Lower Eyelid Reconstruction

Abstract

Reconstruction of the lower eyelid seeks to restore both anatomic function and prereconstructive lid aesthetics. A sound understanding of the nature of lower eyelid anatomy and function is required to acheive these goals. The lower eyelid differs in several crucial ways from the upper eyelid, and only by appreciating these differences can optimal lower eyelid surgery be achieved. A multitude of approaches to lower eyelid reconstruction exist. The proper choice of technique is guided by two major factors: size of defect and involvement of anterior or posterior lamellae. Lower eyelid anatomy and function Medial and lateral canthal tendons The lower eyelid has a number of unique anatomic features. The height of the tarsus of the lower eyelid is approximately 3 to 4 mm, far shorter than the 10 to 12 mm found in the upper lid [1]. The lower eyelid is in apposition with the globe for the full length of the eyelid and is suspended on either side by tendinous attachments to the orbital rim. The inferior crus of the lateral canthal tendon inserts just inside the lateral orbital rim at a bony protuberance named Whitnall’s tubercle [2]. The medial canthal tendon attaches to the lacrimal crest both anteriorly and posteriorly. These two portions of the medial canthal tendon envelop the lacrimal sac, which rests in the lacrimal sac fossa [3]. Importantly, it is the posterior portion of the medial canthal tendon that maintains the integrity of medial eyelid support. Functionally, the tarsal plate and its canthal tendon insertions act as a sling for the lower eyelid, referred to as a tarsoligamentous band [4]. This band not only maintains the eyelid in a normal anatomic position, but also supports the globe and orbital contents. The lower eyelid also is subject to the vertical