction. It
is the most common eyelid malignancy and accounts for approximately 90% of
eyelid tumors.
BCC is the most common eyelid malignancy. Squamous cell carcinoma (SCC),
sebaceous cell carcinoma (SebCC), and cutaneous melanoma are other neoplasms
that involve the eyelids.
In addition to surgical excision of tumors, eyelid defects may result from trauma or
burns, or they may be congenital.
2-Surgical therapy
In order to address the reconstructive options in an organized manner, lower eyelid
35
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
1270-11604-33871 ocular
29/11/06
10:19
Página 36
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
defects are divided into:
• 1 anterior lamellae -Skin and Orbicularis Oculi.
• 2 medial lamellae - Tarsus, O.S (Orbital Septum), Fat.
• 3 posterior lamellae –Lid Retractors (capsulopalpebral fascia),conjuntiva
and thickness defects according to size. : Partial Thikness PT and Full Thickness FT
inferior or superior to 50%.
Zone II - (Partial-Thickness)
- PT involving less 50%.
Closure with local tissue advancement
- PT involving more than 50%
The complications encountered in this areas with local flaps and others,
demostrated that the best solution are:
- a FTSG
- myocutaneous transposition flap from Upper Lid
Preoperatively, several factors must be analyzed carefully since they affect the
surgical plan and outcome. These include the size and orientation of the defect,
patient's age, vascular supply to surrounding tissues, biologic behavior of the
tumor, previous treatment, age of the wound, and other factors such as prior
radiation treatment.
For example, the Hughes tarsoconjunctival flap initially was described in 1937 for
reconstructing full-thickness defects involving the central portion of the lower
eyelid. The use of this flap has evolved, and the flap has been refined and modified
over the last 60 years.
Problem: Eyelid defects are classified according to size and location. A common
way of breaking down full-thickness defects is as follows:
• For young patients (tight lids)
o Small - 25-35%
o Medium - 35-45%
o Large - Greater than 55%
• For older patients (lax lids)
o Small - 35-45%
o Medium - 45-55%
o Large - Greater than 65%
36
1270-11604-33871 ocular
29/11/06
10:19
Página 37
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
A typical defect may involve 50% of the central portion of the lower eyelid. Defects
may involve the combination of eyelid and canthi. Involvement of the eyelid
margin should be noted. If the eyelid margin is spared, closure by local flap or skin
graft may suffice. Once the margin is involved, surgical repair must restore the
integrity of the eyelid margin.
Clinical: Patients can present with a lid tumor for primary excision or after excision
performed by another surgeon (commonly post-Mohs surgery performed by a
dermatologist).
Patients also may present after acute trauma or for secondary reconstruction
sometime after primary repair posttrauma.
Zone II - (Full Thickness)
FT involving less 50%
Larger defects of the lower lid can be closed with local tissue advancement or sliding
tarsal-conjunctival flap with skin graft or free tarsoconjuctival graft with the aid
ALWAYS of:
• Lateral canthotomy
• Cantholisis of the superior crus.
"To prevent corneal irritation rigid free cartilage grafts should be avoided
in favor of free or transposed tarsoconjuntival flap"
Tarsoconjunctival bridge flap (modified Hughes procedure)
Lower eyelid defects greater than 50% of the horizontal length of the eyelid may be
repaired with a tarsoconjunctival bridge flap from the upper eyelid .This procedure
effectively recreates the posterior lamella of the lower eyelid through use of a segment
of upper eyelid tarsus and conjunctiva. Since the flap must be left in place from 4-6 weeks
prior to second-stage separation. (Hughes originally described a tarsoconjunctival flap
involving the eyelid margin. This procedure is no longer is performed.)
"This operation is not suited for patients sighted only in the involved eye or of amblyogenic
age."
In such situations, a free tarsoconjunctival graft from the opposite upper eyelid is more
appropriate
37
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
1270-11604-33871 ocular
29/11/06
10:19
Página 38
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
The modified Hughes procedure is performed as follows. A 4-0 silk traction suture is
placed in the upper eyelid margin. The upper eyelid is everted over a Desmarres
retractor. Tarsus and conjunctiva of the upper eyelid are incised horizontally 4 mm
proximal to the eyelid margin. At least 4 mm of tarsus must be left for lid stability and
to prevent the complication of upper lid entropion. A tarsal conjunctival flap is
developed by dissecting the tarsus and conjunctiva away from the levator aponeurosis
and Müller muscle. Dissection continues superior to the level of the Whitnall
ligament.
The bridge flap is advanced into the defect of the lower eyelid; it may be moved
laterally or medially depending on the location of the lower eyelid defect. Edges of the
tarsoconjunctival advancement flap are sutured to the remnants of the medial and
lateral tarsus of the lower eyelid. If the lower eyelid defect involves either the medial
or lateral canthal angle, the tarsoconjunctival flap must be fixated appropriately either
to the lateral orbital tubercle or to the posterior lacrimal crest.
After the flap has been secured in position, a full-thickness skin graft is placed over the
anterior surface. Skin can be harvested from the upper eyelid or from the retroauricular
area. Alternatively, a locally based random flap may be advanced over the posterior
lamella to create the new anterior lamella. The flap is separated at 4-6 weeks. A grooved
director is slid underneath the flap anterior to the cornea, and the flap is divided.
Conjunctiva is sutured to the lower eyelid margin. The Müller muscle and the levator
aponeurosis are dissected away from the overlaying skin and allowed to retract. This
prevents postoperative upper eyelid retraction and lagophthalmos.
Free tarsoconjunctival graft
Free tarsoconjunctival grafts from an upper eyelid also may be used to correct defects
in the lower eyelid. This composite graft is harvested from the upper eyelid tarsus of the
opposing eyelid or from the alternate upper eyelid. A marginal 5 mm strip of tarsus is
left in the donor eyelid. The upper tarsal defect is not closed. Edges of the free
tarsoconjunctival graft are sutured to the edges of the lower eyelid defect. Conjunctiva
at the inferior border of the free tarsoconjunctival graft is sutured to the palpebral
conjunctiva. The anterior lamella is reconstructed by a local musculocutaneous flap.
-FT involving up to 75 %
Composite graft with cheek advancement flap.
Lower eyelid defects involving the entire lower eyelid may be reconstructed using a
Mustarde cheek rotation flap .This large skin muscle flap is rotated from the cheek to
repair large lower eyelid defects. Incision begins at the lateral canthal angle like a
progression in size from the smaller Tenzel-Type rotationals flaps, extends upward onto the
temple, and swings posteriorly just anterior to the ear and then inferiorly across the
mandible. Establishing good vertical height to this flap is important so the correct
38
1270-11604-33871 ocular
29/11/06
10:19
Página 39
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
position of the lateral canthal angle can be achieved postoperatively. Other materials for
the posterior lamellar defect include tarsal grafts from either the ipsilateral (Hughes) or
contralateral (free) upper eyelid, Alloderm with free cartilage graft, or palatal
mucoperiosteum. Once the posterior lamella has been reconstructed, the medial edge
of the upper border of the chondromucosal graft is sutured to the superior margin of
the cheek flap by running 5-0 cat gut suture to form the eyelid margin. Next, the lateral
canthus is formed by suturing the deep layer of the dermis of the rotational graft to the
superior and inner aspect of the lateral orbital rim near the lateral border of the
chondromucosal graft. Additional upward traction at the apex of the flap can be
provided by using 4-0 vicryl sutures to the lateral rim periosteum. Skin can now be
closed with running 6-0 nylon suture. The eyelids may be sutured together with a
tarsorrhaphy stitch to provide additional upward tension on the flap and removed after
a week.
Median Forehead Flap
Although it is rarely used for eyelid reconstruction, it may be useful for massive tissue
loss or when tissue cannot be borrowed from adjacent tissues.
The flap is created in the standard fashion. The flap is sewn into place over either a
posterior lamellar graft or advanced conjunctiva. The pedicle can be divided in 6-8
weeks. The flap is very thick and can be thinned carefully at a later date.
Temporal Forehead or Fricke Flap
This flap is useful for very large lateral upper (sometimes lower) eyelid and lateral
canthal defects. It, like the median forehead flap, provides very thick tissue for eyelid
reconstruction so it is reserved for defects which cannot be closed by other means.
The flap is based temporally, sometimes on the superficial branch of the temporal
artery. The flap is marked out with the base of the flap at the lateral canthus for good
rotation. The flap is undermined subcutaneously to avoid injury to the temporal branch
of the facial nerve. The flap is then rotated into position over either a posterior lamellar
graft or advanced conjunctiva. The donor site is closed primarily. The flap can be
trimmed in 6-8 weeks at its temporal aspect if there is excessive bulk or a pedicle was
created
"Cheek islands flaps present an unacceptable donor-site scar and present the same
shortcomings as a cheek advancement"
Cervical facial advancement flaps are most useful in defects of the lower lid extending
to the cheek zone or Zone V (especially in older patients)
"Lateral canthal support procedures shoulbe performed routinely even when the lateral
medial or both canthal tendinous system are not disrupted"
39
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
1270-11604-33871 ocular
29/11/06
10:19
Página 40
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
ZONE III MC
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
Introduction
The medial palpebral ligament (medial canthal tendon [MCT]) is a fibrous band
stabilizing the medial tarsi and is intricately related with the orbicularis oculi muscle
and the lacrimal system. The superficial head of the pretarsal orbicularis muscle lies
anterior to the canaliculi and forms the anterior limb of the MCT. This head is
primarily horizontal but also has a superior supporting extension inserting onto the
frontal bone. The deep head of the pretarsal orbicularis muscle (also constituting the
Horner muscle) inserts into the posterior lacrimal crest and onto the fascia of the
lacrimal sac. FOTO
40
1270-11604-33871 ocular
29/11/06
10:19
Página 41
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
The upper and lower lid preseptal orbicularis have a superficial head that inserts into
and augments the MCT and deep heads that insert into the lacrimal sac fascia. Thus,
the lacrimal sac, encased in fascia, is related anteriorly, laterally, and posteriorly to
constituents of the MCT and medially to the bony fossa of the lacrimal sac.
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
2-Surgical therapy
Medial canthal defects are more difficult to repair than lateral canthal defects The
medial canthal area is important for lacrimal drainage as well as eyelid support. One
difficulty is the lacrimal drainage system, which usually needs repair in a medial
canthal defect. The other difficulty is that to anatomically reconstruct the medial
canthus, the attachment needs to be at the posterior lacrimal crest. If one canaliculus
is cut, an attempt at reconstruction should be made with either a pigtail probe or
Crawford stents. If the punctum has been removed, the cut end of the canaliculus
should be marsupialized into the conjunctival fornix. If the canaliculus is not
reconstructed, then the medial canthus should be reattached at theposterior lacrimal
crest with a permanent suture. Occasionally, the remaining tendon will need to be
reattached via transnasal wiring.
The lacrimal system must be evaluated when the defect involves the medial canthus.
Tumors of the medial canthal area may involve the deep structures of the canthus as
well as extend along the lacrimal drainage system. Resection may require multiple
frozen section determinations to assure clear margins.
Superficial defects of the medial canthal region may be reconstructed using skin
advancement flaps or free skin grafts
Defects greater than 10mm are usually best closed using a free skin graft so as to not
distort the upper or lower lids.
Deeper defects involving the medial canthal tendon require precise repair in order to
41
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
1270-11604-33871 ocular
29/11/06
10:19
Página 42
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
reestablish the functional support of the area as well as achieve a good cosmetic result.
The pretarsal fibers of the orbicularis oculi muscle of both eyelids divide medially
into superficial and deep heads. The superficial heads form the medial canthal tendon
and the deep heads pass posterior to the lacrimal sac to insert on the posterior
lacrimal crest. The deep head is important to structural support of the eyelid as well
as cosmesis to this area. Disruption of the deep head leads to lateral and anterior
displacement of the medial canthal angle.
After ensuring no damage to the lacrimal system, the medial canthal region can be
repaired directly. The superficial head of the medial canthal tendon should be
repaired if possible but if the skin and orbicularis is re-approximated then no
significant cosmetic deformity should result.
If the deep head of the medial canthal tendon is injured but is accessible for
reconstruction , it must be repaired or the medial canthal angle will be distorted. If
adequate soft tissue remains attached to the lacrimal bone, the tendon can be directly
sutured using a heavy nonabsorbable suture.
If no soft tissue remains or the medial orbital wall is fractured, the tendon can be wired
to the adjacent intact medial wall, transnasally to the contralateral medial orbital wall,
or to the contralateral medial canthal tendon. If the deep head of the medial canthal
tendon has been resected, other methods must be sought to reconstruct the medial
canthal region.
If sufficient upper and lower tarsus remains after resection, upper and lower tarsal
rotation flaps can be performed.
If insufficient tarsus remains, the remaining tarsi can be anchored to the posterior
lacrimal crest to assist with healing in a posterior direction. The rest of the wound can
be reduced with other skin flaps with the medial canthal region left to granulate over
several weeks. A medial forehead flap is another flap to consider, especially if there is
poor vascularity of the tissue from previous radiation therapy.
Lacrimal Drainage System Reconstruction
Examination of the lacrimal system is essential in any defect medial to the punta or
involving the medial canthal area. The examination should be done using lacrimal
probes and a cotton-tipped applicator. Anesthesia can be obtained with Tetracaine
eye drops and the infratrochlear nerve block previously described. Repair of
lacerations to the lacrimal drainage system should be performed as soon as possible.
We recommended to repair canalicular trauma first, and then align "landmarks,"
starting with the eyelid margin and working outward.
42
1270-11604-33871 ocular
29/11/06
10:19
Página 43
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
An important part of repairing the canalicula is finding the cut end: "the bubble
test:"
• Apply swabs saturated with 4% cocaine or epinefrine to the inferior meatus;
• Dilate the opposite puncta;
• Pool saline in the medial canthus;
• Apply pressure over the lacrimal sac; and
• Inject air into the opposite canaliculus. Bubbles should come out of the cut end
Canalicular injury repair depends on the length of the remaining segments.
If only the distal portion of the canaliculus is resected, the cut end should be
marsupialized because the superior canaliculus alone rarely drains tears satisfactorily.
The cut end is brought superior and medial to the new eyelid margin and sutured in
four quadrants. A silicone stent is then placed and sutured to the skin for at least 3
weeks. If the damaged canaliculus is separated from the lacrimal sac, it should be
reanastomosed to the lacrimal sac if possible and left stented for 2-4 weeks. If there
is more considerable damage to the lacrimal system with disruption of drainage
system, silicone tubing should be placed through both canaliculi and down into
nasolacrimal duct. The tubing should be left in place for 3 months.2 If a
dacryocystorhinostomy is thought to be necessary, many authors suggest deferring
this for at least one year and done only if epiphora is a problem.
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
43
1270-11604-33871 ocular
29/11/06
10:19
Página 44
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
ZONE IV LC
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
Introduction
Lateral canthal tendon and his retinaculum
For surgical and anatomicals purpouses de complex lateral canthy is composed by
:
• Upper fibrous crura and Lower crura join at the lateral commisure to form the
Lateral Lanthal Angle.
44
1270-11604-33871 ocular
29/11/06
10:19
Página 45
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
1- Common lateral canthal tendon is 5mm to 7mm in legnth. It represents the
distance from the lateral aspect of the tarsal plate to the lateral orbital rimof the
nonprominent eye. This point it is very important for reconstructives options .
• Ligamentous structures from :
2- The lateral Horn of the levator aponeurosis
3-Whitnall´s superior suspensory ligament, lateral aspect (inserts into orbital lobe
of the lacrimal gland)
4- Lockwood´s inferior suspensory ligament
5-Cheek ligaments from the lateral rectus muscle.
Converge with the lateral canthal tendon
• Anterior structures from :
6-pretarsal orbicularis oculi
7-orbital septum
Insert on the anterior aspect of the orbital rim
8-skin
45
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
1270-11604-33871 ocular
29/11/06
10:19
Página 46
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
2-Surgical therapy.
Importants factors to consider in Reconstructive Canthal Anchoring
A-Distance from the lateral aspect of the tarsal plate to the lateral
orbital rim
LESS THAN 1 CM
You can use :
• WEDGE RESECTION
• TARSAL STRIP –TS• INFERIOR RETINACULAR LATERAL CANTOPEXY –IRLC-
46
1270-11604-33871 ocular
29/11/06
10:19
Página 47
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
MORE THAN 1 CM
R
E
C
O
N
S
T
R
U
C
T
I
O
N
47
1270-11604-33871 ocular
29/11/06
10:19
Página 48
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
You can use :
• INFERIOR RETINACULAR LATERAL SUSPENSION -IRLC• DERMAL ORBICULAR PENNANT LATERAL CANTHOPLASTY
–DOPLC• PERIOSTEAL FLAP
• SUTURE SUSPENSION
• FASCIAL GRAFT
• IRLC convert to DOPC + TS
B- Vector Analisis
Relationship of the ocular globe to the lower lid and malar eminence.
A positive relationship or Vector + is when the most anterior projection of the globe
lies behind the lower eyelid, which lies behind the anterior projection of the malar
eminence.
A negative relationship or Vector – is when the most anterior projection of the globe
lies anterior to the lower eyelid and malar eminence. (patients use to present escleral
show)
Lateral Canthal Reconstruction
Defects involving the lateral canthal area can usually be closed by direct repai using :
-Cheek advancement flap
-Skin Graft.
It is important to evaluate the possibility of injury to or resection of the lateral
canthal tendon. This is usually identified by rounding of the lateral canthus. If the
tendon has been severed, it should be repaired with 4-0 nonabsorbable sutures. If
the lateral end cannot be found, the tendon should be sutured to the periorbita or
through holes drilled through the lateral orbital rim at the orbital tubercle. It is
important to remember that the lateral canthal tendon attaches to the orbital tubercle
located 5mm posterior to the lateral orbital rim. If not repaired correctly, the lateral
canthal angle will be displaced too far anteriorly.
Canthal anchoring is often performed as part of a reconstructive procedure to
correct complications following trauma. In many cases, the soft tissue in the
canthal angle (periosteum, connective tissue) has lost its integrity because of
damage and scarring and will not support canthal refixation by itself. In cases that
48
1270-11604-33871 ocular
29/11/06
10:19
Página 49
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
have milder changes, the reanchoring of the lateral canthus can be reinforced with
a local periosteal flap or a fascial graft.
In more severe cases, direct anchoring to the bone of the internal orbital rim is
needed, with drill-hole fixation. Drill-hole anchoring of the lateral canthus is not
new and has been used by some as a means of primary fixation.
A single drill hole in the lateral orbital rim is used. To determine the position of the
drill hole, the lateral canthus is grasped and tucked against the lateral orbital rim
until the desired lower-lid position is obtained. The position is marked with
methylene blue dye, and a drill hole is made at that point, slanting inward .A
double-armed Mersilene suture with half-circle needles is used for fixation. If no
lysis is needed, the suture is double-looped into the canthal tissue and then both
suture arms are brought through the single hole. If lysis is needed, a single loop of
suture is brought through the canthal edges of the lids, and then the arms are
brought out through the hole. Both arms of the suture are secured to the deep
temporal fascia.
Canthal fixation methods
Direct suturing to periosteum –lateral tubercle)
Periosteal flap
Wire or suture with drill holes in bone
Miniplate fixation
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
49
1270-11604-33871 ocular
29/11/06
10:19
Página 50
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
ZONE V PERIOCULAR
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
PERIOCULAR FACE AND ANEXE
1-Introduction
Areas involved :
Upper part.
. Temple
. Brow
. Glabella
50
1270-11604-33871 ocular
29/11/06
10:19
Página 51
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
D
E
C
I
S
I
O
N
M
A
K
I
N
G
Lower part
I
N
. Nasal jugal
. Cheek
. Malar
. Midface
E
Y
E
L
I
D
Orbicularis Oculi M.
Infraorbital nerve
branches
Levator labii superioris M.
Levator of the ala
of the nose M.
51
R
E
C
O
N
S
T
R
U
C
T
I
O
N
1270-11604-33871 ocular
29/11/06
10:19
Página 52
Cirujanos
Plástikos
Mundi
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
2-Surgical therapy
Basics using cervicofacial flaps:
1- Consider aesthetic unit.
2- Periosteal fixation.
3- De-epithelialized Tip.
4- Lateral Canthoplasty or cantopexy
5- Burrow’s triangle.
R
E
C
O
N
S
T
R
U
C
T
I
O
N
52
1270-11604-33871 ocular
29/11/06
10:19
Página 53
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
D
E
C
I
S
I
O
N
M
A
K
I
N
G
I
N
E
Y
E
L
I
D
R
E
C
O
N
S
T
R
U
C
T
I
O
N
53
1270-11604-33871 ocular
29/11/06
10:19
Página 54
Cirujanos
Plástikos
Mundi
Laboratory dissection.
ZONE IV
L
A
B
O
R
A
T
O
R
Y
Canthoplasty
Inferior Lateral Retinaculum
D
I
S
S
E
C
T
I
O
N
54
1270-11604-33871 ocular
29/11/06
10:19
Página 55
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
L
A
B
O
R
A
T
O
R
Y
D
I
S
S
E
C
T
I
O
N
55
1270-11604-33871 ocular
29/11/06
10:19
Página 56
Cirujanos
Plástikos
Mundi
Tarsal Strip:
L
A
B
O
R
A
T
O
R
Y
D
I
S
S
E
C
T
I
O
N
56
1270-11604-33871 ocular
29/11/06
10:19
Página 57
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
L
A
B
O
R
A
T
O
R
Y
D
I
S
S
E
C
T
I
O
N
57
1270-11604-33871 ocular
29/11/06
10:19
Página 58
Cirujanos
Plástikos
Mundi
Dermal Orbicular Pennant:
L
A
B
O
R
A
T
O
R
Y
D
I
S
S
E
C
T
I
O
N
58
1270-11604-33871 ocular
29/11/06
10:19
Página 59
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
L
A
B
O
R
A
T
O
R
Y
D
I
S
S
E
C
T
I
O
N
59
1270-11604-33871 ocular
29/11/06
10:19
Página 60
Cirujanos
Plástikos
Mundi
B
I
B
L
I
O
G
R
A
P
H
Y
Bibliography:
Clark, R. A., Isenberg, S. J., Rosenbaum, A. L., & Demer, J. L. (1999). Posterior fixation sutures: a revised mechanical explanation for the fadenoperation based on rectus
extraocular muscle pulleys. American Journal of Ophthalmology, 128(6), 702-714.
[PubMed]
Clark, R. A., Miller, J. M., & Demer, J. L. (1997). Location and stability of rectus
muscle pulleys. Muscle paths as a function of gaze. Investigative Ophthalmology and
Visual Science, 38(1), 227-240. [PubMed]
Clark, R. A., Miller, J. M., & Demer, J. L. (1998). Displacement of the medial rectus
pulley in superior oblique palsy. Investigative Ophthalmology and Visual Science,
39(1), 207-212. [PubMed]
Clark, R. A., Miller, J. M., & Demer, J. L. (2000). Three-dimensional location of
human rectus pulleys by path inflections in secondary gaze positions. Investigative
Ophthalmology and Visual Science, 41(12), 3787-3797. [PubMed]
Clark, R. A., Miller, J. M., Rosenbaum, A. L., & Demer, J. L. (1998). Heterotopic
muscle pulleys or oblique muscle dysfunction? Journal of the American Association for
Pediatric Ophthalmology and Strabismus, 2(1), 17-25. [Pubmed]
Collins, C. C., O'Meara, D., & Scott, A. B. (1975). Muscle tension during unrestrained human eye movements. Journal of Physiology (London), 245(2), 351-369.
[PubMed]
Collins, C. C., Scott, A. B., & O'Meara, D. M. (1969). Elements of the peripheral
oculomotor apparatus. American journal of optometry and archives of American
Academy of Optometry, 46(7), 510-515. [PubMed]
Demer, J. L. (2000). Orbital connective tissues in binocular alignment and strabismus.
In G. Lennerstrand & J. Ygge (Eds.), Advances in Strabismus Research: Basic and
Clinical Aspects. London: Portland Press.
Demer, J. L. (2002). The Orbital Pulley System - A Revolution in Concepts of Orbital
Anatomy. Annals of the NY Academy of Science, 956, 17-32. [PubMed]
Demer, J. L., Kono, R., & Wright, W. (2003). Magnetic resonance imaging of human
extraocular muscles in convergence. Journal of Neurophysiology, 89, 2072-2085.
Demer, J. L., Miller, J. M., & Poukens, V. (1996). Surgical implications of the rectus
extraocular muscle pulleys. Journal of Pediatric Ophthalmology and Strabismus, 33(4),
208-218. [PubMed]
Demer, J. L., Miller, J. M., Poukens, V., Vinters, H. V., & Glasgow, B. J. (1995).
Evidence for fibromuscular pulleys of the recti extraocular muscles. Investigative
Ophthalmology and Visual Science, 36, 1125-1136. [PubMed]
Demer, J. L., Oh, S. Y., & Poukens, V. (2000). Evidence for active control of rectus
extraocular muscle pulleys. Investigative Ophthalmology and Visual Science, 41(6),
1280-1290. [PubMed]
Demer, J. L., Poukens, V., Miller, J. M., & Micevych, P. (1997). Innervation of
extraocular pulley smooth muscle in monkeys and humans. Investigative
Ophthalmology and Visual Science, 38(9), 1774-1785. [PubMed]
60
1270-11604-33871 ocular
29/11/06
10:19
Página 61
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
Duke-Elder, S., & Wybar, K. C. (1961). The Anatomy of the Visual System (Vol. II).
London: Henry Kimpton.
Dutton, J. J., MD, PhD, & Waldrop, T. G., MSMI. (1994). Atlas of Clinical and
Surgical Orbiotal Anatomy. Philadelphia: WB Saunders.
Fink, W. H. (1948). Ligament of Lockwood in relation to surgery of the inferior
oblique and iunferior rectus muscle. Archives of Ophthalmology, 31, 781-795.
Keller, E. L., & Robinson, D. A. (1971). Absence of a stretch reflex in extraocular muscles of the monkey. Journal of Neurophysiology, 34(5), 908-919. [PubMed]
Keller, E. L., & Robinson, D. A. (1972). Abducens unit behavior in the monkey during vergence movements. Vision Research, 12(3), 369-382. [PubMed]
Kestenbaum, A. (1963). Applied Anatomy of the Eye. New York: Grune & Stratton.
Kono, R., Poukens, V., & Demer, J. L. (2002). Quantitative analysis of the structure of
the human extraocular muscle pulley system. Investigative Ophthalmology and Visual
Science, 43(9), 2923-2932. [PubMed]
Koornneef, L. (1974). The first results of a new anatomical method of approach to the
human orbit following a clinical enquiry. Acta morphologica Neerlando-Scandinavica,
12(4), 259-282. [PubMed]
Koornneef, L. (1977a). The architecture of the musculo-fibrous apparatus in the
human orbit. Acta morphologica Neerlando-Scandinavica, 15, 35-64. [Pubmed]
Koornneef, L. (1977b). Details of the orbital connective tissue system in the adult. Acta
morphologica Neerlando-Scandinavica, 15, 1-34. [PubMed]
Koornneef, L. (1977c). New insights in the human orbital connective tissue. Result of
a new anatomical approach. Archives of Ophthalmology, 95, 1269-1273. [PubMed]
Koornneef, L. (1991). Orbital connective tissue. In W. Tasman & E. A. Jaeger (Eds.),
Duane's foundations of clinical ophthalmology, rev. ed. (Vol. 1). Philadelphia: J.B.
Lippincott.
Lockwood, C. B. (1886). The anatomy of the muscles, ligaments, and fasciae, etc. J
Anat Physiol, 20, 1-25.
Ludwig, I. H., & Brown, M. S. (2001). Strabismus due to flap tear of a rectus muscle.
Transactions of the American Ophthalmological Society, 99, 53-63.
Miller, J. M. (1989). Functional anatomy of normal human rectus muscles. Vision
Research, 29(2), 223-240.
Miller, J. M. (1999). Orbit™ 1.8 Gaze Mechanics Simulation User's Manual (1 ed.).
San Francisco: Eidactics.
Miller, J. M., Demer, J. L., & Rosenbaum, A. L. (1993). Effect of transposition surgery on rectus muscle paths by magnetic resonance imaging. Ophthalmology, 100(4),
475-487
Miller, J. M., Pavlovski, D. S., & Shamaeva, I. (1999). Orbit™ 1.8 Gaze Mechanics
Simulation. San Francisco: Eidactics.
Oh, S. Y., Clark, R. A., Velez, F., Rosenbaum, A. L., & Demer, J. L. (2002).
Incomitant strabismus associated with instability of rectus pulleys. Investigative
Ophthalmology and Visual Science, 43(7), 2169-2178.] Porter, J. D., Poukens, V.,
61
B
I
B
L
I
O
G
R
A
P
H
Y
1270-11604-33871 ocular
29/11/06
10:19
Página 62
Cirujanos
Plástikos
Mundi
B
I
B
L
I
O
G
R
A
P
H
Y
Baker, R. S., & Demer, J. L. (1996). Structure-function correlations in the human
medial rectus extraocular muscle pulleys. Investigative Ophthalmology and Visual
Science, 37(2), 468-472.] Quaia, C., & Optican, L. M. (1998). Commutative saccadic
generator is sufficient to control a 3-D ocular plant with pulleys. Journal of
Neurophysiology, 79(6), 3197-3215. [
Raphan, T. (1998). Modeling control of eye orientation in three dimensions. I. Role
of muscle pulleys in determining saccadic trajectory. Journal of Neurophysiology, 79(5),
2653-2667. [
Robinson, D. A. (1981). Control of eye movements. In V. B. Brooks (Ed.), The nervous
system, handbook of physiology (Vol. II, pp. 1275-1320). Baltimore: Williams & Wilkins.
Sappey, P. C. (2001). The motor muscles of the eyeball [translation from the French].
Strabismus, 9(4), 243-253.
Skavenski, A. A., & Robinson, D. A. (1973 abducens neurons in
Stager, D. R. (1996). The neurofibrovascular bundle of the inferior oblique muscle as
its ancillary origin. Transactions of the American Ophthalmological Society, 94, 1073Tenon, J. R. (1806). Mémoires sur l'anatomie, la pathologie et la chirurgie et sur l'organe de la vue. Paris.
Von Noorden, G. K. (1990). Binocular vision and ocular motility: Theory and management of strabismus. (4th ed. ed.). St. Louis: Mosby.
Emergency War Surgery Second United States Revision of The Emergency War
Surgery NATO Handbook Warwick, R. (1976). Eugene Wolff's Anatomy of the eye
and orbit (7 ed.). Philadelphia & Totonto:
. Gioia, V. M., Linberg, J. V., and McCormick, S. A. The anatomy of the lateral canthal tendon. Arch. Ophthalmol. 105: 529, 1987.
. Edgerton, M. T., and Wolfort, F. G. The dermal-flap canthal lift for lower eyelid support: A technique of value in the surgical treatment of facial palsy. Plast. Reconstr. Surg.
43: 42, 1969.
. Jelks, G. W., and Jelks, E. B. The influence of orbital and eyelid anatomy on the
palpebral aperture. Clin. Plast. Surg. 18: 183, 1991.
. Rees, T. D. Prevention of ectropion by horizontal shortening of the lower lid during
blepharoplasty. Ann. Plast. Surg. 11: 17, 1983.
. Lisman, R. D., Rees, T., Baker, D., and Smith, B. Experience with tarsal suspension
as a factor in lower lid blepharoplasty.Plast. Reconstr. Surg. 79: 897, 1987.
. Tenzel, R. R. Treatment of lagophthalmos of the lower lid.Arch. Ophthalmol. 81:
366, 1969.
. Montandon, D. A modification of the dermal-flap canthal lift for correction of the
paralyzed lower eyelid. Plast. Reconstr. Surg. 61: 555, 1978.
Marsh, J. L., and Edgerton, M. T. Periosteal pennant lateral canthoplasty. Plast.
Reconstr. Surg. 64: 24, 1979.
62
1270-11604-33871 ocular
29/11/06
10:19
Página 63
Pe r i o c u l a r Re c o n s t r u c t i v e M a n u a l
9. Anderson, R. L., and Gordy, D. D. The tarsal strip procedure. Arch. Ophthalmol.
97: 2192, 1979.
Hamako, C., and Baylis, H. I. Lower eyelid retraction after blepharoplasty. Am. J.
Ophthalmol. 89: 517, 1980.
11. Jelks, G. W., and Jelks, E. B. Repair of lower lid deformities. Clin. Plast. Surg. 20:
417, 1993.
. Jordan, D. R., and Anderson, R. L. The lateral tarsal strip revisited: The enhanced
tarsal strip. Arch. Ophthalmol. 107: 604, 1989.
Jelks, G. W., and Smith, B. C. Reconstruction of the Eyelids and Associated
Structures. In J. G. McCarthy (Ed.), Plastic Surgery. Philadelphia: W.B. Saunders,
1990. Pp. 1671-1784.
Whitaker, L. A. Selective alteration of palpebral fissure form by lateral canthopexy.
Plast. Reconstr. Surg. 74: 611, 1984.
1 Ortiz-Monasterio, F., and Rodriguez, A. Lateral canthoplasty to change the eye slant.
Plast. Reconstr. rg. 75: 1, 1985.
16. Paterson, R. S., Munro, I. R., and Farkas, L. G. Transconjunctival lateral canthopexy in Down's syndrome patients: A non-stigmatizing approach. Plast. Reconstr.
Surg. 79: 714, 1987.
. Shore, J. W. Changes in lower eyelid resting position, movement, and tone with age.
Am. J. Ophthalmol. 99: 415, 1985.
. Flowers, R. S. Canthopexy as a routine blepharoplasty component. Clin. Plast. Surg.
20: 351, 1993.
Koornneef, L. Orbital septa: Anatomy and function. Ophthalmology 86: 876, 1979.
. McKinney, P. Use of tarsal plate resection in blepharoplasty on atonic lower lids. Plast.
Reconstr. Surg. 59: 649, 1977.
. Hinderer, U. T. Correction of weakness of the lower eyelid and lateral canthus:
Personal techniques. Clin. Plast. Surg. 20: 331, 1993.
. Carraway, J. H., and Mellow, C. G. The prevention and treatment of lower lid ectropion following
. Jelks, G. W., Glat, P. M., Jelks, E. B., and Longaker, M. T. The inferior retinacular
lateral canthoplasty.
. Edgerton, M. T., and Wolfort, F. G. The dermal-flap canthal lift for lower eyelid support: A technique of value in the surgical treatment of facial palsy
. Jelks, G. W., Glat, P. M., Jelks, E. B., Wood, M., Gadangi, P. K. and Longaker, M.
T. The Evolution of the Lateral Canthoplasty: Techniques and Indications. Presented at
the American Association of Plastic Surgeons, 74th Annual Meeting, San Diego, April
30 to May 3, 199 5.
63
B
I
B
L
I
O
G
R
A
P
H
Y
1270-11604-33871 port traz 30/11/06 12:46 P gina 2