The eyelids and orbit 2

INTRODUCTION AND ANATOMY of the orbit and its contents is beyond the scope of this chapter.
Suffice it to say, however, that neoplasms may arise from any of
these structures mentioned above or from connective tissues of
The eyelids are a complex set of paired, anatomical structures that the eye and orbit. Salient features of the anatomic structures in the
protect the eye. Cross-sectional anatomy of the eyelids reveal that orbit as well as cross-sectional anatomy of the eyelids is shown in
their exterior is covered by skin while the inner surface is covered Big. 2.1.
by conjunctiva. In between is the tarsal plate with the orbicularis
Benign as well as malignant neoplasms may arise from the eye-
oculi muscle, the hair follicles of the eyelashes, and the meibomian
lids and the orbit. Benign lesions include cutaneous keratosis and
glands. Most of the movement during closure of the eyelids is per-
papillomas as well as inclusion cysts, dermoid cysts, and cysts arising
formed by the upper eyelid, with the lower eyelid being relatively
from obstruction of sebaceous and sweat glands. In addition to
less mobile. The lacrimal apparatus consists of the lacrimal gland,
these, benign sweat gland tumors such as syringoma, myo-
the upper and lower lacrimal puncta opening into the lacrimal
epithelioma, and sebaceous adenoma can also occur in the eyelids.
canaliculae leading to the lacrimal sac which continues in the
On the other hand, the most frequently seen malignant lesions of
lacrimal fossa as the nasolacrimal duct which eventually opens
the eyelids include basal cell carcinomas, squamous cell carcinomas,
into the inferior meatus of the nose.
malignant melanomas, Merkel cell tumors, as well as malignant
The orbit contains the eyeball, the optic nerve, extraocular muscles, sweat gland tumors and sebaceous gland carcinomas. Tumors in
as well as the oculomotor, trochlear and abducent nerves, ciliary the orbit may arise from nerves and nerve sheath, extraocular
ganglia and nerves, the first division of the trigeminal nerve (frontal muscles, lacrimal apparatus, orbital bones, as well as soft tissues in
nerve) and the infraorbital nerve (second division of the trigeminal the orbit including lipomas, fibromas, hemangiomas, and their
nerve). The major arterial supply in the orbit comes from the malignant counterparts. Lymphoma, pseudotumor and metastatic
supraorbital artery as well as the anterior and posterior ethmoidal tumors also occur in the orbit. Examples of some orbital tumors
arteries and the lacrimal artery. Detailed description of the anatomy are shown in Figs 2.2-2.17.

Fig. 2.1 Anatomy of the orbit and eyelids.

Fig. 2.2 Basal cell carcinoma of the lateral canthus. Fig. 2.4 Melanoma of the lower eyelid.

Fig. 2.3 Advanced squamous cell carcinoma of the lower eyelid w i t h Fig. 2.5 Melanoma of the conjunctiva.
metastasis to the cervical lymph nodes.

Fig. 2.6 Hemangioma of the upper eyelid. Fig. 2.7 Plexiform neurofibromatosis involving Fig. 2.8 Coronal CT scan of the patient shown*
the upper eyelid and forehead. in Fig. 2.7 demonstrating intraorbital extension
of the tumor.
Fig. 2.9 Neuroblastoma of the orbit. Fig. 2.10 Liposarcoma of the orbit. Fig. 2.11 Liposarcoma of the orbit.

Fig. 2.12 Liposarcoma of the orbit. Fig. 2.13 Liposarcoma of the orbit. Fig. 2.14 Recurrent malignant fibrous
histiocytoma of the orbit.

Fig. 2.15 Chondrosarcoma of the orbit. Fig. 2.16 Orbital pseudotumor.

Surgical treatment planning for excision of malignant lesions of reconstructive surgery of the eyelids include prevention of exposure
the eyelids must include an appropriate plan for reconstruction keratopathy due to lack of ability to close the eyelids, inadequate
of the surgical defect. Most lesions of the upper or lower eyelid can drainage of the lacrimal secretions leading lo epiphora, eversion
be repaired using local tissues, however more advanced lesions or exposure of the conjunctiva leading to traumatic conjunctivitis
require complex reconstructive procedures. The important issues in and impairment of peripheral visual fields due to excessive closure
Fig. 2.17 Orbital pseudotumor. Fig. 2.18 Basal cell carcinoma involving the skin of the lower eyelid.

Of the palpebral fissure, l o r more complex reconstructions, the

reader is advised to consult more detailed textbooks of oculo-
plastic surgery. On the other hand, complex reconstructive pro-
cedures are best handled by adequately trained and experienced
oculoplastic surgeons.

EXCISION OF CARCINOMA OF THE SKIN OF THE

LOWER EYELID

Fig. 2.19 The plan of surgical excision

Skin carcinomas involving the lower eyelid are easily managed by
wide excision and closure by mobilizing skin from the lateral
aspect of the cheek and the temporal region. When excision of a
skin lesion of the lower eyelid is performed in a transverse axis
with primary closure of the defect, ectropion will often result; so,
whenever feasible, the surgical excision is planned in such a
manner that a lateral advancement flap can be brought in to close
the surgical defect, thus avoiding ectropion. The patient shown in
Fig. 2.18 has a basal cell carcinoma involving the skin of the
lower eyelid. The lesion does not reach the tarsal margin and is
not infiltrating the underlying musculature or cartilage.
The plan of surgical excision is outlined in F i g . 2.19. The
surgical defect resulting from this excision is of a triangular shape.
The upper transverse skin incision is extended along the lateral Fig. 2.20 The completed closure.
canthus into the temporal region and the skin flap is elevated. The
skin from the temporal region is thus advanced into the surgical
defect. The apex of the flap thus slides into the surgical defect
permitting its closure. Adequate mobilization of the lateral skin is
necessary to avoid tension on the suture line and secondary pull
on the lower eyelid.
The completed closure shows skin sutures w i t h 6-0 nylon in
place (Fig. 2.20). Note that the skin sutures beneath the lower
eyelid are left long and their ends are taped to the skin of the
cheek to avoid trauma to the cornea from the stumps of the sutures.
No dressings are necessary, but Bacitracin ophthalmic ointment is
applied to the suture line.
The postoperative appearance of the patient approximately
eight weeks after surgery is shown in Fig. 2 . 2 1 . Note that the scar
of the surgical excision is almost imperceptible and the position of
the lower eyelid remains w i t h i n normal limits without any
ectropion. Surgical excision of skin lesions of the lower eyelid is
best managed by repair of the surgical defect with advancement of Fig. 2.21 The postoperative appearance of the patient approximately
skin from the lateral aspect of the cheek. eight weeks after surgery.
EXCISION OF CARCINOMA OF THE SKIN OF THE that site is oriented vertically while excision of the skin of the
UPPER EYELID upper eyelid is oriented transversely, like an inverted letter'T'.
The surgical defect following excision of the lesion is shown in
Fig. 2.24. Frozen sections must be obtained from the margins of
Unlike the lower eyelid, the upper eyelid has a generous amount the surgical defect to ensure adequacy of excision, and care should
of lax skin available making primary closure of the surgical defect be taken to avoid sacrifice of undue amounts of underlying mus-
possible following excision of even a large skin cancer. The patient culature. After achieving satisfactory hemostasis, the skin edges
shown in Fig. 2.22 has a superficially infiltrating squamous cell are undermined on the lateral aspects of the upper portion of the
carcinoma involving the skin of the upper eyelid which extends surgical defect. Closure of the upper part of the surgical defect is
into the eyebrow. On palpation, the lesion is confined to the skin accomplished vertically using interrupted 3-0 chromic catgut sutures
and does not infiltrate into either the underlying musculature or to restore the continuity of the eyebrow between its medial and
the tarsal plate. lateral parts. The rest of the surgical defect in the skin of the upper
On closure of the eyelid, the true extent of the lesion becomes eyelid is closed transversely in two layers, the completely closed
evident. This involves a significant portion of the skin of the wound resembling an inverted letter "P. The postoperative
upper eyelid with extension into the eyebrows (Fig. 2.23). appearance of the patient approximately eight weeks after surgery
Surgical excision of this lesion will require sacrifice of a large is shown in Fig. 2.25. Note that the eyebrow is reconstructed to
portion of the skin of the upper eyelid including some of the eye- its normal shape and that the upper eyelid has essentially no
brow. In the plan of surgical excision and repair, it is important to disfigurement because closure of the skin defect is transverse. The
remember that the shape of the eyebrow be retained or restored. esthetic result of this repair is quite satisfactory.
In order to maintain shape of the eyebrow, surgical excision at

Fig. 2.22 A superficially infiltrating squamous cell carcinoma involving Fig. 2.24 The surgical defect following excision of the lesion.
the skin of the upper eyelid which extends into the eyebrow.

Fig. 2.23 This lesion involves a significant portion of the skin of the Fig. 2.2S The postoperative appearance of the patient eight weeks after
upper eyelid w i t h extension into the eyebrow. surgery.
Fig. 2.31 A pigmented basal cell carcinoma involving the skin of the Fig. 2.33 The surgical defect shows adequate excision of the skin cancer
lower eyelid and the medial canthus. w i t h resection of the medial canthus and a generous portion of skin
around the primary lesion.

Fig. 2.32 Skin incisions are marked out for the planned surgical excision Fig. 2.34 The postoperative appearance of the patient three months
and the skin flaps to be elevated for reconstruction. following surgery.

EXCISION OF SKIN CANCER INVOLVING THE MEDIAL rotated inferiorly and medially, and the cheek flap is advanced
CANTHUS medially to accomplish closure of the surgical defect.
The postoperative appearance of the patient approximately
three months following surgery is shown in Fig. 2.34. Note that
Skin lesions involving the medial canthus of the lower eyelid can the patient does not have ectropion. Since eyelashes in the medial
be excised and repaired with a medially based skin flap from the- part of the reconstructed lower eyelid are missing, there is some
upper eyelid as described in the previous operative procedure. esthetic deformity but, functionally, the patient has no other
However, if the extent of surgical excision reaches the base of the problems. Thus, the combination of medial advancement of skin
medially based upper eyelid skin flap then that particular method of the lateral aspect of the cheek and advancement rotation flap
of reconstruction is not applicable. The patient shown in Fig. from the skin of the upper eyelid proves to be a satisfactory
2.31 has a pigmented basal cell carcinoma involving the skin of combination for reconstruction of surgical defects in the region of
the lower eyelid and the medial canthus. Because of the extent of the medial canthus.
surgical excision that would be necessary in this patient, the
medially based upper eyelid skin flap is not applicable here. So the
plan of surgical excision and reconstruction would include a
laterally based upper eyelid skin flap which would be rotated 'V EXCISION OF THE LOWER EYELID
interiorly and medially to reach the region of the medial canthus.
Medial advancement of skin of the cheek from the lateral aspect When skin lesions involving the lower eyelid in the region of the
allows repair of the resultant surgical defect in the skin of the tarsal margin demand the need for lull-thickness resection, a 'V
lower eyelid. excision is most satisfactory as long as the extent of surgical
Skin incisions are marked out for the planned surgical excision resection is limited. Up to one-third of the lower eyelid can be
and the anticipated skin flaps to be elevated following excision resected in a wedge excision with primary repair.
(Fig. 2.32). The surgical defect shows adequate excision of the The patient shown in Fig. 2.3S has a nodular basal cell carcinoma
skin cancer with resection of the medial canthus and a generous involving the tarsal margin of the lower eyelid. A through-and-
portion of skin around the primary lesion (Fig. 2.33). Frozen through wedge excision of the lower eyelid is performed including
sections must be obtained from several margins of the surgical the skin, the tarsal plate, and the conjunctiva. Frozen sections are
defect to ensure adequacy of excision. Laterally based skin flaps obtained from the margins of the surgical defect to ensure adequacy
are elevated as previously outlined; a flap from the upper eyelid is of resection. Reconstruction of the surgical defect requires
 r/
• p

Fig. 2.35 A nodular basal cell carcinoma Fig. 2.36 Accurate alignment of the tarsal plate Fig. 2.37 The postoperative appearance of the
involving the tarsal margin of the lower eyelid. using Vicryl suture is crucial to achieving a patient three months after surgery.
good cosmetic result.

reapproximation of the tarsal plale which is accomplished using

a 4-0 Vicryl suture (Fig. 2.36). The suture begins at the gray line
of the tarsal edge, entering through the tarsal margin and the
underlying tarsal plate; it then exits through the transected edge of
the tarsal plate on one side, re-enters the transected edge of the
tarsal plate on the opposite side, and exits from the tarsal margin
at the opposite end of the surgical defect. This suture is snugly tied
to reapproximate the tarsal plate, and the remaining surgical
defect is closed in two layers using 6-0 silk sutures for the
conjunctiva and 6-0 nylon sutures for the skin of the lower eyelid.
Meticulous attention should be paid to accurate reapproximation
of the tarsal cartilage defect, otherwise indentation at the site of
the surgical closure will develop, leading to an unpleasant
appearance.
The postoperative appearance of the patient three months after
surgery is shown in Fig. 2.37. Note that the tarsal margin is
accurately reapproximated without any indentation, leaving no
Fig. 2.38 An adenocarcinoma of adnexal origin involving the lower
functional or esthetic deformity at the site of surgical excision. eyelid.
Wedge resection of the lower eyelid is a very satisfactory operative
procedure, best suited for lesions which need through-and-through
resection of limited portions of the lower eyelid.

FULL-THICKNESS RESECTION AND RECONSTRUCTION

OF THE LATERAL CANTHUS AND THE LOWER EYELID

Lesions involving the tarsal margin at the lateral third of the lower
eyelid require a through-and-through resection of the lower eyelid
which reaches the lateral canthus. Repair of the surgical defect
under these circumstances requires a cartilage support to restore
the defect in the tarsal plate and advancement flap of skin from
the lateral aspect of the cheek to provide skin coverage. The
patient shown in Fig. 2.38 has an adenocarcinoma of adnexal
origin involving the lower eyelid. The lesion involves at least the
lateral third of the lower eyelid and therefore the surgical excision
will entail resection of the lateral half of the lower eyelid. The
planned incision for resection of the tumor and advancement of Fig. 2.39 The outline for resection of the tumor and advancement of
the lateral cheek flap.
the lateral cheek flap are outlined in Fig. 2.39. A through-and-
through resection of the lower eyelid including the skin and
underlying tarsal plate is completed with preservation of the appropriate piece of cartilage is harvested to replace the resected
palpebral conjunctiva of the lower eyelid since this is a skin lesion portion of the tarsal margin. The skin at the donor site after
(Fig. 2.40). Frozen sections are obtained from the margins of the harvest of the cartilage is closed with interrupted sutures (Fig.
skin to ensure adequacy of surgical resection. A cartilage graft is 2.41). The lateral cheek flap is now elevated, remaining superficial
now harvested from the external ear on the same side. A skin to the orbicularis oculi muscle along the previously drawn line of
incision is placed on the anterior aspect of the pinna and the incision. The orbicularis oculi muscle is elevated from the under-
cartilage is exposed. By alternate blunt and sharp dissection, an lying conjunctiva to create a pocket for insertion of the cartilage
 < I t ) i I I I I I I I I » I I I I I I I I I 1 I 1 I I I I 1 1 1

Fig. 2.46 The surgical specimen demonstrates adequate excision of the Fig. 2.47 The postoperative appearance of the patient approximately
cutaneous adenocarcinoma of adnexal origin. t w o months following surgery.

Fig. 2.46 demonstrates adequate excision of the cutaneous adeno-

carcinoma of adnexal origin. The postoperative appearance of the
patient approximately two months following surgery shows satis-
factory reconstruction of the surgical defect following through-
and-through resection of the lateral half of the lower eyelid (Fig.
2.47).

RADICAL RESECTION OF THE LOWER EYELID AND

RECONSTRUCTION WITH A MUSTARDE FLAP

When the entire lower eyelid has to be resected for a malignant

lesion, the reconstruction becomes a significant problem. The
patient shown in Fig. 2.48 has a nodular melanoma involving
the skin and the tarsal margin of the lower eyelid. The extent of
surgical resection for the primary tumor is outlined (Fig. 2.49).
The entire lower eyelid is resected along with a generous portion Fig. 2.48 A nodular melanoma involving the skin and the tarsal margin
of the lower eyelid.
of the skin of the cheek. A portion of the palpebral conjunctiva is
excised but the bulbar conjunctiva remains intact. The skin
incision necessary for elevation and advancement rotation of the
Mustarde flap is shown in Fig. 2.50. Note that the skin incision
for the Mustarde flap must be taken higher than the lateral
canthus in the temporal region to prevent ectropion. The skin
incision in the temporal region is taken high and then turned
inferiorly towards the preauricular skin crease continuing on to
the upper part of the neck where it curves anteriorly to permit
satisfactory elevation and rotation of the skin flap. The latter is
elevated superficial to the terminal branches of the facial nerve to
prevent any injury to them.
The surgical defect following superficial parotidectomy and
upper neck dissection with elevation of the Mustarde flap is
shown in Fig. 2.51. Note that the entire lower eyelid is resected
to encompass the primary tumor.
The surgical specimen following full-thickness resection of the
lower eyelid with the underlying soft tissues is shown in Fig.
2.52. The appearance of the patient on the operating table
Fig. 2.49 The extent of surgical resection for the primary tumor is
following complete closure of the surgical defect with the outlined.
Mustarde flap is shown in Fig. 2.53. The flap is advanced medially
and rotated inferiorly to fill the surgical defect. A temporary
tarsorrhaphy is performed. restoration of the lower eyelid, but functionally the patient has no
The postoperative appearance of the patient at two months after trouble with the eye. He does have minimal epiphora due to
surgery is shown in Fig. 2.54. Note that because of the lack of eversion of the palpebral conjunctiva, but the cornea is fully pro-
tarsal plate and the support necessary for the lower eyelid, some tected. The Mustarde advancement rotation flap provides an
degree of ectropion is present, and there is eversion of the con- excellent choice for reconstruction of a full-thickness defect
junctival mucosa. The absence of eyelashes also impairs the esthetic following resection of the entire lower eyelid.
 TRICI 2 3 4 5

luuluillllllluilluil luiiltlllSilll! LLLLLLLi

Fig 2.50 The skin incision necessary for Fig. 2.51 The surgical defect following Fig. 2.52 The surgical specimen following full-
elevation and advancement rotation of the resection of the tumor, superficial thickness resection of the lower eyelid with the
Mustarde flap is outlined. parotidectomy and upper neck dissection w i t h underlying soft tissues.
elevation of the Mustarde flap.

Fig. 2.53 Completed

closure of the surgical
defect w i t h the
Mustarde flap. A
temporary
tarsorrhaphy is
performed.

Fig. 2.54 The postoperative appearance of the patient at t w o months

after surgery. Figs 2.48-2.54 by courtesy of Ronald Spiro MD.

The plan of surgical excision is outlined in Fig. 2.56. A

FULL-THICKNESS RESECTION AND RECONSTRUCTION
rectangular portion of the full thickness of the upper eyelid is
OF THE UPPER EYELID
resected. The shaded triangular areas at the two upper corners of
the rectangular excision are wedges of skin which will be excised
Full-thickness resection of any portion of the upper eyelid poses a to permit advancement of the skin of the upper eyelid for
significant reconstructive problem, unlike the lower eyelid which reconstruction (Fig. 2.57). A ceramic corneal shield is inserted to
is relatively easy to repair. Since the upper eyelid provides most of protect the cornea. Two heavy, silk sutures are taken through the
the lubricating function and protection to the cornea and globe, full thickness of the tarsal margin of the upper eyelid on the peri-
its accurate reconstruction is extremely important to prevent any phery of the intended site of excision; these stay sutures are held
subsequent injury to the cornea. The patient presented in Fig. with hcmostats to stabilize the eyelid during excision.
2.55 has a pigmented basal cell carcinoma involving two-thirds of Through-and-through resection of the upper eyelid along the
the width of the upper eyelid, the tarsal margin and the adjacent previously outlined area of rectangular excision is completed I Fig.
conjunctiva. Surgical excision of the lesion will require a full- 2.58). Note that the surgical excision is just medial to the stay
thickness through-and-through resection of that part of the upper sutures which help stabilize the cut edges of the surgical defect.
eyelid with immediate, appropriate repair. Complete hemostasis is obtained by ligating and/or coagulating
 Fig. 2.58 Through-and-through resection of the upper eyelid along the
previously outlined area of rectangular excision is completed.

Fig. 2.55 A pigmented basal cell carcinoma involving two-thirds of the

width of the upper eyelid, the tarsal margin and the adjacent conjunctiva.

Fig. 2.59 The tarsal plate of the lower eyelid is exposed through a skin
incision at the gray line.

Fig. 2.56 The outline of surgical excision, and skin advancement on the
upper eyelid.

Fig. 2.60 The composite conjunctival flap containing a portion of the

split tarsal plate from the lower eyelid is advanced cephalad and sutured
Fig. 2.57 The shaded triangular areas at the two upper corners of the to the horizontal cut edge of the conjunctiva of the upper eyelid in the
rectangular excision are wedges of skin which will be excised to permit rectangular surgical defect.
advancement of the skin of the upper eyelid for reconstruction.

the bleeding points during the excision. Similar silk stay sutures surgical defect of the upper eyelid, and the incision is taken down
are applied to the tarsal margin of the lower eyelid and an incision to its reflection over the globe. This w i l l , therefore, provide a
is made through the gray line of the tarsal margin of the lower composite conjunctival flap containing a portion of the split tarsal
eyelid between the two stay sutures. The skin is retracted interiorly plate from the lower eyelid, which is then advanced cephalad
to expose the tarsal plate (Fig. 2.59). Using a sharp, fine knife, the and sutured to the horizontal cut edge of the conjunctiva of the
tarsal plate is divided in a coronal plane through its thickness in tipper eyelid in the rectangular surgical defect d i g . 2.60). The
order to retain the inner aspect of the tarsal plate attached to the conjunctival sutures are taken with 6-0 plain catgut sutures.
palpebral conjunctiva, while its outer aspect remains continuous Several interrupted sutures arc applied and the knots are kept on
with the rest of the tarsal plate. the undersurface of the conjunctiva to be buried in the soft tissues.
Using sharp scissors, two incisions are made in the palpebral Once this bridged conjunctival repair is completed, skin incisions
conjunctiva with the attached split tarsal plate, to match the are made in the upper eyelid further cephalad from the rectangular
Fig. 2.61 The previously marked triangular wedges ot skin are excised. Fig. 2.63 The remaining skin closure is completed along the lateral
aspect of the skin flap and then transversely through the region of the
excised wedges of the skin.

Fig. 2.62 Approximation of the lower edge of the upper eyelid skin flap Fig. 2.64 At eight weeks after the first stage of the operation, the
and the skin margin of the lower eyelid is completed. patient's fused eyelids are divided under topical and local anesthesia.

x
,4

Fig. 2.65 The postoperative appearance of the Figs 2.66 and 2.67 The functional and esthetic restoration is complete, and the final postoperative
patient one week following division of the result is very gratifying.
bridged lower eyelid flap.

defect to match the previously outlined triangular areas of .skin local anesthetic is infiltrated along the palpebral fissure through
to be sacrificed and these are excised (Fig. 2.61). This allows the fused eyelids. A line, lacrimal probe is introduced from the
downward advancement of the skin flap from the upper eyelid palpebral fissure medial to the bridge of skin, and is brought out
which is sutured to the cut edge on the skin side of the tarsal mar- through the fissure lateral to the bridge to protect the cornea
gin of the lower eyelid, using 6-0 nylon sutures. Thus approxi- during division of the fused eyelids. Using sharp, curved scissors,
mation of the lower edge of the upper eyelid skin flap and the skin the bridge of the fused eyelids is divided along the line of the
margin of the lower eyelid is completed (Fig. 2.62). The remaining palpebral fissure, and full-thickness through-and-through division
skin closure is completed along the lateral aspect of the skin flap of the bridged reconstruction is performed to separate the recon-
and then transversely through the region of the excised wedges of structed upper eyelid from the lower eyelid. Some minimal bleeding
the skin; this is the first stage of reconstruction of the upper eyelid is to be expected from the cut edges of the reconstructed area, but
(Fig. 2.63). At the conclusion of the operation, the upper and this will stop with slight pressure.
lower eyelids are fused, and remain so for eight weeks. Skin sutures The postoperative appearance of the patient one week following
are removed in approximately one week. During fusion, the division of the bridged lower eyelid flap to reconstruct the upper
patient is instructed to irrigate the eye and keep the area as clean eyelid is shown in F i g . 2.65. The functional and esthetic
as possible. restoration is complete, and the final postoperative result is very
At eight weeks after the first stage of the operation, the patient gratifying (Figs 2.66, 2.67). Bridged repair of the upper eyelid
is returned to the operating room where the fused eyelids are defects using a split tarsal plate and conjunctival composite flap is
divided under topical and local anesthesia (Fig. 2.64). Two drops a very satisfactory means of immediate reconstruction of sizable
Of topical anesthetic are introduced into the conjunctival sac and defects of the upper eyelid.
REHABILITATION OF THE PARALYZED EYELIDS Fig. 2.68 Paralysis of
the upper eyelid
following radical total
Sacrifice of Ihe facial nerve or destruction of the nerve due lo parotidectomy with
sacrifice of the facial
tumor invasion leads fo complete paralysis of facial muscles on nerve.
the ipsilateral side. On the other hand, isolated dysfunction of a
branch of the facial nerve leads to paralyisis of its corresponding
muscles. Thus, loss of function of the frontal branch leads to para-
lysis of the frontalis muscle causing inability to raise the forehead
and drooping of the eyebrow. Dysfunction of the zygomatic branch
of the facial nerve causes paralysis of the orbicularis oculi muscle
which causes inability to close the palpebral fissure. Epiphora and
exposure keratopathy are significant complications which require
appropriate management. Dysfunction of the buccal, marginal
mandibular and cervical branches of the facial nerve causes
paralysis of the muscles of the lower half of the face including
buccinator, orbicularis oris, and platysma as well as the elevators Fig. 2.69 A dummy of
and depressors of the commissure of the mouth. the correct weight is
chosen to determine
Rehabilitation of the paralyzed eyelid is of crucial importance to the w e i g h t of the gold
alleviate the symptom of epiphora and constant irritation of the pellet insert necessary
conjunctiva as well as blurring of vision secondary to exposure to achieve adequate
keratopathy. There are three procedures which aid in restoring the palpebral closure.
paralyzed eyelid: (I) gold weight implant; (2) lateral tarsorrhaphy;
and (3) lateral canthoplasty.

GOLD WEIGHT IMPLANT

Insertion of a gold weight in the upper eyelid provides closure of

the eyelid by gravity which occurs in harmony with the opposite
eye. Restoration of upper lid function in this manner works
extremely well in young patients. In the older patient, additinoal Fig. 2.70 The actual
gold w e i g h t is a curved
procedures may be necessary to repair ectropion of the lower
pellet w i t h three holes
eyelid in addition to placement of the gold weight in the upper in it which are used to
eyelid. suture the weight
The postoperative appearance of a patient who required a radical securely in place.
total parotidectomy with sacrifice of the facial nerve including
resection of the lateral temporal bone shows paralysis of the upper
eyelid during closure of the eye (Fig. 2.68). The procedure of
placement of gold weight is generally done under local anesthesia.
Prior to the operative procedure, however, a determination is
made regarding the weight of the gold pellet insert necessary to
counteract the levator palpebrae superioris muscle. A series of
dummies of varying weights are available to choose from. The
correct weight necessary to be used in this patient is shown in Fig.
2.69. The weight is temporarily applied over the skin of the upper
eyelid with adhesive tape and the patient is asked to dose the
Fig. 2.71 A transverse
eyes. If satisfactory closure is achieved, then that is the correct incision is marked in a
weight to be used. The weight should also be tested with the eye- skin crease on the
lids open to ensure that excessive weight does not cause drooping upper eyelid
of the eyelid. The actual gold weight is a curved pellet with three approximately 6 mm
holes in it which are used to suture the weight to retain its above the tarsal
margin.
placement (Fig. 2.70).

An incision is marked in a skin crease over the upper eyelid

approximately 6 mm above the tarsal margin (Fig. 2.71). Local
anesthetic is infiltrated and the skin incision is placed to expose the
orbicularis oculi muscle (Fig. 2.72). Using a hemostat, the muscle
fibers are spread apart to create a pocket between the muscular
layer and the underlying tarsal plate. The pocket is created large
enough to permit easy insertion of the weight which should be
placed in the pocket without any tension (Fig. 2.73). Ihe weight
is anchored to the undersurface of the orbicularis oculi muscle
 Fig. 2.79 Postoperative appearance of a patient w i t h lateral
tarsorrhaphy.

Fig. 2.77 A 3-0 silk suture is used to approximate the raw areas and is
passed through rubber booties to prevent it from cutting t h r o u g h .

Fig. 2.80 A full-thickness wedge of the lower eyelid is resected at its

lateral end to achieve satisfactory inversion and closure of the palpebral
fissure.

Fig. 2.78 The suture is pulled snug and tied over the lower booty.
LATERAL CANTHOPLASTY

Elderly patients with significant ectropion leading to eversion of

suture is applied as shown in Fig. 2.77. Complete hemostasis is the lower eyelid, excess laxity and epiphora often develop sig-
secured. The suture is then tightened as shown in Fig. 2.78. The nificant conjuntivitis secondary to irritation of the everted lower
approximation of the upper and lower eyelid is thus achieved eyelid. Lateral canthoplasty provides adequate tightening of the
completely apposing the raw areas without any space in between. lower eyelid, inversion of the everted eyelid and restores satis-
'Ihe suture is then pulled snug and tied over the lower booty. The factory drainage of the tears into the lacrimal collecting system
suture is left in position for approximately three weeks at which from the lower fornix. The operative procedure is done under
time it is removed. Postoperative appearance of a patient with local anesthesia whereby a wedge of the lull thickness of the lower
lateral tarsorrhaphy is shown in Fig. 2.79. Lateral tarsorrhaphy eyelid is resected at its lateral end (Fig. 2.80). Appropriate length
adequately protects the cornea from exposure keratopathy and of the lower eyelid margin to be resected should be checked to
directs drainage of the tears medially to the lacrimal collecting achieve satisfactory inversion and closure of the palpebral fissure
system. upon repair. Following full-thickness wedge resection, complete
hemostasis is secured. A 4-0 Vicryl suture is used to approximate Fig. 2.82 Endoscopic
the stump of the transected tarsal plate to the lateral canthal view of the nasal
cavity showing the
ligament and through the periosteum of the lateral margin of the ends of the stent tied
orbit to achieve suspension and restoration of the lateral canthus. together.
Once this suture is applied, the remaining wound is closed in two
layers using 6-0 plain catgut sutures for the conjunctiva and 6-0
nylon for Ihe skin.

NASOLACRIMAL DUCT CANNULATION AND

PLACEMENT OF A STENT

Stenosis of the nasolacrimal duct is often encountered following

surgical resection of malignant tumors of the maxillary antrum,
lateral wall of the nasal cavity and the ethmoid complex. Patients
who experience stenosis of the nasolacrimal duct secondary to Fig. 2.83
fibrosis in the nasal cavity experience epiphora and often Postoperative
dacryocystitis secondary to obstruction and infection in the appearance of the
lacrimal sac. patient showing the
stent looping across
Cannulation of the nasolacrimal duct and placement of the the upper and lower
stent are performed under general anesthesia. The anatomy of the puncta at the medial
nasolacrimal duct system is shown in Fig. 2.81. The stent is a fine canthus.
soft nylon tube with wire-like probes at each end of the stent to
facilitate cannulation of the collecting duct system through the
upper and lower punctum. Insertion of the stent should be done
in a gentle and meticulous fashion without excessive force or
rough manipulation. Excessive pressure or force may result in a
false passage and an unsatisfactory insertion of the stem through
the false passage. The probes are inserted along the expected
direction of the upper and lower lacrimal ducts into the lacrimal
sac and thence into the nasal cavity through the stump of the
nasolacrimal duct in the nasolacrimal fossa at the inferior medial detached and the two ends of the stent are tied to each other with
quadrant of the orbit. The probe is observed coming out of the multiple knots to prevent extrusion. The ends are cut short such
stump of the nasolacrimal duct in the nasal cavity with the aid of that the knotted ends of the stent remain high in the nasal cavity.
a nasal endoscope. Both the upper and lower probes are relreived An endoscopic view of the ends of the nasolacrimal stent tied
in the nasal cavity and the stent is prilled snug. The probes are together is shown in Pig. 2.82. Postoperative appearance of the
patient shows the presence of the stent at the medial canthus in
the upper and lower punctum of the left eye (Fig. 2.83). The stent
provides satisfactory drainage of tears through the nasolacrimal
collecting system and prevents recurrent stenosis of the
nasolacrimal duct.

SURGERY FOR ORBITAL TUMORS

It is truly beyond the scope of this work to present the full spec-
trum of surgical procedures for neoplasms in the orbit, however
the concepts of surgical resection for orbital neoplasms will be
presented with examples for excision of a benign tumor as well as
radical resection with orbital exenteration for a malignant tumor.
The surgical approaches for tumors of the orbit vary upon the
location and the size of the tumor as well as its tissue of origin and
the proximity of other vital neurovascular structures and the
globe.

EXCISION OF A HEMANGIOMA OF THE ORBIT

The patient shown in Fig. 2.84 presented with proptosis of her

left eye of several years' duration with discomfort and diplopia on
Fig. 2.81 The anatomy of the nasolacrimal duct system and a schematic right lateral gaze. Vision in her left eye was normal although sig-
representation showing insertion of a stent. nificant proptosis could be appreciated on clinical examination.
 Radiographic studies of this patient entailed a CT scan with
contrast in the axial and coronal planes (Figs 2.85, 2.86). In the
axial plane, a well-demarcated contrast-enhancing mass is seen in
the left orbit posterior to the globe and inferior to the optic nerve.
Phe mass was contained within the bony orbital socket and did
not infiltrate into the periorbita or the adjacent bone. On coronal
CT scan, the mass again is vividly demonstrated in the left orbit
lying inferomedial to the optic nerve and medial and inferior recti
muscles. Due to contrast enhancement of the lesion, the radio-
graphic diagnosis of a hemangioma was rendered.
Surgical excision of this lesion required an orbitotomy per-
formed under general endotracheal anesthesia through the upper
part of a lateral rhinotomy incision along the nasolabial skin crease
extending up to the medial edge of the left eyebrow (Fig. 2.87).
The skin incision is deepened through the underlying soft tissues
to expose the rim of the orbit in its inferior medial compartment
(Fig. 2.87). The medial canthal ligament is identified and is
Fig. 2.84 This patient presented w i t h proptosis of her left eye of several detached from the orbital wall and retracted with a 4-0 neurolon
years' duration w i t h discomfort and diplopia on r i g h t lateral gaze. suture. The nasolacrimal duct demonstrated in Fig. 2.88 is
divided flush with the orbital wall at the lacrimal fossa. Using a
periosteal elevator, the orbital periosteum is now carefully and
very slowly elevated without inadvertently entering the tumor.
Fig. 2.85 Axial view of Meticulous and diligent elevation of the orbital periosteum
the CT scan w i t h permits its lateral retraction with a malleable retractor, bringing
contrast showing a
the underlying purplish-red vascular lesion into view (Fig. 2.89).
retrobulbar t u m o r i n
the left o r b i t .
A close-up view of the surgical field clearly demonstrates a
purplish spongy lesion occupying the inferior medial quadrant of
the orbit in the extraperiosteal plane (Fig. 2.90). Using a fine-tip
electrocautery, meticulous slow dissection of the tumor is
performed, carefully separating it from the underlying periorbita
and the bony orbital socket without inadvertent injury to the
contents of the orbit or the globe. Careful mobilization and
meticulous dissection permit the delivery of the lesion in a
monobloc fashion. The surgical field following excision of the
tumor shows the empty space created by removal of the lesion in
the inferior medial quadrant of the left orbit, permitting the globe
to be returned to its normal position (Fig. 2.91). The medial
canthal ligament is reapproximated to the bony medial wall of the
orbit. No attempt is made to resuture the transected nasolacrimal
Fig. 2.86 Coronal view duct which rests into the lacrimal fossa and will spontaneously
of the CT scan shows
epithelialize along its natural course. A small Penrose drain is
the t u m o r in the left
orbit in its inserted in the inferior portion of the medial aspect of the orbit
inferomedial quadrant. and the skin incision is closed in two layers.
The surgical specimen measuring approximately 2.5 cm shows
the entire lesion excised in a monobloc fashion in toto (Fig.
2.92). The cut surface of the specimen shows a fairly thick-walled
but spongy lesion which on histological analysis proved to be a
cavernous hemangioma (Fig. 2.93). The postoperative appear-
ance of the patient approximately three months following surgery
shows that the globe has returned to its normal position, the
patient no longer has proptosis, her discomfort is relieved, and
diplopia has disappeared (Fig. 2.94).
Fig. 2.87 The rim of the orbit in its inferior Fig. 2.88 The nasolacrimal duct is divided flush Fig. 2.89 The purplish-red vascular lesion is
medial compartment is exposed t h r o u g h a w i t h the orbital wall at the lacrimal fossa. brought into view.
lateral rhinotomy incision.

Fig. 2.90 Close-up view of the surgical field Fig. 2.91 The surgical field following excision Fig. 2.92 The surgical specimen.
showing the purplish spongy lesion. of the tumor.

Fig. 2.93 The cut

surface of the
specimen.

Fig. 2.94 The appearance of the patient three months following surgery.
RADICAL RESECTION WITH ORBITAL EXENTERATION aspect shows loss of the superior orbital rim as well as the lateral
wall of the orbit all the way up to the middle cranial fossa. The
floor of the orbit medially and the medial wall of the orbit are
High grade malignant neoplasms of the orbit often require the preserved (Fig. 2.99). The surgical specimen shown in Figs 2.100
need for orbital exenteration to achieve a satisfactory three and 2.101 demonstrates a monobloc resection of the tumor with
dimensional tumor resection. The extent of surgery, whether the contents of the orbit and the bony superior and lateral wall of
orbital exenteration or exenteration of the orbital contents with the orbit as the superior and lateral margins to the tumor. A com-
orbitectomy (resection of a part of the bony wall of the orbit), plete resection of the tumor has thus been achieved. Surgical
depends on the histology of the primary tumor, its local extent, defect in this patient was repaired with a rectus abdominis myo-
and the presence or absence of bone invasion. The CT scan of a CUtaneous free flap with the microvascular anastomosis to the
patient with adenoid cystic carcinoma arising in the lacrimal superficial temporal artery and vein. Postoperative appearance of
gland is shown in Fig. 2.95. Ihe axial view shows a large soft the patient is shown in Fig. 2.102. Major orbitectomy, particu-
tissue tumor situated posterolateral to Ihe globe in the orbit and larly when the roof of the orbit has been resected, warrants the
adjacent to or involving the lateral wall of the orbit. A higher need for free tissue transfer to avoid brain herniation. A composite
section of the axial view of the CT scan shows the presence of the free flap provides satisfactory support to the brain and obliterates
tumor cephalad to the globe and the extraocular muscles approxi- Ihe orbital defect completely, requiring essentially no maintenance
mating the orbital process of the frontal bone at the roof of the on the part of the patient with regard to cleaning of the orbital
orbit. (Fig. 2.96). In addition to this, the tumor extends through defect.
the superior orbital fissure to Ihe anterior aspect of Ihe floor of the
middle cranial fossa.
The surgical procedure required a cranio-orbital exposure (Fig. Fig. 2.97 Incisions
2.971 to gain access to the cranial cavity to protect the brain and outlined for cranio-
orbital exposure.
provide satisfactory resection of the intracranial component of
the tumor. The step by slcp details of craniofacial surgery are
presented in Chapter 4. The surgical field following removal of Ihe
lumor shown in Fig. 2.98 demonstrates wide resection of Ihe
lumor with a portion of the dura exposing the brain at the floor
of the middle cranial fossa. A superior and lateral orbitectomy has
been performed to achieve monobloc resection of the tumor along
with the contents of the orbit. The dural delect was repaired with
a free graft of pericranium. Surgical defect seen from the anterior

Fig. 2.9S Axial CT scan

shows a left-sided
intraorbital tumor that
was an adenoid cystic
carcinoma arising from
the lacrimal gland.

Fig. 2.98 Surgical field

viewed from the
cranial aspect.

Fig. 2.96 The tumor

extended cephalad to

V p*\ the globe and

extraocular muscles
approximating the
roof of the orbit.

A
Fig. 2.99 The surgical defect viewed from the Figs 2 . 1 0 0 and 2.101 Surgical specimen showing adequate monobloc resection of the tumor.
anterior aspect.

Fig. 2.102 Postoperative appearance of the patient following Fig. 2.103 This patient has an adenocarcinoma of the left lacrimal sac.
reconstruction with a microvascular rectus abdominis free flap.

Fig. 2.104 Axial view

If the bony confines of the orbit arc able to be preserved and the
of the preoperative CT
patient needs only orbital exenteration (exenteration of the globe scan.
and adnexa as well as of all the soft tissues including the periosteum
of the orbit), then a free flap is generally not required. Such a
patient can be easily rehabilitated with a facial orbital prosthesis
which obliterates the defect and also provides an excellent
cosmetic result.

ORBITAL EXENTERATION

Exenteration of the contents of the orbital cavity is indicated for

malignant tumors arising from the globe, with invasion of the
periorbita or malignant lesions arising from the adnexal structures
including the periorbita, the conjunctival sac, and the lacrimal involving the medial compartment of the left orbit with invasion
gland and nasolacrimal duct system. The patient shown in Fig. of the subcutaneous soft tissues overlying the nasal bone and the
2.103 has a high grade adenocarcinoma of the lacrimal sac tumor extending up to the lamina papyracea of the left orbit (Fig.
presenting in the medial aspect of the left orbit with displacement 2.104).
of the globe laterally. The extraocular muscles are involved by the The operative procedure is performed under general endo-
tumor causing ophthalmoplegia and the tumor has caused tracheal anesthesia. The operative field is isolated with sterile
complete obstruction of the nasolacrimal drainage system causing drapes and the skin incision is marked out (Fig. 2.105). The skin
continuous epiphora. The tumor involves the skin overlying incision extends from the lateral canthus along the tarsal margin
the medial aspect of the lower eyelid. A preoperative contrast of the upper eyelid up to the medial canthus. A similar incision is
enhanced CI" scan in an axial view demonstrates the tumor placed on the lower eyelid extending from the lateral canthus
 Fig. 2.105 The skin Fig. 2.107 A Freer
incision is outlined. periosteal elevator is
used to elevate the
periosteum of the
orbit.

Fig. 2.106 The skin Fig. 2.108 The

incision is deepened in extraocular muscles
a plane superficial to and the optic nerve
th« orbicularis oculi are divided at the
muscle. orbital apex with
angled scissors.

towards the medial canthus but both the upper and the lower of the orbit. A Freer periosteal elevator is used to elevate the
eyelid incisions are extended along the nasolabial fold to encom- periosteum of the orbit in its outer half as shown in Fig. 2.107.
pass the involved portion of the skin overlying the lacrimal fossa Brisk hemorrhage from small bleeding points between the bony
and nasolacrimal duct. The skin incision is deepened through orbit and the periosteum is to be expected. This is, however,
the subcutaneous tissue, however, remaining superficial to the promptly controlled with the electrocautery. Mobilization of the
orbicularis oculi muscle (Fig. 2.1061. A generous portion of soft entire orbit is carried on posteriorly as far as possible up to the
tissue is sacrificed under the medial aspect of the incision where apex of the orbit. Care should be exercised to avoid perforating
the skin is involved. Here the skin incision is deepened straight the periosteum, otherwise herniation of the periorbital fat will
down to the nasal bone medially and the anterior wall of the occur compromising the exposure and adequacy of the operation.
maxilla laterally. F.levation of the upper and lower skin flaps No attempt is made to mobilize the periosteum in the lower
continues with the use of an electrocautery up to the orbital rim medial quadrant of the orbit where the lacrimal apparatus and the
in a circumferential fashion. In the infero-medial quadrant of the lacrimal fossa will be resected en bloc with the orbital contents.
orbit, however, the soft tissues along the nasolabial fold are Using a power saw, the orbital rim in its lower medial quadrant is
retained on the specimen. divided, remaining lateral to the lacrimal fossa and medial to the
Using the electrocautery, a circumferential incision is made in infraorbital canal. Similarly, the medial aspect of the bony orbital
the periosteum of the orbit at the orbital rim, extending from the rim is also divided with a power saw. Finally the lateral aspect of
supraorbital foramen superiorly up to the infraorbital foramen the left nasal bone is divided with a power saw to completely
interiorly, thus encompassing the lateral half of the circumference mobilize the bony lacrimal fossa in continuity with the orbital
Fig. 2.109 The surgical defect. Fig. 2 . 1 1 0 The skin graft is sutured to the Fig. 2.111 The Xeroform gauze retains the skin
edges of the skin of the upper and lower graft in position.
eyelids.

contents. At this juncture, the apex of the orbit posteriorly is

nearly completely mobilized. The attachment of the extraocular
muscles and the optic nerve now need to be divided. Using curved
orbital retractors, the apex of the orbit is exposed to permit an
angled scissors to divide the origin of the extraocular muscles and
the optic nerve as shown in Fig. 2.108. Brisk hemorrhage is to be
expected from the central retinal artery as well as the ophthalmic
artery and the cut ends of the extraocular muscles. This is, how-
ever, promptly controlled with bipolar cautery and ligation of the
central retinal and ophthalmic arteries with suture. Finally, using
a heavy Mayo scissors, the surgical specimen is removed in a
monobloc fashion encompassing the contents of the orbit and the
tumor of the lacrimal apparatus, in continuity with the full length
of the nasolacrimal duct up to the lateral wall of the nasal cavity.
The surgical defect thus shows the cxenterated left orbit with
resection of the lacrimal fossa (Fig. 2.109). The stump of the optic
nerve and the stumps of the divided extraocular muscles can be Fig. 2 . 1 1 2 Postoperative appearance of the patient approximately one
seen at the apex of the orbit. Absolute hemostasis from the m o n t h following surgery shows excellent healing of the skin graft within
structures at the apex of the orbit can be secured using a chromic the orbital socket.
catgut suture ligature on a small curved needle.
A previously harvested split-thickness skin graft is now
employed to provide lining for the raw surfaces of the exenterated
orbit. The skin graft is sutured to the edges of the skin of the upper
and lower eyelids (Fig. 2.110). A Xeroform gauze packing is
employed to snugly apply the skin graft over the bony orbital
walls permitting secure contact. The orbital socket is completely
packed with Xeroform gauze which retains the skin graft in
position (Fig. 2.111). The skin incision is closed in two layers.
Postoperative appearance of the patient approximately one
month following surgery shows excellent healing of the skin graft
within the orbital socket (Fig. 2.112). Minor debridement of the
orbital defect is necessary until absolute healing of the skin graft
is achieved. The patient is instructed regarding irrigation of the
orbital defect and employment of a 4 x 4 gauze soaked with
mineral oil to maintain moisture in the orbital cavity to avoid
crusting. Approximately three months following surgery, an orbital
prosthesis is fabricated which provides esthetic rehabilitation of
Fig. 2.113 Postoperative appearance at six months, shows excellent
the exenterated defect (Fig. 2.113).
esthetic rehabilitation w i t h an orbital prosthesis.