Eyelid Anatomy Research Articles

Microanatomy of Sensory Nerves in the Upper Eyelid: A Cadaveric Anatomical Study.

Plastic surgery requires detailed knowledge of upper eyelid anatomy, but few authors have sufficiently described the specifics of upper eyelid nerve anatomy. This study aimed to provide a thorough description of sensory nerve anatomy in the upper eyelid and to propose considerations for upper eyelid surgery. Sixteen orbits were dissected from 16 fixed, adult human cadavers. Microscopically, the authors identified the main trunks of the infratrochlear, supratrochlear, and supraorbital nerves and all branches that projected toward the upper eyelid. The number, size, and distribution of nerve branches were recorded. The branches of the infratrochlear, supratrochlear, and supraorbital nerves covered a wide range in the upper eyelid. The mean numbers of branches per nerve were 1.6 ± 1.2, 3.2 ± 1.5, and 2.6 ± 1.4, respectively. The branches of the infratrochlear nerve were distributed throughout the medial area of the upper eyelid. Those of the supratrochlear nerve were distributed throughout the medial and central areas, and the palpebral branches of the supraorbital nerve were distributed throughout the central and lateral areas of the upper eyelid. The lateral branches of the supraorbital nerve and the cutaneous branches of the lacrimal nerve were distributed in the lateral region of the orbit. The authors show that upper eyelid sensation is transmitted mainly by the supratrochlear and supraorbital nerves, and the authors provide a map of the distribution of upper eyelid sensory nerves. This precise anatomical knowledge about upper eyelid sensory nerves will facilitate pain control and help minimize nerve injuries during surgery.

Anatomic Considerations in Thyroid Eye Disease.

To review and summarize the clinical findings in thyroid eye disease (TED) related to the unique anatomical structures of the eyelids and orbit. A PubMed search was performed searching for anatomical relationships between eyelid and orbital anatomy and the clinical findings of TED. The major clinical findings associated with TED are varied. They typically involve both the eyelid and the orbit. In the eyelid, usual findings include upper eyelid retraction, contour abnormalities, eyelid edema, prolapsed orbital fat, conjunctival injection and chemosis, caruncular edema, and meibomian gland dysfunction. The exact causes of these changes remain a matter of controversy, but numerous hypotheses have been proposed, most with limited experimental support. In the orbit, inflammation and congestion characterize the acute active phase, with tissue expansion and fibrosis persisting into the chronic inactive phase. All of these findings result, at least in part, from the unique anatomy of the eyelids and orbit and their interaction with the immunologic processes underlying TED. Here we review these major characteristics of TED, with special reference to their anatomic relationships. The major findings characterizing TED are related to unique anatomic features in the eyelid, including Müller muscle, the levator palpebrae superioris muscle, and suspensory ligaments of the conjunctiva. In the orbit, Graves-related remolding results from the special physiologic features of the extraocular muscles, the structure of the orbital walls and their relations to adjacent paranasal sinuses, and the reaction of orbital fat to immunologic challenges.

Review of Eyelid Reconstruction Techniques after Mohs Surgery.

Mohs micrographic surgery achieves high cure rates while preserving healthy tissue making it the optimal treatment for skin cancer. The goals of eyelid reconstruction after Mohs surgery include restoring eyelid structure and function while attaining acceptable aesthetic results. Given the variety of eyelid defects encountered after Mohs surgery, a thorough understanding of the complex eyelid anatomy as well as an in-depth knowledge of the numerous reconstructive techniques available are required to accomplish these reconstructive goals. In this article, the authors review eyelid anatomy and discuss a variety of techniques used for the reconstruction of defects involving the periocular region.

The Relationship of Lid Wiper Epitheliopathy to Ocular Surface Signs and Symptoms.

There has been interest in determining whether lid wiper epitheliopathy (LWE) plays a key role in causing ocular discomfort. Conflicting reports have made it difficult to discern whether LWE is more prevalent in certain populations, what characteristics are associated with its severity, and what its role is in symptomology. This cross-sectional study on a large and diverse population attempts to answer these questions. Subjects were asked to complete questionnaires related to dry eye and to ocular discomfort. A comprehensive set of ocular surface parameters were assessed, including LWE length and width, tear-film lipid layer thickness, fluorescein tear breakup time (FTBUT), lid-parallel conjunctival folds (LIPCOF), and corneal staining. A total of 287 subjects participated in the study. LWE was observed in 45% of the study cohort and was twice as prevalent in Asians than non-Asians (P < 0.005). LWE was more likely to present in contact lens wearers than non-contact lens wearers (P = 0.03). Decreased FTBUT was associated with increased LWE length and width (P < 0.005 and P = 0.01, respectively), although only a small effect size was noted. Presence of LIPCOF was linked with a 0.25-grade increase in LWE width (P = 0.01). Only LWE width was associated with greater symptoms in contact lens wearers. LWE was associated with decreased tear-film stability, contact lens wear, lid anatomy, and LIPCOF. LWE was not associated with symptoms in non-contact lens wearers. LWE width was associated with greater symptoms in contact lens wearers but was only clinically significant with moderate to severe LWE width.

Upper Blepharoplasty: Management of the Upper Eyelid and Brow Complex via Transblepharoplasty Approach.

Upper blepharoplasty is one of the more common facial plastic procedures. The upper lid and brow complex are managed together. Whether upper blepharoplasty is performed for medical or cosmetic reasons, the aim is to improve appearance while retaining natural shape and maintaining (or improving) function. For optimal results, it is important to understand relevant eyelid anatomy and the concept of maintaining youthful volume and position of the eyelid brow orbit complex. Management of patient expectations, meticulous planning, and a degree of surgical finesse all contribute to the desired outcome. The article will focus on the assessment, techniques, and complications of upper blepharoplasty, which involve management of the skin, orbicularis oculi, preaponeurotic fat, levator aponeurosis and muscle as related to concomitant ptosis, and lateral brow complex via transblepharoplasty (internal) brow lift and fixation.

Eyelid Reconstruction.

After reading this article, the participant should be able to: 1. Describe eyelid anatomy and demonstrate full understanding of the critical structures and basic principles of eyelid reconstruction. 2. Evaluate individual defects, analyze the missing components, and formulate a reconstructive algorithm. 3. Anticipate potential complications and design effective strategies to manage and treat common complications following eyelid reconstruction. Defects of the eyelid can result from trauma, burns, or resection of cutaneous malignancies. Repair of eyelid defects presents unique challenges to reconstructive surgeons. A fundamental understanding of eyelid anatomy and familiarity with the myriad of options for reconstruction are critical for achieving optimal outcomes. Under ideal circumstances, the aims of reconstruction should be to restore form and function and to replace "like with like."

Anatomy of lower eyelid and eyelid–cheek junction

Understanding the anatomy of the lower eyelid and the lid-cheek junction is important for surgical and non-surgical approaches. It is important to understand the correlation between the clinical presentation and the individual anatomy to direct an adequate treatment. A review of the literature based on the authors experience combined with anatomical dissections was conducted to reveal the current concepts of the surgical and non-surgical anatomy. The various anatomical structures important for the understanding of the symptoms and the proposed treatment are described in this article. The anatomy of the lower eyelid and the lid-cheek junction has to be understood as a unit. Structures are continuous from the eyelid to the cheek influencing each other during aging. The concept of superficial, i.e. superficial to the orbicularis oculi muscle and deep facial fat compartments, i.e. deep to the orbicularis oculi muscle has to be applied in order to understand the relevant anatomy regarding the ligaments, fat compartments, muscular and tarsal structures and the vascularization. The understanding of the layered arrangement of the lower eyelid and eyelid-cheek junction anatomy enables practitioners to perform safe and effective surgical and non-surgical procedures.

Interlower and postlower eyelid retractor fat pads: a cadaveric microscopic study

BackgroundTo report the histological microscopic anatomy of the interlower and postlower eyelid retractor (LER) fat pads.MethodsIn this experimental microscopic study, 31 exenterated orbits from 31 Japanese cadavers (19 right and...

Application of Palpebral Spring in Asian Patients With Paralytic Lagophthalmos.

Literature on palpebral springs is scarce, and even more so for the Asian population. In this study, the authors evaluated their experience with palpebral spring placement for paralytic lagophthalmos in an Asian population. The authors report the unique challenges encountered due to the distinctive features in Asian eyelids and how they overcome them. To the best of our knowledge, this is the first report on the application of palpebral springs in Asians. All patients treated for paralytic lagophthalmos in the Department of Surgery, Queen Mary Hospital, from November 2013 to December 2015, were included in this study. The authors retrieved and analyzed the demographic data, preoperative assessment details, and treatment outcomes. A total of 17 patients were recruited. The median interval between facial palsy occurrence and surgery was 66 months. Preoperatively, vertical palpebral fissure was 12.3 ± 1.7 mm with margin reflex distance 1 of 3.7 ± 0.3 mm and margin reflex distance 2 of 8.6 ± 1.6 mm. Lagophthalmos before surgery was 9.6 ± 2.3 mm. After the palpebral spring surgeries, vertical palpebral fissure was reduced to 9.1 ± 1.4 mm. margin reflex distance 1 is slightly reduced (3.3 ± 0.8 mm) and margin reflex distance 2 improved to 5.8 ± 1.0 mm. Lagophthalmos reduced significantly to 0.8 ± 1.3 mm. Seven patients required revision procedures. Palpebral spring is a safe and effective treatment for Asian patients with paralytic lagophthalmos. However, surgeons should be aware of the unique challenges associated with the anatomy of Asian eyelids. Special adaptation of the procedure is required to optimize the outcome.

Staged complex treatment of paralytic lagophthalmos (case report)

Paralytic lagophthalmos, resulting from facial nerve palsy, is a difficult medical and social issue that requires cooperation of different specialists. Complications that arise in paralytic lagophthalmos may cause significant vision loss and even eye loss. Various techniques of paralytic lagophthalmos correction are used to protect the cornea and restore eyelid anatomy and functions. These comprise palliative (conservative), surgical, and alternative treatments (such as botulinum toxin type A therapy). Surgical treatment of paralytic lagophthalmos patients often has to be staged and complex. This article presents a clinical case of a female patient with paralytic lagophthalmos complicated by corneal perforation. Her staged complex treatment included lower eyelid surgery, chemodenervation of the upper eyelid levator and optical reconstructive surgery. The following positive results were achieved: the protective function of the eyelids was restored, residual visual functions - preserved, the risk of eye loss - eliminated, and the asymmetry between the two halves of the face - corrected.

Value of levator shortening for correction of high supratarsal fold after cosmetic upper blepharoplasty

Objective To correct the high supratarsal fold after cosmetic upper blepharoplasty is a challenge because of the shortage of both upper eyelid skin and fat. Levator shortening has been a procedure of choice selected by the surgeons to correct this condition. Methods Under local anesthesia, the desired crease was marked according to the characteristics of eyelid anatomy and aesthetic consideration for Asian women. The incision was made through the marked new skin crease and the old incision with surrounding scar tissue was incised. The adhesion between the skin and the levator aponeurosis was completely released. The levator aponeurosis was then divided above the tarsal plate. It could be shortened and then reattached to the tarsal plate depending on the amount of the upper eyelid skin and the degree of the ptosis. The skin incision was then closed to form new but lowered fold. Results Between 2003 to 2015, a total of 34 Chinese women underwent bilateral levator shortening for correction of high supratarsal fold after previous unsatisfactory upper blepharoplasty by other surgeons. There were no surgical complications postoperatively in this series and 32 patients (94.1%) were satisfactory for the outcome of the proper height of the supratarsal fold with at least 1 month follow-up. Only one patient (2.9%) required surgical revision for asymmetry of supratarsal folds and one patient (2.9%) for correction of deepened supratarsal fold. Conclusions The levator shortening can be an effective procedure to correct high supratarsal fold after unsatisfactory upper blepharoplasty in Asian women. It is especially useful to correct such a condition where there is shortage of the eyelid skin combined with the eyelid ptosis. Key words: Upper blepharoplasty; Levator palpebrae shortening; High supratarsal fold

Secondary Blepharoplasty: Correction of the High Fold.

Blepharoplasty is a common aesthetic surgery performed worldwide. In Asians, too high eyelid folds after blepharoplasty cause an unsatisfactory aesthetic outcome that is difficult to correct. In this article, the authors propose surgical techniques to correct the high eyelid fold after blepharoplasty. During a 4-year period, 213 secondary blepharoplasties were performed to correct high folds. Postoperative results were reviewed, graded, and analyzed. Of 213 cases of secondary blepharoplasty to correct the high eyelid fold, almost all could achieve reduction of the fold size (98.59%). One hundred and nine cases (51.17%), 69 cases (32.40%), and 32 cases (15.02%) were classified as excellent, good, and fair results, respectively. Only three cases (1.41%) were classified as poor results. Secondary blepharoplasty to correct a high fold is a challenging procedure for aesthetic surgeons. Surgeons performing this operation need to have a thorough understanding of eyelid anatomy and its dynamics together with familiarity with secondary blepharoplasty to avoid any further injury to the levator muscle. The key points of this surgery are levator advancement and intervening between the levator aponeurosis and the overlying skin by in situ tissue or fat grafting. This journal requires the authors to assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. www.springer.com/00266 .

English

INTRODUCTION: The eyelids are mobile tissue curtains protecting the eyes from injuries. The position of the eyelid against the globe is vital for maintaining the normal function and integrity of the underlying eyeball. Embryologically eyelids arises from two folds of ectoderm and mesoderm at about 8 weeks of gestational age. These two folds fuse by the age of tenth week. By seventh month of gestation they separate again to form eyelids. The lower lid position in relationship to the globe is due to various forces acting on the eyelid by its different anatomic attachments. Superior and posterior traction which keeps the eyelid margin in proper position are the medial and lateral canthal tendons. The lower lid retractors provides an inferior traction. An opposing force to the lower lids is provided in the anterior direction by the globe and various other orbital contents. In case of malfunction of one of the supporting structures or imbalance in the forces acting on the eyelid, the eyelid cannot properly maintain its position in relation to the globe. As a result, inversion or eversion of eyelid margin can occur. AIM OF THE STUDY: To evaluate the etiology and outcome of different surgical modalities applicable in the management of various types of ectropion. METHODS OF EVALUATION: It was a prospective interventional study conducted at Orbit and Oculoplasty department, RIOGOH, Egmore, Chennai for a period of 12 months.25 patients presented with ectropion were included in this study. RESULTS: Out of 25 patients, 19 patients (76%) had involutional ectropion. Among them lateral tarsal strip with medial canthoplasty was done in 10 patients (40%), 9 patients (39%) underwent lateral tarsal strip procedure. Two patients (8%) with mild cicatricial ectropion were subjected to Z Plasty. Of the remaining 4 patients (16%) who underwent scar excision with skin grafting for severe cicatricial ectropion, 1 patient (4%) had a unsatisfactory result with persistent eversion of the eyelid due to insufficient graft uptake. All other 24 patients (96%) had satisfactory surgical outcome outcome in the form of improvement of symptoms like watering, preservation of anatomy (opposition of eyelid to the globe) and better cosmesis. CONCLUSION: `Lateral tarsal strip procedure and medial canthoplasty procedure gives the successful surgical outcome in the form of alleviation of symptoms like watering,restoration of eyelid anatomy,corneal protection in the lateral aspect of the eye and better cosmesis in the management of involutional and paralytic ectropion. Both these procedures are simple with a short learning curve. Z Plasty and skin grafting is the procedure of choice in the management of cicatricial ectropion with local and generalized defect respectively. Thus planning appropriate surgical approach according to the type and pathogenesis of ectropion is the key for successful surgical outcome.

ω-3 Tear Film Lipids Correlate With Clinical Measures of Dry Eye.

Purposeω-3 and ω-6 polyunsaturated fatty acids modulate inflammatory processes throughout the body through distinct classes of lipid mediators that possess both proinflammatory and proresolving properties. The purpose of this cross-sectional study was to explore the relationship between lipid profiles in human tears and dry eye (DE) symptoms and signs.MethodsForty-one patients with normal eyelid and corneal anatomy were prospectively recruited from a Veterans Administration Hospital over 18 months. Symptoms and signs of DE were assessed, and tear samples was analyzed by mass spectrometry–based lipidomics. Statistical analyses comparing the relationship between tear film lipids and DE included Pearson/Spearman correlations and t-tests.ResultsArachidonic acid (AA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA) were present in more than 90% of tear film samples. The ratio of ω-6 (AA) to ω-3 (DHA+EPA) fatty acids was correlated with multiple measures of tear film dysfunction (tear breakup time, Schirmer 2 scores, and corneal staining; all P < 0.05). Arachidonic acid–derived prostaglandin E2 was detected in the majority of samples and correlated with low tear osmolarity, meibomian gland plugging, and corneal staining.ConclusionsBoth ω-3 and ω-6 lipid circuits are activated in the human tear film. The ratio of ω-6:ω-3 tear lipids is elevated in DE patients in proportion to the degree of tear film dysfunction and corneal staining. Metabolic deficiency of ω-3 tear film lipids may be a driver of chronic ocular surface inflammation in DE.

State of the Art in Congenital Eyelid Deformity Management.

The eyelids are crucial in maintaining the health of the ocular surface and have an important role in facial aesthetics. Interruption in eyelid development can lead to congenital eyelid deformities. This article reviews eyelid anatomy, the most common congenital eyelid abnormalities such as congenital ptosis, eyelid coloboma, and epiblepharon, and the management of these conditions.

One-Stage Alternatives to the Hughes Procedure for Reconstruction of Large Lower Eyelid Defects: Surgical Techniques and Outcomes.

To present the results of 1-stage surgical advancement flaps for the repair of large full thickness lower eyelid defects. These avoid the disadvantages of the 2-stage Hughes procedure and provide favorable functional and aesthetic outcomes. A retrospective case series of 36 lower eyelid repairs performed on 31 patients by a single surgeon in Sydney, Australia is presented. The selection criterion was a horizontal defect size 10 mm or greater that could have "classically" been repaired with a 2-stage Hughes procedure. Three different 1-stage surgical repair techniques were utilized, all incorporating local advancement-type flaps: 1) a lateral-based full thickness advancement flap; 2) a vertical tarsal plate advancement flap combined with a full thickness skin graft; and 3) a vertical skin advancement flap combined with a mucosal graft. The postoperative outcomes evaluated included flap viability, lower eyelid margin position and contour, characteristics of the new eyelid margin and patient satisfaction. Thirty-six lower eyelid repairs were performed in 31 patients. There were no cases of flap ischemia, necrosis, or failure. There was 1 case (3%) of postoperative eyelid retraction, 1 case (3%) of eyelid entropion requiring surgical repair, 1 case (3%) of pyogenic granuloma, 2 cases (6%) of eyelid margin cyst, and 7 cases (19%) of eyelid distichiasis. In 34 cases (94%), the patient was satisfied with the aesthetic result. The techniques described provide successful alternatives to the Hughes procedure. They are 1-stage and do not render the patient temporarily monocular, or alter the upper eyelid anatomy or function. All maintained favorable long-term functional and aesthetic outcomes for the reconstructed lower eyelid.

Commentary on: Visual, Physiological, and Aesthetic Factors and Pitfalls in Asian Blepharoplasty.

Upper blepharoplasty (or double eyelid surgery) is one of the most commonly performed cosmetic surgical procedures for Asians.1 Just like any other cosmetic surgical procedure, careful evaluation of patient anatomy, proper selection of the procedure, precisely performing the procedure, and suitable postoperative care are key for an optimal outcome after Asian upper blepharoplasty.2 This Special Topic article, entitled “Visual, Physiological and Aesthetic Factors and Pitfalls in Asian Blepharoplasty,” is a good example of an article written by an experienced Asian blepharoplasty surgeon.3 It starts by emphasizing the importance of upper eyelid anatomy in Asian patients, followed by analyzing some of the common problems in Asian upper blepharoplasty, including the less optimal height of the upper eyelid skin crease, the wrong placement of non-absorbable suture in the upper eyelid that changes its normal anatomy, and the careless closure of the upper eyelid incision, causing functional and anatomic disturbance of the upper eyelid. In general, the upper eyelid is a 7-layer structure that contains skin, orbicularis muscle, orbital septum, preaponeurotic fat pads, the levator muscle, the Mueller's muscle, and upper tarsus, and conjunctiva. One should always pay attention to the differences between Asian and Caucasian upper eyelids in terms of the anatomy, especially preseptal fat, which does not exist in Caucasians.2,4 A schematic diagram clearly demonstrates the distinctive anatomy of the Asian upper eyelid in comparison with that of a Caucasian (Figure 1). Figure 1. A schematic diagram showing the differences of anatomic structures between Asian and Caucasian upper eyelid. Adapted from Park DD.2 We agree with the author that levator function should always be evaluated as one of the important preoperative evaluations for any potential Asian upper blepharoplasty patients. As a matter of fact, levator plication during an open Asian upper blepharoplasty may enhance cosmetic …

Determining Tarsus Curvature in Relation To Direction of Gaze Using Non-contact Ultrasound Video Assistance.

Plastic surgery on the eyelids for the purpose of aesthetic or functional correction requires precise knowledge of lid anatomy. Changes in the tarsal curvature of the upper eyelid relative to line of vision are important, particularly when a surgical correction of paralytic lagophthalmos is undertaken. We used a computer-based image-processing algorithm to establish a relationship between changes in the curvature of the tarsus relative to the line of vision. A dynamic, ultrasound examination of the upper eyelids of 100 participants (100 eyes) was performed transpalpebrally using a 7.5 MHz scanner with the patient looking straight ahead, away from and towards the midline of the body. A computer-aided examination of the upper eyelid tarsus was then performed, followed by the calculation of the radius of curvature of the tarsus relative to the line of vision in each position. Using regression of a Taylor polynomial, the shape of the tarsus was mapped by a quadratic function, and the change in tarsal curvature relative to line of sight could be demonstrated. With objective evidence of change in the tarsal curvature relative to the line of sight, this may influence the treatment of pathological changes in the upper eyelid.

Blepharoplasty Basics for the Dermatologist.

Blepharoplasty is amongst the more frequently performed aesthetic procedures with surgery performed by physicians and surgeons across a variety of sub-specialities. This paper, aimed at a dermatology audience, describes patient selection, eyelid anatomy, clinical examination and surgical steps to achieve successful upper and lower lid blepharoplasty outcomes. Recommendations for minimising complications are made and photographs used to illustrate important clinical and surgical features.

Differences Between Single and Double Eyelid Anatomy in Asians Using Ultrasound Biomicroscopy.

The aim of this study was to clarify the differences between single and double eyelid structures quantitatively using an ultrasound biomicroscopy. A single-center observational study. Upper eyelids of Asian volunteers were evaluated with a 50-MHz ultrasound biomicroscopy. The skin-orbicularis oculi complex (SOOC), levator aponeurosis, Mueller muscle-conjunctival complex, and tarsus were imaged at the eyelid crease in the double eyelid group and 7 mm above the eyelid margin in the single eyelid group. The SOOC was also measured 2 mm above the eyelid margin and 5 mm above the eyelid crease. Forty-two upper eyelids of 42 subjects were studied. Mean SOOC thickness at the eyelid crease was 0.62 ± 0.12 mm in single eyelids and 0.57 ± 0.08 mm in double eyelids (P = 0.03). Mean SOOC thickness at 2 mm above the eyelid margin and 5 mm above the crease was not significantly different between single and double eyelids (P = 0.004 and P = 0.62, respectively). The levator aponeurosis, Mueller muscle-conjunctival complex, and tarsus measured 0.38 ± 0.12 mm, 0.86 ± 0.28 mm, and 10.84 ± 1.10 mm in single eyelids and 0.39 ± 0.14 mm, 0.88 ± 0.34 mm, and 10.61 ± 1.36 mm in double eyelids (P = 0.75, P = 0.81, and P = 0.54, respectively). Single eyelids showed slightly thicker SOOC in the pre-tarsal area and at the eyelid crease but not 5 mm above the eyelid crease. The levator aponeurosis, Mueller muscle-conjunctival complex, and tarsus showed no differences in thickness.