Mask of young woman Roman period
Mask of young woman Roman period
Ophthalmic plastic surgery deals with various disorders in three major areas: eyelids, lacrimal and orbit.
In order to understand the following presentation, the initial chapter will describe the surgical eyelid anatomy. The second chapter will include the main functions to preserve during the surgery, while general considerations on oculoplastics will be exposed in the third chapter.
Then further chapters will describe reconstructive eyelid surgery, repair of eyelid injuries, eyelid malposition surgery, ptosis and lid retraction surgery, enucleation and socket repair, lacrimal surgery and finally cosmetic eyelid surgery.
The skin crease is more marked in the upper eyelid than in the lower eyelid.
In the upper eyelid, the levator aponeurosis inserts between the bundles of orbicularis muscle to form the skin crease. The skin crease separates the upper lid in two portions : the preseptal and pretarsal areas. Above the skin crease, the preseptal skin can stretch with age. Excess of preseptal skin may be resected to serve as a skin graft or for a cosmetic reason. Below the skin crease, the pretarsal skin is very thin but does not stretch at all. The skin crease has a great interest in upper eyelid surgery : to dissimulate a scar, incision in the upper lid is made in the skin crease.
The lower skin crease is due to the insertion of the lower lid retractors, at the lower border of the tarsus. Preseptal skin in lower eyelid stretches much less than in upper eyelid.
The skin below the brow is thicker than the skin close to the lid margin, which is the thinnest of the body.
There are two or three rows of eyelashes in the upper eyelid and one or two rows of eyelashes in the lower eyelid. During surgery upper eyelashes should be preserved because any defect of eyelashes in the upper eyelid is very visible. There are no eyelashes medially to the lacrimal puncti.
The eyelids are divided in two lamellae :
- an anterior lamella including skin and orbicularis muscle ( seventh nerve ),
- a posterior lamella including tarsal plate and conjunctiva, and eyelid retractors : levator muscle ( third nerve ), aponeurosis and Muller's muscle ( sympathetic nerve ) in the upper lid, lower lid retractors in the lower lid.
The tarsal plates include the meibomian sebaceous glands which may lead to chalazion.
Orbital fat is distributed in the upper eyelid in two compartments, medial fat pad and preaponeurotic fat pad. Prolapse of the brow fat pad may contribute to form a preseptal fat pad in the upper eyelid. Orbital fat in the lower lid includes three compartments : medial, central and lateral fat pads. Resection of fat in the lower lid may be performed for cosmetic reason via a transconjunctival approach with no cutaneous scar visible.
The objectives of eyelid surgery are both functional and cosmetic.
Restoring normal three dimensional anatomy allows the eyelids to keep their protective and tear excretory functions.
Optimal cosmesis may be restored if symmetric eyebrows, symmetric skin creases and fat pads, good lid contour, continuity of the lashes, etc.. are obtained.
Instruments :
The surgical oculoplastic set may include :
-Ocular shield to protect the eye.
-A millimeter ruler
-A No. 15 blade
-Saint-Martin forceps
-Stevens scissors and Wescott's scissors
-Castroviejo needle holder
-Skin hooks
-Desmarres retractor
-Gauze swabs for bleeding
-Cotton tipped applicators
-Rugine
-Monopolar or bipolar cautery to stop bleeding
-Vaseline gauze
-Pressure dressing
-A carbon dioxide laser used either for resurfacing of periocular wrinkles, using ablation mode, either for removal of skin, soft tissue or fat, using continuous cutting mode.
Sutures :
Preparation for surgery :
Some drops of topical anesthetic are instilled on each cornea for comfort during surgical preparation. The patient's entire face is prepared with povidone-iodine. An ocular shield is placed over the eye and under the eyelids. Lines of skin incisions are drawn with a marking pen.
Anesthesia :
Local anesthesia is usually used : two per cent lidocaïne is injected subcutaneously or subconjunctivally throughout the lid for short operations.
For longer operations, two per cent lidocaïne with bupivacaïne may be associated with intravenous sedation. Indications for eneral anesthesia are : infants and children, patient preference, patients with mental disorders or uncooperative patients.
Chalazion
Certain benign eyelid tumors are easily recognized with the clinical examination: the chalazion is a frequent affection developed in a gland of Meibomius.
It carries out an inflammatory attack of the gland associated with the obturation of the glandular orifice. It can interest one or more eyelids, even several glands inside a same eyelid. When the medical treatment by eye drops and antibiotic and corticoid ointment is not sufficient, a surgical treatment is proposed : the surgical excision is generally done by transconjunctival approach.
 Chalazion preoperative view |
 Chalazion preoperative view |
 Postoperative view |
 Postoperative view |
Argon laser ablation of benign eyelid tumors :
Indications
Only benign tumors are indicated for laser ablation : kysts, papillomas, milia, keratosis, xanthelasma.
Laser is performed with the magnifying glass of the slit lamp and so, even lesions situated between the eyelashes or on the lid margin can be ablated very precisely with laser.
Method
Infiltrative anesthetic as lidocaïne is used. Laser is set for a spot size of 50 to 250 Micrometers, in a continuous mode, at 250 to 750 mW.
The defect will heal by granulation with vaseline and antibiotic ointment in one or two weeks. Skin depigmentation is present in nearly all patients after laser ablation.
 Benign tumor involving the lid margin |
 Immediate result after argon laser |
 Long term result after argon laser |
