Introduction In a full-thickness reconstruction of the upper or lower eyelid it is important to reconstruct the posterior lamella of the lid to give support to the reconstructed anterior lamella. In the upper lid it is essential that the posterior lamella is lined with mucosa. In the lower lid this is less important but still desirable. If a skin flap is available for the anterior lamella…

Introduction The eyelids have two lamellae – an anterior lamella of skin and orbicularis muscle and a posterior lamella of tarsal plate and conjunctiva. Partial-thickness defects of the lid or periocular region require reconstruction of only the anterior covering layer. This is achieved with a skin graft (separated from its blood supply) or a skin flap (with its blood supply intact). Full-thickness eyelid defects require the…

Introduction In this chapter the direct closure of defects of the eyelid margin is described. Smaller defects may be closed directly without additional tissue. Larger lid margin defects may be closed directly with the addition of extra tissue from beyond the lateral canthus. Lid margin defects that are too large to be closed directly require separate reconstruction of the anterior covering lamella and the posterior lining…

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Introduction The emotional distress which frequently accompanies the removal of an eye is reduced considerably by a cosmetic final result. The appearance of the prosthesis will be enhanced and its mobility will be improved if a buried orbital implant is inserted (see Ch. 13 ) following an evisceration or enucleation. 12.1 Evisceration with removal of the cornea 12.1a–c Make a 360 degree conjunctival incision and recess…

Introduction Corneal exposure is the most serious sequel to eyelid retraction. It may also occur with the eyelids in a normal position if there is poor closure, especially in the presence of reduced tear production, a poor Bell's phenomenon or reduced corneal sensitivity. In these situations, or if there is cosmetic asymmetry even without exposure, an upper lid may need to be lowered or a lower…

Introduction A predictable sequence of changes occurs in the face as we age. Early changes are barely discernible and few seek a surgeon's help. Later, more obvious changes lead to a wide variety of cosmetic and functional surgical interventions. The eyelids are the focus for many seeking advice. However, the whole face is ageing and more subtle changes beyond the eyelids must also be addressed to…

Introduction More than any other oculoplastic surgery ptosis surgery depends on a thorough understanding of eyelid anatomy. Particular care must be taken in the assessment because not all ptosis should be corrected surgically. Classification Myogenic: Isolated congenital ptosis (congenital levator dystrophy) Blepharophimosis syndrome Progressive external ophthalmoplegia Myasthenia gravis Neurogenic: Third nerve palsy Horner's syndrome Marcus Gunn jaw-winking Aberrant regeneration of third nerve Aponeurotic: Defects in levator…

Introduction Although ingrowing lashes are usually only a minor irritant they may cause permanent scarring of the cornea and threaten sight, especially if the cornea is insensitive or the eye is dry. Classification: Trichiasis Distichiasis Trichiasis is a common, acquired, misdirection of eyelashes arising from their normal site of origin. Distichiasis is a rare, congenital growth of an extra row of eyelashes arising from the meibomian…

Introduction Neglected ectropion leads to epiphora and secondary cicatricial changes in the skin. A vicious circle is set up which is increasingly difficult to reverse the longer surgery is delayed. Classification Involutional Cicatricial – generalised – linear Paralytic Mechanical Exclude a mechanical cause for the ectropion and identify any abnormality of facial nerve function ( Sect. C ). Look for cicatricial changes in the skin –…

Introduction Entropion of the upper or lower eyelids causes pain and leads eventually to corneal scarring. The changes occur more rapidly if there is also a poor tear film. Classification: Involutional Cicatricial Congenital Although less common than involutional entropion, cicatricial entropion should be excluded early in the examination. Look for cicatricial changes in the conjunctiva. If present try to establish the cause before considering surgery (…

Introduction In this chapter a basic set of instruments for ophthalmic plastic surgery is suggested. Extra instruments for particular procedures may be added. 5.1 The basic instruments The basic instruments Top row, left to right: Castroviejo needle holders Barraquer needle holders Jayle's forceps Lister's forceps Moorfield's forceps St Martin's forceps Measuring calliper Blunt-ended dissecting scissors Sharp-ended dissecting scissors Curved spring scissors Corneal guard spatula Fine suction…

Introduction Local anaesthesia is very satisfactory for most ophthalmic plastic procedures. Children and some adults require general anaesthesia. Extensive procedures are more conveniently done under general anaesthesia because of the volume of local anaesthetic that would be required. Premedication A mild sedative may be beneficial for anxious patients having surgery under local anaesthesia. Temazepam 10 mg orally, 2 hours before operation, is usually sufficient. An alternative is…

Introduction In this chapter many of the techniques of examination used in ophthalmic plastic surgery are described. After taking an accurate history it is helpful to approach the examination in a methodical way. The relative importance of each test varies with the condition being assessed and this is discussed in later chapters. Obvious pathology Check the visual acuity. Look for scars, inflammation, tumours, lid malpositions and…

Introduction Ophthalmic plastic surgery shares many basic techniques with general plastic surgery. During the past 100 years, new techniques have been developed which take maximum advantage of the specialised anatomy of the eyelids and periorbital region. The patient lies supine for ophthalmic plastic surgery and we find it helpful to stand to operate. By standing rather than sitting the surgeon can place himself/herself in the best…

Introduction The eyelids protect the eyes. Disease which alters eyelid structure or function threatens sight and an understanding of eyelid anatomy and physiology is fundamental to good reconstructive surgery. The eyelids should not be studied in isolation but in the context of the surrounding structures – the forehead, temples and cheeks. Safe surgery in these regions of the face depends on an understanding of the sometimes…